Appendix D: Better Quality Information Site Visit Summaries
Regional Coalition Collaboration Guide
Center for Health Information and Research-Arizona State University, Phoenix, Arizona
During the visit to the Center for Health Information and Research on May 21, 2007, the Delmarva team attended the center's weekly staff meeting. The weekly meetings give team members the opportunity to discuss the status of current projects and potential opportunities for new business and to work through any issues the team may be experiencing. Observing the center's weekly staff meeting provided insight on the operational side of running a regional coalition.
Later in the day, Delmarva met with Roger Hughes, executive director of St. Luke's Health Initiatives. During this meeting, Delmarva was able to gain a better understanding of how St. Luke's Health Initiatives has supported Arizona HealthQuery and initiated a new, related research project, namely the Phoenix Healthcare Value Measurement Initiative.
For the last portion of the site visit, Delmarva was invited to observe an Arizona HealthQuery data partner meeting. The meeting brings together all of the data partners to discuss current and future initiatives. A goal of the meetings is relationship building. The idea is that, once the relationships are built and subsequently maintained, the relationships will foster more collaboration and sharing of information, with the ultimate goal of improving community health in Arizona.
During these productive meetings, Delmarva identified five major themes associated with the forming and sustaining of a successful regional coalition:
- The need for visionary leadership in the coalition.
- The importance of establishing the credibility of the project through aligning and affiliating it with national initiatives and well-known community groups and associations.
- Overcoming suspicions and building trust between competing stakeholders and among participating groups and honestly addressing perceived ulterior motives behind participating in any project that involves sharing data among different organizations.
- Tirelessly building and maintaining relationships among a diverse array of community organizations.
- The need for communication with and among stakeholders and for developing effective strategies for marketing the coalition.
California Cooperative Healthcare Reporting Initiative, San Francisco, California
The Delmarva team met with the leadership of Pacific Business Group on Health in their San Francisco office on July 18, 2007. In addition to themes already identified during the Arizona site visit, the informative meeting with the experienced group that manages California's innovative coalition yielded many new insights into building and, most importantly, operating an effective regional coalition.
David Hopkins, director of quality measurement and improvement at the Pacific Business Group on Health, and Cathie Markow, senior manager, provided a detailed overview of the projects the California Cooperative Healthcare Reporting Initiative leads or participates in. They also provided practical information on the challenges involved in keeping a coalition moving forward.
With 14 years of experience managing the California coalition, the Pacific Business Group on Health offered practical insight into running a large regional coalition. In particular, Peter Lee, chief executive officer of the Pacific Business Group on Health, stressed the importance of ensuring the expertise of those on the leadership team overseeing key aspects of the coalition. Mr. Lee pointed out that having the right people competently and consistently doing the right job in an unbiased way is crucial to establishing and reinforcing credibility among coalition participants.
Two other important factors in maintaining "buy-in" from the California cooperative's stakeholders are integrating processes for communication and transparency in the coalition's operational structure. Mr. Hopkins and Ms. Markow cited an instance in which they were unable to get charts to participants because their copying service encountered problems with its equipment. Although this glitch caused much anxiety among participants, project staff helped to allay the stress by honestly acknowledging the situation and sending daily updates about what was being done to fix it.
In addition to this initial meeting, the Pacific Business Group on Health team invited Delmarva to observe the California Cooperative Healthcare Reporting Initiative's biannual All Participants Meeting in Oakland on the following day. At this meeting, the cooperative staff presented to stakeholders 2007 results for the:
- Healthcare Effectiveness Data and Information Set (HEDIS) data collection project.
- Health maintenance organization Consumer Assessment of Healthcare Providers and Systems member survey.
- Patient assessment survey.
- Special studies.
During the HEDIS results presentation, the analyst identified quality improvement opportunities based on low rates, large variation across California Cooperative Healthcare Reporting Initiative plans, and poor performance compared to National Committee for Quality Assurance 2006 national percentiles. For measures with rates below 60 percent, the analyst highlighted ones that could potentially be improved through sharing best practices and others that indicate where an opportunity exists for all plans to improve.
Throughout each presentation, members of the group were encouraged to ask questions and raise concerns. At the meeting's conclusion, participants were invited to provide thoughts on opportunities for improvement for particular measures.
During the meeting, the Delmarva team observed California Cooperative Healthcare Reporting Initiative staff members demonstrate their skill sets and dedication to communication with and transparency to participants. Expert analysts contracting with the cooperative presented the data results clearly and thoroughly to the group, while stakeholders were encouraged throughout to ask questions or express concerns.
Massachusetts Health Quality Partners, Boston, Massachusetts
The Delmarva team met with the leadership of the Massachusetts Health Quality Partners in their Boston office on July 26, 2007. The group included: Barbra Rabson, executive director; Janice Singer, director of Operations; and Melinda Karp, director of Programs. Additionally, the following members of Massachusetts Health Quality Partners' governing board contributed to the discussion: Harris Berman, M.D., board chair; Judith Melin, M.D., Physician Council representative; John Mason, Ph.D., Health Plan Workgroup representative who works for Blue Cross Blue Shield of Massachusetts; and David Smith, board representative and senior director of health data policy who works for the Massachusetts Hospital Association.
The site visit built on key themes raised during the Arizona and California site visits, such as carefully building and maintaining trust with stakeholders. The Massachusetts coalition brands itself as a source of trusted information. According to Ms. Rabson, Massachusetts Health Quality Partners earns its reputation as a trusted source of information because of its collaborative process.
In this process, those being measured are involved in the measurement and reporting process, data aggregation across health plans results in more robust performance data, and the coalition's attention to methodology results in more reliable information. Massachusetts Health Quality Partners also provides a consensus-driven context for how the data can be used rather than simply providing data that are open to interpretation and available to all (i.e., a more "neutral" data source).
The group also reinforced the need during the startup of a coalition for visionary leaders who will tirelessly drum up community support and convey the importance of developing effective communication strategies. In particular, Ms. Rabson and Mr. Smith stressed the highly sensitive nature of public reporting and how, if not communicated well, it can cause much more harm than good.
Group members related how Boston health care leaders convened Massachusetts Health Quality Partners after a Boston Globe article in 1994 published mortality rates in Massachusetts hospitals. Consequently, Ms. Rabson emphasized how effective and consistent communication with the press and stakeholders is critical to the ongoing success of a regional coalition.
The group also spoke on the Massachusetts Health Quality Partners Physician Council, a unique aspect of the coalition's governance. The Physician Council has helped the coalition engage a broad range of physician groups in the collaborative process and in governing the coalition. Among the responsibilities physician groups share on the council is selecting two representatives from its members to serve on Massachusetts Health Quality Partners' board of directors.
Minnesota Community Measurement, St. Paul, Minnesota
The Delmarva team met with a large group of Minnesota Community Measurement staff and stakeholders in St. Paul on August 2, 2007. The group included:
- Diane Mayberry, director of program development.
- Michelle Ferrari, project manager.
- Carrie Trygstad, project manager.
- Anne Snowden, director of quality reporting.
- Julie Brunner, Minnesota Council of Health Plans.
- Brian Osberg, Minnesota Department of Human Services.
- Becky Sherman, Minnesota Medical Association.
- Doug Hiza, First Plan of Minnesota.
- Terry Murray, director of quality management at Quello Clinic, Ltd.
- Linda Davis, a consultant for LCS Solutions.
During the meeting, the group presented an overview of the coalition's origin, structure, challenges, and accomplishments over the previous 5 years.
All of the major themes that emerged during previous site visits were reinforced by Minnesota Community Measurement's successful experience:
- Having visionary leadership that can bring together diverse interests.
- Establishing the coalition's credibility.
- Building relationships and continually earning the trust of participants.
- Creating a process that effectively gathers, validates, and reports data.
- Cultivating media relationships and developing public relations strategies.
- Being alert for unexpected legal issues (in this case, antitrust concerns).
- Evolving from an informal group or project to a formal organization.
One aspect of the coalition's background was significantly different from the other sites visited thus far: Minnesota's nonprofit health care system. The nonprofit system fosters an inherently collaborative culture that is more conducive to building a coalition than a competitive, for-profit health care market. The legislature also has mandated quality improvement and public reporting in health care.
Although other sites have expressed the need to persuade stakeholders that quality should rise above competitive interests, Minnesota's health plans agreed from the beginning that competing on the quality of clinical health care would not contribute to improving the quality of care or health overall. Although this predisposition toward collaboration made it easier for stakeholders to work together on improving quality of clinical care, issues of building trust and credibility and ensuring the transparency of the process were still crucial factors in building the coalition.
Although quality of clinical health care competition may not be a big factor in Minnesota, skepticism and a reluctance to cooperate are still issues with which the Minnesota coalition contends. A key lesson the coalition has learned is that listening to skeptics and bringing them into the process strengthens and enhances the coalition's product.
Indiana Health Information Exchange, Indianapolis, Indiana
The Delmarva team met with the leadership of the Indiana Health Information Exchange in their Indianapolis office August 15, 2007. The group included:
- J. Marc Overhage, M.D., Ph.D., chief executive officer and president.
- Greg Larkin, M.D., director of corporate health services for Eli Lilly.
- Dave Kelleher, president of HealthCare Options, Inc., and executive director of the Employers' Forum of Indiana.
- Tom Penno, chief operating officer.
- Chris Schultz, director of clinical quality.
- Debbie Banik, M.H.A., program director for clinical messaging services.
- Jennifer Siminski, marketing and public relations director.
The Indiana Health Information Exchange shares many thematic similarities with the other Better Quality Information (BQI) sites, but a key difference is the method in which the Indiana coalition began. While the other sites initially focused on public reporting and later moved toward developing value-added services for participants, the Indiana coalition started as a way to create value and marketable services for stakeholders. The importance of this difference is that the Indiana Health Information Exchange has developed a number of self-sustaining services. One example is the DOCS4DOCS® Clinical Messaging Service that delivers patient data results directly to physicians. The Indiana exchange recognizes that second- and third-generation products that spin off from this service may create potential sources of funding. Other sites, such as Massachusetts Health Quality Partners and Minnesota Community Measurement, are exploring ways to generate revenue to support coalition activities (for example, Massachusetts Health Quality Partners offers oversampling of data for clients).
The Indiana coalition has successfully worked with other groups in the country in replicating Indiana's health information services. In Tennessee, for example, the Indiana Network for Patient Care model helped a group move from an informal group of stakeholders to a fully running coalition within 3 years. However, as the exchange points out, one potential drawback to its approach may be that, as it moves forward with public reporting, it does not have the same cohesion among stakeholders that other BQI sites have cultivated during the startup phase. The coalition has primarily concentrated on developing services in the Indianapolis area, and as it begins to expand regionally, it may encounter challenges in getting buy-in for public reporting from statewide associations.
Although the Indiana Health Information Exchange's origins are alike with academic and other community organizations, health providers, and grassroots efforts, its entrepreneurial approach also has been influenced by large Indiana employers like Eli Lilly and Company, General Motors, Anthem Blue Cross Blue Shield, and WellPoint. In particular, Eli Lilly played a prominent role in convening leadership to provide internal support and structure to the Quality Health FirstSM program. One of the important lessons learned from this approach is that smaller employers often do not have the time or energy to focus on the health issues central to regional coalitions. Many of these employers look to the large employers, like Eli Lilly, and follow its lead.
The Indiana Health Information Exchange site visit also reinforced a recurring theme about the role of public reporting and consumers. Because many consumers do not have time to seek out data reporting or understand the complexities behind it, the Indiana team used two business truths to underscore its concern about focusing too much of its efforts on consumers:
- Many people buy mutual funds because they lack the time or knowledge to research stocks.
- Consumer ratings on cars mostly serve to motivate car manufacturers.
The Indiana coalition also has an entrepreneurial focus that uniquely addresses the question of sustaining regional coalitions. Its leadership has developed a number of business ventures around the Indiana Network for Patient Care database that not only provide valuable services, but also directly improve health care delivery.
The exchange has successfully generated revenue through its DOCS4DOCS® services. This service creates value because it:
- Reduces the need to create outbound interfaces as providers adopt electronic health records.
- Offers faster, cheaper, more reliable delivery of results.
- Requires less effort to maintain physician contact information.
- Provides economies of scale.
- Frees health care personnel to provide billable services rather than answering the phone and finding misplaced or undelivered results.
- Creates increased provider satisfaction from a single source for their clinical results.
Wisconsin Collaborative for Healthcare Quality, Madison, Wisconsin
The Delmarva team met with a large group of Wisconsin Collaborative for Healthcare Quality staff and stakeholders in Madison August 23, 2007. The group included:
- Chris Queram, president and chief executive officer.
- Don Logan, M.D., medical advisor.
- Jack Bowhan, administrator and medical management, Dean Health System.
- Cheryl DeMars, chief executive officer of The Alliance.
- Kirsten Albers, Meriter Hospital, the first organization to join when the collaborative became a membership organization in 2004.
- Chris Baker, administrative director for quality and safety systems, St. Mary's Hospital.
The group presented an overview of the coalition's origin, structure, challenges, and accomplishments since its founding in 2002. Although Delmarva observed many thematic similarities with the other Better Quality Information (BQI) sites, a key difference is Wisconsin's physician-driven approach. Where other "payer-centric" sites have worked hard to establish credibility among providers, the Wisconsin Collaborative for Healthcare Quality began with physicians and draws its data from them.
Participants' comments underscore the observation that coalitions in the Midwestern part of the United States develop more easily in the inherently collaborative culture of the region. However, unlike in Minnesota, where a nonprofit health care system is mandated by the legislature, there are tensions emerging in Wisconsin between for-profit commercial plans and not-for-profit, physician-sponsored health care in the State. These tensions are most evident in the Wisconsin collaborative's relationship with the Wisconsin Health Information Organization, which the collaborative helped launch in 2005 to create an administrative claims database measuring and reporting the resource use and cost of care for ambulatory services.
Based on its experiences, the Wisconsin collaborative identifies effective communication between purchasers and providers as a key element of its success. It is important to clearly define who will be driving the effort and to what end. For example, participants cannot use data for marketing purposes. Because payers and providers often define and use terms differently, the coalition makes certain that all participants agree on what terms, such as collaborate and partnership, mean in the context of coalition.
As an example of the strength derived from teamwork, the Wisconsin Collaborative for Healthcare Quality benefits tremendously from the participation by one of its business partners, The Alliance. This employer-owned and -directed not-for-profit cooperative provides a variety of in-kind services to the collaborative, including the preparation of risk-adjusted charge data used in the coalition's innovative "quadrant analysis" for hospital efficiency, a unique relationship among the BQI sites. Founded in 1990, The Alliance has developed a network of health care providers on behalf of its more than 170 member employers and their 85,000 employees and dependents. Through its QualityCounts™: Consumer Information for Better Health Care" initiative, The Alliance also publishes its own quality ratings of local health care providers to help consumers make more informed health care decisions.
The Wisconsin Collaborative for Healthcare Quality also reinforced a recurring theme about the role of public reporting and consumers. The coalition sees public reporting as more effectively helping clinicians to measure and improve their work, while recognizing the importance of assessing methods to make its information more relevant to and accessible by consumers.