KCP : Launching The Kidney Care Quality Initiative

Launching The Kidney Care Quality Initiative (KCQI)

Background
The KCQI was formed to develop a well-designed pay for performance program that meets the needs of patients, other members of the kidney care community, and federal policy-makers.

In Phase I, the KCQI seeks to develop a pay for performance program that includes clinical and quality of life measures and takes into account the unique needs of pediatric patients. KCQI seeks to develop a program that federal policy-makers could implement immediately and for which there is current consensus among the members of the kidney care community.

In Phase II, the KCQI will consider how to build upon this foundation and propose appropriate revisions to clinical and quality of life measures, as well as the payment structure.

Goals
The KCQI will rely upon a consensus process when developing its proposals. Although this document outlines this process in detail, the KCP Steering Committee will periodically review this process and revise it asnecessary.

The Kidney Care Quality Initiative Structure

The KCQI in Phase I relied upon the work from four entities:

1- Expert Work Group
2- the Kidney Care Partners (KCP) Steering Committee;
3- the KCP Board; and
4- the Kidney Care Quality Alliance

The KCQI Work Groups
There are four Work Groups that address the areas of:

Clinical Measures
Quality of Life/Patient Perspective
Pay for Performance
Pediatrics

The Work Group Members were nominated by the KCP Board and selected by the KCP Steering Committee.

Members were selected primarily for their content expertise and experience. The membership of a Work Group represented a balance of perspectives on the matter being considered.

The Work Groups were composed of individuals possessing relevant knowledge and/or experience related to the subject matter of its charge. While the goal was to have balanced representation from all major stakeholder constituencies (i.e., patients, physicians, and facilities) on each Work Group, it is recognized that the nature of some subjects did not always make this possible. Each Work Group consisted of 5-7 members.

KCQI Workgroup Members and Meetings Summaries:
PHASE I PROCESS

Clinical Measure Work Group Members
Clinical Measure Work Group Meeting Summaries

Quality of Life/Patient Perspective Work Group Members
Quality of Life/Patient Perspective Work Group Meeting Summaries

Pay for Performance Work Group Members
Pay for Performance Work Group Meeting Summaries

Pediatric Domain Work Group Members
Pediatric Domain Work Group Meeting Summaries

The KCP Steering Committee
The Steering Committee considered Work Group nominees. For each Work Group, the Steering Committee provided a description of desirable knowledge, skills, and experience needed on the Work Group.

Along with the KCP Board, Steering Committee members identified and proposed persons to be considered for inclusion on the Work Group. Self-nomination was not acceptable.

The Steering Committee provided guidance to the Work Groups formally through "Guiding Principles" and informally.

The Steering Committee was advised and informed by the Work Groups. The Steering Committee reviewed and commented on the recommendations prepared by the Work Groups and, with the assistance of the Work Group facilitator/leaders, prepared specific pay for performance proposals. The Steering Committee members were selected and approved by the KCP Board.

KCQI/KCP Steering Committee Member
KCQI/KCP Steering Committe Members Meeting Summaries

The Kidney Care Quality Alliance (KCQA)
The KCQA reviewed, provided comments, and endorsed when appropriate pay for performance proposals presented by the KCP Steering Committee (after they had been reviewed by the Board).

The KCQA consists of members of the kidney care community, as well as members of the broader health care community. The KCP invited a variety of organizations, including members of the kidney care community, medical professional associations, and other stakeholders.

KCQA Members
KCQA Alliance Meeting Summary

July 26, 2006

THE KIDNEY CARE QUALITY INITIATIVE (KCQI) PROCESS

The KCQI process is divided into two phases.

Phase I:
The Work Group focused on reviewing existing publications, legislation, and other policy statements and developed a consensus document based upon these existing quality resources.

The Work Groups provided the Steering Committee with a set of specific recommendations that formed the basis of an initial pay for performance program.

Phase II:
The Work Groups will not only reviewed existing relevant sources, but also considered new approaches about which consensus has yet to develop in the community.

The KCQI's general consensus development process consists of four principal steps:

Development of Work Group Recommendations
The Clinical Measures, Quality of Life/Patient Perspective, Pay for Performance, and Pediatric Work Groups developed specific recommendations related to their area of expertise.

During Phase I, each Work Group reviewed existing sources (e.g., the K/DOQI Guidelines) related to pay for performance, including supporting potential performance measures, quality indicators, preferred practices, and structural design.

They advised and informed the KCP Steering Committee through documents that synthesized their analysis and included specific recommendations that could be implemented immediately.

During Phase II, the focus of the Work Group will expand beyond existing sources to consider new ideas and proposals. Based upon their discussions, the Work Groups will provide specific recommendations to the KCQA Steering Committee about how to modify the Phase I proposal.

All Work Group final documents, as well as other products, explicitly described the scientific evidence, other support, and experience underlying the recommendations, the criteria for selecting them, and the rationale for recommending the particular item or approach.

The Work Groups presented their recommendations to the KCP Steering Committee for review, discussion, and integration into a comprehensive document before discussing them outside of the Work Groups, making them available for public comment, or submitting them to the KCP Board for approval. The Steering Committee considered these recommendations and provided substantive feedback to the Work Group facilitator/leaders, or their representatives.

As part of this process, the Steering Committee and the facilitator/leaders sought to achieve consensus on a comprehensive document that incorporated the recommendations before requesting review and approval from the KCP Board.

KCP Steering Committee Consultation
The KCP Steering Committee guided and oversaw the efforts of the Work Groups. Among other things, the Steering Committee provided advice about the Work Group recommendations and assisted in preparing
a comprehensive quality proposal that met the needs of patients, physicians, providers, facilities, and other members of the kidney care community, as well as federal policy-makers. The Steering Committee was not asked to approve or reject recommendations.

If a Work Group was unable to reach consensus by a deadline established by the Steering Committee, the Steering Committee attempted to resolve the conflict with the facilitator/leaders and offer a proposal to the Work Group.

If a Work Group failed to reach consensus again, the Steering Committee with the advice and counsel of the Work Group facilitators/leaders developed a recommendation to include in the comprehensive proposal.

Upon completion of the comprehensive proposal, the Steering Committee submitted it to the KCP Board for approval. The Steering Committee facilitated communications between the Work Groups and the KCP Board.

Kidney Care Partners Board Approval
Upon receipt of a comprehensive proposal from the Steering Committee, the KCP Board reviewed and considered approving the document. If the KCP Board had concerns or questions, it submitted these comments to the Steering Committee, which considered them with the Work Groups, as appropriate. Once the KCP Board approved a proposal, the Steering Committee submitted it to the KCQA.

All KCP Board members in good standing (i.e., current on dues, other invoices, etc.) had the opportunity to vote on any comprehensive proposal. The KCP Board considered these proposals consistent with its existing approval procedures, which included verbal approval on Board calls or at Board meetings or written approval via email. Suggested modifications to any comprehensive proposal were submitted in writing to the Steering Committee and approved by the Steering Committee before being incorporated in to the final documents and forwarded to the KCQA.

Distribution of Information
Lists of Steering Committee, Work Group, and KCQA members, the Guiding Principles, minutes of the Work Group meetings, any draft products for public review, and other relevant materials were posted on the website kidneycarepartners.org as they become available. Some materials (e.g., meeting agendas, background materials, and draft recommendations) may be limited in distribution to Work Group and/or Steering Committee members.

Distribution of interim project information of a proprietary nature (e.g., confidential business information (CBI) related to a potential voluntary consensus standard) was limited to Steering Committee members only.

All information held as CBI was fully disclosed to KCQI participants and the public if the Steering Committee recommended further consideration, at which time all information available to the Steering Committee was fullydisclosed to KCQI members and the public. No information held as CBI was disclosed to KCQI members and the public if the Steering Committee did not recommend that the item(s) advance.

KIDNEY CARE QUALTY INITIATIVE GUIDING PRINCIPALS

The KCQA Steering Committee developed Guiding Principles to direct the development of the initial policy by the four KCQA Work Groups. The Guiding Principles are divided into four categories that reflect the organization of the Work Groups:

General
Clinical Measures
Quality of Life
Pediatric, and
Pay for Performance

General Principles

The Work Group and Steering Committee process will be transparent.
The Work Groups and Steering Committee will maintain clear minutes of their meetings.
The Steering Committee will not have veto power over the Work Groups' products. There will be clear process rules set forth in a separate document describing the interaction between the Work Groups and the Steering Committee.
The goal of Phase I is to develop a legislative/regulatory proposal for CMS and Congress. During this phase, members of the kidney care community will collaborate to develop and design set of clinical and quality of life measures to incorporate into a patient-center pay for performance program that recognizes the unique needs of children with kidney failure and that can evolve over time.
Upon completion of Phase I, the Work Groups and Steering Committee will begin work on Phase II to develop the next generation of clinical and quality of life measures, as well as new ideas for implementing pay for performance.
As they develop their recommendations, the Work Groups will pay particular attention to ensuring that the pay for performance program does not encourage "cherrypicking" of patients or otherwise disadvantage patients because of their comorbidities, economic status, or other similar factors

Clinical Measures Principles - for Phase I
Clinical Measures should:

Address independent dialysis facility (facility), hospital-based provider (provider), and nephrologist activities.
Include both process- and outcome-based measures.
Allow for mastering benchmarks and demonstrating improvement.
Be reliable, valid, precise, based on sound scientific evidence, and predictive of overall quality performance.
Produce consistent and credible results.
Build upon existing dialysis-related reporting requirements and use measures that are available and accessible without imposing undue burden on providers and caregivers.
Be aligned with the priority areas of the K-DOQI guidelines and Institute of Medicine report.
Be based on a strong consensus.
Focus on improving the safety, effectiveness, and efficiency of care.
Facilitate meaningful comparisons among facilities, providers, and nephrologists and be risk adjusted.
Reflect an array of aspects of care.
Encourage improved quality and effective practices.
Be based on standardized definitions, technical specifications, and methodologies.
Allow for variations in individual patient care regimens.
Be standardized, transparent, explicit, and measurable.
Be public to ensure integrity and allow for understanding of reported data by patients and their families.

Quality of Life Principles - for Phase I
The Quality Metrics should:

Be patient-centered.
Be reliable, predictive, valid, meaningful, and precise.
Be equitable and ensure that sicker patients continue to receive high quality care.
Reflect patient values and needs.
Allow for public reporting and comparisons among facilities, providers, and nephrologists.
Be consistent with the patient-physician relationship, as well as the relationship between patients, providers, facilities, and other health care professionals.

Pediatric Principles - for Phase I
The Pediatric Work Group should:

Ensure that the clinical measures, quality of life issues, and pay for performance program address the unique needs of children with kidney failure.
Incorporate the Clinical Measures, Quality of Life, and Pay for Performance Principles.

Pay for Performance Principles - for Phase I
The ESRD Pay for Performance Program should:
Generally

Be designed primarily to improve the effectiveness and safety of patient care.
Reward behavior that results in improved patient outcomes.
Acknowledge that high quality care of patients results from the interaction of the care provided by dialysis facilities, providers, and nephrologists
Encourage strong alignment between facilities, providers, and nephrologists for their shared responsibilities, while recognizing the importance of their individual contributions.

Include Clinical and Quality of Life Measures

Establish a set of core clinical and quality of life measures related to providing dialysis care at all levels.
Allow for the evolution of measures over time to improve the efficiency of reporting activities and to recognize new measures that incorporated advances in patient care.

Link Performance to Payments

Align reimbursement with high quality care for patients with kidney failure.
Not fund performance payments using a withhold mechanism.
Recognize the cost of providing care in accordance with accepted standards of practice and in light of the lack of an annual update mechanism for dialysis facilities and current problems with the reimbursement policy for nephrologists.
Avoid any incentive structure that could undermine the provision of safe, high quality care and could decrease access to care for patients with complex needs and risks.
Align incentives with professional responsibility and control.
Tailor financial incentives to ensure the desired behavior changes and support high quality care.
Include non-financial incentives (e.g., differential intensity of oversight or public acknowledgment of performance).
Establish a system to assist sub-threshold performers to develop and implement plans to improve their performance.

Provide for Public Reporting

Incorporate standardized electronic reporting to minimize the burden and cost of reporting; increase uniformity and compatibility; and promote interoperable standards for collecting, transmitting, and reporting information.
Provide for a public reporting system.

Be Implemented through a Phased-In Process

Allow for voluntary participation during the first year by providing an update to facilities and providers and fixing the current problems in the physician fee schedule for nephrologists that report the required clinical and quality of life measures.
Provide timely feedback to facilities and nephrologists about their performance to facilitate behavior changes within specific time periods.
Incorporate periodic reviews of the program that evaluate objectively the system of payment and incentives and its effectiveness in improving the quality of care provided to patients.
Provide for some flexibility to allow for adjustments in the program based upon these periodic reviews.

Launching The KCQI

Background
KCQI Structure
KCQI Process
KCQI Guiding Principles

Creating The KCQA
Accomplishments - KCQI
KCQA - Phase II