A recent blog suggested that CMS’ efforts to standardize assessment data was based on a goal of “….creating a functional measurement tool that could be used throughout the industry.” In fact, CMS has been working since 2005 to meet the Congressional directive to standardize assessment information at hospital discharge, and post-acute care (PAC) admission and discharge for payment and quality reporting purposes (Deficit Reduction Act of 2005). The CARE tool was developed as part of the national Post-Acute Care Payment Reform Demonstration (PAC PRD). The conceptual domains and items were selected with the input of the wide range of stakeholder communities working with PAC populations. Clinicians from acute hospitals and each of the four PAC settings, including long term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies (HHAs) identified items to test in four areas: medical status, functional status, cognitive status, and some social support factors. Input was given by physicians, nurses, physical therapists, occupational therapists, speech and language pathologists, social workers and case managers working in each of the different levels of care. Initial item selection was based on a review of existing assessment items, including those in the three Federally-mandated instruments, (the IRF-PAI, MDS 2.0, and OASIS-B which were in effect at this time) and the input of each of the scientific communities working in these areas.

Developers of proprietary systems such as the UDS-MR©, Inter-RAI ©, and AM-PAC ©, as well as public domain items tested in clinical trials such as the PROMIS items, were all reviewed as part of this process. The selected items needed to be in the public domain so the measures could be modified as science advanced practice.

Over 200 providers participated nationwide to submit over 53,000 CARE assessments over the course of the PAC PRD. Participating clinicians also provided feedback during training and exit interviews. In general, positive feedback was provided on most items. Feedback showed that almost all items were commonly collected on existing instruments in hospitals and PAC providers, although some of the information may have been informally noted in charts rather than provided in the structured form of the CARE items.

The items were tested for reliability so they could be applied consistently across populations and settings. Most of the items were previously tested and found reliable in at least one of the five levels of care. Two types of reliability tests were conducted on the final CARE tool item set used in the PAC PRD. The results showed that most items when applied to the other four settings were at least as reliable as the existing Federal assessment items (Kappa scores of 0.6 or better) ensuring their reliable use in future quality measures or payment models would reach consistent results. Complete reports on item reliability and PAC PRD results can be found here.

Data standardization is critical to allow providers to exchange information as they follow the patient. The Deficit Reduction Act of 2005 directed CMS to use standardized assessment items at acute hospital discharge and PAC admission and discharge to allow for empirical comparisons of key questions arising out of changing incentives in the Medicare payment policies. The standardized CARE items are consensus-based versions of the items already collected by clinicians. These and additional items being incorporated into CMS’ assessment item library represent the “best in class.” The team developing the CARE item set represented the leading experts in each of the areas – Dr. Margaret Stineman of the University of Pennsylvania, developer of the function-related groups associated with the proprietary FIM©, Dr. Deborah Saliba, UCLA, lead developer of the MDS 3.0, and Dr. Chris Murtaugh of the Visiting Nurse Service of New York. Team members included Drs. Anne Deutsch and Trudy Mallinson of the Rehabilitation Institute of Chicago. Input was also given by Dr. David Hittle, of the University of Colorado who has worked closely with the OASIS tool, Dr. Samuel Markello, formerly of the UDS-MR©, and Dr. Patrick Murray of Case Western University.

The blog suggested that, “the early reviews of the CARE tool have been poor.” While this clearly is not true, it is worth pointing out that the author owns one of the key proprietary assessment instruments. The CARE items have been evaluated for reliability and they meet the national standards; they allow providers and others the opportunity to download the e-specification of the items without charge and to have the clinicians trained for free under CMS’ regular assessment training initiatives. CMS is currently developing quality measures using the “best in class” assessment items which all meet scientific standards. The quality measure development process already requires CMS to submit measures for endorsement by the National Quality Forum. The “loophole” identified by the UDS-MR© author is non-existent. The Measures Application Partnership is part of the existing NQF process included in the IMPACT legislation. Further, use of uniform data elements across settings, such as those used in the currently collected pressure ulcer measure, allows for exchangeability and improves communication across the system, finally creating a “data follows the person” system.

Editor's Note: On Thursday Brookings Visiting Fellow, Amb. Norm Eisen addressed the Italian Parliament to discuss ethics in government, highlighting efforts in the US to improve transparency and accountability. In the speech, Amb. Eisen argues that while ethics reform can be difficult, it is an absolutely essentially part of any democratic system.

As Prepared For Delivery

Signora Presidente Boldrini, Madam President Brasseur, honorevoli Parlamentari, fellow panelists and distinguished guests, buon pomerigo. Thanks for inviting me to address the urgent subject of ethical standards in political life. It is an honor to be here in the Italian Chamber of Deputies, in this beautiful and ancient city, to which we Americans owe so many elements of our system of government. And in my town of Washington, DC we also borrowed a lot of your architecture, so we owe you for that as well.

In exchange for all that, as a small form of repayment, I would like to offer some perspectives from the U.S. as you consider the adoption of a code of ethical conduct for the Italian Parliament.

Since we are in the Chamber of Deputies, the equivalent of our U.S. Congress’ House of Representatives, I will start with best practices in that body, based on years of my professional life—too many—spent addressing alleged violations of its codes of conduct, including as a defense lawyer and later as the co-founder of a government watchdog group.

And I think there are also important lessons to be drawn from the new, innovative code of conduct for White House officials we established while I served as the "Ethics Czar" of President Obama. At his direction I helped write that new code, the Obama "ethics pledge," and although I am biased I think it has been effective so far, knock wood, there have been no major White House scandals. So I will talk about the lessons of that code of conduct a bit as well. My reflections are those of a friend and partner nation with plenty of challenges of our own. So I approach the issue with genuine humility in sharing our successes and failures.

I. Government ethics while standing on one leg

So—what is our U.S. view of best practices for the contents of government codes of ethics? In the U.S. and dare I say internationally, there is a pretty well developed set of best practices. In our House of Representatives, for example, our equivalent of this Chamber of Deputies, Rule XXIII is the Code of Official Conduct. It provides rules in four core areas;

• one, for regulating conflicts of interest, that is, situations where personal interests or financial holdings may conflict with official parliamentary duties;
• two, for gifts, particularly those from lobbyists and other persons interested in parliamentary decisions;
• three, for outside employment of parliamentarians before, during and after government service, particularly with lobbyists, a situation which we call in the US the revolving door; and
• four, for parliamentarians’ proper use of official resources, that is, hiring, staff, budget, travel and such.

There is much more detail in our code of conduct, and a few other rules as well, but those four items—conflicts, gifts, employment and resources—are the key. These same four key areas are also at the center of our codes of conduct for employees of our executive branch, as codified in our statutes and regulations, as well as in the Obama ethics pledge.

I emphasize these four key items because, having helped draft one code of conduct, and having often delved into many other codes, I sometimes find that I lose the forest for the trees when working with these codes, that the priorities at least for me sometimes get lost in the detail. So I try to keep the core always in mind, though I should add that the content of any such code must of course be particularized for the circumstances of particular government bodies and jurisdictions. Thus our U.S. House code is five pages long, elaborating on those four core items, and the House Ethics Manual of official guidance for the code is 456 pages long. Our Obama ethics pledge we got onto one page, we were proud of that. And we made everyone read and sign that page. To be fair, we could do that because we built on and added to other rules which already existed, and we did have several pages of definitions and references attached to the pledge.

II. Enforcement and transparency

But a good code is only the beginning. In our U.S. experience, just as important as the code, maybe even more important, is its enforcement. And here is where I want to share some lessons drawn from U.S. challenges in recent years, and how we responded. I am going to add two more items to our check list: enforcement and transparency.

Candidly, even with our parliamentary code of conduct in the U.S., our enforcement has sometime lagged. That is in part because under our Constitution, the ultimate enforcers are the parliamentarians themselves, and so they can at times be understandably reluctant to sanction their colleagues and friends. It's human nature.

For example, from about 1998 to 2004, there was a seven-year truce in filing complaints in our House of Representatives. The government watchdog organization I co-founded helped end that in 2004 by writing a complaint together with a brave but lonely member of Congress who was willing to file it with the House Ethics Committee. The resulting investigation resulted in the discipline of the member investigated, and ultimately helped lead to his party losing majority control of the body.

Out of all of that came a new enforcement tool in 2008, in our House of Representatives, that I strongly recommend to you: the creation of a new, independent entity, the Office of Congressional Ethics (OCE). This is a nonpartisan fact-finding body that investigates allegations from any source, including whistleblowers who might otherwise be afraid to step forward. OCE then recommends action to the parliamentarians who constitutionally maintain the ultimate decision-making power. Most importantly, the OCE referrals become public, allowing press, civil society and voter accountability. As a result, I believe, since the creation of the OCE for our House in 2008, there have been a significantly higher number of meritorious investigations there than in our Senate, which does not have a comparable body. The total is about 46 OCE referrals and about 20 House disciplinary actions versus just four letters of admonition by our Senate in that period. To be fair the Senate is a smaller body—but not that much smaller!

That last aspect of OCE enforcement—transparency, and the accountability it brings from media, NGOs and the public—is the sixth and final point I want to emphasize. In our U.S. parliamentary ethics system we have many transparency mechanisms: asset disclosures that our parliamentarians file, disclosures that lobbyists must make about their activities, information in campaign finance filings, and more.

To explain the value of transparency, I would like to close by turning to one of our Obama White House ethics transparency innovations. Starting in 2009, we for the first time put on the Internet virtually all visitor records of those coming to the White House. It used to be that just to get a handful of these records you had to file litigation and wait for years to know who was coming to the White House, who they were meeting with and what the subject of the meeting was. Now millions of Obama White House visitor records are online, each with a dozen or so basic categories of information: the name of the visitor, the person visited, the subject of the meeting and so on.

Why is that important? I began by referencing the Obama White House's record in avoiding major scandal. I think there are a number of reasons for that, including the President's own integrity and the new code of conduct we put into place. But an important part of that success story has also been the fact that records of White House meetings go on the Internet for everyone to see. That transparency brings accountability from the press, civil society and the public. That transparency and accountability has in turn powerfully reinforced the code of conduct: it has discouraged people from having meetings they shouldn't have, and if you don't have the meeting, you can't get in trouble for it.

So the U.S. view in one sentence: regulate conflicts, gifts, employment, and resource use, with strong enforcement and above all transparency. Thanks again for inviting me to share the U.S. perspective. Grazie!

On June 20, I moderated a conversation on the future of the Department of Veterans Affairs with Secretary Robert McDonald. When he took office almost two years ago, Secretary McDonald inherited an organization in crisis: too many veterans faced shockingly long wait-times before they received care, VA officials had allegedly falsified records, and other allegations of mismanagement abounded.

Photo: Paul Morigi

Since he was sworn into office, Secretary McDonald has led the VA through a period of ambitious reform, anchored by the MyVA program. He and his team have embraced three core strategies that are securing meaningful change. They are important insights for all government leaders, and private sector ones as well.

1. Set bold goals

Secretary McDonald’s vision is for the VA to become the number one customer-service agency in the federal government. But he and his team know that words alone won’t make this happen. They developed twelve breakthrough priorities for 2016 that will directly improve service to veterans. These actionable short-term objectives support the VA’s longer term aim to deliver an exceptional experience for our veterans. By aiming high, and also drafting a concrete roadmap, the VA has put itself on a path to success.

2. Hybridize the best of public and private sectors

To accomplish their ambitious goal, VA leadership is applying the best practices of customer-service businesses around the nation. The Secretary and his colleagues are leveraging the goodwill, resources, and expertise of both the private and public sector. To do that, the VA has brought together diverse groups of business leaders, medical professionals, government executives, and veteran advocates under their umbrella MyVA Advisory Committee. Following the examples set by private sector leaders in service provision and innovation, the VA is developing user-friendly mobile apps for veterans, modernizing its website, and seeking to make hiring practices faster, more competitive, and more efficient. And so that no good idea is left unheard, the VA has created a "shark tank” to capture and enact suggestions and recommendations for improvement from the folks who best understand daily VA operations—VA employees themselves.

3. Data, data, data

The benefits of data-driven decision making in government are well known. As led by Secretary McDonald, the VA has continued to embrace the use of data to inform its policies and improve its performance. Already a leader in the collection and publication of data, the VA has recently taken even greater strides in sharing information between its healthcare delivery agencies. In addition to collecting administrative and health-outcomes information, the VA is gathering data from veterans about what they think . Automated kiosks allow veterans to check in for appointments, and to record their level of satisfaction with the services provided.

The results that the Secretary and his team have achieved speak for themselves:

• 5 million more appointments completed last fiscal year over the previous fiscal year
• 7 million additional hours of care for veterans in the last two years (based on an increase in the clinical workload of 11 percent over the last two years)
• 97 percent of appointments completed within 30 days of the veteran’s preferred date; 86 percent within 7 days; 22 percent the same day
• Average wait times of 5 days for primary care, 6 days for specialty care, and 2 days for mental health are
• 90 percent of veterans say they are satisfied or completely satisfied with when they got their appointment (less than 3 percent said they were dissatisfied or completely dissatisfied).
• The backlog for disability claims—once over 600,000 claims that were more than 125 days old—is down almost 90 percent.

Thanks to Secretary McDonald’s continued commitment to modernization, the VA has made significant progress. Problems, of course, remain at the VA and the Secretary has more work to do to ensure America honors the debt it owes its veterans, but the past two years of reform have moved the Department in the right direction. His strategies are instructive for managers of change everywhere.

Fred Dews and Andrew Kenealy contributed to this post.