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Tag: Quality

Rethinking the Provider Certification Game

Quality is the new watchword in healthcare; it’s what we seek – and increasingly, what we try to measure.  Medications, devices, care delivery, hospital services – all are now scrutinized as we seek to gauge their benefit, and justify their cost.

The idea of using metrics to evaluate quality make sense, but only if we can trust the metrics themselves.  Otherwise, we risk becoming party to an updated version of craniometry, systematized false-precision that focuses on easily-measurable parameters (such as head circumference) that may not represent meaningful proxies for the assessments we’re really after (i.e. intelligence).

The good news is that the science of testing, of developing evaluation instruments, has improved over time.  We’re now better able to recognize the qualities and properties of good tests – and to identify where they’re likely to fall short.

We’re also getting more comfortable with demanding robust evaluation instruments.  For example, the FDA’s approach to patient-reported outcomes places exceptional (and appropriate) emphasis on the assessment tool chosen, and requires that it demonstrates the appropriate properties before relying on its results.

Unfortunately, one critically important area within our healthcare system that seems to have escaped such careful review is the way the competence of care providers is typically assessed and certified.

Whether you are an X-ray technician, a physical therapist, a registered nurse, or a transplant surgeon, you are required to pass through a gauntlet of costly certification exams.  These tests, already significant, are assuming an even greater importance as the healthcare system increasingly looks to them as proxies for quality.  Certification can be required for employment and for admission privileges, and frequently impacts the reimbursement rate for healthcare providers.

All this makes complete sense – provided the certification tests themselves are sound.

Unfortunately, the world of healthcare worker certification remains a bit like the wild west, as medical organizations and professional societies approach certification testing with profoundly different degrees of rigor — and generally little-to-no transparency.

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Why Do Academic Medical Centers Do Poorly on Quality Report Cards?

In September 2012, the Joint Commission recognized 620 hospitals (about 18% of the total number of accredited American hospitals) as “top performers,” but many were surprised when some of the biggest names in academic medical centers failed to make the cut.  Johns Hopkins, Massachusetts General Hospital, and the Cleveland Clinic (perennial winners in the US News & World Report best hospital competition) did not qualify when the Joint Commission based their ranking not on reputation but on specific actions that “add up to millions of opportunities ‘to provide the right care to the patients at American hospitals.’”

The gap between the perceived reputation of America’s “best” hospitals and medical schools and their performance on an evidence-based medicine report card provides an interesting lens through which to understand the role and performance of America’s academic medical centers in the 21stcentury.

The most pressing challenge for American medicine has been summarized in the triple aim:  how to cut the per-capita cost of healthcare, how to increase the quality and experience of the care for the patient, and how to improve the health and wellness of specific populations.

Can we expect academic medical centers to lead the country in meeting the challenge?  If history is any guide, the answer may be no.  In a 2001 article titled “Improving the Quality of Health Care:  Who Will Lead?” the authors write:

“We see few signs that academic medical leaders are prepared to expend much effect on health care issues outside the realms of biomedical research and medical education.  They exerted little leadership in what may arguably be characterized as the most important health policy debates of the past thirty years:  tobacco control, health care cost containment, and universal access.”

Having been a professor at several medical schools (UCSF, University of Iowa, Allegheny University of the Health Sciences, and Michigan State), I learned early on that the key to academic advancement was NIH funded basic science research.  While lip service was paid to the ideal triple threat professor (great clinician, superb teacher, and peer reviewed published investigator), the results of the tenure process clearly resulted in a culture where funded research counted far more than teaching and clinical care delivery.

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Waste Not

In some ways, the Insititute of Medicine is like the famed “Academy” of Motion Picture Arts & Sciences. Having membership conferred is the ultimate accolade in a field full of brains, competition, money, and ego. A major difference is that the IOM doesn’t give out annual awards for best studies or best theories–the whole institute is comprised of lifetime achievement award winners.

That’s why when the IOM issues a report, it garners a lot of attention.

Their most recent, “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America” attracted the usual spate of headlines:

I’ve looked over the report–it’s been released in ‘pre-publication’ form on their website, and you can read the whole thing. It’s a worth a click over, because even if you can’t slog through 350+ pages, they’ve made several executive summary features (including a top ten list) andgraphics that do a great job of conveying the authors’ findings and recommendations. A few things jumped out at me:

  • $750 billion of our collective annual $2.3 trillion health care outlay does not improve health
  • we still have far too many errors in hospitals
  • too many patients discharged from hospitals are readmitted in less than a month (20%!)
  • which points to the lousy job we do ‘transitioning’ people from hospital to home
  • communication amongst medical personnel is abysmal

The report uses analogies from many industries. There’s the requisite comparison to aviation, since the safety record of commercial airlines is enviable. But there are also comparisons to hotels, manufacturing, general contractors, engineers, and even ‘mission control’ at NASA. [Health care does not compare favorably to NASA. Doctors should, but are not working for a common purpose like getting people to the moon.]

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Asking the Wrong Questions About the Electronic Health Record

The wrong question always produces an irrelevant answer, no matter how well-crafted that answer might be.  Unfortunately the debate on health information technology seems to be increasingly focused on the wrong question.  An Op-Ed in the Wall Street Journal argues that we have had a “Major Glitch” in the use of electronic health records (EHRs).  This follows on a series of recent studies that have asked the question “do EHRs save money?” Or “do EHRs improve quality?” with mixed results.

While the detractors point to the systematic review from McMaster, boosters point to the comprehensive review published in Health Affairs that found that 92% of Health IT studies showed some clinical or financial benefit. The debate, and the lack of a clear answer, have led some to argue that the federal investment of nearly $30 billion for health IT isn’t worth it.  The problem is that the WSJ piece, and the studies it points to, are asking the wrong question.  The right question is:  How do we ensure that EHRs help improve quality and reduce healthcare costs?

The fundamental issue is that our healthcare system is broken – our costs are too high and the quality is variable and often inadequate.  Paper-based records are part of the problem, creating a system where prescriptions are illegible, the system offers no guidance or feedback to clinicians, and there is little ability to avoid duplication of tests because the results from prior tests are never available.  Even more importantly, the paper-based world hampers improvement because it makes it hard to create a learning environment.  I have met lots of skeptics of today’s health information technology systems but I have not yet met many physicians who say they prefer practicing using paper-based records.

The problem is that some Health IT boosters over-hyped EHRs.  They argued that simply installing EHRs will transform healthcare, improve quality, save money, solve the national debt crisis, and bring about world peace.  We are shocked to discover it hasn’t happened – and it won’t in the current healthcare system.

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Getting the Right Benchmarks For Stroke Care

Late last week, thanks to Liz Kowalczyk (@globeLizK) of the Boston Globe, I discovered the statewide report on quality of stroke care in Massachusetts.  It’s a plain document, mostly in black and white, much of what you might expect from a state government report.  Yet, this 4-page document is a reminder of how we have come to accept mediocrity as the standard in our healthcare delivery system.

The report is about 1,082 men and women in Massachusetts unfortunate enough to have a stroke but lucky (or vigilant) enough to get to one of the 69 Massachusetts hospitals designated as Primary Stroke Service (PSS) in a timely fashion. Indeed, all these patients arrived within 2 hours of onset of symptoms and none had a contradiction to IV-tPA, a powerful “clot busting” drug that has been known to dramatically improve outcomes in patients with ischemic stroke, a condition in which a blood clot is cutting off blood supply to the brain.  For many patient-ts, t-PA is the difference between living a highly functional life versus being debilitated and spending the rest of their lives in a nursing home.  There are very few things we do in medicine where minutes count – and tPA for stroke is one of them.

So what does this report tell us?  That during 2009-2010, patients who showed up to the ER in time to get this life-altering drug received in 83.3% of the time.  Most of us who study “quality of care” look at that number and think – well, that’s pretty good.  It surely could have been worse.

Pretty good?  Could have been worse?  Take a step back for a moment:  if your parent or spouse was having a stroke (horrible clot lodged in brain, killing brain cells by the minute) – you recognized it right away, called 911, and got your loved one to a Primary Stroke Service hospital in a fabulously short period of time, are you happy with a 1 in 5 chance that they won’t get the one life-altering drug we know works?  Only 1 in 5 chance that they might spend their life in a nursing home instead of coming home?  Is “pretty good” good enough for your loved one?

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What Business Can Learn From Cleveland Clinic: How To Report Quality To The Public

This summer I spent some time exploring how big teaching hospitals publicly report clinical outcomes to the public. For a given set of patients, how many live or die? And with what complications?

Patients can rarely find this information before getting elective surgery, or when deciding to commit to a given institution for a long-term course of treatment.

The problem is that right now there are few short-term incentives for hospitals to be transparent  to the public. Patients are used to finding care based on proximity, word-of-mouth, and referrals from trusted physicians. (None of these are bad methods, by the way.)

Meanwhile insurers and public programs rarely pay for better outcomes, so they do not build networks that steer patients to quality. Paternalism pervades the entire system, where insurers and providers alike do not trust patients to shop for the best care.

Thus it is only the most long-term focused institutions that decide to become radically transparent. And there’s one that stands out above the rest: Cleveland Clinic.

The Ohio institution is already known for excellent care, especially in cardiology, for being a “well-oiled machine”, and for being an economic bright spot in the otherwise dreary environs of Cuyahoga County. (Sorry, as  Pittsburgher it’s hard for me to say nice things about the Mistake By The Lake.)

But something else Cleveland Clinic should be known for is its public outcomes reporting. Every year since at least 2005 Cleveland Clinic has published Outcomes Books on its Web site. For each clinical category it releases data on mortality, complication rates, and patient satisfaction. It also mails paper copies of these books to specialists around the country as a kind of transparency-marketing. No other hospital system comes close to reporting this level of detail about the quality of its care.

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Health Care Innovations Hiding in Plain Sight

While the nation has been focused on the recent Supreme Court ruling on the Affordable Care Act, innovations in hospitals and physician practices far from Capitol Hill have been triggering an historic transformation of our health care system. Propelled by a mix of urgency and vision, innovators at hospitals, physician groups and companies are remaking American health care by demonstrating that more effective and affordable care is achievable quite apart from statutory changes in Washington.

These organizations are working to achieve the Triple Aim: improve the health of the population; enhance the patient experience of care (including quality, access, and reliability); and reduce, or at least control, the per capita cost of care. This approach, developed by the Institute for Healthcare Improvement, is a sharp break with the traditional focus on single encounters with patients within the strict walls of health care delivery, typically addressing only the most immediate problems.
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A Tale of Two Systems

It was the worst of systems. It was the worst of systems.

For decades, policy analysts have debated how we to strike a proper balance among access, quality and cost in our healthcare system. This debate has missed a crucial point: we do not have one healthcare system, we have two. And both are broken. Fortunately, if we fix one the other may heal itself.

The first system is the one that we encounter when we seek treatment for an illness. This system defines how much we pay out of pocket, which depends which providers we seek and what treatments they deliver. This system also defines how much our providers are paid, including rewards for exceptional quality and penalties for substandard quality. Historically, patients have relied on their physicians to guide them through the complexities of this system. In recent years, supporters of consumer-driven healthcare have argued for a bigger role for patients. They make the important point that patients will never make a serious effort to balance access and quality against cost unless they are responsible for all three.

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Profits, Quality, and U.S. Hospitals

The recent articles in the New York Times about the Hospital Corporation of America (HCA) have once again raised important questions about the role of for-profit hospitals in the U.S. healthcare system.  For-profits make up about 20% of all hospitals and many of them are part of large chains (such as HCA). Critics of for-profit hospitals have argued that these institutions sacrifice good patient care in their search for better financial returns.  Supporters argue that there is little evidence that their behavior differs substantially from non-profit institutions or that their care is meaningfully worse.

To me, this is essentially an empirical question. Yet, I read the through the articles, I was struck by the dearth of data provided on the quality of care at these hospitals.  Based on the comments that followed the stories, it was clear that many readers came away thinking that these hospitals had sacrificed quality in order to maximize profits.  Here, I thought an ounce of evidence might be helpful.

Measuring quality:

There is no perfect way to measure the quality of a hospital.  However, the science of quality measurement has made huge progress over the past decade.  There is increasing consensus around a set of metrics, many of which are now publicly reported by the government and even are part of pay-for-performance schemes.  While one can criticize every one of these metrics as imperfect, taken together, they paint a relatively good, broad picture of the quality of care in an institution.  We focused on five metrics with widespread acceptance:

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To Gauge Hospital Quality, Patients Deserve More Outcome Measures

Patients, providers and the public have much to celebrate. Recently, the Centers for Medicare and Medicaid Services’ Hospital Compare website added central line-associated bloodstream infections in intensive care units to its list of publicly reported quality of care measures for individual hospitals.

Why is this so important? There is universal support for the idea that the U.S. health care system should pay for value rather than volume, for the results we achieve rather than efforts we make. Health care needs outcome measures for the thousands of procedures and diagnoses that patients encounter. Yet we have few such measures and instead must gauge quality by looking to other public data, such as process of care measures (whether patients received therapies shown to improve outcomes) and results of patient surveys rating their hospital experiences.

Unfortunately, we lack a national approach to producing the large number of valid, reliable outcome measures that patients deserve. This is no easy task. Developing these measures is challenging and requires investments that haven’t yet been made.

The addition of bloodstream infections data is a huge step forward. These potentially lethal complications, measured using Centers for Disease Control and Prevention’s methods, are among the most accurately measured outcomes. In addition, the science of how to significantly reduce these infections is mature, and hundreds of hospitals of all types and sizes have nearly eliminated them. A program to reduce these infections that started at Johns Hopkins Hospital was spread throughout Michigan, and is now being implemented throughout the U.S., demonstrating substantial reductions.

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