Hospitals In Focus

Shantanu Agrawal Discusses How the National Quality Forum Impacts Health Care


Shantanu Agrawal leads the National Quality Forum — one of the most important organizations that you’ve probably never heard of. NQF was originally created during the Clinton administration as a tool to promote and ensure patient protections and health care quality through measurement and public reporting for Medicare. Today their work touches all patients using three tenets: improvement, accountability and transparency. In this episode, Chip and Shantanu discuss why NQF was needed, the role it fills today and how the organization is uniquely positioned to lead quality efforts for health care’s high-tech future.

Chip Khan (00:12):
Hello, and welcome again to Hospitals in Focus. My name is Chip Khan, and I’m happy to join you today. We are speaking with Shantanu Agrawal, President and CEO of the National Quality Forum, one of the most important groups you’ve maybe never heard of that plays a role here in Washington in guarding and ensuring the nation’s quality healthcare. Thanks for joining us today, Shantanu.

Shantanu Agrawal (00:39):
Thank you, Chip. I’m really happy to be here.

Chip Khan (00:40):
It’s really a pleasure to have you. I’ll start off by just giving my perspective that the quality enterprise to assure Americans both the quality of their care and the performance of those who are providing that care is based on three principles. One, we need a system where there’s measurement and feedback, so that providers and clinicians can improve. There’s the means to measure what they do so they can be held accountable to the patient, to the payers, to the regulators. And, finally we need measurement, good measurement, so that we can produce the kind of information that consumers can use so that healthcare, their healthcare, will be transparent to them and to others in the community.

With those sort of basic concepts, and noting that the National Quality Forum is central to the quality and performance enterprise, tell us a little bit about the role it plays.

Shantanu Agrawal (01:47):
Sure, so NQF, or the National Quality Forum has now been around for 20 years. We’re celebrating our 20th anniversary this year. We’re a nonprofit located in DC, and I think our core function really from the very beginnings of the organization have been focused on ensuring the scientific rigor and the agreement around quality measurement and quality improvement. Those have been our primary areas of focus since day one. What we typically do from a measurement side, I think people know us best, those who know us, they know us most for endorsement of measures, and this is a process by which we and our extremely diverse committees review measures, compare them against scientific criteria that we’ve implemented and iterated on over the years to really ensure that measures are accurate, that they are highly evidence-based and rigorous, and as I mentioned earlier that there is a great deal of agreement around them.

These measures, once endorsed, are used by public and private payers. They can also be used by delivery systems for internal quality improvement efforts. We know that the measures themselves can be very high stakes, and so we take great care in really assessing measures to make sure that they’re ready for healthcare improvement.

Chip Khan (03:05):
That’s a great start. Give us a sense though, Shantanu. How did you get to be CEO of NQF? How did you have a pathway that led you to lead this important organization?

Shantanu Agrawal (03:18):
Yeah, it’s been a a little circuitous. I feel really honored to be in this role. I am an emergency medicine physician, so after my training, of course … I went to med school at Cornell. I was at the University of Pennsylvania for residency, really learned a lot about, particularly working in west Philadelphia, healthcare disparities and the limits of our current delivery model. I came out, and we moved to the DC area, my wife and I, and I started practicing here, and I think knew all along that I wanted to have more impact than I could through a clinical career alone, that I wanted to have broader system and policy impact.

My first stop immediately after working for a little while was actually in healthcare consulting where I worked with hospitals and health systems directly on quality improvement. That was my first real exposure to all of the challenges that health systems can face in focusing on the right areas of improvement and actually driving the improvement they want. I spent a few years doing that, and then actually one of my final clients as a consultant was CMS. The ACA had just passed. There was a lot of change occurring in the organization. Obviously, quality was being attached to payment and there was real thinking around that, so I joined CMS for a total of six years actually working in program integrity, which on the face of it might seem really different, but to me it was really all about ensuring the value of healthcare and ensuring the safety of patients that are insured through CMS programs.

From there, I spent a little bit of time at a full risk delivery model based in Florida called ChenMed, which was really educational seeing what true reform can really look like. That all led me to NQF, which has been a great journey. I think it’s taught me a lot about the place of quality, quality improvement, how to really make that connection to value, and as I said, it’s a really great honor and a really interesting set of challenges to be here now.

Chip Khan (05:26):
Thanks, Shantanu. I know how important that position is and really appreciate your leadership. I did in previous years in full disclosure here serve on the board of NQF, as well as a have served in other positions, which we’ll talk about and feel that the organization plays a critical role in what I’ll call here the quality enterprise. You’ve told us what NQF does, but what’s the value proposition? What does it mean, NQF’s work, for patients, providers, clinicians and policy makers?

Shantanu Agrawal (05:59):
That’s a great question. So first, we definitely appreciate your leadership. Without organizations like this and without people like you, I don’t think NQF would have the impact that it has. I think look, fundamentally what NQF has done over the last several years is focused on patients, which is very central to our DNA. We actually were founded out of a Clinton administration report. There was a specific recommendation that called for the creation of a private entity that really ultimately became NQF, and that report itself was very focused on the consumer or patient role in healthcare, essentially consumer patient protection in healthcare. That patient focus, that patient voice is central to everything that we do. I think our second big impact over the years has been proving that this model of measuring and improvement actually works. I think there were a lot of questions. If you think back to 1999, the Institute of Medicine report, To Err is Human, had just come out.

There was a lot of conversation around quality and safety challenges, particularly in hospital settings in the inpatient environment, and frankly there were some fundamental questions about whether quality could be improved, whether that measurement would really work, whether we could capture the complexity that exists in healthcare in measurement, and this organization was on the cutting edge, along with all of our partners and stakeholders, of demonstrating that in fact, one could do that, that you could put really meaningful measures behind healthcare, that those measures could be made transparent to patients, that patients would find them meaningful, and that providers would still find them meaningful for improvement.

I think we’ve now gotten past that. When I was going through my training, there was no question that measurement could work and that measures could be implemented ,and that it could capture the complexity of healthcare. I think that was a major philosophical shift that NQF was certainly a part of.

Chip Khan (07:55):
One of the unique roles that NQF plays, and it started back in just after 2010, is to review the metrics that Medicare is considering adopting for the program in advance of the regulatory process. That’s done by a group inside of NQF called the Measures Application Partnership and here, too, to disclose, full disclosure, I’m a chair of one of the committees that oversees that process. Can you talk a bit about that process, its uniqueness and the importance it plays for Medicare patients?

Shantanu Agrawal (08:36):
Yeah, absolutely. So, maybe just taking a step back for a second, we talked about endorsement, and endorsement is really available for anyone that wants to use it, and again it’s that rigorous assessment of measures. The MAP, I think, is a great and interesting program because it allows as you indicated CMS to come to NQF, and really leverage NQF as a resource for garnering outside stakeholder input on measures prior to the rule making process, prior to those measures being inserted across programs in the agency. So again, another element that’s extremely central to NQF is that we do all of our work through extremely diverse committees.

I mentioned earlier the importance of patients, consumers and caregivers in our work. We make sure that patients are on all of our committees, including the MAP, including endorsement, but also they’re sitting alongside physicians, hospitals, payers, other thought leaders and quality experts, and it’s really that diversity of review, that consensus that emerges from I think some really meaningful conversation that both endorsement works, and frankly that measure selection process for CMS works. It’s really I think a robust process for the agency to get input before they go through their usual formal processes.

Chip Khan (09:58):
Could you give us some sense of the broader implications of this process you’re talking about, because even though it may directly affect CMS setting Medicare policy, these measures are about a lot more than just Medicare patients, aren’t they?

Shantanu Agrawal (10:14):
Yeah, they absolutely are. A lot of CMS measures we know, you know, are picked up by other payers, private insurance companies. They’re also picked up by delivery systems. They really can drive the field as a whole. I think what the MAP process really allows is for CMS to get insight. They get that pressure testing from a variety of external organizations and stakeholder types to ensure that again, the measures are good and that there’s a great deal of agreement around them.

I think what MAP has also been able to do over the years is drive a lot of alignment of measures between CMS programs, so whether that’s within different aspects of Medicare or across Medicare and Medicaid, there’s a real possibility of external stakeholders being able to essentially provide input to CMS as they are going through their measurement and improvement journey. I think that’s been really helpful for reducing measures where appropriate, aligning them where appropriate and just getting more focus and a single strategic direction that the agency can take advantage of.

Chip Khan (11:20):
I guess I’d like to put an exclamation point on one of your themes, which is this multi-stakeholder consideration. It really goes back to the earliest days of NQF when it was formed. Can you just maybe take a little bit of a deeper dive into what groups, and I know you went over some, but we know we’re talking about … and what the chemistry of that policy consideration is by this diverse group that makes up NQF?

Shantanu Agrawal (11:50):
Yeah, I think again, it’s extremely critical for us. It’s central to the way we operate that we are not aligned with any particular industry in healthcare. The way I speak about it is everyone is welcome at the NQF table, and indeed we need everyone participating at the NQF table, so that certainly starts with patients through providers, hospitals, payers, the industries such as pharmaceutical companies and medical device companies. All of those organizations and players have to be at the table. They have to be debating measures, they have to be debating quality improvement approaches.

Part of our work, we also do help to create quality improvement tools. And, in all of that, evidence and the science lead the way, but also this multi-stakeholder input and consensus are extremely vital. Frankly, what that means for us, and I know you’ve experienced this as you engaged in the work, is the conflicts and tensions that exist in healthcare very much exist at the NQF table as well, but that is really important. We need diverse sometimes highly viewpoints that are in high disagreement with each other to actually emerge because that’s what allows NQF and our stakeholders then to identify a path forward.

I think we can help to find solutions, find compromise where if the conversations were not happening frankly around NQF, they not might not be happening at all, and so that possibility of compromise wouldn’t come forward. That can make the day-to-day a little bit challenging as you know in the committees, but I
think it’s extremely critical and over the years has led to some real change that I think might not have otherwise occurred.

Chip Khan (13:38):
So, we have two processes that are fundamental to NQF. We have this blue-ribbon consideration of measures that leads to potentially for measures endorsement or sending them back for more consideration by those who are developing the measures, and second we have this Measures Application Partnership, the MAP, which reviews the work of CMS in thinking about what measures ought to be used in their programs. What other functions does NQF fulfill, and looking to the future, where do you see NQF going beyond endorsement and the MAP process.

Shantanu Agrawal (14:25):
I would really talk about three strategic priorities beyond the programs that you just talked about. First, we’ve had I think an important historical role in the evolution of measurement itself, and we continue to play that role now. Every year, we do work for CMS, for others, that really lays out the future of measurement in any particular area. So, for example, in recent years we’ve done work on telehealth and how telehealth measurement might work as it compares to let’s say the in- person clinical encounter. We’re doing this year some work on health system readiness and the trauma care system.

These are all different projects and approaches to make sure that we’re identifying the right path for evolution of measurement. We’re also doing really important work on social risk adjustment in measurement, which we know is an important and emerging area. So, I think that can really help to drive projects like the science of measurement, the strategic development of measurement to make sure it’s always doing the best that it can for healthcare. Second, we’ve done work throughout our history and I think are really focused on it now to create quality improvement tools that connect measurement to the actual front lines of care delivery.

I feel particularly passionate about this as an emergency medicine physician. I really do think that we can bring our capabilities in following the evidence and best practice generation, and producing that very diverse multi-stakeholder consensus to quality improvement. In recent years we’ve released tools in, for example, opioid stewardship and antibiotic prescribing, serious mental illness care, tele-behavioral health, and again, I hope these QI tools can really be used by delivery
systems for actual improvement.

The final thing, I think it’s important to talk about. It undercuts all of our work, but I take great care to talk about it explicitly is we’re doing a lot in addressing healthcare disparities and the social determinants of health. That’s been, again, a central element of our work for well over a decade, but I think as we’ve seen along with so many others the data in how the healthcare system works for different populations differently, how health outcomes really change by various populations in the US, we, NQF, and frankly the system as a whole, we’ve got to bring every tool to bear that can address these areas, and we are definitely focused on that as well.

Chip Khan (16:56):
Great. You know, one thing that occurs to me as we’re having this conversation is the issues that are in NQF future are so critical to making the quality and performance enterprise work for all patients. But, there also are developments in electronic health records being available to feed into artificial intelligence, and decision support for physicians, which has been around but is everyday at a much more sophisticated level. In terms of making measurement work for these new and developing systems, how do you see NQF fitting in there?

Shantanu Agrawal (17:37):
Yeah, that’s a great question, so let’s just take the example of addressing the social determinants. I think for us as an organization, or for us as a system of stakeholders, to have real impact, we’ve got to be looking at areas that you’re identifying, right? Whether it’s artificial intelligence or other sources of data. We’re taking a multi-pronged approach. First, I mentioned we’re really trying to lead the way on social risk adjustment in measurement, and that’s so that we’re really clear on what measures are showing, and especially because our measures are high stakes measures that are used in accountability programs, I want to make sure that providers feel that they are on a level playing field just like when it comes to clinical risk adjustment.

But, risk adjustment cannot stand alone, right? It needs to be part of a very multifactorial approach, so the second thing that we’re doing directly to your question is we’re working now on how to leverage different kinds of data systems and technology approaches to address the social determinants. We have a whole … we’re calling action team … really focused on identifying data sources that perhaps are not commonly used in healthcare today to really leverage them, and perhaps show what populations in our communities are at highest risk for various kinds of health care disparities.

That kind of work, I think, can really help again to light a way, identify a path for how to use different kinds of data sources together. And third, and I think quite exciting, we are of course just as healthcare has started … more than started … has really developed in connecting quality measures to payment, we are really asking the question of how payment can be leveraged to address social determinants as well. So, this year we’ll be convening just in a few weeks a major payments summit of lots of different stakeholders to first produce a call to action that payments should be leveraged to address SDOH, and second to identify best practices based on science and evidence about what works in addressing various social determinants of health.

This again, as an example area, I think just shows how multifactorial we as an organization can be and how we can try to address various dimensions of the same problem so that we’re really being balanced in our approach.

Chip Khan (19:55):
You know, for any endeavor particularly one is significant as NQF, frankly there’s no free lunch. You’ve got to have funding, and if we go back to the earliest days of NQF, 20 years ago, it originally was funded through dues of the stake holders and grants from a number of foundations, but we turned a corner in 2006 … going way back there … A number of us got together and the multi-stakeholders got together and formed Friends of NQF, and we supported Congress funding part of NQF’s functions. And, that was the beginning. This federal funding has been an important portion, an important ingredient in making NQF what it is in terms of meeting its mission. Where are we in that funding cycle? And, I know there’s an Energy and Commerce Committee hearing in the House that touches on this issue of NQF funding. Can you just give us some sense of how you see that developing in the next few months?

Shantanu Agrawal (21:04):
Yeah, absolutely. You are, of course, absolutely right that the funding is extremely critical for our activities and we very much appreciate the work of Friends of NQF, which as you know, gets into action every two to three years depending on the funding cycle. I think that is a great demonstration of our stakeholders and how critical we are to all of these different kinds of stakeholders. It’s a great vote of confidence in the organization. So, look, as far as the criticality of the funding, of course funding is funding and that’s important, but at the same time, this funding, because it originates with Congress and flows through CMS, it shows the connection that the Hill also has to NQF, and
the work that we do and the funding, again, because of the way it flows, keeps us highly connected to the priorities that HHS and CMS have.

At the same time, it’s one dimension of the overall set of funding that we seek. You know, we of course, also do seek private sector funding from grants and other sources so that we are doing, again, that full dimension of work that I talked about. Again, going back to SDOH, CMS and the Hill indirectly have funded a lot of work in health equity in the social determinants that we’ve been able to execute over the years. But, we’ve also looked to other grant making organizations to do some of that work. For example, the payment summit that I mentioned is funded this year by the Aetna Foundation.

So, I look at really thinking about a lot of these different sources coming together to make sure that we are representing healthcare fully and doing the full and diverse set of work that we ought to be doing. On a cyclic basis, there is important leadership that is demonstrated by the House Ways and Means Committee, House Energy and Commerce and Senate finance to make sure that NQF gets the funding that it needs. What’s important, I think, for listeners to know is that the funding designated by the Hill directly taps the Medicare trust fund, which shows you, I think again, how vital NQF is. I do not know many organizations that are in the private sector outside of the government that actually tap the trust fund, so that’s a huge vote of confidence, and again, we take our role as a result very seriously

Chip Khan (23:23):
Shantanu, one of the areas that’s been a sticking point with frankly hospitals and the Medicare program has been the hospital star ratings. We believe consumers need to have ratings that are very simple, ut the question of what the right metrics are and whether they actually reflect the hospital care patients can expect from one institution versus another has been an issue. So, is NQF doing anything to directly address this issue of how to make hospital stars work for patients?

Shantanu Agrawal (24:00):
Absolutely. I think the stars program is extremely important because it hits on the central principles of both accountability and transparency to the public, which I think is what measurement and improvement are really built on. As I mentioned, we are trying to do much more about considering measures and context, and the stars program is extremely important context. And you’re right, there is a lot of tension and I think disagreement within a few different sectors of the ecosystem about the utility of the program. We certainly think that when something like that happens, NQF can play a role, and so we’ve decided to convene a special summit on the stars program, really bringing together the leading organizations from the hospital communities, from the consumer patient and purchaser communities, along with just subject matter experts to ultimately give CMS actionable recommendations on how to improve the program, again, from that multi-stakeholder view.

We hope that the recommendations will be helpful to the agency, that they will be near term implementable, and that they again will help to identify a compromise path between different parts of healthcare that we know really sit in disagreement today. I’m very optimistic. This is the first time that we’re doing this kind of program. As I said earlier, anytime there’s a tension in healthcare, it tends to be represented at the NQF table. That can make for a hard set of discussions initially, but it’s really also the foundation on which we as a whole work to make progress, and so we’re looking forward to it. Again, I’m really hopeful about what it will produce.

Chip Khan (25:41):
Are you doing anything specific here to ensure that you maintain your independence because this is bringing together people on a contentious issue frankly?

Shantanu Agrawal (25:51):
Yeah, absolutely right. So, part of our independence is driven by the fact that we bring lots of different stakeholders to the table. Again, to be really clear that we’re not aligned with any particular party, and in this case we are taking, I think, the more unique step of funding internally this work. As we discussed earlier, a lot of our funding does come from the government.

We felt with this being the first time we were really doing a convening around stars specifically, that we needed it to stand extremely independently, that it needed to be clear to external audiences that we are trying to play the best possible mediation role between these differing viewpoints, and so have decided to fund this effort from our own resources, which will hopefully and very clearly send that message.

Chip Khan (26:38):
Let me close out on the legislation just by asking this question. Beyond literally the funding for endorsement and the continuation of the measure application partnership, the MAP process, are there other things you’d like to see in the legislation to help guide the future pathway of the NQF, at least
in terms of its relationship to this legislation?

Shantanu Agrawal (27:02):
Yeah, I think it’s important to continue to update the legislation and put in certain capabilities that are germane to healthcare today. And, as you know, the legislation has done that in past years. So, while I think it’s important to continue our roles in endorsement and MAP, we’re also looking to discuss with the Hill and our stakeholders new language around measure alignment and burden reduction as a major priority. Second, around incorporating some of the newer technologies that you talked about, artificial intelligence, etc, to make sure that we are regularly assessing how to incorporate those technologies in the development of both measurement and improvement, and I think there are other parties as well. We have really at NQF started to think not just about measures, but measures acting in context, particularly as we’ve gotten so many years now as an ecosystem and connecting measures to payment and value improvement.

We’ve really started to ask what greater role can we play? And, one of the things that we’ve really started to think about is considering the methodologies that underlie some of the big national programs and quality improvements, so things like the stars program or the Readmission Reduction Program. Those programs are extremely critical, and not just because of the measures they utilize, but also the other methodological choices that are made beyond the measures. So, again, I think that with our focus on science and focus on bringing that diverse set of multi-stakeholders and the associated consensus and compromise, I think we can bring that approach to programs like stars to make sure that we are fully assessing measures and contexts.

Chip Khan (28:46):
Shantanu, thank you so much for taking time today to be part of Hospitals in Focus. Before we leave, can you just tell us how people can learn more about the National Quality Forum?

Shantanu Agrawal (28:55):
Absolutely. Well, of course we have a website that people can go to which is QualityForum.org, but I’d also just love for them to reach out to me directly. My information is pretty easy to find on that website. As we discussed, our core mission is in the folks that we can bring together. So, if you want to sit at the NQF table we’d welcome it.

Chip Khan (29:17):
Thanks so much and look forward to our listeners tuning in to this podcast, and future podcasts from Hospitals in Focus.

We hope you found this conversation interesting and will join us every other week as we talk with leaders on a broad spectrum of healthcare issues. Don’t forget to subscribe to Hospitals in Focus. We can be found on Apple Podcasts, Google play, and now Spotify. Be sure to rate and review us and tell a friend. Thanks for listening.

Shantanu Agrawal