We know that measuring healthcare quality helps healthcare systems improve. But we could and should be doing it a lot better.
The way we measure quality in healthcare is pretty darn primitive. Even how we think about what constitutes quality is flawed. Just look at the examples I've been compiling and tell me I'm wrong. You may share your own observations in the comments below. Or email me directly.
Part I covers items 1 –6 on my list. Here are the rest:
7. Quality Measures Come and Go
What we call a legitimate measure for payment or reporting is usually endorsed by a long negotiated process within the National Quality Forum, a 14-year old organization contracted by CMS to come up with valid ways to measure quality in most healthcare settings. But 15% of the 700 or so measures used today have not received NQF endorsement.
What's more, the number of measures that receive its imprimatur changes drastically. According to Robert Panzer, MD, chief quality officer and associate vice president for the University of Rochester Medical Center in Rochester, NY, in the last year, NQF withdrew endorsement for more than 100 of its endorsed measures, and added another 90.
The NQF process is largely hidden from public view. How do hospitals keep up with all this?
8. We Look Only Where the Light Is
Measures force hospital teams to put their resources into improving what is paid or penalized, and ignore other parts of their operations that may cry for attention.
According to Panzer and colleagues, "the total of the current and planned measures from different sources can be overwhelming, hence, the sense some organizations leaders have of excessive and potentially overwhelming measurement and reporting requirements."
Mandates may "crowd out" initiatives that would have more relevance for a particular institution's patients, staff and leadership, they add.
"For example, a hospital may internally detect problems with the safety of transitions in care and be unable to focus sufficient attention to this important patient safety issue, due to the volume of other measures to which they must direct their attention."
9. Variables are Inconsistent
I've learned from hospital leaders that healthcare quality measurement is a tower of Babel. The point at which one hospital reports an infection or a severe pressure ulcer, may vary depending on the organization.
I've heard that for some surgeons, a retained surgical object is not declared a serious adverse event if the patient is still under anesthesia when the lost object is identified and if the surgical wound can be reopened in the same surgical session without the patient being the wiser.
For others, the instance would be counted and reported.
10. Poor Competence is Hidden
Knowledge of poor provider competency, especially among surgeons, is well known among medical staff, operating room nurses and techs. Yet it's unclear whether most, or even if, any hospitals have a system to curtail that physician's practice until remedial training shows sufficient improvement.
On the contrary, the usual course of business is to stay quiet, and let malpractice insurers and lawsuits weed out the inadequate providers, eventually. The reason: There's fear the poor performer might file a claim against colleagues claiming restraint of trade.
11. There are Too Many Measures
How many is too many? Let me start counting them. There are measures under the Patient Protection and Affordable Care Act that carry financial penalties that eventually will total as much as 6% of a hospital's federal reimbursement. There are private registry measures and federal measures to obtain meaningful use incentive payments.
There are pay-for-reporting measures, emergency department speed-of-care measures, surgical measures, and process measures. There are private measures from third party non-profit organizations that rank structural improvement initiatives, such as computerized physician order entry systems.
Panzer and colleagues sum up their findings by saying that "although the current state of healthcare is, on occasion, disorganized, inefficient, confusing and misleading, it is better now than prior to the Institute of Medicine's reports To Err Is Human and Crossing the Quality Chasm, when many incorrectly assumed that patients were uniformly safe and care delivery was always efficient and reliable."
If that's true, and things are better, the fact that we now measure such things is certainly the reason. But we need to get much better at it, in a way that people can understand.