Health Care Quality Measurement: The National Quality Forum Has Begun a 4-Year Contract with HHS
Published: 2010-07-14T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) directed the Department of Health and Human Services (HHS) to enter into a 4-year contract with an entity to perform five duties related to health care quality measurement and authorized $40 million from the Medicare Trust Funds for the contract. In January 2009, HHS awarded a contract to the National Quality Forum (NQF), under which HHS will reimburse NQF for its costs and pay additional fixed fees. Established in 1999, NQF is a nonprofit member organization that fosters agreement on national standards for measuring and public reporting of health care performance data. This is the first of two reports MIPPA requires GAO to submit on NQF's contract with HHS. In this report, which covers the first contract year--January 14, 2009, to January 13, 2010--GAO describes (1) the status of NQF's work on the five duties under MIPPA; (2) the costs and fixed fees NQF has reported; and (3) what NQF and HHS do in order to help ensure that NQF's reported costs are proper. GAO reviewed relevant MIPPA provisions and reviewed HHS and NQF documents, such as HHS's contract with NQF, monthly progress reports and invoices for the first contract year, and policies and other documents that describe how HHS and NQF review invoices. GAO also interviewed NQF and HHS officials responsible for implementing and overseeing the contract.
section_title: What GAO Found
paragraphs: NQF has begun work for each of five duties required by MIPPA related to quality measures: (1) make recommendations on a national strategy and priorities; (2) endorse quality measures, which involves a process for determining which ones should be recognized as national standards; (3) maintain--that is, update or retire--endorsed quality measures; (4) promote electronic health records; and (5) report annually to Congress and the Secretary of HHS. As of January 13, 2010--the end of the first contract year--NQF's work for four MIPPA duties was in progress and it had completed its first annual report for the fifth duty. For example, NQF had begun the duties related to endorsement and maintenance by initiating the endorsement process for three projects HHS selected and by starting maintenance reviews for a set of measures of interest to or used by HHS. While NQF began work for each of the duties in the first contract year, HHS determines on an annual basis the work NQF will be expected to perform under the five duties each contract year. NQF reported costs and fixed fees totaling approximately $6.5 million for the first contract year, including direct and indirect costs as well as fixed fees. Specifically, NQF reported about $3.2 million in direct costs, or 49 percent of the total. These were costs specifically incurred for the NQF contract, such as direct labor for NQF employees. NQF also reported about $2.9 million in indirect costs, which cover additional items such as employee benefits and overhead. Finally, NQF reported about $360,000 in fixed fees for the first contract year. Over $5 million of the reported costs and fixed fees were incurred in the second half of the contract year. NQF and HHS rely on reviews of NQF invoices in order to help ensure that NQF's reported costs are proper. At NQF, officials told us that they review the invoices prior to submitting them to HHS and carry out other activities, such as using an electronic system to track labor hours, in order to help ensure that the costs they report in the invoices are proper. Like NQF, HHS relies on reviews of NQF invoices in order to help ensure NQF's reported costs are proper. These reviews are governed by HHS policies and procedures and by requirements applicable to federal contracts generally. While NQF has begun work under the MIPPA contract, it is too early for GAO to assess whether, or to what extent, NQF will be successful in carrying out the five MIPPA duties. This report describes NQF's work for the first of 4 contract years. In the remaining 3 years of the contract, HHS will determine on an annual basis specific work for NQF to complete under each of the five MIPPA duties. Therefore, it is not yet known exactly what work NQF will be expected to complete during the remainder of the contract period. GAO's second report, which is due in January 2012, will provide another opportunity to review NQF's performance and costs. HHS and NQF reviewed a draft of this report and provided technical comments, which GAO incorporated as appropriate.

section_title: Letter
paragraphs: Health care quality measures are used to evaluate how health care is  delivered, and information obtained from such measures can promote  accountability among health care providers and help consumers make  informed choices about their care. The Department of Health and Human  Services (HHS) encourages use of quality measures through programs that  provide financial incentives to health care providers who voluntarily  collect and report information on certain quality measures, which HHS  then makes publicly available. For example, as part of one program, HHS  reported that in fiscal year 2009, almost all—96 percent—of eligible  hospitals participating in Medicare reported on their performance against  certain quality measures. Recent legislation requires HHS to implement  additional programs that will rely on quality measures, such as a pay-for- performance program under which HHS will pay incentives to hospitals  based on their performance on selected quality measures.
The Medicare Improvements for Patients and Providers Act of 2008  (MIPPA) directed HHS to enter into a 4-year contract with an entity to  perform five duties related to health care quality measurement: (1) make  recommendations on a national strategy and priorities, (2) endorse quality  measures, (3) maintain endorsed quality measures, (4) promote electronic  health records, and (5) report annually to Congress and the Secretary of  HHS. MIPPA authorized $10 million per year—$40 million in total—from  the Medicare Trust Funds for this 4-year contract, which covers the period  from January 14, 2009, through January 13, 2013. In addition, the Patient  Protection and Affordable Care Act (PPACA), which was enacted in March  2010, established additional duties for the entity.
On January 14, 2009, HHS awarded the 4-year contract required by MIPPA,  after issuing a solicitation seeking competitive proposals, to the National  Quality Forum (NQF), a nonprofit organization established in 1999 that  fosters agreement on national standards for measurement and public  reporting of health care performance data. NQF uses a process recognized  under the National Technology Transfer and Advancement Act of 1995  that grants quality measures and other standards endorsed by consensus- based entities, such as NQF, standing as national voluntary consensus  standards. NQF uses its process to evaluate available quality measures to  determine which ones are qualified to be endorsed—that is, recognized— as national standards. NQF-endorsed quality measures have been used by  HHS in its quality measurement programs. In 2008, prior to receiving the  contract award, NQF’s revenue from all sources was approximately $10  million. NQF staff told us that while NQF has previously received funding  from HHS for some of its work related to quality measures, the $10 million  per year authorized by MIPPA for the contract is larger than previous  funding.
HHS’s 4-year contract with NQF is a cost-plus-fixed-fee contract, under  which HHS will pay NQF for its costs and additional fixed fees for its  services. The Federal Acquisition Regulation (FAR) provides that cost- plus-fixed-fee and other types of cost-reimbursement contracts may only  be used when the contractor’s accounting system is adequate for  determining costs under the contract and appropriate government  surveillance during performance will provide reasonable assurance that  efficient methods and effective cost controls are used. For the purposes of  this report, we refer to costs that are allowable under the contract as  “proper.”
MIPPA required GAO to study the performance of and costs incurred   by NQF under its 4-year contract with HHS and submit a first report by  July 14, 2010, and a second report by January 14, 2012. This first report  covers the first contract year that began January 14, 2009, and ended  January 13, 2010. In this report, we describe (1) the status of NQF’s work  on the five duties related to health care quality measurement required  under MIPPA, (2) the costs and fixed fees that NQF has reported under its  contract, and (3) what NQF and HHS do in order to help ensure that NQF’s  reported costs are proper.
To describe the status of NQF’s work on duties related to health care  quality measurement required under MIPPA, we focused our review on the  status of NQF’s work related to the five MIPPA duties as of the end of the  first contract year, January 13, 2010. We reviewed relevant provisions in  MIPPA, and HHS and NQF documents related to implementing health care  quality measurement duties in MIPPA. Specifically, we reviewed HHS’s  contract with NQF and NQF’s 2009 annual work plan, which established  specific activities for implementing these duties as well as scheduled time  frames for the activities. We also reviewed the monthly progress reports  NQF is required to submit to HHS on its efforts for the first contract year,  and we reviewed NQF’s first annual report to HHS and Congress. We  interviewed NQF officials responsible for implementing the contract and  HHS officials responsible for managing the contract and overseeing NQF’s  performance. For NQF activities in progress at the end of the first contract  year, we gathered information about their planned completion dates as of  January 13, 2010. Our finding is limited to the duties established under  MIPPA and does not include additional duties mandated by PPACA, which  was enacted after the end of the first contract year.
To describe the costs and fixed fees that NQF has reported under its  contract, we reviewed NQF invoices submitted to HHS for the first  contract year—January 14, 2009, through January 13, 2010. These invoices  include the amounts of costs and fixed fees reported by NQF. We also  reviewed NQF’s monthly progress reports to HHS for the first contract  year. We interviewed NQF officials responsible for reviewing and  approving the costs and fixed fees submitted to HHS under the contract.  We also interviewed HHS officials responsible for reviewing NQF’s costs  and fixed fees reported under the contract. Based on our review of  relevant documents and interviews with NQF and HHS officials, we  determined that the reported costs and fixed-fee data were sufficiently  reliable for the purposes of this report.
To describe what NQF and HHS do in order to help ensure that NQF’s  reported costs are proper, we interviewed NQF and HHS officials and  reviewed relevant policies and procedures. For NQF, we interviewed  officials about their process for reviewing NQF invoices submitted to HHS  and about the other policies and procedures that NQF has in order to help  ensure that the costs they report to HHS in the invoices are proper. We  focused our discussions on policies and procedures related to employee  labor costs and payments to contractors and consultants, which are the  majority of NQF’s direct costs. We also reviewed the invoices that NQF  submitted to HHS during the first contract year for evidence of NQF  approval by NQF officials. Additionally, we examined the files that NQF  maintained on its subcontracts to review documentation for the eight  subcontractors and consultants that performed work related to the HHS  contract in the first contract year. We compared documentation that NQF  maintains for the eight subcontractors and consultants with the  requirements in NQF’s January 2010 procurement policy. For HHS, we  interviewed officials responsible for reviewing NQF invoices, the project  officer and the contracting officer for the NQF contract. We identified  requirements in relevant HHS policies and procedures as well as relevant  federal contracting requirements for oversight of cost-reimbursement  contracts. We interviewed HHS officials about how they review NQF  invoices. We also reviewed documentation in the file HHS maintained on  the NQF contract for the first contract year to describe whether HHS  officials followed the invoice review procedures they explained to us.  Additionally, we reviewed documentation in the NQF contract file related  to NQF’s use of eight subcontractors and consultants that performed work  under the contract for the first contract year. Our work was limited to  describing what NQF and HHS do to help ensure that NQF’s reported costs  were proper and did not include a determination of whether the costs  were proper.
We conducted this performance audit from September 2009 through June  2010 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: NQF is a nonprofit organization established in 1999 that fosters agreement  on national standards for measurement and public reporting of health care  performance data. Its membership includes more than 400 organizations  that represent multiple sectors of the health care system, including  providers, consumers, and researchers. NQF uses a consensus  development process to evaluate and endorse consensus standards,  including quality measures, best practices, frameworks, and reporting  guidelines. NQF has endorsed over 600 quality measures in 27 areas, such  as cancer and diabetes. NQF endorses quality measures developed by  other organizations, such as the Joint Commission, the National  Committee for Quality Assurance, and the American Medical Association,  rather than developing quality measures itself. HHS has used a number of  NQF-endorsed measures in initiatives to promote quality measurement,  and NQF continues to endorse quality measures separate from this  contract.
subsections: section_title: Duties Established in MIPPA
paragraphs: MIPPA established five duties related to the use of quality measures. See  table 1 for a description of the duties.
section_title: NQF Contract
paragraphs: For the NQF contract, HHS selected a cost-plus-fixed-fee contract—NQF’s  first cost-reimbursement contract. Under the cost-plus-fixed-fee contract,  HHS will reimburse NQF for costs incurred under the contract in addition  to a fixed fee that is paid regardless of other costs. Cost-plus-fixed-fee  contracts are used for efforts such as research, design, or study efforts  where cost and technical uncertainties exist and it is desirable to retain as  much flexibility as possible in order to accommodate change. However,  this type of contract provides only a minimum incentive to the contractor  to control costs. As we reported in 2009, these contracts are suitable when  the cost of work to be done is difficult to estimate and the level of effort  required is unknown.
Under the FAR, cost-reimbursement contracts may only be used when the  contractor’s accounting system is adequate for determining costs under  the contract to help prevent situations where contractors bill the  government for unallowable costs. One method an agency can use to  determine if an accounting system is adequate is to perform a preaward  survey of a potential contractor’s accounting system prior to awarding a  contract. This review serves as a key control to determine whether the  potential contractor has an adequate accounting system in place to  accurately and consistently record costs and submit invoices for costs.  HHS conducted two preaward surveys of NQF’s accounting system. HHS’s  initial review, in November 2007, found that NQF’s accounting system was  inadequate because the system could not identify and separate  unallowable costs, among other issues. NQF subsequently replaced its  accounting system, and a second HHS review in November 2008 found that  the system was adequate.
Under the FAR, contracts are to contain provisions for agency approval of  a contractor’s subcontracts. HHS’s contract with NQF contains this  provision and also requires the approval of consultants. This review  requires appropriate support documentation provided by the contractor to  the agency, including a description of the services to be subcontracted, the  proposed subcontract price, and a negotiation memo that reflects the  principal elements of the subcontract price negotiations between the  contractor and subcontractor.
Two HHS components are principally responsible for administering the  NQF contract: the office of the Assistant Secretary for Planning and  Evaluation (ASPE) and the Centers for Medicare & Medicaid Services  (CMS)—an operational division within HHS. To conduct oversight of the  NQF contract, HHS assembled staff in these two units with experience in  acquisitions, contract management, and program management.  Specifically, the project officer for the NQF contract, responsible for  program management and performance assessment, is a representative of  ASPE. The contracting officer for the NQF contract, responsible for  administering the contract, is a representative of CMS. The contracting  officer and project officer should perform a comprehensive review of  contractor invoices to determine if the contractor is billing costs in  accordance with the contract terms and applicable government  regulations.
section_title: NQF Has Begun Work for Each of the Five Duties Required by MIPPA Related to Quality Measures
paragraphs: As of January 13, 2010—the end of the first year of HHS’s 4-year contract  with NQF to implement the MIPPA duties—NQF had begun work for each  of the five duties required by MIPPA related to health care quality  measures: (1) make recommendations on a national strategy and  priorities; (2) endorse quality measures; (3) maintain endorsed quality  measures; (4) promote electronic health records; and (5) report annually  to Congress and the Secretary of HHS. While NQF began work for each of  the duties in the first contract year, HHS determines on an annual basis the  specific work NQF will be expected to perform under the five MIPPA  duties in each contract year.
Recommendations on a National Strategy and Priorities for Quality  Measurement. NQF has taken steps to begin the duty of making  recommendations on a national strategy and priorities for quality  measurement. In October 2009, NQF established a committee of  stakeholders that is expected to develop recommendations about a  national strategy and priorities for quality measurement. NQF published  the recommended priorities in May 2010. The committee’s  recommendations are expected to be based on a synthesis of evidence that  NQF has collected, using a subcontractor, on 20 conditions that account  for the majority of Medicare’s costs. The subcontractor collected  evidence on existing quality measures for these conditions and identified  gaps where quality measures did not exist. The subcontractor also  collected evidence related to each condition, such as information on each  condition’s prevalence, treatment costs, variability in providers’ treatment  of the condition, disparities in treatment for patients with the condition,  and potential to improve quality of care for the condition. The committee  is expected to consider this evidence when developing recommendations  on a national strategy and priorities for quality measurement. Under  PPACA, NQF’s recommendations on a national strategy and priorities  must be considered by HHS when it develops a national strategy for  quality improvement, which HHS is required to submit to Congress by  January 1, 2011.
Endorsement of Measures. NQF has taken steps to provide for the  endorsement of quality measures. Prior to its contract with HHS, NQF  established a process for endorsing quality measures. Under this process,  organizations that develop quality measures submit them to NQF for  consideration, in response to specific solicitations by NQF. NQF forms a  committee of experts from its member organizations as well as other  organizations and agencies to review these quality measures against NQF- established criteria, such as the usability and feasibility of the measure.  After this committee evaluates the measures against these criteria, NQF’s  process allows for a period during which its member organizations and the  public may comment on the committee’s recommendation for each  measure. The process also provides for a period for its member  organizations to vote on whether the measures should be endorsed by  NQF as a national standard. Ultimately, NQF’s board of directors makes a  final decision on whether NQF should formally endorse the measures.  (See app. I for a detailed description of NQF’s endorsement process.)
In order to provide for the endorsement of quality measures under this  duty, NQF has taken several steps. Specifically, NQF initiated projects and  solicited measures to be endorsed using its process for each of these  projects. These projects relate to quality measurement in nursing homes,  patient safety, and patient outcomes, and are scheduled to be completed  between December 2010 and May 2011. In addition to endorsing measures,  NQF also hired a subcontractor to evaluate its endorsement process and  recommend ways to improve its efficiency and effectiveness. The  subcontractor’s report and NQF’s approval of proposed enhancements to  the process are due January 2011.
Maintenance of Endorsed Quality Measures. NQF has taken steps to  ensure that endorsed measures are maintained—that is, updated or  retired. Prior to its contract with HHS, NQF established a process for  maintenance of measures. According to NQF, once a quality measure has  been endorsed, updated information on the measure’s specifications  should be submitted to NQF annually and the measure should be  comprehensively reviewed under the maintenance process every 3 years.  NQF’s maintenance process is similar to NQF’s endorsement process, in  that it involves a review of measures against NQF-established criteria, a  period for public comment, and a final decision by NQF’s board of  directors. In order to implement this process under its contract with HHS,  NQF began maintenance reviews for 191 measures in 14 areas such as  diabetes and cardiovascular care. The measures were identified by HHS as  being of interest to, or actually used by, HHS programs. By the end of the  first contract year, NQF had not determined completion dates for  maintenance of the 191 measures. As of May 2010, maintenance of the 191  measures identified by HHS is scheduled to be completed by the end of  2012.
Promotion of the Development and Use of Electronic Health  Records. NQF has taken steps towards completing the duty of promoting  the development and use of electronic health records for use in quality  measurement. As of January 13, 2010, NQF had begun to implement a  framework that defines a standardized set of data that should be captured  in patients’ electronic health records. The framework, known as the  Quality Data Set (QDS), is intended to allow data from electronic health  records to be collected and used in quality measurement. Implementation  and maintenance of the QDS is scheduled to continue through the end of  the 4-year contract, which ends January 13, 2013. To further promote the  development and use of electronic health records in quality measurement,  NQF began additional activities. For example, NQF established a panel of  experts to recommend additional capabilities to measure utilization.  According to NQF officials, efforts under this duty are scheduled for  completion between March 2010 and January 2013.
Annual Report to Congress and the Secretary of HHS. NQF  submitted its first annual report to Congress and the Secretary of HHS on  March 1, 2009. HHS published this report, with its comments, in the  Federal Register on September 10, 2009. NQF submitted its second annual  report, which also covers activities it performed during the first contract  year, to Congress and the Secretary on March 1, 2010.
While NQF has begun work for each of the duties in the first contract year,  HHS determines on an annual basis the specific work NQF will be  expected to perform under the five MIPPA duties each contract year.  Specifically, HHS gives direction for and then approves annual plans that  NQF develops. These plans can include work begun in prior contract years  that has not been completed. HHS can adjust work in the annual plans in  support of each of the five duties. For example, HHS officials told us that  in future contract years, they may select additional projects for the  endorsement of quality measures, and additional measures for  maintenance reviews.
section_title: NQF Reported about $6.5 Million in Costs and Fixed Fees for the First Contract Year
paragraphs: NQF reported costs and fixed fees totaling approximately $6.5 million for  the first year of its contract with HHS, which ended January 13, 2010. The  amount NQF reported included direct and indirect costs, as well as fixed  fees. Direct costs, which are costs incurred specifically for this contract,  represented the largest percentage—about $3.2 million, or 49 percent—of  the amount NQF reported (see fig. 1). NQF’s reported direct costs were  largely labor costs for NQF employees and payments to subcontractors  and consultants. In addition to direct costs, NQF reported about   $2.9 million in indirect costs for the first contract year. Indirect costs cover  additional items, such as employee benefits, overhead, and administrative  costs. NQF calculates its indirect costs based on a formula that takes into  account an indirect-cost rate approved by HHS and the amounts of certain  direct costs. For example, the formula estimates indirect costs such as  employee benefits by multiplying an indirect-cost rate by the amount of  direct costs for labor. Finally, in addition to its direct and indirect costs,  NQF reported fixed fees of approximately $360,000 during the first  contract year. HHS pays these fixed fees to NQF in addition to reimbursing  the organization for its costs.
Of the approximately $6.5 million in costs and fixed fees NQF reported for  the first contract year, most were incurred in the second half of the  contract year. Costs and fixed fees in the second half of the contract year,  from July 1, 2009, to January 13, 2010, totaled over $5 million. NQF staff  told us that costs in the first half of the contract year were primarily for  activities such as development of solicitations for subcontractors. Costs in  the second half of the contract year were primarily for activities related to  quality measurement, such as endorsement of quality measures and  promotion of electronic health records for use in quality measurement.
section_title: NQF and HHS Rely on Reviews of NQF Invoices in Order to Help Ensure That NQF’s Reported Costs Are Proper
paragraphs: NQF reviews invoices and carries out other activities prior to submitting  them to HHS in order to help ensure that reported costs are proper. HHS  requires its officials to follow certain procedures when reviewing these  invoices.
subsections: section_title: NQF Reviews Invoices and Carries out Other Activities in Order to Help Ensure That Its Reported Costs Are Proper
paragraphs: NQF officials told us their organization has several ways to help ensure  that the contract costs it reports to HHS are proper. According to NQF  officials, invoices are electronically generated using NQF’s accounting  system and then reviewed before submitting the invoices to HHS for  payment. These reviews are conducted by two senior staff—the NQF  Project Director, who manages the contract, and the Chief Financial  Officer. These officials meet to review costs reported in each month’s  invoice. NQF officials told us that as part of their reviews, the two officials  compare the current month’s invoice to the previous month’s invoice to  identify discrepancies or cost trends that seem unusual and that the  officials investigate such discrepancies or trends when necessary. After  this review, the Chief Financial Officer signs the invoice. During our  review of NQF’s invoices for the first contract year, we found that the  Chief Financial Officer signed the invoices as the officials described to us.
In addition to the review of invoices, NQF officials described other ways  the organization helps to ensure that the costs it reports to HHS are  proper. In particular, NQF officials told us NQF uses an electronic  timesheet system in order to track employee labor hours. NQF officials  told us that the timesheet system allows NQF employees to track their  labor hours by project and have their labor hours reviewed and approved  by the appropriate NQF officials. In addition to the timesheet system, NQF  officials told us that their organization established a written procurement  policy in August 2009 and revised it in January 2010 to guide how they  track other direct costs—specifically, payments to subcontractors and  consultants—that are reported in NQF’s invoices. NQF officials told us  that under its procurement policy, NQF officials are to obtain the  appropriate approval signatures for payments on invoices as well as other  payments for subcontractors and consultants once the services have been  received. Furthermore, according to the policy, NQF officials are to  document how key procurement decisions are made, such as the basis for  setting an award cost or price for a subcontractor or consultant. Having a  well-designed procurement policy can help reduce the risk of  inappropriate payments or pricing related to subcontractors and  consultants. During our review of NQF subcontractor and consultant files  for the period prior to January 2010—before NQF revised its procurement  policy—we found that NQF did not always document approvals for  subcontractor payment and did not document that it had determined that  its consultant pricing was reasonable.
section_title: HHS Requires Its Officials to Review NQF Invoices following Certain Procedures in Order to Help Ensure That Reported Costs Are Proper
paragraphs: Like NQF, HHS relies on reviews of NQF’s invoices in order to help ensure  that reported costs are proper. Two HHS officials assigned to oversee the  NQF contract, the project officer and the contracting officer, are  responsible for these reviews. When conducting their reviews, the two  officials are required to follow certain procedures established in HHS  policies. For example, under these policies, the project officer is required  to review NQF’s invoices to determine whether billed services were  actually provided and are supported with adequate documentation.  Similarly, the contracting officer is required to review the invoices to  determine whether NQF’s reported costs are consistent with its contract,  accurately calculated, and have adequate documentation. Both officials  are required to document when they approve invoices for payment to  NQF. When we reviewed HHS documentation and interviewed HHS  officials during the course of our work, we found that the contracting  officer and project officer had generally followed the review procedures  required by HHS policy.
Table 2 provides more detailed information on the procedures that the  project and contracting officers are required to follow when reviewing  NQF invoices. Table 2 also provides information we obtained from HHS  officials on how they implemented these requirements.
section_title: Concluding Observations
paragraphs: While NQF has begun work in the first year of its contract for the five  duties related to quality measurement established by MIPPA, it is too early  for us to assess whether, or to what extent, NQF will be successful in  carrying out these duties. This report describes NQF’s work for the first of  4 contract years, and HHS has flexibility to determine on an annual basis  the specific work it expects NQF to perform for each of the MIPPA duties.  Therefore, it is not yet known exactly what work NQF will be expected to  complete during the remainder of the contract period. In addition, other  events related to quality measurement, such as the completion of HHS’s  national strategy for quality improvement, are expected to occur before  the end of the 4-year contract period and may have some influence on  NQF’s specific work for the five MIPPA duties. Our second report will  provide another opportunity to review NQF’s performance and costs.
section_title: Agency and Other External Comments
paragraphs: We provided drafts of this report to HHS and NQF for comment. Both HHS  and NQF provided technical comments, which we incorporated as  appropriate.
We are sending copies of this report to the Secretary of Health and Human  Services and other interested parties. In addition, the report will be  available at no charge on GAO’s Web site at http://www.gao.gov.
If you or your staff have any questions about this report, please contact me  at (202) 512-7114 or at kohnl@gao.gov. Contact points for our Office of  Congressional Relations and Office of Public Affairs can be found on the  last page of this report. Other major contributors to this report are listed in  appendix II.
section_title: Appendix I: National Quality Forum’s Endorsement Process and Example Project
paragraphs: The National Quality Forum (NQF) established its endorsement process in  2000. NQF’s process includes the nine steps described in table 3 below.  The table also provides information on the endorsement process as  applied to a project to endorse a number of measures related to home  health care, such as measures on education provided to patients and  caregivers on medications for care and increases in the number of  pressure ulcers. This project was initiated prior to the NQF contract with  the Department of Health and Human Services (HHS) that was required by  the Medicare Improvements for Patients and Providers Act of 2008. NQF  announced a call for nominations for steering committee members for this  project in August 2008 and the final set of 20 endorsed measures was  announced on March 31, 2009.
section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Will Simerl, Assistant Director; La  Sherri Bush; Helen Desaulniers; Krister Friday; Natalie Herzog; Carla  Lewis; Lisa Motley; Ruth S. Walk; Rasanjali Wickrema; and William T.  Woods made key contributions to this report.