The origins of efforts to improve quality and safety can be traced back at least a century or more. However, systematic efforts in measuring an improving quality and safety have only reached the front lines of healthcare in the past three decades. While improvements in technology have had an impact, much of the progress is been due to a relatively small amount of individuals and organizations with the passion and persistance to foster healthcare improvement. One of those individuals is Peggy O'Kane, the founding and current president of NCQA, who both personally, and through her organization, has had a profound influence on driving healthcare improvement through measurement and reporting over the past 25 years. I personally had the privilege of being part of Peggy's leadership group at NCQA for nearly 12 years, as executive vice president for measurement and research. It is our hope that hearing a small part of her story and her vision for quality and safety will inspire and encourage you to become involved in these efforts yourself. Thank you. Good day, I'm here today with Peggy O'Kane, the founder and current president of NCQA. Peggy, you've been recognized as an outstanding leader in quality. You've been recognized by your peers for this as one of the most powerful women in medicine and you've been elected to the Institute of Medicine. Is there a story or belief that has really driven the passion and persistence as you've had in thriving quality for over 25 years? >> Yeah, first of all, I have to say, it's been an incredible privilege to be doing this work and especially to be kind of at the starting end of it. I have to say that my own personal drive and persistence, comes out of being able to tap into the feeling that patients suffer when quality is poor, because something went wrong, or something wasn't done, and so forth. There is unnecessary suffering in the world, particularly in the United States, because of healthcare, that we have a lot of good practitioners, and it's not organized right. So I think, tapping into my own emotions about that, it's really one of the things that drives me. And then on the other side, it's very, very challenging and interesting, so it's never the same, the job is always different, and so I don't get bored with it. So those are the kind of highlights of what I would say. >> Was there a particular instance, or time, or set of circumstances that you especially drew your inspiration from? >> I think you know I was a respiratory therapist when I first worked in healthcare. And I worked for five years, and I worked in a number of different hospitals of varying quality. But I think, to a place, it was kind of lone rangers coming together around the patient, even the respiratory therapy department didn't work as a team. And we certainly didn't work as a team with all the doctors that were seeing the patients and so on. So, I mean I'm not like a born manager as you know, I'm not a great operational person. But it just was so obvious that there was no way that the right thing could happen, unless we kind of agreed on what was supposed to happen, whose job was it to do what and when. And when we didn't agree, we needed to work it out, so that was a very kind of nascent set of feelings, but, the longer I work in quality, the more I understand that it's really all about execution and management. And we've got the people part covered, we've got a lot of good people. People do not go in to healthcare for bad reasons, in my view. >> Mm-hm. So, some of that passion that you were talking about, and drive actually came from clinical experience that you had as a respiratory therapist. >> Yes, yes, yes. >> That's interesting. >> And you know, remember, right, we were working with the sickest patients in respiratory therapy. >> True. >> People on ventilators. >> Yeah. >> People who were dying. And just, there were many things that I saw that were, I think about, well there's an anecdote. I was moving to Washington, my husband got transferred here, and I was applying for jobs. And I went to apply for a job at a hospital, that's no longer in business, and they had the respiratory therapist on an incentive program. So that if you could keep patients on ventilators, you would get paid more. >> [LAUGH] >> I was completely shocked and appalled. I wasn't very assertive at the time, so I did my interview and I left, and then I called them back from the phone booth, we still have phone booths in those days. And I said, I'm appalled that you're doing this, I would never want to work in your hospital. So, I feel like there are all these little vignettes that happened during my tenure as a respiratory therapist that I then learned about later as policy issues. >> Interesting, so you saw the ineffective sort of systems failures almost immediately. >> Exactly, yes. Yeah, and fee for service. >> So, obviously systemness you mentioned, what are the other factors that you think are most important in really going from what is now to what kind of quality of healthcare we should be providing going forward. >> Okay, well I think there's a whole patient issue, of the whole patient issue is what I mean. I think we're into some very awkward conversations about doing socioeconomic risk adjustment for measures. So my conclusion to that is, so that means we have lower expectations for people whose lives are more difficult? And really, is that really okay, and we don't want to adjust away things that need to be dealt with. And it's not that it isn't more difficult if you're dealing with a homeless person, or if you're dealing with a person whose life is completely chaotic. But I think that there are remedies to that that come more about risk adjusted payment than hiding differences in measures. So, just to go back to your question though, I think kind of really talking to the patient, and this is one of the things that feels so half, we're half way there. We do the patients center medical home program. >> Mm-hm. >> We're very proud of the program. But I see in the implementation, that if it's not a complete transformation of practice styles, it winds up, kind of falling on the physician to a degree that I think is not appropriate, and it's leading to burn out. >> Uh-huh. >> I mean, we’re going from kind of a transactional situation in primary care to a much more relationship base. >> Uh-huh. >> Panel based way of thinking. But if we don't put the extra resources there, then I think we've just made the life of the primary care physician more difficult. It's really ironic when I think the PCMH really was developed to try to make primary care more rewarding for the people that choose to do it, because it's so critical to quality. >> So what factors do you see if you walk into a, some kind of healthcare facility, where they are really clicking on quality? What things are there aren't there- >> Well, I mean, I think of advanced practices that I've been to and so what I'm talking about, a complete transformation, I'm thinking about the HEDIS measures that are now being, kind of doctors are being punished or rewarded for achieving HEDIS measures. Like, did this lady have a mammogram who was supposed to have one? Well, in a transformed practice, the doctor doesn't have to deal with that. That can be something that the person that checks the person in can say, if they've got the data in front of them, you're due for a mammogram, can I make you an appointment today, that's what I say. It's getting the job done with people practicing to the top of their licenses. And by the way, nurses, and nurse practitioners, and even medical assistants, I think, it transforms their jobs in a positive way. And by the way, takes some of the burden off of the doctor, so the doctor can worry about the panel and also deal with the more difficult patients, and the ones that really need to have that kind of clinical relationship. This is not a finished product, by the way. I think that when we think about systemness, we also have to guard against, kind of an impersonal situation, so people value the relationship with the doctor. And so what we want to do is free them from all the hamster wheel activity, so as they can do the meaningful things that patients really want. Be heard, and so forth. >> So I've heard teamwork. >> Teamwork. >> I've heard systemness, but personalized, systems. >> Yes. >> What about sort of culture and leadership, come into play? >> Yes, of course, culture and leadership are, I mean, we all know, and we used to say this at NCQA when you were here, that culture eats strategy for breakfast, and it's very true. I think every culture is a work in progress, but when you go to an organization that has really embraced the change and is excited. I say, when you show doctors their data, it's amazing, they find it incredibly interesting and they've been practicing in the dark. I think that there are things that can advance the culture without focus groups and people falling into each others arms. And so I think that there are things that are transformational nature that affect the culture, so I think it's both. >> You and the organization of NCQA have been incredibly involved in promoting patient involvement- >> Yes. >> In patient centeredness and care. Can you talk a bit about that? >> Yeah, I feel like we're not there, by any means, I think of patient engagement as a challenge that's kind of like. I've been following with great interest all the stuff about behavioral economics. And the paradigm with economics for a long time was you just give people the information and they'll make the rational choice, right? And then Kahneman transformed the whole field by making us see that we're irrational about a lot of choices. I think we're irrational about our health behaviors and our adherence to advice, as well, and I don't think that this is well understood. There's been a tendency to say well, I told them to quit smoking, but they didn't do it, so we yell louder. In a sense, somebody named Jeff Harris once said, we yell louder, and people still don't change their behavior. So we don't really understand this very well. But I also think we're at a moment when apps, and iPhones, and so forth, can help people remember people that have embraced the desire to change and just kind of need little prompts, or, I mean I have, you see my Fitbit, it motivates me. I will take an extra lap around the office between meetings and so forth, so I think that it's a combination of things as usual, but I think there's a science there of motivating patients. There's a whole task of not accepting that people aren't health literate. >> Mm hm. >> I think people can be made health literate, they can be helped to achieve that for themselves. I don't think that's been embraced by anyone. So there are a lot of pieces there, but we have a long way to go, or if you like, a whole lot of low hanging fruit. >> You've mentioned a couple times that we have a ways to go- >> We do. >> Although we clearly have made some substantial progress. What would you say to people who might have a beginning interest in quality and safety, at this point? >> I can't think of a better field to go into. It is so interesting if you care about patients and if the idea of excellence and innovation is interesting to you, we're at of time of so much changes that's positive. I mean for, I think for people that are just trying to get their work done, I think of the basic PCP, the primary care physician in his or her office. And I know my primary care physician's incredibly busy, it feels like it's being imposed on people, but where organizations have embraced it, and allowed people to kind of design their own work situations, I think it can't be more exciting. But look for the right organization. We're going to have hospital ratings from CMS this month. There going to be 87 five star hospitals, so look at the rating before you go to work for a place. Places that are doing this well it's going to be made more and more obvious. So look for a place that really embraced the challenge. >> Sounds like that sort of advice for just about anybody in healthcare. >> Yes. >> Being sort of part of this. >> Be part of it, because it's exciting and it's fantastic. >> Maybe a little bit about what your vision in the future of quality, where do you think it's going? >> So, I know you've heard about MACRO, the Medicare Access and Chip Reauthorization Act, which is really redefining the way doctors are going to be paid. And there are two sides to it, one is the merit based incentive program, and that is kind of the old way. So you send in your measures for you or your practice, and you get paid fee for service. And the way it's designed, the curve of payment is designed to make it more and more unappealing. What they want people to do is go to alternative payment models, which means bundled payments for hips and knees, which is being implemented for capitation and so forth. There'll be a lot of variations on this. But I think the real goal is to, if you make the care delivery model more efficient and the opportunities are out there right now, you get to keep some of that money. You don't get punished for being more efficient. I mean, that has been one of my kind of wake up calls in maybe ten years ago, is to just realize, that if you get better at doing this more efficiently, you lose money. >> Mm-hm. >> And that can't be, so I think that there will be a lot of swirl around alternative payment models, there'll be a lot of squawking about it. And I'm sure that whatever we start with will be viewed to be not adequate. But I think we're on a path to the right place. And so I think that provides the opportunity to really transform the way care is delivered. >> What role do you see performance measure playing in that and do you see some evolution in that? >> Yeah, it's interesting, I do. I think that we're now in a kind of an early stage of performance measurement where we're looking for, did you do the right thing for these people? In the ideal system, you the doctor, would be sitting there and you would have been provided, first of all, all of the hamster wheel stuff that we talked about, would have been taken care of by somebody other than you. But if there is something that's a problem, you would be aware of it right at the time of the visit, and you'll be able to counsel the patient, or refer them to wherever you need to refer them. It wouldn't be this retrospective thing that's so frustrating. Doctors are very competitive people and they want to do well. So being told you're average or below average isn't fun. And so, having the data at the point of care when you need it is going to transform things, I think. Now what will the accountability look like? I think that there's a lot of desire for only outcome measures, but, I don't know, I guess I keep thinking about difficult patients and what is the outcome measure for a very old person that is close to death? Maybe it's just their satisfaction or the family's satisfaction. So it feels like we haven't quite sorted out In a fair way, we're the accountability lies. I think being organized structured in the right way, being accountable for what you're able to control and then looking at the outcomes and submitting your outcomes to some learning machine is my idea of what good accountability looks like. >> Anything else that you'd like to comment on or- >> Well, I mean, I just, I'm going back to the privilege thing and I have the privilege of working with you and other people who have come in here with such a tremendous sence of dedication and really contributed over the years and it's just been my luck and my >> A good fortune to work with people and a board of directors who are passionately about the mission so it's just happy to be able to say that. >> Thank you.