Fewer Quality Metrics, More Infection Preventionists, Less Harm

Indiana University Health system has cut the metrics used to measure quality of care in its facilities from 199 to just 10. They are seeing successive monthly declines in preventable harm.

How many quality measures is too many? At what point does a healthcare organization's quest for performance improvement yield diminishing returns?

While many healthcare organizations have begun to refine the way they approach quality, the specifics depend on what matters to populations of patients and those providing their care, according to Jonathan E. Gottlieb, MD, chief medical executive for Indiana University Health system.

About a year and a half ago, Gottlieb overhauled the way IU Health measures its quality of care in its facilities, cutting the metrics used to measure it from 199 to just 10.

This past January, the team similarly whittled its priorities for population health, focusing now on just four "utilization" population health metrics and another eight related to quality of care.

Gottlieb spoke with me recently about how a tighter focus on quality has reduced preventable harms.  The following transcript has been lightly edited.

HLM: How did you go about honing down these metrics?

Gottlieb: We began by asking our physician leaders, nursing leaders, and quality leaders to reflect on which measures were most meaningful to their family and friends receiving care, which would be enduring even as payment mechanisms came and went.

HLM: What kinds of tools have you given clinicians to help them improve?

Gottlieb: The best resources we have are our experts in infection prevention, which include both nurses and physicians. Their expertise, combined with sophisticated information systems, help us figure out how to reduce infections.

Without the help of the infection preventionists, it's very hard for a physician to determine that an outbreak might be related to a particular operating room, for example, or a piece of equipment.

HLM: What are your results?

Gottlieb: They are improving. Our targets are to reduce our preventable harm by 20% year over year. For the last four months, we've seen four months of successive decline.

HLM: Do you think you'll need to evolve your approach over time?

Gottlieb: Yes, in the next phase we're going to have to combine these general enduring metrics with a little more specificity. A patient who needs a knee replacement, for example, probably isn't looking at CAUTI [catheter associated urinary tract infection] rates.

And that will be something we'll need to balance because we don't want to balloon up to hundreds or thousands of metrics again.

We have formal safety and quality meetings quarterly. I think our focus has helped our leaders and clinicians look at the right things and not get distracted every time a CMS rule changes or a metric is added that we need to report.

We still report those, but we're not asking every frontline clinician to all of a sudden change their focus.

HLM: How will MACRA implementation affect your strategy for population health?

Gottlieb: The good news is that our enduring metrics are for the most part pretty aligned, so it's not as though we're reinventing something. I think we're mostly editing and focusing on the core metrics.

With MACRA, we are looking to participate in an ACO model.

For parts of our organization that doesn't apply, we'll participate with MIPS and look for maximum overlap and coordination between the metrics that we think are near and dear to the hearts of our patients and those that satisfy regulatory requirements.