And now, our final presenter today for this session, Heidi Bosley, is a healthcare consultant who works with healthcare associations, measure development groups, clinical quality registries, and others to create strategies for performance measurement development, integration into electronic health records and registries, and appropriate selection of measures. Sorry, I'm stumbling here. She also advises physicians, nurses, and medical staff in hospitals and physician practices on quality improvement through workflow and process redesign, and she provides technical and clinical expertise on measure construction, specification, and testing. Ms. Bosley was the Vice President of Performance Measures at NQF, and she served as the Director of PCPI Operations for Clinical Performance Evaluation at the American Medical Association Convened Physician Consortium for Performance Improvement. So we've been hearing a lot about, you know, all the different things people are doing, and in a few minutes, you guys are going to go into breakout sessions to talk about ideas, but this is important for us to hear about how do we measure what we're doing to know if it works. So welcome, Ms. Bosley. Thank you. Thank you. So I do want to say one thing. Those of us who live in the measurement world like to make it sound very complicated. It's not. It's not rocket science. What I wanted to kind of walk you through today is if I was sitting down with a group that really wanted to focus on quality improvement, measuring your progress, tracking where you have been and where you want to go, these are the things I would think about and how I would start approaching the process. So the first thing, and I say this to everyone, it doesn't make sense to go from your viewpoint as a GI doc or as a primary care doc. We should be really following the path of the patient. I want to know who they touch, who they're interacting with. I want to know every opportunity where I may be collecting or gathering data. All those pieces are things, the sooner you think about that from the start, the easier it will be for you to be able to track progress. If you, you will always forget something, just like me with my slides, but if you think this through and really I've seen groups kind of do put a patient in the center and track process, every outcome, actually start from the time when you would identify that patient at risk, right, and follow them through until wherever your optimal outcome is. But you have a better chance of success of not forgetting something if you have kind of thought of it from the patient lens. It doesn't always happen. Sometimes it's easier to look at what you know and that's the comfort level, but we should think a little bit broader. One of the things to also think about is what are the intended use or uses of the measures. From what I'm hearing today and the conversation, it really is about quality improvement, and when you talk about quality improvement, you have the ability to be a little less rigorous on how everyone collects something. You can leave some variations there based on what's happening at the point of care. You can also think about how would I stratify this data in a little more detail because those individual pieces of information like race, ethnicity, or location where a patient originated from, those things might be useful in a way that you hadn't thought about. What are the opportunities, gaps in care? Usually when I start working with a group, we don't know that. I heard a lot this morning. You know where those gaps are. You know where those challenges are. Start there, so that's part of your patient journey here. What are the settings? Who are the players? Like I said before, that's important. And then what is the optimal outcome? And I usually live in a world where it's all about pay for performance. There's money on the table. I don't think we're talking about that here today. That changes the conversation in a really good way. You could get innovative. You could push the envelope on that outcome if you wanted to. So some questions to consider. I don't know the answer to all of these, but if you figure it out, let me know. So how do we measure team-based care? It's not silos. We don't operate in silos. Patients don't see us operating in silos. So how do we approach this looking at roles from primary care, also gastroenterology, anyone else, right? There are other specialties, other groups, nurses, techs, everyone else who's involved. So how do we pull them in? How do we get them invested? How do they understand what they're documenting actually leads into the measures and helps them track progress, right? They're a part of this as well. What are the potential collaborations to incentivize and track progress? So are there groups out there that you hadn't thought of before in the community that should be pulled in and a part of it? There might be some registry out there that you could be either providing data to or linking data and all of that could be incredibly useful. What tools and resources are needed? I'm working on a CDC quality improvement project around immunizations. And one of the things we're struggling with is what are the tools and resources that are needed at the point of care around vaccine hesitancy? You're going to deal with things like that with a patient not wanting to get a colonoscopy. You're talking to someone right here who didn't want to do it. I did do it this year. It took a lot of convincing. But what are those things that you should be developing, not just the metrics but also those resources? Is there a quick tips tool that would help people understand how they're going to document something? That's another piece to this, right? What are the components that you know will need to be built, maybe not to help build your metrics but make sure the data you're getting is consistent and standardized as much as possible? So thinking about those things up front is really important. And then what could serve as potential data sources? I threw in fire. I don't know how many of you are familiar with that term. Most people who say it don't actually know how to spell it. I know enough to be dangerous. But I think there are some technologies out there, and we're on that tipping point, I'm hoping, with interoperability where we could have some greater chances of data being exchanged in a somewhat seamless way. I will always remain a resident skeptic. I work with groups, and the day that we get ejection fraction actually documented in a discrete field in the EHR, I'll be happy. We still don't have that, right? So how do we get – but how do we get innovative? Are there ways and tools out there that we could use? Are there nontraditional sources of information that you should consider? So those are all the kinds of things I would say up front. Start thinking about it. You may not have the answer, but it's important to consider it early on. So key reminders. This is one of the slides I pulled over because I wanted – I realized I had missed it. I would encourage you to be thoughtful not only of what measures you use but also how you're going to roll this out. So how will you collect the data, and what's the potential burden on providers and patients? Always important to understand. That goes along with the tools and resources, right? The quick tips, the guidance. Have them at the table as you're going about developing these metrics. That's very important. How will you use the data? So are you going to benchmark against peers? I don't think you're going to public report at some point. But if you are, do people know that? And do they understand at what level you're going to do it? Having transparency from the start really can help you offset some questions and concerns that might happen in the future. I would encourage you to build a process where you can innovate and adapt real time if you can. Setting something in stone gets you some value, but if you're really trying to drive improvement, be prepared and be willing to adapt, revise things, change the metric. Be sure you actually say when you changed it so you can track, is it the change in a number because I just changed how you're capturing it, or is it actually true change? But be willing to do that because you will not be able to have the true quality improvement piece I think you are looking for if you don't. And then seek feedback at all levels throughout your process. This is another one. Someone mentioned this earlier. Good intentions, but I have seen measures that really are good measures blow up. And I talk to every group that I can think of about unintended consequences. Because number one, some people don't even talk about it. Number two, when people do talk about it, they don't do anything about it. That's probably my biggest pet peeve. So always think as you're designing these measures, what could I be doing that could either be due to measure design or possibly implementation? So I heard one potential unintended consequence this morning and I can't remember who raised it, sorry. But if I only look at those who had a positive test and I don't look at who's screened, I could actually have a really good number on follow-up, but I could have a whole host of people who should have been even considered for the denominator in that population in the positive test and I just, I didn't do it, right? Doesn't mean there's something wrong with the measure. Means I implemented it without thinking the whole picture through. So I really encourage you to think about it. Think about it early. Think about it often. Because it will happen. I have examples if you all want to hear some of them. And I would also say monitor the performance to ensure your results are reliable and valid. And then also that it's providing useful information. Over time, depending on how long this goes, there may be some things that you decide it's not worthwhile. You're going to move on to the next thing. There may be things that you constantly continue to report and provide feedback on. So I just, I made this up, but I just thought here are some of the things if I was going to start mapping out from a patient perspective around just colorectal cancer screening and what we're talking about today, what are the pieces that I might want to start thinking about measuring? So who's at risk? Who had the initial screen? Have any patients had difficulty accessing screening, right? That could be a metric that you target depending on the populations you have. Who requires the follow-ups and who are your positives? Who's receiving it? You may want to also under the ones who are in that gap in between, like some of you talked about this morning, is it due to transportation issues? Is it due to the fact that they just never had anyone give them a call? Those are the kind of discrete pieces that are worthwhile pulling out and possibly developing a metric on. Possibly having interventions around. So I would encourage you to think about that. And then I put an optimal goal. Could you see the rate of cancer detection increased, right? And maybe the stage is less of a later stage, it's to an earlier stage. I was a labor and delivery nurse. This is not my area. So that's just me making this up. But think about that because that might be your optimal outcome. So just a couple of things that if it helps to kind of see the way I would approach this is start with your optimal outcome. Think about it from the patient lens. Determine what structures and processes need to be in place. So those are all those little pieces along the path that I was showing you. And be broad in how you approach this. So what can or should be measured? Not everything can be measured. Not everything should be. But what should at least have it on the table as a possibility. What specialties, settings of care need to be involved? How will disparities in care or access to treatment needs be addressed? How will data be collected and how will the measures be used? So just a few thoughts. I'll stop there.

performance measurement development

quality improvement

patient's perspective

data collection

continuous monitoring