Quality Measures Advisory Board - Charter

Refer to: OQ

1. Purpose. The purpose of the Indian Health Service (IHS), Quality Measures Advisory Board (QMAB) is to ensure the selection, validation, alignment, and prioritization of system-level quality measures. The QMAB determines and evaluates the quality measures, including clinical and non-clinical measures, data requirements for patient-centered, safe, timely, equitable, and effective health care. The QMAB will provide advisory support to IHS Area Offices and Service Units. By identifying and implementing new quality data measures QMAB will ensure sustainability and usability of proposed measures for quality improvement efforts. The QMAB will convene with federal experts within IHS and partner agencies to strengthen the current IHS system metrics approach to align measures with partner agencies.
2. Authority. The QMAB functions under the guidance and authority of the IHS Deputy Director for Quality Health Care (DDQHC) and Chief Medical Officer (CMO).
3. Membership. The QMAB is a permanent IHS board consisting of federal IHS employees. The QMAB membership is in two components, an Executive Committee as described below and a General Board. The QMAB will determine the number of members needed to fulfill its responsibilities and review membership at least every two (2) years. The General Board membership represents federal end-users with knowledge and expertise of the Indian Health System. Initial General Board membership will be solicited from federal employees working at IHS Area Offices and federal Service Units. The General Board members will make recommendations to determine the need for Ad Hoc subcommittees and the subcommittees’ memberships. If the Executive Committee disagree with the Ad Hoc recommendation the QMAB will seek a final decision from the DDQHC and CMO. The DDQHC and CMO will provide final approval of all membership.
   1. Executive Committee includes the following:
      1. Chairperson (selected by the Office of Quality),
      2. Vice Chairperson,
      3. Secretary, and
      4. Senior Sponsor (Headquarters Chief Health Informatics Officer).
      The Chairperson is appointed by the Office of Quality. The Vice Chairperson, and Secretary Officers serve two-year terms, but may hold consecutive terms. The Vice Chairperson and Secretary will be selected by the General Board members by consensus.
   2. General Board Members. Membership will be comprised of five (5) Headquarters staff and twelve (12) Field Representatives from the Area Offices and Service Units (one representative per Area). Ad Hoc subject matter experts will be utilized based on current and proposed measure reviews and analysis. This includes representation from practicing clinicians and an IHS Privacy Officer. The Executive Committee solicits members and members are approved by relevant Area Directors and Office Directors. Headquarters Members include:
      1. Director, Office of Quality or Designee,
      2. Director, Office of Public Health Support or Designee,
      3. Director, Division of Program Statistics or Designee,
      4. Director, Office of Clinical and Preventive Services or Designee, and
      5. Director, Office of Information Technology or Designee.
4. Elections. No voting required.
   1. Chairperson. The Chairperson will be appointed by the Director, Office of Quality.
   2. Vice Chairperson. The Vice Chairperson will serve two-year terms, but may hold consecutive terms. The Vice Chairperson will be selected by the General Board members by consensus.
   3. Secretary. The Secretary will serve two-year terms, but may hold consecutive terms. The Secretary will be selected by the General Board members by consensus.
   4. Senior Sponsor. The Senior Sponsor will be the Headquarters’ Chief Health Informatics Officer.
   5. Board Members. When a vacancy occurs in board membership, it will be up to the Area Director or Office Director to submit a recommendation.
5. Roles and Responsibilities .
   1. Quality Measures Advisory Board. The primary roles and responsibilities of the QMAB are to:
      1. identify a core set of metrics that align across the Indian health care delivery system;
      2. identify and evaluate emerging local and national IHS data needs and define requirements;
      3. inventory existing data sources, infrastructures, and measures that support those analytic needs;
      4. conduct gap analysis between current data assets and analytic capabilities versus those desired and needed including any duplicative measures;
      5. strengthen system level metrics for quality and accountability;
      6. serve as a conduit to other groups to:
         1. recommend formal measures definitions and data reporting requirements within the IHS Health Information Technology environment; and
         2. collaborate to develop and disseminate training and communication material, e.g., user manuals, and communication rollouts.
      7. align metrics across stakeholders, e.g., IHS, Centers of Medicare and Medicaid Services, Health Resources and Services Administration, Area Offices, and Service Units, when possible;
      8. identify the feasibility and usability of metrics;
      9. develop and disseminate requirements for actionable reports to hospitals, Service Units, Area Offices, and IHS Headquarters;
      10. review and recommend appropriate system level metrics on an annual basis to:
          1. understand IHS, Tribal and Urban (I/T/U) programs reporting needs;
          2. establish the pros and cons of metric recommendations;
          3. identify metrics that are comparable to new or established benchmarks;
          4. discuss and recommend the infrastructure needed to sustain the system level approach within IHS; and
          5. establish priorities in developing and piloting core set measures e.g., Emergency Department measures.
      11. support change management process by addressing new measures requested for approval and support change management process with Office of Information Technology (OIT) for development; and
      12. provide advisory support to IHS Area Offices and Service Units to identify and implement new quality data measures.
   2. Chairperson. The QMAB Chairperson will:
      1. preside over all meetings and conference calls;
      2. appoint federal employees (with approval from Area Director or Office Director) to Ad Hoc subcommittees as needed to achieve the goals of the QMAB;
      3. coordinate updates and reports among Ad Hoc subcommittees;
      4. present position statements and recommendations to the Senior Staff and other groups as requested;
      5. represent the position(s) of the QMAB at Senior Staff meetings or other meetings, as required;
      6. assign and coordinate the draft of reports, position statements and to represent the QMAB as requested by the Executive Committee; and
      7. conveys priorities from Senior Staff to the QMAB.
   3. Vice Chairperson. The QMAB Vice Chairperson will:
      1. assume the duties of the QMAB Chairperson in the event of his or her absence; and
      2. serve in any capacity as requested by the QMAB Chairperson.
   4. Secretary. The QMAB Secretary will:
      1. coordinate the preparation of quarterly meeting agendas, meeting minutes and communicate information to the Executive Committee; and
      2. serve in any capacity as requested by the Executive Committee, the QMAB Chairperson, or the Vice Chairperson (when assuming the role of Chairperson).
   5. Senior Sponsor (Headquarters Chief Health Informatics Officer). The Senior Sponsor will provide quality health IT support and expertise to the Executive Committee.
6. Decision Making. Key decisions on stakeholder requests for measure and reporting development or the utilization of existing measures should be reached with input from the Executive Committee and the General Board members with consensus approval. If a consensus approval cannot be reached, the Chairperson shall seek approval from the

   DDQHC and CMO for final decision(s) within 60 days.

7. Consultation and Conferring.
   1. To gain understanding of the reporting needs of Tribal and Urban programs, the QMAB may invite the submission of information and opinions from Tribal and Urban programs, on topics including:
      1. Clinical Quality Measures development; and
      2. Clinical Quality Measures reporting.
   2. Tribal consultation and conferring with Urban Indian Organizations (UIO) will be carried out in accordance with the IHS Indian Health Manual (IHM) directives. Refer to Tribal Consultation Policy, IHS Circular No. 2006-01 and Conferring with UIO, IHM Part 5, Chapter 26. Regarding Tribal programs, it is IHS policy that consultation with the Indian Tribes will occur to the extent practicable and permitted by law before any action is taken that will significantly affect Indian Tribes. Such actions refer to policies that have Tribal implications and substantial direct effects on one Indian Tribe or more regarding the relationship between the Federal Government and the Indian Tribe(s) or on the distribution of power and responsibilities between the Federal Government and the Indian Tribe(s). Regarding UIO, it is the IHS policy to confer with UIOs, to the maximum extent practicable, whenever a critical event or issue arises in implementing or carrying out the Indian Health Care Improvement Act, 25 U.S.C. §§ 1601-1683.
8. Meetings.
   1. Scheduled Meetings. The QMAB will meet at least quarterly via teleconference, but may have additional Ad Hoc meetings as needed. The QMAB will also seek to involve stakeholders throughout the IHS on any issue.
   2. Meeting Minutes. The meeting minutes will be developed by the Secretary and distributed within 30 days of the meeting. These meeting minutes will be maintained in accordance with the IHS records management policies and procedures. Minutes should be available electronically for review and comment by any QMAB member within the IHS.
   3. Additional Meetings. Additional meetings will be scheduled if the need arises or as requested by the Executive Committee, the Resource and Patient Management System Program Manager, OIT Investment Manager or Ad Hoc subcommittee to achieve the goals of the QMAB.
9. Ad Hoc Subcommittees. The Chairperson of the QMAB shall appoint federal employees to Ad Hoc subcommittees as needed to achieve the goals of the QMAB.
10. Supersede. None.
11. Effective Date. This charter becomes effective on the date of signature.
/Michael D. Weahkee/
RADM Michael D. Weahkee, MBA, MHSA
Assistant Surgeon General, U.S. Public Health Service
Director, Indian Health Service