Measuring Health Care

Using Quality Data for Operational, Financial, and Clinical Improvement

Yosef D. Dlugacz

• Publisher: Jossey-Bass
• Year: 2012
• Print ISBN:
  9780787983833
• eBook ISBN:
  9781118429877
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

This invaluable guide shows students and professionals how measurements and data can be used to balance quality services and financial viability and how measures can help to evaluate and improve organizational, clinical, and financial processes. The book explains the various performance measurement methods used in health care and shows their practical impact on clinical patient outcomes.

Chapter One

Overview

What Measures Measure

Imagine that hospital rankings have just been released in the local newspapers and made available on the Web. Members of the health care organization’s board of trustees begin calling its senior leadership and asking questions—hard questions, such as why wasn’t the hospital’s cardiac mortality rate the lowest in the state? They want to know what the problems are and what is being done to improve the situation. Chief executive officers (CEOs), senior leadership, and administrators often try to ignore the data and to assure the community that negative reports do not reflect what is actually happening in their hospital. They stress that their excellent, well-trained physicians and nurses are doing a great job. But this response is not always convincing in the face of the numbers.

Health care administrators, managers, policymakers, and executives are expected to have the information to respond intelligently to negative data. That’s part of their job. In order to respond, they need to be able to use broad enough brush strokes to create a high level of understanding, yet they must also offer enough specific detail to encompass the complexity of the questions—and the answers.

If, for example, the news media report a high infection rate in a hospital, what does that mean? In other words, what exactly is the measure infection rate measuring? Interpreting such measures for the general public can be a challenge for health care leaders because the data that describe complex medical phenomena may not be congruent with the assumption that there is a straightforward relationship between cause (treatment) and effect (outcome). To understand this infection rate measure, leadership should have information about whether the problem is limited to one hospital unit or is running rampant across many units, or whether the infection is connected to a single procedure, physician, staff member, operating room, or technological process. Perhaps the infection occurs only in patients who have been transferred from a specific nursing home or who live in a particular neighborhood. Data can reveal whether the infection rate has increased over time (and if so, by how much) and can identify the group of patients or staff involved. Data can expose how severe the infection is, where the cases are located (which department or unit in the hospital), how long the length of stay (LOS) is for those patients with the infection, and what costs are associated with their care.

The data to address these and many other questions are available through quality management and various other databases, and health care leaders need to acquire the familiarity and skill to interpret the data and must also be able to communicate about the issues with the clinical staff, the media, and the community.

The successful health care professional is committed to running an efficient organization, and that entails understanding data from quality indicators and measurements and how these data can be used to link clinical results and policy formation. Because most administrators are concerned with how to do damage control when the public reads about poor outcomes in the local newspapers, it is essential that they become familiar with the dynamics of care and position themselves to introduce changes that will improve the reports—and the care.

Recently I attended a meeting of the medical board of a small community hospital and spoke to two staff cardiologists who were understandably upset that they both had fared poorly on the mortality ranking published in their local newspaper. They said they were reluctant to go to the supermarket because people were asking them questions they couldn’t answer. These physicians didn’t know what was wrong with the care they delivered and in fact were convinced that their care was excellent and that the rankings were faulty.

The CEO of the hospital, also being questioned, didn’t know where to look for explanations of the high mortality. In such circumstances it is easy to make excuses: the coding was inaccurate; the patients were sicker than average, with complications; the physicians do great work but are too busy to document the charts and therefore the measure is a reflection merely of inaccurate paperwork and not the inadequate delivery of care. Excuses, which may calm some people in the supermarket, don’t take the measure seriously, or worse, they prevent leadership and physicians from analyzing their processes, the delivery of services, or the gaps in their care. This denial and blame mentality does not lead to self-criticism or self-improvement. Outcomes analysis, such as an examination of the reasons for a high mortality rate, requires data that can explain a clinical phenomenon, such as death. Data can help to determine whether the intervention (or lack of it) contributed to the mortality or whether the existing clinical and organizational environment is appropriate for preventing poor outcomes.

Familiarity and comfort with quality measures encourage leaders, administrators, and policymakers to understand important variables in clinical areas as well as in organizational processes. Measures can focus attention on potential problem areas; measures can specify small issues before they result in major incidents; measures can monitor improvements. Most important, measures provide a method of communication among medical staff and hospital administrators.

MEASURES AND THE MEDICAL STAFF

Paradoxically, the very physicians on whom a measure depends do not always feel obligated to meet the expectations of that measure. For example, the federal government, through the Centers for Medicare and Medicaid Services (CMS), has developed a measure that is based on evidence from research, clinical trials, and medical expertise showing that patients suffering heart attacks (technically referred to as acute myocardial infarctions, or AMIs) have a more positive outcome when they receive an aspirin (ASA) within four hours of coming to the emergency department (ED). The CMS collects the data about the rate of aspirin administration to AMI patients in order to monitor, and one hopes improve, patient outcomes. However, it is the physician who controls whether or not a patient is administered an aspirin, and it is the physician’s responsibility to document the medical record so that the CMS indicator can be aggregated for the hospital. Without physician acceptance the intent of this measure cannot be met.

The Centers for Medicare and Medicaid Services (CMS) is the governmental agency responsible for administering the Medicare program, and it also works with the states to administer Medicaid. In addition to providing health insurance, the CMS is involved in quality standards. State surveyors visit a number of health care organizations annually to determine compliance with CMS quality standards and to investigate complaints. The CMS contracts with medical organizations to ensure that the medical care paid for with Medicare funds is reasonable and necessary, meets professionally recognized standards, and is provided economically. The CMS is working to improve the quality of health care by measuring and improving outcomes of care, educating health care providers about quality improvement opportunities, and educating the public to make good health care choices.

Typically, administrators have relied on physicians to explain medical phenomena, and physicians have done so by discussing the characteristics of their patients’ illnesses. However, more and more research points to the realization that explanations for medical phenomena can be found in aggregated data about global process issues and not solely in the analysis of individual patient problems. Measurements that reflect aggregated processes of care objectively, as well as outcomes of that care, help physicians move past their own patients to understand how to improve outcomes and performance for all patients.

In other words, measures can be used by administrators and physicians to generalize across the patient population and to develop policies and make decisions based on aggregated data. Measures can provide a common language for physicians and administrators by interpreting objective variables. Through a shared language—that is, the measures—a hospital can be transformed from a collection of groups with specific and differing agendas to an integrated working team with similar goals.

MEASURES AND PATIENTS

Patients today are reacting to the media attention to medical errors and the dangers involved in hospitalization. Having been informed by such an august body as the Institute of Medicine (IOM), an independent organization of medical experts who study the health care industry, that almost 100,000 deaths occur unnecessarily every year in the United States due to medical mistakes, the public is scared, where once it was trusting. Reinforcing this fear, the Institute for Healthcare Improvement (IHI) has launched a campaign to save 100,000 lives by enlisting hospitals to commit to implementing changes in care that would avoid preventable deaths. Although this campaign is laudable, it underlines the lack of patient safety in hospitals and the fact that senior administrators seem unable to fix existing problems that affect patient safety.

People have begun to approach health care services in a new way—informed, suspicious, and eager to take responsibility for their own care. Patients ask questions of their physicians and of health care leaders as they have never done before. Today’s baby boomers are not about to settle for a patronizing pat on the head, and a leave-it-to-the-expert attitude that perhaps worked well in the world of their parents. Patients are eager to be well informed and to research solutions to their health care problems. They look further than their personal physicians for information. They find answers by examining the data available: how many procedures has a specific specialist performed; what was the mortality rate on those procedures, for the hospital and for the physician; how many disciplinary actions are recorded for the physician and how many malpractice claims? In addition, hospital and individual physician profiles are now available for public scrutiny. Public pressure is mounting, as can be seen by the increase in drug advertisements on television and in magazines, and by the technological innovations that patients demand as solutions to medical issues. These types of social forces shape organizational change.

The following selected Web sites provide information about health care services:

webapps.ama-assn.org/doctorfinder	Provides background information and achievements and certifications of physicians
bestdoctors.com	Offers peer review of physicians who have met standards of care
compareyourcare.org	Rates quality of care with national guidelines
healthfinder.gov	Provides ratings of hospitals and nursing homes
healthgrades.com	Ranks physicians, hospitals, and nursing homes
jcaho.org	Presents comparison information for health care organizations
leapfroggroup.org	Reports on and compares hospital quality outcomes
ncqa.org	Ranks health plans, including information about their performance
qualitymeasures.ahrq.gov	Compares quality measures across institutions
ratemds.com	Provides patients’ ratings of doctors

Responding to the needs and interests of the modern patient, the state and federal governments are providing the public with research-based information about appropriate disease management (evidence-based medicine) and making available algorithms of care—what should be done, when, why, and to whom. Patients are encouraged to partner in their health care decisions, to get second opinions, and to learn the details of appropriate expectations through informed consent forms that describe the risks and benefits of procedures. It is insufficient to provide patients with excellent, hotel-like services (as many institutions are now doing to try to bolster their patient satisfaction rates); the hospital must also be able to report good patient outcomes.

MEASURES AND HEALTH CARE LEADERS

In order to meet the new challenges head-on, today’s health care professionals need to equip themselves to evaluate the product delivered in their organization. Through using measures an organization can prove that its product is good, reassuring the public about safety and thus maximizing revenue. Achieving this goal requires an understanding of how to measure, what to measure, how to interpret measures, and how to monitor care through measures on an ongoing basis. Most important, information from the analysis of measures should be applied to improve the delivery of care and increase patient safety.

For example, how would you, as a senior administrator, respond if the chief finance officer reports that the intensive care units (ICUs) are costing the hospital a fortune and should be reevaluated? What criteria should be used to make improvements and change practices? The physicians will tell you their patients need to be in an ICU because they require specialized care. Are they right? How would a nonclinician evaluate what the physicians say? Have standards been established for admission to the unit? Are there other units in the hospital that might be as appropriate for caregiving? Most important, are there any data to support the physicians’ stance, or are any data available to indicate that expensive ICU care may not improve the health and well-being of their patients?

Of course health care managers and administrators are in no position to argue medical care with physicians. But they can put themselves in a position to understand utilization issues, to document the patient population, to develop policies about end-of-life care, to track the relationship between processes and outcomes, and to evaluate how money is being spent. If an administrator has data that show that the ICU is not necessary for patients to receive appropriate care, that the outcomes are the same in less resource-intensive units, that, for example, it is unnecessary for patients to be in an ICU while awaiting a stress test that could be administered in a physician’s office, physicians and the governing body will take notice. Availability of da...

Table of contents

• Cover
• Contents
• Title
• Copyright
• Dedication
• Figures and Tables
• Preface
• Acknowledgments
• The Author
• Introduction
• Chapter One: Overview
• Chapter Two: Fundamentals of Data
• Chapter Three: Using Data to Improve Organizational Processes
• Chapter Four: What to Measure—and Why
• Chapter Five: Promoting Accountability Through Measurements
• Chapter Six: The Rationale for External Drivers of Quality
• Chapter Seven: Integrating Data for Operational Success
• Chapter Eight: Internal Drivers of Quality
• Chapter Nine: Using Data for Performance Improvement
• Conclusion
• Bibliography
• Index