2016-08403. Agency Information Collection Activities: Proposed Collection; Comment Request

AGENCY:

Agency for Healthcare Research and Quality, HHS.

ACTION:

Notice.

SUMMARY:

This notice announces the intention of the Agency for Healthcare Research and Quality (AHRQ) to request that the Office of Management and Budget (OMB) approve the proposed information collection project: “AHRQ ACTION III—Measurement for Performance Improvement in Physician Practices.” In accordance with the Paperwork Reduction Act, 44 U.S.C. 3501-3521, AHRQ invites the public to comment on this proposed information collection.

DATES:

Comments on this notice must be received by June 13, 2016.

ADDRESSES:

Written comments should be submitted to: Doris Lefkowitz, Reports Clearance Officer, AHRQ, by email at [e-mail].

Copies of the proposed collection plans, data collection instruments, and specific details on the estimated burden can be obtained from the AHRQ Reports Clearance Officer.

FOR FURTHER INFORMATION CONTACT:

Doris Lefkowitz, AHRQ Reports Clearance Officer, [phone], or by email at [e-mail].

SUPPLEMENTARY INFORMATION:

Proposed Project

AHRQ ACTION III—Measurement for Performance Improvement in Physician Practices

This two-year project is an important first step to fully understanding measurement for performance improvement in medical groups. This exploratory research is expected to set the stage for informing future research and policy discussions, both of which could ultimately have a more direct impact on providers, payers, and patients. As a critical first step this research breaks new ground in an important area of health care research by looking at the current landscape to better understand how medical groups are using measurement internally to improve performance and what that means to them, and how internal measurement relates to external measurement obligations and identifying where the gaps are.

Project success for this exploratory work will be more relevant given the complete context of the current landscape of performance measurement, gleaned through an environmental scan, expert input, and qualitative data collection. Ultimately, success will be measured by our ability to answer the research questions that are guiding this research project (see below).

The overall goal of AHRQ's Measurement for Performance Improvement in Physician Practices project is to identify the current gaps in our knowledge about how practices are using data, if at all, for performance improvement. AHRQ has developed this project to address the lack of current evidence on internal performance measurement in medical groups, identifying the following research questions:

• What gaps exist in the research literature regarding management for performance improvement in medical groups?
• What factors, both internal and external, drive efforts to use measurement to improve medical group performance?
• How are measures used to support internal management and improvement processes?
• What additional activities support use of internal performance measures?
• How are internal performance measures derived and reported? What specific measures, benchmarks, and comparisons are used?
• How have physicians responded to these measurement processes?
• What are the perceived benefits of internal measurement activities? What types of costs and other burdens are directly associated with internal measurement? How feasible is it to specify actual costs of reporting?
• What implications does evidence on internal measurement for performance improvement have for payers, policy makers, executives in delivery systems, and clinical leaders?

Specific Project Objectives

• Identify specific measures/metrics used internally by medical groups to assess performance and support improvement activities.
• Describe how internal measurement activities/measures are used in medical groups to support improvement in individual, team, or organizational performance including, but not limited to, how these activities are tied to “internal” financial incentives.
• Identify types of costs and other types of burdens (e.g. staff resources, IT resources, etc.), directly related to internal measurement and reporting activities. Assess the feasibility of capturing information on costs and burdens of internal and external performance measurement, and, if feasible, collect data on the actual costs and other associated burdens of internal and external performance measurement.
• Based on the findings, identify implications, potential impacts, and future research opportunities for payers, regulators, and medical groups regarding internal measurements for performance improvement.

Efforts to improve performance among health care providers through measurement and reporting have evolved over time and have taken many forms and many names. For example, Triple Aim, Public Reporting, Performance Measurement, Quality Improvement, Pay for Performance are all common concepts today. And, most health care providers, including medical groups, are monitoring their performance using a wide array of quality measures that reflect care processes, clinical outcomes, and patient experiences. Increasing numbers of providers are required to report their performance on quality measures by payers such as the Centers for Medicare and Medicaid Services (CMS) and external regulatory bodies such as the National Committee for Quality Assurance (NCQA) or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

Little is known, however, about how providers make use internally of measures that are required by external bodies for payment or reporting. Nor is it known what other measures providers collect and use to improve performance. This project aims to fill this knowledge gap. In doing so, it may also inform payment and reporting initiatives by providing indications of the degree to which providers view externally mandated measures as valuable for their internal quality assessment and reporting efforts.

As an initial step in understanding the landscape of measurement for performance improvement, this research will look to understand how medical groups define and measure performance improvement.

This work is being conducted by AHRQ through its contractor, Westat, pursuant to AHRQ's statutory authority to conduct and support research on health care and on systems for the delivery of such care, including activities with respect to the quality, effectiveness, efficiency, appropriateness and value of health care services and with respect to quality measurement and improvement. 42 U.S.C. 299a(a)(1) and (2).

Method of Collection

For this study, AHRQ will conduct field data collection through semi-structured in-depth interviews. The unit of analysis for this work is the medical group. To understand measurement for performance improvement in each medical group, AHRQ will interview up to 5 administrators and frontline clinicians per medical group. Interviews with both administrators and clinicians will be facilitated using the same protocol. As discussed below, given the different levels of involvement and experience with internal performance measurement, interviews will vary in detail and thus length. But, as AHRQ works to uncover the story of each medical group involved in the study, the same guiding protocol will apply. AHRQ will audio-record and professionally transcribe each interview conducted. And, all interviews will be loaded into Dedoose for coding and analysis.

The information collected in the data collection effort will be used for one main purpose: Identify the current gaps in internal measurement in physician practices. The results from the data collection will give AHRQ a snapshot on the current practices being undertaken for internal performance measurement and inform best next steps to move beyond this exploratory research phase.

The intended target audiences expected to benefit most from the project include the medical groups using this information to improve performance, the health care professionals who work in these medical groups working to improve their care to patients, and the patients that can benefit from improved care. One way this research could benefit these audiences is by informing payment and reporting initiatives by providing indications of the degree to which providers view externally mandated measures as valuable for their internal quality assessment and reporting efforts.

Estimated Annual Respondent Burden

Exhibit 1 shows the estimated annualized burden hours for the participants' time to take part in this research. To recruit medical groups to participate, AHRQ will engage groups in a short call to assess interest and obtain a commitment to participate. AHRQ expects the need to reach out to approximately 100 medical groups to obtain a sample of 45 groups that are conducting some type of measurement for internal performance improvement, are interested in taking part, and are able to take part during the data collection window. In-depth, semi-structured qualitative interviews will then be conducted with up to 5 staff members at 45 medical groups using a single protocol. AHRQ will target small (2-9 eligible professionals (EP)), medium (10-24 EPs), and large (25+ EPs) medical groups from across the Unites States. The goal is to recruit approximately 3 administrators and 2 frontline clinicians in each Group, understanding that depending on the size and organization of the medical group staff members may operate in multiple roles.

Based on the pilot study conducted for this project, AHRQ estimates that the recruitment call will average 15 minutes, and that the longest interviews will be 1.5 hours. These longest interviews will be with the highest level administrators working on internal performance measurement at the most complex medical groups. AHRQ believes these will be the largest medical groups that are part of complex systems and payment relationships. These complex organizational relationships will require more time to understand in order to understand the place, role, and operation of internal measurement for performance improvement within the group. For equivalent administrators from medium and small groups, AHRQ estimates the longest interviews will be 1.25 hours. For all other administrators and frontline clinicians, AHRQ estimates the interviews will be 1 hour.

The total annualized burden is estimated to be 295 hours. Again, interviews with both frontline clinicians and all medical group administrators will use the same protocol. The screening call will be an informal conversation in which AHRQ looks to learn if the medical group self-identifies as using measurement for performance improvement and provides consent to take part. AHRQ will answer any questions the medical group has about the study on this call and confirm some basic, publicly available background information about the group that AHRQ has obtained is accurate and up to date. This background information will help put the information learned during the interview in better context. The types of background information AHRQ is looking at includes medical group size, organizational structure, specialty mix, and payment relationships.

Exhibit 1—Estimated Annualized Burden Hours

Form name	Number of respondents	Hours per response	Total burden hours
Frontline clinicians	90	1	90
Medical group administrators	235
Medical group administrators: Administrator with authority to agree to participate in the study	100	0.25	25
Medical group administrators: Initial, highest level administrators	45	1.5	67.5
Medical group administrators: All other administrators	90	1.25	112.5
Total	325	NA	295

Exhibit 2 shows the estimated annualized cost burden associated with the participants' time to take part in this research. The total cost burden is estimated to be $27,270.45.

Exhibit 2—Estimated Annualized Cost Burden

Interviewee type	Total burden hours	Average hourly wage rate *	Total cost burden
Frontline clinicians	90	$103.54 a	$9,318.60
Medical group administrators	205	87.57 b	17,951.85
Total	295	NA	27,270.45
a Based on the average hourly wage for one physician (29-1060; $103.54).
b Based on the average hourly wage for one Chief Executive (11-1011; $87.57).
* National Industry-Specific Occupational Employment and Wage Estimates, May 2014, from the Bureau of Labor Statistics (available at http://www.bls.gov/​oes/​current/​naics4_​621100.htm [for Offices of Physicians, NAICS 622100]).

Request for Comments

In accordance with the Paperwork Reduction Act, comments on AHRQ's information collection are requested with regard to any of the following: (a) Whether the proposed collection of information is necessary for the proper performance of AHRQ health care research and health care information dissemination functions, including whether the information will have practical utility; (b) the accuracy of AHRQ's estimate of burden (including hours and costs) of the proposed collection(s) of information; (c) ways to enhance the quality, utility, and clarity of the information to be collected; and (d) ways to minimize the burden of the collection of information upon the respondents, including the use of automated collection techniques or other forms of information technology.

Comments submitted in response to this notice will be summarized and included in the Agency's subsequent request for OMB approval of the proposed information collection. All comments will become a matter of public record.

Sharon B. Arnold,

Acting Director.