Late Breaking News
Deﬁning and Measuring Healthcare Quality
- Categorized in: June 2009 Issue
WASHINGTON—As legislators look at ways to reform the nation’s healthcare system, one of the questions they ﬁnd themselves needing to answer—one that must be answered before any signiﬁcant progress can be made—is exactly what healthcare quality is and how to measure it. At a hearing last month, legislators were told both private and federal healthcare research leaders that there is a gap between best practice and actual practice, and that the current healthcare system does not necessarily reward physicians for improving the health of their patients.
Brent James, M.D., chief quality ofﬁcer at Intermountain Healthcare, a private healthcare system headquartered in Utah, and member of the Institute of Medicine, has made a career out of examining quality of care and investigating how to marry best quality to frontline practice. At a Senate Finance committee hearing last month, he explained to legislators that quality measurement can only be done with proper information, and that current data that most hospitals use to measure care is incomplete. “We assume at some level that the data systems are sufﬁcient and adequate when in fact they are not,” Dr. James explained.
During testing of Intermountain’s quality measurement systems, Dr. James and his staff discovered outliers representing physicians who were shown to be doing poorly using the existing quality measurement data. However, a review of the measurement techniques found that those outliers were the result of inadequate data and not poor physician care.
According to Dr. James the existing care management data systems that most of the nation’s hospitals rely upon are missing about one-third to one-half of the information needed to actually manage and determine care quality. “The measurement system itself is a source of variability,” he said.
In his testimony, he explained that poorly constructed quality measurement systems often lead to “data gaming,” where hospitals exploit weaknesses in the measurement system to tweak the data to make their outcomes look better than they actually are. The more rewards or punishment that are attached to achieving a better quality number, the higher the likelihood that hospitals will do this, or shift resources to the area under scrutiny at the expense of care areas not under the measurement spotlight.
“There are principles of quality measure that are very understood in other industries. They’re just not widely applied in health-care. Frankly, most of our national measurements have missed the mark along the way,” Dr. James declared. “For us people at the frontline where the rubber meets the road, we greatly need better information on best care delivery processes. AHRQ (the Agency for Healthcare Research and Quality), the primary federal resource assigned to that task, has provided absolutely critical leadership. We need to do a lot more.”
Regulators as the Enemy
Committee chair Sen. Jay Rockefeller, D.-W.Va., asked Dr. James what role federal regulators can play in the quality assurance process and how to resolve the missions of the numerous federal agencies tasked with healthcare oversight.
“How do you take all these federal agencies—the AHRQ, CDC, CMS, FDA, HRSA and VA, which is a huge player in all of this—and bring any sense of coordination to them, or is that just something that a government bureaucrat would want to do but isn’t necessary? I think it is necessary,” Sen. Rockefeller said.
“Some agencies like AHRQ mostly supply critical information to us about best care. That’s their role. They do it very well,” Dr. James said. “Frankly, they need to do a lot more, but they are hugely useful. CDC is largely the same. But there’s another group of entities that impose measures upon us. The last count I did, there were over 1,600 [different regulating entities within federal and state agencies]. And it’s an effort just to meet the reporting needs. I’m a little bit jaded about this, but so far as I can tell it produces almost no result.”
Dr. James admitted that, like many administrators, he sees his role as a buffer between federal agencies and his healthcare employees. “One of my roles at Intermountian is to somehow stand between [those entities] and my frontline teams so they can get to the business of improving healthcare. There’s a growing groundswell of people who are generating a bottom-up change,” Dr. James said.
He cited team-based medical care as a prime example of quality improvement changes generated from the frontline of care. “Real healthcare reform is happening in hospitals across this country at a pretty good clip. The medical profession, the nursing profession, decided to move to a team-based model of care. It’s a sea-change. It’s the ﬁrst big change we’ve had in the profession like this in a hundred years. It’s profound. It ties very heavily into our electronic medical records. I believe [federal reform efforts] should support that effort.”
“While direction from federal agencies on exactly what best practices are is greatly appreciated, ways to measure and actually improve care quality works better when coming from experience at the bedside rather than imposed from federal headquarters’,” Dr. James explained.
He added, “We need to move quality measurement much closer to the frontline of care. If I build data systems to manage care at the bedside, I can roll up data and get the accountability measures we need to treat very accurately. When I impose them top down, the opposite is not true. Almost always, those measures are not sufﬁ cient or deﬁned by bedside care measures, and they actually compete. We actually have some examples now of how they harm care on the frontline.”
The Bad Financial Model
Hospitals still ﬁnd themselves stuck in a ﬁnancial model that can actually punish healthcare improvements and innovations, Dr. James told legislators. It is a problem, he said, that lies at the heart of any effort to create a healthcare system driven by quality.
“We just ran a project at a [little community hospital] with a big birthing service. You get what are technically term infants who develop respiratory distress syndrome. How we’ve traditionally managed them is you stick them on a respiratory ventilator in an ICU at great expense. It’s not that easy on the kids,” Dr. James explained. “We had a team that came up with a great idea. It’s called nasal continuous airway pressure, those machines we use for sleep apnea. [It turns] out if you use one in a neonate, you can keep their lungs inﬂated.”
The hospital went from 78% of infants with respiratory distress being transferred to 18 percent—a massive improvement in quality of care for those infants. However, when Dr. James tracked the expenditures he discovered that while the income coming into the community hospital increased by $550,000, the income at the newborn ICU, which Intermountain also owns, dropped by $950,000. “We came out at about $330,000 in the red because we were reducing the volume of care,” Dr. James said.
“I currently realize I get paid to harm my patients,” he admitted. “In the current system I am actively ﬁnancially encouraged to harm my patients. And I am ﬁnancially penalized when I help them by ﬁguring out a clever [new method].”
Carolyn Clancy, M.D., director of the AHRQ told legislators that the question the nation’s healthcare leaders should be asking themselves is not “What is quality?” but rather how they can improve quality. “The deﬁnition I like to use is the right care for the right patient at the right time every time. And unfortunately for our healthcare system right now, that’s a stretch goal. This is borne out every year in data from AHRQ’s National Healthcare Quality Report,” Dr. Clancy said.
“We’ve seen that healthcare overall has improved by 1.5 percent per year,” she said. “In most cases the pace [of improvement] is pretty glacial.” She agreed with Dr. James’ assessment of the nation’s reliance on a hurtful ﬁnancial model of care. “We’re still in an environment where many CEOs lie awake at night worrying about the ﬁnancial bottom line and not the quality bottom line, and for them there’s not yet an established link between the two,” Dr. Clancy said. “We very much need to establish and reinforce that link so that quality becomes the guiding line for all of healthcare.”
“Our infrastructure is pretty fragile. The processes are laborious and often not as effective as they should be,” she said. “We don’t make it easy to do the right thing. What we’ve seen is that it’s very easy to make measures, but it’s much harder to put them into practice.”
Opportunities for Improvement
Despite the systemic challenges in measurement and management, there are near-term opportunities for improving quality of care, Dr. Clancy said. The ﬁrst of those is in improving care for people with chronic illnesses. “Because of all of our successes in biomedical science, we now have increased dramatically life expectancy because we have effective treatments for diseases that were previously lethal and we’ve seen an increase in the proportion of Americans with chronic illnesses,” Dr. Clancy explained. “The quality reporting [has] been very effective at publicizing and motivating those processes that are under the direct control of a physician or a healthcare organization. It reminds [physicians] to order tests to check diabetes, blood pressure and so forth. Where we haven’t seen improvements is in the outcomes. Part of that is that the real improvement takes place after the patient leaves the ofﬁce. We need to make more effective partnerships between clinical care and community resources.”
The second near-term area of improvement s in healthcare for America’s children, Dr. Clancy said. The recent reauthorization of the State Children’s Health Insurance Program and the quality requirements contained within that bill provide an opportunity for federal agencies to begin tracking care quality for children. “Many low income children move frequently between Medicaid, CHIPP, private coverage and no coverage,” Dr. Clancy said. “We’re really excited about working closely with CMS, states, and all stakeholders [to track quality].”
The biggest opportunity for improvement, Dr. Clancy said, is in area of health disparities. “Every major report on quality has the same two major ﬁndings. It doesn’t matter under what conditions or where it was done,” Dr. Clancy declared. “The ﬁrst ﬁnding is a substantial gap between best possible care and actual care. The second ﬁnding is a larger gap between people of ethnic or minority groups, are poor, have low education, or live in remote or rural areas.”
The data and the ability to reduce those disparities exist and just need to be widely implemented. “The tools and data needed to improve quality can be used simultaneously to close those gaps. In some instances a focused approach to quality improvement has closed those gaps. In other areas we’re going to need to ﬁgure out how to close those gaps more effectively for those population subgroups,” she said.