If you have ever tried to choose a physician or hospital based on publicly available performance measures, you may have felt overwhelmed and confused by what you found online. The Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the Joint Commission, the Leapfrog Group, and the National Committee for Quality Assurance, as well as most states and for-profit companies such as Healthgrades and U.S. News and World Report, all offer various measures, ratings, rankings and report cards. Hospitals are even generating their own measures and posting their performance on their websites, typically without validation of their methodology or data.
The value and validity of these measures varies greatly, though their accuracy is rarely publically reported. Even when methodologies are transparent, clinicians, insurers, government agencies and others frequently disagree on whether a measure accurately indicates the quality of care. Some companies’ methods are proprietary and, unlike many other publicly available measures, have not been reviewed by the National Quality Forum, a public-private organization that endorses quality measures.
Depending where you look, you often get a different story about the quality of care at a given institution. For example, none of the 17 hospitals listed in U.S. News and World Report’s “Best Hospitals Honor Roll” were identified by the Joint Commission as top performers in its 2010 list of institutions that received a composite score of at least 95 percent on key process measures. In a recent policy paper, Robert Berenson, a fellow at the Urban Institute, Harlan Krumholz, of the Robert Wood Johnson Foundation, and I called for dramatic change in measurement. (Thanks to The Health Care Blog for highlighting this analysis recently.)
We made several recommendations, including focusing more on measuring outcomes such as mortality and infections rather than processes (e.g. whether patients received the recommended treatment) or structures of care (e.g. whether ICUs are staffed around the clock with critical care specialists). We urged that measures be at the organization level rather than clinician level, to reflect the fact that safety and quality are as much products of care delivery systems as of individual clinicians. We propose investments in the “basic science” of measurement so that we better understand how to design good measures. You can read these and other recommendations in the analysis.
Of the proposals, perhaps the biggest game-changer would be the creation of an entity to serve as the health care equivalent of the U.S. Securities and Exchange Commission. Rather than wading through a bevy of competing and often contradictory measures, patients and others would have one source of quality data that has national consensus behind it. We write:
“Under this model, this entity would set the rules for the development of measures and the transparent reporting of performance of these measures, analyze progress (with input from clinicians, patients, employers, and insurers), and audit publicly-reported quality measure data. Private sector information brokers could then conduct secondary analyses of the reports, much like happens in the financial industry through companies like Bloomberg. This SEC-like model would thus ensure that all publicly-reported quality measure data are generated from a common basis in fact and allow apples-to-apples comparisons across provider organizations.”
Before the SEC was created, in the aftermath of the Wall Street Crash of 1929, information provided by one business typically could not be compared to another, as there were no common standards for reporting financial performance. It’s more than 80 years since then, and health care is stuck in a similar situation, despite great efforts to create measures to drive improvement and inform patients’ decisions. It’s time that we catch up. A SEC-like entity could have private sector rule-setting, public sector auditing and transparency, and private sector reanalysis, working from a common book of truth.
Advancing the science of measurement is one of three content tracks in Johns Hopkins’ first Forum on Emerging Topics in Patient Safety, to be held Sept. 23-25 in Baltimore. Experts from a wide range of backgrounds will gather to help generate ideas around this crucial issue. Among the speakers on this track are Patrick Conway, Chief Medical Officer for the Centers for Medicare and Medicaid Services; John Santa, Director of the Consumer Reports Health Ratings Center; Niek Klazinga, Coordinator of the Health Care Quality Indicator Project at the Organisation for Economic Co-operation and Development; and Robert Berenson of the Urban Institute. Aimee Guidera, founder of the Data Quality Campaign, which has encouraged the creation and use of high-quality data in education, will provide perspectives from her field that may translate to health care. If you are interested in this topic and would like to contribute to the recommendations that come from the forum, please join us in September.
Director of the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Peter Pronovost, MD, PhD is a practicing anesthesiologist and critical care physician who is dedicated to making hospitals and health care safer for patients. Pronovost has chronicled his work in his book, Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out. His posts appear occasionally on THCB and on his own blog, Points from Pronovost.
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This is brilliant, this is necessary, I and others have talked about this for years: Standardized, published outcome measures. Of course, they need to be carefully selected. We need continuing study of the science of measurement in healthcare. But they are very necessary, especially if combined with pricing transparency, so that, put simply, whoever the true “buyer” is in a given situation (employer, insurer, government, patient), they can have a pretty good idea what they are getting for their money.
No, it would not work out like “No Child Left Behind.” There, the outcomes are test scores, which are supposed to stand in for the true goals: the all-around education and development of children.
In healthcare, we can measure the true goals against acuity and the general health of a population: How many of your patients die? How many are re-admitted? How many diabetes patients in your care end up blind or needing amputations? These are not stand ins for outcomes, they are the outcomes. If standardized measurement results in the people who run healthcare “obsessing over” getting the best possible outcomes for the lowest possible cost, that is completely fine with me. What would you rather have them “obsessing over?”
Great idea Dr. Pronovost. I believe that this was first suggested by Dr. Regina Herzlinger of the HBS (who coined the term ‘Consumer Driven Healthcare’). Let us make certain, however, that this entity is wholly separate from the CMS so as not to cloud the picture of the reporting agency that you propose.
In regards to Rob’s comment above…I get that concern completely. What we we need to do in addition to instituting Dr. Pronovost’s innovative idea on transparency in healthcare is that we need to forego our tired model of 3rd-party middleman-controlled healthcare.
This near 50 year old & broken model using 3rd party intermediaries (gov’t, insurers) ruins any chance of a virtuous cycle developing between the recipients of care (us patients) and the providers of care (us doctors). Thus, no one is paying attention to costs and there is no financial benefit or incentive for patients to engage in healthy behaviors. Instead of win-win healthcare we have lose-win-lose healthcare with the only winners being the middlemen. All boats are not rising by whatever measure we want to choose: our health (obesity, diabetes, etc.), our costs, virtually any public health measure.
We need to give Americans control of where they spend their health care dollars and the industry will change dramatically.
What I am suggesting is also what Regina has recommended for years: consumer-driven healthcare.
It is no coincidence that the two most competitive economies in the world utilize such a model, Singapore and Switzerland. America should too.
This would make the healthcare industry much more efficient and focused on the right payer; the patient.
Could not agree more: in economic terms, US health care is one of the most ‘inefficient markets’ ever seen. The recent NYT colonoscopy article was illustrative: http://www.nytimes.com/2013/06/02/health/colonoscopies-explain-why-us-leads-the-world-in-health-expenditures.html?hp
Among the ‘bad behavior’ described:
– Lack of cost and pricing transparency
– Lack of performance / outcomes / quality data
– Indiscriminate consumers / patients
– Indiscriminate providers / doctors
– Indiscriminate payers / insurers
No wonder it’s such a mess, but change is in the air (if my recent attendance at Datapalooza was any indication)!
This seems pretty spot on to me, Dr. Pronovost. As patients increasingly expect to be included in their own medical decisions, plans of care, etc., they’ll need a clearinghouse to get accurate, fair information.
I plan to read your paper later, so forgive me if this is a question you answered there previously, but how would this Health SEC treat differences in patient population? Previously, I worked at Stanford Hospital and the University of Mississippi Medical Center, and comparing outcome measures between the two would be like comparing apples to… poorer, less healthy apples. Would the Health SEC set measures, or would it leave this issue for the private sector Bloomberg-ites that pop up?
While I am not against the idea entirely, I think about other areas where “quality” was measured. The most notorious of this is in childhood education. The “No Child Left Behind” legislature created a culture of slavish attention to test results to the detriment of children. I do see measurement as important, even in childhood education, but it is not a means to reform. Measuring quality and reporting it causes focus on metrics, not process. When the problem is in the process (which it clearly is in health care and in education), measurement often draws attention even further away from the dysfunction that creates the problems.
Choice of metrics and method of reporting is critical to this. If you get too granular (like they did with education), they do more bad than good. The other risk is that folks with agendas will get hold of metrics and use them to their own end (such as the pushing for PSA testing by urology groups in the past).
Again, I am not against measurement, I am just very, very wary of it as a means to any significant end.
Yes, I think the time has clearly come for someone to do something, and this may in fact be it. The idea of a SEC for healthcare may sound ridiculous but only to outside observers.
If you know anything about the changes on the ground in healthcare over the last few years, you know how much trouble well-intended initiatives have been causing. It doesn’t take much imagination to see that we’re headed for real problems (read: woe, conflict and confusion) if we build an elaborate system on a science that isn’t actually a science …
Measurement has become a management and tech industry and government buzzword, largely because the concept sounds very forward-thinking and precise. The problem is that isn’t. And won’t be until we start doing a better job of measuring things. And that’s not going to happen until some order is imposed. Maybe what we REALLY need is an SEC for Science.
Frankly, while it may be theoretically attractive to have a single entity to serve as the quality regulator, equating health care to stocks is off base. Ensuring appropriate accounting procedures and fairness in trading is one thing, but applying this same model to health care, where there are very legitimate variations in ways in which quality can be measured is quite a different proposition. This sounds like one more added layer of bureaucratic and regulatory nonsense. While the current system may be sub-optimal, concentrating even more power in the hands of a few is not the right answer.
I believe you and Berenson are on the right track. It will be easy for health care providers to oppose a health care-oriented SEC as more bureaucracy, etc, but the truth is they like the current chaos in evaluations as it allows arguments over methodology to supersede improvements in the delivery of care. This is something that both parties should embrace, if they genuinely care about improving quality and controlling costs.