Christine Cassel, M.D., starts a new chapter in her career this month as she joins the leadership team that’s working to build the brand-new Kaiser Permanente School of Medicine, set to open in 2019 in Southern California. She takes the new role after serving as president and CEO of the National Quality Forum in Washington, D.C., since 2013. Cassel, an expert in geriatric medicine and the first woman president of the American College of Physicians, reflects on the work of the NQF and delves into what’s exciting about the new opportunity at Kaiser.
What interested you in this opportunity with Kaiser’s new medical school?
CASSEL: Before I came to NQF, I had a career in academic medicine, and I was a department chair and ultimately dean of the medical school at Oregon Health and Science University. So, I do have medical education in my background, and I have a strong commitment to quality and patient safety and the new directions that I think the health care system needs to move in in terms of using teams and data analytics and trying to understand better how we can make health care organizations continuous-learning organizations. When I was approached by the Kaiser leadership about helping them get this new school started — and, as difficult as it is for me to leave NQF at this point because NQF is doing so well and our work in measurement science has really accelerated — this really was a once-in-a-lifetime opportunity for me, and the board at NQF understands that. You can’t do two jobs, much as I’d like to, particularly when one is in California and one is in Washington. I can’t say too much about the Kaiser school at this point because I haven’t started yet, and I have a lot to learn, but the vision is to have a medical school in which the students, from Day 1 are really immersed in a high-performing health system. Instead of just getting lectures about quality and safety, they see it in front of them and work with it every day in teams, and they really get a sense of a different way of thinking about their role as doctors and leaders of health care transformation.
What’s the status of finding your replacement?
CASSEL: Bruce Siegel, who’s chair of the board at NQF, has appointed Helen Darling, who’s the recently retired president of the National Business Group on Health, a very prominent health care person, and she will be the interim CEO. She was the chair of our board earlier, and there’s already a committee that’s been formed, and they will be hiring a search firm to do a national search. It’s good to have your readers know about this, in part, because they may know some good candidates, but I think people want to know who’s in charge now and how, given all this momentum that we’ve built, is it going to be continuing. And the answer is absolutely, yes, with Helen’s capable leadership.
How will your time as head of NQF shape your work as you move into this new role?
CASSEL: That’s a great question. I think it will have a lot of impact in my thinking. My experience at NQF is of this fully transparent and interactive process of all the different stakeholders getting together to understand and agree on how quality is measured and reported to the public, and so working directly with patient leaders and patient groups and consumer groups who have a very strong voice and very prominent seat at the table at NQF has given me even more appreciation for how important it is to see health care from the perspective of the people who benefit from it or who might be harmed by it. I think that one of the aspects is to have the students who are in the new Kaiser Permanente Medical School really be thinking about patient-centered care every day, all day. That’s No. 1, and the second thing is to get them comfortable with being measured. We all live in this world. I mean, medical school students are used to taking exams but, in addition to that, we owe it to the public to measure our performance, to use those measures to improve where we need to and to make clear to the public and patients and consumers and payers what constitutes value as we move into a time where more and more payment is going to be attached to these performance measures. I think the physician community has made major inroads in understanding this and helping to create more meaningful measures, but the students who are just starting now are going to grow up and practice in a world where data is truly ubiquitous and much easier to access than it has been over the past five to 10 years. They need to not only be comfortable with the idea that it’s good to be transparent about performance, but they also need to understand how to use data and how to think of data as part of their tools, and understanding population health, understanding precision medicine and understanding patient-centered care.
What is it like trying to design a school of medicine in 2016? Could you talk about that process? How might that differ from when you went to med school?
CASSEL: Well, it’s going to be very different. The first thing I want to do is give a lot of credit to the Kaiser Permanente group primarily in Southern California, but involving other regions as well, who have been working on this for a number of years, exploring the possibility and coming to the point where the Kaiser board agreed last fall to go ahead with it. It isn’t that there is a totally blank slate. There is a lot of very thoughtful work that has already been done, but there are a lot more questions to be answered, so it will be very different. One thing is that their goal is to keep it quite small and have personalized approaches to students, to make sure that student wellness is as important as patient wellness. I went to medical school in the old days when it was really like boot camp and you were expected to work really, really hard and never complain. Nowadays, there is a lot of burnout and depression among medical students and residents, and so Kaiser is very committed to the principle that you can’t take good care of patients if you don’t take good care of yourself. It’ll be really interesting to work with other people in medical education to figure out how to focus on the principles of adult learning so that you’re not just putting people in classrooms and feeding them lots of information that they will remember only until the next exam and then forget, which all too often was what people in my generation experienced. There are some really exciting new ways of thinking of interactive learning and getting students much more engaged with what they’re working on.
NQF celebrated its 15th anniversary in 2014. Can you talk about how the acceptance and use of standardized health care quality measures has evolved since NQF was founded?
CASSEL: It really is amazing to look back and see the dramatic impact that the use of quality and performance measures has had. The reason that NQF was set up 15 years ago was because people were looking ahead at how the marketplace was going to be driving improvements in quality and cost in health care, and if that was going to happen, there was going to have to be trusted, reliable and consistent information that everybody was dealing with that could tell them what was the quality and how to assess value. Since we have both private sector and public sector payers and providers, there needed to be one place where all of those entities, all of those stakeholders, got together around one table to agree on what measures could be used, and to have that based on evidence and done in a transparent and publicly accountable fashion, and that became NQF. What then happened was the whole world of consumer information accelerated because of the growth of internet sources of information. Data sources expanded exponentially, in part because of [electronic health records] but also just because big data is around everywhere and, increasingly, the payers began attaching payment to these performance metrics, which did not really start 15 years ago, it started about 10 years ago, but has dramatically increased in the last decade. So for all those reasons, NQF’s work has become ever more important. We have 430 organizations that are members of NQF. Some people don’t realize that, not only are we a standards-setting organization, but we have members who are organizations from throughout the entire spectrum of health care. As a matter of fact, a large number of hospitals and health systems are members, and we’re finding that a lot more of those systems are joining NQF as the stakes get higher and as people want to have a seat at the table and be part of these deliberations to come up with these decisions. It’s a very interesting and intense time for everybody in health care as all these changes are occurring, and right at the center of all the changes is the need to be able to accurately measure what you’re doing, and we’re finding ourselves right at the center of that.
For the unacquainted, could you talk a little about the current decision-making process of selecting which measures to endorse?
CASSEL: First of all, the endorsement process is one that covers a wide range of topics. It’s everything from hospitals and clinicians, doctors, nurses and others, post-acute care, nursing home, home care. The [Centers for Medicare & Medicaid Services] has asked us to do a special program for dual eligibles, as well. We work in the Medicaid space as well as in the Medicare space, and we work with private sector payers to align the measures with what CMS is doing. So, how does it work? Well, one of the ways it works is CMS decides to ask NQF to analyze the measures that are available in a certain area, let’s say in cardiovascular care or post-acute rehab care, and NQF will assemble an expert committee of people from multiple stakeholder groups and bring together all of the evidence from the field in an open process that allows stakeholders to have input into the process, and then we’ll issue a report about what are the best measures in that area, and then that report goes out for public comment, and we take the public comment in and include it in the revision of the report, and then a final report is issued. These days, though, there are so many measures that are already in use, we actually have an open pipeline so that, if people develop new measures that they think are better in a certain area or that fill certain gaps, for example, in mental health, then they can just submit the measure to us whenever they want to and [we] have standing committees that are at the ready and prepared to do that analysis.
Speaking of there being too many measures, we hear a lot about measurement fatigue from clinicians. Do you agree that there are too many measures out there, and what can be done to address such fatigue?
CASSEL: I definitely agree there are too many measures, but I also want to point out that there are not enough of the right kind of measures. I call that the Goldilocks problem. We have too many, we have not enough, and we need just the right ones. That leads to what we call measurement science, that there really needs to be a way to develop better measures more quickly and understand how to better retire the measures that aren’t as good. Now, in all of the measurement fatigue that you’re hearing about out there, NQF is actually the only national organization that has the ability to say, at a national level, these are the best measures for hypertension or heart disease or diabetes or post-acute care. Unfortunately, because we have such a complex health system, and many of the payers have come up with their own measures, people at the state level have come up with their own measures, it’s led to the burden that providers, hospitals and clinicians have to report different measures to different entities. Part of the reason for having measures come to NQF is that, if everybody agreed to use the same measures, then the provider could collect the data once and just push a different button on their computer, depending on who they were reporting it to. That’s the goal and where we’d ultimately like to be. I think that, if you’re familiar with the Institute of Medicine report on vital signs, that’s exactly what they are calling for — for everybody in the country to agree to use the same or similar enough measures that you would not have to collect data separately for every different purpose.
THE CASSEL FILE
Cassel previously served as CEO of the American Board of Internal Medicine and the ABIM Foundation. Among numerous other appointments, Cassel advised the nation’s top elected officials as one of 20 experts on the President’s Council of Advisors on Science and Technology. Cassel has authored or co-authored 14 books and more than 200 articles on geriatric medicine, aging, bioethics and health policy.
What first attracted you to working in the health care field?
I always was interested in science, but I wasn’t thinking of pursuing a career. I was actually a major in philosophy in college, and then I fell down and broke my arm in a very remote place where I was hiking with some friends, and a doctor who was actually a military doctor took me in and helped me fix my arm. I couldn’t pay him for it, and I said, thank you for this, and he said, I will just file this under H for humanitarian. It blew my mind, and I said, I bet I could do this, and so while my arm was healing, I went to the local library and started reading some chemistry books and tried to figure out whether I could go to medical school. I applied, and it was the best decision I ever made. I wish I could find that guy and thank him, because he was such an inspiration.
Who was the biggest influence on your career?
I would say that doctor, but there’s not just one person. There are many, many people who have influenced me and who have been real inspirations. I’ve had many wonderful physicians and nurses. I have to say that I’ve learned as much from my colleagues in nursing as I have from my [physician] colleagues. But the most inspiring people to me have been my patients. As a geriatrician, I have the honor of taking care of people who have a lot of life experience, and when I was at the University of Chicago, I had a lot of patients who were retired University of Chicago professors who had great perspectives on life and who were dealing with great difficulties and disabilities. At the same time, I had patients who were not professors but who were from the South Side of Chicago who had had very tough lives and who had really close families, and I learned from how their families helped them deal with old age. So, I think I've described to you that I have both this philosophical bent and a practical bent, and it’s the patients who really teach you the practical side of when people are facing serious medical conditions, how they solve the problems and what kind of help they actually need from us.