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May 17, 2016

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Better Care, Healthier People and Communities, More Affordable Care: 5 Years of the National Quality Strategy: May 17, 2016 [Slide 1]

Operator: Ladies and gentlemen, thank you for standing by. Welcome to this National Quality Strategy Webinar: Better Care, Healthier People and Communities, More Affordable Care: 5 Years of the National Quality Strategy. I would now like to turn the conference over to Heather Plochman. Please go ahead.

Housekeeping [Slide 2]

Heather Plochman: Thank you so much for joining today's Webinar. On your screen you'll see a few housekeeping notes to take care of before we get started today. During the Webinar, please submit your technical questions via the chat box and we will attempt to answer those there. If you lose your internet connection, please reconnect to the Webinar using the link that was emailed to you. We've also included the ReadyTalk support line if you are having any difficulties, as well as the closed captioning link, which we also put in the chat box, so that you can easily copy and paste that.

Agenda [Slide 3]

Heather Plochman: Here you'll see today's agenda. First, Dr. Nancy Wilson will offer a brief history of the National Quality Strategy, then Dr. Ernest Moy will provide an overview from the 2015 National Healthcare Quality and Disparities Report and 5th Anniversary Update on the National Quality Strategy, and finally Dr. James Venza will then spotlight the Lourie Center for Children's Social and Emotional Wellness, a National Quality Strategy Priority in Action. After Dr. Venza's presentation, we will have an open discussion on the impact of the National Quality Strategy over the past 5 years, so we'd like everyone to be thinking of how the Strategy has impacted and continues to impact your organization.

History of the National Quality Strategy, Nancy Wilson, B.S.N., M.D., M.P.H. [Slide 4]

Heather Plochman: Now I will turn it over to Dr. Nancy Wilson, Executive Lead for the National Quality Strategy.

Nancy Wilson: Thanks, Heather, and welcome, everyone. I am delighted that you were able to join us.

History of the National Quality Strategy [Slide 5]

Nancy Wilson: Here you have the history of the National Quality Strategy, which was mandated by the Affordable Care Act. The challenge that we were given was to improve the delivery of health care service, patient health outcomes, and population health—it was really about the health care system. To go about it, we developed a consensus with more than 300 groups, organizations, individuals, the public, and the private sector, to identify what the strategy should look like, and we published it in 2011. Our goal for the Strategy was to provide a nationwide focus for improvement activities across the country.

Timeline of the National Quality Strategy: [Slide 6]

Nancy Wilson: Here is the brief timeline of the National Quality Strategy, which really focuses on the early adopters that were at the Federal and State levels. In addition, there are dozens of private-sector organizations that are adopting and embracing the aims and the priorities of the National Quality Strategy each year. Each year we learn about more organizations, and we love learning about those of you that are working on this, because then we get to feature you and all of your organizations.

Aims, Priorities, and Levers [Slide 7]

Nancy Wilson: So what are we really talking about here, and what is it that you can do to align to the Strategy? First and foremost, you can adopt the three aims, which are to provide better care, more affordable care and to improve the health of people and communities. Next, you can focus your improvement activities and initiatives on one or more of the priorities. These are cross-cutting issues: patient safety, person- and family-centered care, care coordination, prevention and treatment of the leading causes of morbidity and mortality, enabling the healthy living and well-being of people and communities, and making quality care more affordable. Within these broad cross-cutting priorities, we feel that there's opportunities for everyone to participate. The third way to embrace the National Quality Strategy is to think about your core business, and how you might be able to weave the work that you are doing on the aims and or the priorities into those core business functions. We call those levers, and I am going to run through some of them here: we have performance measurement and feedback, public reporting, health information technology; consumer incentives and benefit designs. If you are a certifying board or agency, how do you weave the National Quality Strategy into the credentialing that you do?

We also have workforce development. I just got a request today from someone saying that they are writing a textbook chapter on quality improvement for a nursing curriculum and asked if we could use some of the tables and graphs from our Working for Quality Web site. I said to her, that's why they're there—we want to get the word out. You can take a look at these levers—I haven't even listed all of them—that you can use to embrace and frame your quality improvement activities.

The Relationship Between the Institute for Healthcare Improvement's Triple Aim and NQS Three Aims [Slide 8]

Nancy Wilson: Here you'll see a slide that compares the National Quality Strategy three aims to the Institute for Healthcare Improvement's Triple Aim. We built the three aims off of the Triple Aim, which was truly foundational work. The Triple Aim is improving the patient experience of care, including quality and satisfaction, improving the health of populations, and reducing the per capita cost of health care.

As we were working with our consensus-building process, what we found was that people wanted a little bit more elaboration or specificity, to make some things more explicit. So, better care, we try to clarify, is about improving overall quality. With healthy people and healthy communities in particular, one of the things that we heard very clearly was the importance of making explicit the need for proven interventions to address behavioral, social, and environmental determinants of health. That movement has been building momentum for the past 5 years as we really started thinking much more broadly about the health of people and communities. We try to look at total population health in a way that's not simply from a hospital or a health care delivery perspective, where it might be a panel of your patients.

Last, we have affordable care, because when the Affordable Care Act was passed one of the things that was really distressing for many folks was how much they were paying in out-of-pocket costs. The per capita cost of care is certainly a critically important indicator of how we're doing on this aim. In the broader sense, it's about reducing the cost of quality health care for individuals, families, employers as well as the nation as a whole.

NQS Priorities and Their Improvement Initiatives [Slide 9]

Nancy Wilson: On this slide you'll see a graphic that includes a list of the priorities as well as improvement initiatives that are in various levels of maturity, having been identified over the years for each priority. For example, I would suspect that many of you have been part of the Partnership for Patients efforts to improve patient safety.

We also have the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS), the National Partnership for Women and Families, and PatientsLikeMe, which are all focused on person- and family-centered care. It's not patient and family centered care, because we want it to be beyond just the experience of the patient—it's really about the whole person. Later today you'll hear from Dr. James Venza about the Lourie Center for Children's Social and Emotional Wellness, who will discuss care coordination, which I think you'll all be excited to hear about. As you are looking through these initiatives, you may even see initiatives that can prompt improvement on more than one priority.

Ongoing Federal Implementation Activities [Slide 10]

Nancy Wilson: This slide illustrates a number of ongoing Federal implementation activities. Every Agency in the Department of Health and Human Services is supposed to write and update an annual Agency Specific Plan for addressing the National Quality Strategy aims and priorities. These are all posted on our Working for Quality Web site. In addition to that, we've found that there is a real interest among our broader Federal community—including the departments of Labor, Housing, and Education—about thinking through how we can come together to align our activities to improve the health of people and communities.

Ongoing Implementation Activities [Slide 11]

Nancy Wilson: Here you'll see two of our team's major implementation activities. We have two series, the Priorities in Focus and the Priorities in Action. The Priorities in Focus illustrate the current state of primarily quantitative progress made for each of the National Quality Strategy priorities, and are co-released with the National Healthcare Quality and Disparities Report Chartbooks over a roughly 6-month period. Each Priority in Focus correlates to the Chartbook that discusses care improvements for that priority.

In addition to that, in the past five years, we've been looking for promising and transformative Federal, State, and local organizational initiatives that have shown measureable improvement on one or more of the priorities. These are all posted on our Web site, with the hope that looking through some of these might give you ideas for what you might be doing in the future or getting in touch with us to discuss your initiatives so that we can feature you.

5-Year Anniversary Stakeholder Toolkit [Slide 12]

Nancy Wilson: For the 5-year anniversary of the Strategy, our team created this special 5-year anniversary toolkit to provide you with materials that you can use to demonstrate your alignment to and support of the National Quality Strategy. There are new promotional materials, graphics, Web content, and the like, including press releases that can be tailored to your needs. We just want to help you promote your good, valuable, quality improvement work.

Overview of the 5th Anniversary Update [Slide 13]

Nancy Wilson: Here we have key findings from our 5th Anniversary Update Report on the National Quality Strategy. We saw a dramatic improvement in access, and an improvement in quality, though it's not as fast as any of us would want. We did find that there are still quite a number of persistent disparities. Now Dr. Moy will take you through an elaboration of the data that we've been summarizing.

National Quality Strategy Progress: Data from the 2015 National Healthcare Quality and Disparities Report. Ernest Moy, M.D., M.P.H., Medical Officer, Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality [Slide 14]

Nancy Wilson: Dr. Moy is a Medical Officer in the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality, and for more than 10 years he has led the creation of the National Healthcare Quality and Disparities Report. He also supports our Excellence Centers for the elimination of ethnic and racial disparities and our patient safety organization program. With that, I will turn it over to Ernest.

National Healthcare Quality and Disparities Report [Slide 15]

Ernest Moy: Thank you, Nancy. I am going to tell you a little bit about the National Healthcare Quality and Disparities Report (QDR) today. I think the information from the QDR is critical to the success of the National Quality Strategy, because it gives us the ability to understand what parts of the Strategy and its priorities are working and what parts are not, so that more focus can be applied to areas lagging behind. Over the last couple of years, we have been working more and more closely with Nancy to make sure our reporting and the Strategy line up and this past year, the fifth anniversary year, we are totally synced up and combined the NQS and QDR into a single activity and report. I think this is a wonderful time, 5 years into the Strategy, to assess again what parts are working and what parts are not.

Here you'll see a bit of background on the QDR reports. In 1999, Congress mandated that the QDR be an annual report to Congress and we have been creating them ever since. These reports provide a comprehensive overview on the state of health care quality and disparities in the country. We were instructed to hone in on race and socioeconomic status as the primary tracked disparities, though we also track disparities for the elderly, children, residents of rural areas, LGBT populations, et cetera. Our disparities are framed on two axes: access to health care and quality of health care. Each year, we receive input on the measures included in the Reports from an Interagency Working Group that includes membership that cuts across all the HHS Agencies and is provided behalf of the HHS Secretary.

Brief QDR Timeline [Slide 16]

Ernest Moy: This is a brief timeline that hones in on two aspects of the content that we produce. One the initiation 1999, the first reports released in 2003 and trying to emphasize that we try to make changes regularly in the reports to try to keep them fresh. The end of the top line, 2015 was a major change year for us. We've moved from being two separate documents, the quality reports and the disparities report, each roughly 300 pages, into a single integrated group report, which is only 30 pages long. This new report is something that's easier for policymakers to read and is supplemented by a series of Chartbooks.

In addition, over time we've integrated more and more with the NQS. By 2015, we organized the Chartbooks around the six NQS priorities in addition to access to care and priority populations. The orange line at the bottom features our current Chartbooks. Some of these Chartbooks, which are starred, have been released: black health; patient safety, and healthy living. The remaining Chartbooks will be released in the next few months, and the Access Chartbook is expected to come out in May or June 2016.

QDR Role as a Resource in Improving Care [Slide 17]

Ernest Moy: So one of the challenges that we've always encountered with our reporting is that people say, well, what do you do with it? One of the ways that we think the reports are of use is working with the NQS at a very high national and State level, to identify the priorities where progress is being made and priorities that are lagging behind, or populations that are being improved and populations that are not experiencing those improvements. We think that we can provide this sort of helpful feedback to the NQS and its stakeholders so that they can focus on efficient use of resources to maximize quality improvement efforts. Throughout our reports, we have links to things that people can do to try to improve care, because that was one of the early questions we had. So, over the year, we've tried to integrate into the report and into our Web components a number of specific links that send you to implementation resources that people can use to take the next step and improve care.

Quality of health care improved through 2013, but the pace of measure improvement varied by NQS Priority [Slide 18]

Ernest Moy: I've alluded to the fact that the report is meant to be a very, very, high-level summary of quality of care and that we oriented around the National Quality Strategy priorities. Over time, we track many dozens of measures to see how they are changing over time for different populations and in the different priority areas. The reports themselves are intentionally broad in scope but shallow in depth, so we're tracking measures from a number of different sources. Settings of care tracked include hospital and doctor's offices, hospices, nursing home, and home health. We also cover a real gamut of conditions, and you see that on the bottom where it shows that we were able to track the progress of 191 measures this year. Normally, we require more than 4 years of data for a measure to track it and report it. In the green bar you see the measures that are improving. The purple bar includes the measure that are staying roughly the same and then the black bars at the right show measures that are worsening. Across all the priorities, nearly 60 percent of the tracked measures arrayed across the different priorities are improving over time in a significant way. We found the highest performance to be among the person-centered care measures, and the lowest performance to be among the care coordination measures. Effective treatment, healthy living, and patient safety are distributed somewhere in between. So, considering that, our idea is that stakeholders can use this information to help focus and target initiatives to improve care for particular National Quality Strategy priorities.

2015 QDR: Improvements in rates of uninsurance continue for all ages through 2015 [Slide 19]

Ernest Moy: Nancy alluded to the fact that we have observed very, very rapid improvements in access to care over the last couple of years since the implementation of the Affordable Care Act. This graph shows a representation of access to care, as defined by the rate of insurance by age groups. The purple line represents Americans ages 0–17, the orange line represents Americans ages 30–64, the green line represents Americans ages 18–29, and the black line represents the overall total for all age groups. Over time, we've seen a reduction in the rate of uninsured Americans. We've seen the rate drop most dramatically since roughly 2013 and 2014, when the Marketplaces mandated by the Affordable Care Act became operational.

Disparities remained prevalent across a broad spectrum of quality measures [Slide 20]

Ernest Moy: A significant part of the work we do is tracking disparities in care, and here you see the major groups that we look at. We track American Indian/Alaska Natives versus Whites, Asians versus Whites, Blacks versus Whites, Hispanics versus Whites and poor versus high-income individuals. The green indicates that the group is doing better than the comparison population. The green—the left indicates that the group is doing better than the comparison population. So, for instance, Black Americans are doing better than White Americans. The purple bars are when the two groups roughly are the same and the black bars on the right indicate where the comparison group is doing worse, often significantly worse than the other population. The point here is simply that health and health care disparities are very common. We are not going in and finding some rare kind of phenomenon—they are actually very prevalent in our health care system. And you can see at the bottom, the bottom row, which is poor versus high-income individuals that it's a very prevalent problem. Roughly 60 percent of the measures indicate that poor people receive worse quality care than high-income people. But it's also true for many of the racial and ethnic groups that we look at, especially Blacks and Hispanics, where they are experiencing many differences in care compared to White populations

Significant numbers of disparities in quality of care are starting to narrow [Slide 21]

Ernest Moy: This slide shows the type of information that we like to look at-what is happening to disparities over time? If they are getting better, maybe we can worry about them a little bit less. Again, green indicates that the disparities are improving, purple indicates that they are unchanged, and black indicates that they are worsening. We are happy to report this year that, as the years of data available to us increase, and as access to care has improved, we are seeing more and more disparities that are actually getting smaller over the time, and that there are very, very few disparities getting larger over time. When we look at it, we think we're heading in the right direction, which is equalizing the quality of care across the races or across income. Now, I'll turn it back over to Nancy.

The National Quality Strategy in Action: The Lourie Center for Children's Social and Emotional Wellness [Slide 22]

Nancy Wilson: Yes, thank you. It is my great pleasure to introduce Dr. James Venza, who serves as the Senior Director of the Lourie Center for Children's Social and Emotional Wellness, a leadership position that allows him to combine management with extensive clinical expertise. He joined the Lourie Center in 2003 to complete his postdoctoral training in the Center's Therapeutic Nursery and Parent-Child Clinical Services programs. He has extensive experience and training with children, adolescents, and families from diverse ethnic and socioeconomic populations, who are often dealing with trauma, abuse, crisis management, and a wide range of mental health issues. Dr. Venza has presented at local and national conferences on topics such as attachment theory, child placement consultation, and the socioemotional development of children and families, as well as therapeutic interventions for social, emotional, and behavioral disturbances in children.

Lourie Center Legacy [Slide 23]

James Venza: Great. Thank you so much, Nancy. Welcome to all who are joining us today to talk about these important evolutions in our country's care delivery system, particularly for our children and families. I'm excited to tell you a bit more about how the National Quality Strategy gives us a sharper focus and impacts us at a community level. We've had a great experience with the NQS as a framework, because it really helps organizations like ours that impact the lives of young children and families. The Lourie Center was established more than 30 years ago, and it was a collaboration between the leading figures in early childhood care. Many of you will know these names: Dr. Reginald S. Lourie, T. Berry Brazelton, and Stanley Greenspan. The Center grew out of research grants from the National Institute for Mental Health, in particular a study that looked at what makes children and parents from birth to age 5 grow and develop. We really wanted to take a multidisciplinary look at how to best support growth processes and overall enhanced quality of care. In particular, with respect to disparities, we have to bring care to communities who usually don't have access, and that's still very much the mission of the Lourie Center today. So, that's what we do—we support and improve the social and emotional health of young children and families and we do that through prevention, clinical intervention, research, and training. And from our roots, for many years that research really sustained us. Then, funding diminished for the research, and we went into direct service programs. Then, 5 years ago, in alignment with the National Quality Strategy, we recognized the need to return to research and the actual work and to research the actual work where children and their families are living and experiencing life's ups and downs, and it helped us to get more funding.

Quality Care [Slide 24]

James Venza: The National Quality Strategy highlighted our initial research in our Parent-Child clinic, which is a licensed outpatient mental health clinic, as a Priority in Action. We saw some great outcomes for families who had participated in our therapy program for up to 9 months. Looking at key attachment-based measures of emotional availability and caregiver insightfulness, within 6 to 9 months of a family's enrollment in the program, our treatment significantly increased parental emotional availability and insightfulness into the child's emotional cues, improved child and parent relationships, and strengthened the foundation of lifelong healthy development. The Lourie Center provides technical training to government agencies, school systems, and national and international nonprofit organizations across the country and around the world. In terms of our own organizational improvement, the Strategy has really laid the foundation for the next 10 to 15 years at the Lourie Center. Through the initial research and partnership with the National Quality Strategy, we were able to leverage additional funds and look into growing additional research within the Center.

Integrating Theory-Practice-Training-Research [Slide 25]

James Venza: I think one of the key things for the Lourie Center is that we seek to have an integration of both theoretical practice, clinical training, and research activity. We recently published an efficacy study of our attachment-based model, called Practicing Attachment in the Real World, which you'll see up on the screen. It's a great article, because it proved and outlined that you can, in fact, do great clinical work based on our theoretical intervention model, and that you can do it right in the communities where children and families are at the highest risk. The other studies, and indeed many of our core programs, that we have running right now have grown out of that study. We also have a number of current studies running that also focus on efficacy from an attachment-based intervention lens in the other parts of the Center. In May 2016, we're expecting initial results from a study in the Center's Special Education Elementary School that's focused on improving academic achievement, social information processing, and classroom climate. In our Early Head Start program, we have a partnership grant with the University of Maryland that's focused on examining toxic stress, and how to buffer it in toddlers through attachment-based interventions. Initial results from that are expected in summer 2016. In the Therapeutic Preschool Program, we have a study running that examines relationship-based, trauma-informed intervention for families with preschool children, and initial results are expected in 2017. About 80 percent of the children and parents enrolled in this program have experienced serious trauma. We're excited about the studies we have in the pipeline and looking forward to receiving all of the initial results in the near future.

Layers of Challenges & Opportunities [Slide 26]

James Venza: So this is slide is all about how we face challenges and opportunities at the Center and how we've been able to leverage the National Quality Strategy in order to seek additional funding to research and directly serve our constituent populations of young children and families. Our work is not easy, in many ways. Many community mental health places have really struggled recently, and many have closed. Our experience has shown that best practices for survival are to partner with broader organizations or entities, which was borne out when we recently became a member of a broad-based health care organization. This has been critical to our success, but we still do have ongoing struggles, which will likely be familiar to you all. Community-based care doesn't get reimbursed at the same rates as hospital-based care, and indeed the rates for community-based care are much less. Mental health care has limited funding because of insurance limits, in an insurance system built on the adolescent and adult model of health care and mental health care. It doesn't account for young children, when you need to coordinate their care around the parents, school, the courts, and more. So, there's a lot of work to do when you're working with children who are birth to age 12. In the larger picture, we do still have a ways to go in terms of building awareness of the needs of children who experience domestic violence or grow up in a neighborhood with other traumatic experiences that impact their developmental processes. One of the ways that we've been able really effectively to overcome some of the significant ongoing challenges is through multiple source funding. Again and again, the Lourie Center has been able to leverage the National Quality Strategy in this way. Partnership is really key to accessing the Federal, State, and local funding as well as private foundations and donors. It's key to having an ongoing improvement program.

Increasing Coordination of Care [Slide 27]

James Venza: Here I'd like to highlight some of our research-based care coordination efforts. One thing we're really excited about is the new Circle of Security Parenting Intervention, which is an attachment-based reflection program that we're integrating into all of our Center programming. We also trained 110 professionals in the program in 2015, and just trained an additional 60 this past week. Part of the reason we began this training program was that we were receiving feedback from parents who really wanted us to finesse the support we were giving them. Taking all that into account, we've integrated the Circle of Security Intervention into all of our programs at the Lourie Center as well as our in home services. We also started a unique partnership recently with the Montgomery County Department of Health and Human Services, in which we support their high risk emergency related programs, including family shelters and homeless shelters. In that partnership, we try to deliver Circle of Security parenting interventions, while supporting the kids' socialization group, and supporting the frontline staff in these shelters with reflective supervision. As a whole, we think coordinated care is key to really helping the system as a whole achieve our organizational priorities.

Expanding Coordinated Care Across the State, Nation, and Globe [Slide 28]

James Venza: To close my section, I want to discuss how we believe that the momentum that's been built through the ongoing improvement in quality improvement structures that we have in place has really opened up the ability for us to be strong in both our physical foundation and our clinical model. Now, we're able to grow our programs and make services available both throughout the state and internationally. There are two programs I'd like to highlight. Recently, President Obama expanded pre-K services for children from low-income areas, and so part of that funding for the State of Maryland is set aside for children with social and emotional issues and other medically fragile conditions. It's such an important way to reach people, kids, and families who have the greatest needs by providing them with crucial, intensive, and importantly, coordinated care services. The Lourie Center is also partnering with Social Workers Beyond Borders and the government of the Kingdom of Lesotho to help support that government's efforts to improve the early childhood development as well as social and emotional development of their young children—in particular, they are struggling with a lot of orphans because of HIV. I add that part because it's all part of where we began our quality improvement journey 32 years ago, but our activities have a particularly great momentum because we've aligned with the National Quality Strategy. We feel that it's been really crucial to the Lourie Center's success in bringing these early-intervention mental health services to children in our community here, across the country, and around the globe. Thank you very much!

Discussion/Question and Answer [Slide 29]

Nancy Wilson: Thanks so much, Dr. Venza.

Discussion/Question and Answer (continued) [Slide 30]

Heather Plochman: As I previously mentioned, we will now be moving into a discussion around the impact of the National Quality Strategy over the last five years within your organizations.

Discussion/Question and Answer (continued) [Slide 31]

Heather Plochman: We have some questions up on the slide here for you to take a look at and consider. In a minute the operator will open the lines for participants to chime in with examples of how the National Quality Strategy has impacted their organization in the last five years.

Lou Diamond: Hi, Nancy this is Lou Diamond here. I'd like to take the opportunity to share two experiences with you very briefly, using the National Quality Strategy as a framework for action within two different organizations. The first one is through HIMSS, or the Health Information Management Systems Society. When I was chair of the quality committee there, we operationalized a call for case studies. We called the project SOS, for Stories of Success. Each case study was to focus on a quality improvement program explicitly focused on the National Quality Strategy. Respondents had to identify which strategies or levers, as you are now calling them, they were utilizing to facilitate and focus their organization's quality improvement efforts. They were specifically asked to identify how they used health information technology (IT), given that HIMSS is a health information technology-focused organization. How did they use health IT to facilitate quality improvement? This all took place more than a few years ago—it was well received within the organization and got a lot of visibility. It was applied as the framework for disseminating information about the three aims and the National Quality Strategy in general into that organization, which is so IT focused.

The second experience was working with the End Stage Renal Disease (ESRD) Network programs. At a national level, this organization represents the ESRD networks, which are private organizations that are contracted to the Centers for Medicare & Medicaid Services to conduct quality measurements and improvement in the ESRD program. Essentially, they are a smaller version of the quality improvement network-quality improvement organizations we have now. We went through a four-step process to align to the Strategy. The first step was to disseminate information and facilitate discussion at the leadership level so that our leadership could understand the substance and direction of the National Quality Strategy, and achieve buy-in. We then went through what we called a mapping exercise, which is essentially described like this: in column one, describe the priorities of the National Quality Strategy and the levers; column two was a description of what activities were currently being undertaken within the ESRD networks relating to those priorities; the third column was gaps that were identified with regard to current activities against the priorities of the National Quality Strategy; and the fourth column was a set of prioritized action steps that the ESRD networks would then take based on the rest of the mapping. This effort was led by the network organizations. Our third step was to work to engage all of the stakeholders in the ESRD program as well as the other associations, nurses, physicians, providers, et cetera to get their buy-in. Our final effort, step four, was operationalizing organizational activities focused on the Strategy. We also worked to establish an ESRD coalition to figure out how we could build out an information infrastructure to support the National Quality Strategy. For both experiences, it was very helpful to have a framework for action that facilitated the discussion and collective action on the parts of multi-stakeholder organizations.

Heather Plochman: Thank you so much. Would anyone else like to chime into this discussion?

Neal Kohatsu: Hi, it's Neal Kohatsu and Desiree Backman from the California Department of Health Care Services. We wanted to thank Nancy and the whole team for inspiring us across the country at the state level and with California's Medicaid program, Medi-Cal. We just finished our fourth quality strategy, which we modeled after the NQS, and I want to let Dr. Backman share a few elements of the update and where we are in 2016.

Desiree Backman: Thank you, and thanks again to everybody on the call. We've been inspired over these years by the National Quality Strategy, and, as Neal mentioned, it really laid the groundwork for the work that we are doing here in California. We started with a very small little nest egg of quality improvement projects in our department in the first year of this endeavor, one within each of the priority areas; now we are nearly 60 quality improvement projects strong. They run a very wide gamut, and we have very large scale quality improvement efforts now. Our pay-for-performance waiver is a great example of that. We also have very, very narrow, but yet equally important projects that are targeting very specific subpopulations–for example the Native American population in California and every other shade in between. We've got quality improvement projects that are administrative, in addition to ones based on clinical care, health promotion and disease prevention, and many more.

Over the years, we have seen a lot of growth. We've also seen a big shift in the quality culture here at the California Department of Health Care Services, in order to see that kind of growth and maturation in the improvement projects themselves. Of course, you also have to have a good base of folks who are imagining the possibilities of quality improvement, and improvement in the California health population overall, and the health care system at large.

We've been putting a lot assets and a lot of effort into providing training and technical assistance to our staff. In addition, we've been annually monitoring the culture of quality within our organization, and our survey findings are indicating a nice improvement in that area. Now we keep up all of our quality improvement data internally to help guide continuous quality improvement in our projects and in our operations in our organization.

Now, we're pleased to let you know that we are putting together an evaluation system that is not only inward facing to our organization, but is outward facing to all of our stakeholders both in California and abroad. We're hoping that folks can relate what's going on within our quality strategy directly to how each of those quality improvement projects are performing over time. So, there's more to come and if you'd like to see the maturation of our quality strategy just simply Google “DHCS strategy for quality improvement in health care,” and you can see our four different renditions and how they've changed, grown, and matured over time. If you have any comments on them, please do let us know.

Nancy Wilson: Thank you, Lou, Neal, and Desiree. Next up, we will move to questions that we've received in the chat box.

Heather Plochman: Our first question comes from Diane Stollenwerk, who says that she works with organizations all across the U.S.A. that use the National Quality Strategy framework, which she says is the thread that most consistently connects the Nation's diverse efforts to improve health and health care quality. She says that in the five years since the Strategy's publication, there are many more connections created between health care and population health efforts, which is great to see. Her question is for Dr. Wilson: Can you speak to the degree to which health in all policies has played out at the Federal, State and/or local levels?

Nancy Wilson: I can't really speak to the local or state level, but I think that we still have a ways to go at the Federal level with getting health in all policies and getting it embraced more broadly. It's a good question, for future work.

Heather Plochman: The next question is for Dr. Moy. Why do you think that coordination of care struggles to improve? What factors are present and need to be addressed to improve this priority?

Ernest Moy: I think that care coordination is one of these issues that's difficult, because it often involved many different prior providers—after all, that's when you need coordination of care the most, is when you need multiple providers. When you have multiple providers, we've found that getting providers, who are perhaps on different kinds of information technology systems with different kinds of storage, or different electronic health records, to collaborate in some way is difficult. This is in contrast to a lot of the other areas where things are going to be done within just one provider's setting, where we've found that it's easier to make care more effective.

That said, I think we are moving in the right direction, because as providers incorporate more IT elements and these IT elements become more interoperable, there should be new data that will allow providers to better understand and address what the specific barriers are to coordination of care. The other thing that I think is increasingly popular, is the use of personal health records, which makes the patient the owner of the information. Again, this is something that would I think will greatly improve coordination of care, by pulling the power out of the fragmented health care system and into the hands of the person receiving care.

Heather Plochman: Thank you, Dr. Moy. We have one final question. Can you address the BMJ article published this month that notes that medical error is now the third leading cause of death in the United States? How can we say that the quality of health care is improving, as you did earlier today?

Ernest Moy: I appreciate this question, because it emphasizes the value of information and context. Often we don't have all the necessary information, or we just have information that's a cross section of data, as is the case with that article. For the Quality and Disparities Report, we observed significant improvements in adverse events and falling numbers for other, broader patient safety measurements, so we said that patient safety is trending towards improvement.

Certainly there are still a lot of medical errors, and that's why it's the third leading cause of death in America. Really, this is why longitudinal data is helpful in many situations. For example, too, the first and second leading causes of death in America are cancer and cardiovascular disease, and we're seeing dramatic improvements in health care quality in those areas as well, even though they remain a big problem. All in all, there is still much to do.

Thank you for attending today's presentation! [Slide 32]

Heather Plochman: If you asked a question in the chat box, we will try to get that answered and sent to you in the next few weeks. On this slide we have included additional resources if you'd like to learn more about the National Quality Strategy or the Strategy's fifth anniversary. Thank you so much for joining us today. The slides and transcript will be up on the Working for Quality Web site in the coming weeks.

Nancy Wilson: Thank you all for joining. Our team will certainly get back to you with answers to the questions that didn't get addressed on the call. Thanks a lot, everybody—I think that wraps it up. Thank you, Ernest and James, for presenting, and thank you to all who listened and joined in on our discussion today.