Study: Public reporting gaining 'long overdue respect' for quality managers
Solid data are best way to obtain resources
If you were frustrated by a lack of compliance with core measure requirements by medical staff members, would your hospital's CEO get involved? In general, do you feel you are getting more respect from clinical staff?
Public reporting of quality data has given quality professionals more power and attention in myriad ways, according to a new study. Quality professionals surveyed reported explicit inclusion of quality improvement priorities in the hospital's formal strategic planning, and hospital leadership accepting defined responsibilities for reviewing performance data.1
There is no question that public reporting has helped quality professionals, says Jon Rahman, MD, chief medical officer at St. Vincent Health, part of the Ascension Health System, which has 16 facilities throughout central Indiana. "Over the last three years, there has been a tremendous change, both in the board rooms and with senior leadership and management, on the issue of patient safety," says Rahman. "Obviously we're all interested in quality outcomes. The national awareness has been a real help to us."
Interestingly, half of quality officers reported that it was "easier to lobby management for resources," but respondents also said that resources were not adequate. There is growing evidence, however, that quality professionals have more power to obtain resources than they may realize. "The national focus on quality reporting certainly means that there will be a long-term mandate for hospitals to invest in their kind of expertise," says Hoangmai H. Pham, MD, MPH, the study's lead author and senior health researcher at the Washington, D.C.-based Center for Studying Health System Change.
"This is great professionally, as long as it's backed up with adequate resources to get the job done — and as long as the job is manageable and facilitates true quality improvement, rather than getting in the way," she says.
Overall, researchers noticed a sea change in the way quality is viewed by organizations. "We got the distinct impression that quality leaders were finally starting to enjoy long overdue respect from clinical staff," Pham reports.
Clearly, quality professionals are leveraging reporting requirements to demand more resources. "But the reality is that, though reporting and QI have become higher priorities for hospital leadership, hospitals still only spend a miniscule proportion of the operating budget on these activities, compared to say, facility expansions or marketing new specialty service lines," says Pham.
However, one could argue about whether they should spend more, since there is no compelling evidence that individual or combinations of reporting programs improve quality, adds Pham.
Several of the quality professionals surveyed said that they simply pointed out to their CEOs and boards that they couldn't guarantee accurate reporting to the Centers for Medicare & Medicaid Services (CMS) without more staff to collect and process the data. "Usually, citing CMS was the most effective mechanism, because of the payment leverage," says Pham. "They got more resources, but not many of them thought they got enough resources."
Senior leaders champion quality
Quality reporting has always been a part of the quality professional's job, but what has dramatically changed over the past 10 years is the amount of data being asked for by a large number of different sources, says Jan Brewer, PhD, RN, director of quality improvement at Mission Hospital in Mission Viejo, CA. "Often, the data are similar but have enough differences that 75% of the work must be repeated on each of the databases," she says.
Quality professionals have had to seek out electronic means to gather the data, but the majority of the data still are collected by a hand review of charts, says Brewer. "The requesting sources do not seem to be aware of how much time is involved to gather this data," she says. "They are also not cognizant of how much time is required to analyze and format the data for reporting. A major challenge is to use the data in a meaningful way to make care better."
A major stumbling block is that quality is not viewed as direct patient care. When streamlining and efficiencies are being looked at, therefore, one of the first areas considered is the quality department. "Senior leadership has to be a champion for quality, not only for it to function well but to thrive," she says. "The needs and requirements for data continue to grow, and the need for resources grows at the same time."
The reality, however, is that at the same time data collection loads are constantly increasing, hospitals also are challenged to be fiscally responsible, Brewer notes. When she realized that an additional FTE was needed to comply with data collection requirements created by California's CHART Initiative and CMS, she set about compiling data to clearly demonstrate this need.
First, Brewer quantified the time required to gather, review, and input data per patient chart. Next, she analyzed all the different requirements for each of the databases the organization reports to and placed all the resources required in a grid format. "Now, when new databases come forward, we can estimate how many patients will be needed, the time required to gather and enter data, and put a resource 'price tag' on the database," says Brewer. For example, the average time per chart for a typical database is one hour. If 200 patients are required, then 200 hours of work will be required.
Once Brewer had this data, she was able to make her case to administrators and add an additional FTE to the quality/outcomes team. "I showed the executive team how much it costs — not in money, but in time," she says. "Senior leadership responded to the analysis and allowed a new full-time person to be added to the department."
As for compliance, senior leadership involvement from both administrative and medical leadership are critical, says Brewer. At Mission Hospital, physicians have championed various causes for better compliance with quality indicators. For example, one chairman sent personal letters to physicians who were not compliant with orthopedics surgical antibiotics start and stop times. "We'd been challenged by that for years," says Brewer. "Physicians would tell us that was not their standard of practice, and they had practiced for 25 years with good results."
The chairman followed up with face-to-face meetings for the two or three physicians who remained outliers, and compliance improved. To address medication reconciliation, another physician attended all the major medical staff executive meetings to explain the importance of this process. "Another physician is championing the [Surgical Care Improvement Project] indicators, and is working closely with nursing and physicians to establish systems and urge compliance," reports Brewer.
At. St. Vincents, a survey to assess safety culture measures how associates perceive the attention of leadership to patient safety and quality. "Our scores have increased significantly because we have strong support from both our Ascension leadership and our local leadership here at St. Vincents," says Rahman.
The hospital has patient safety forum meetings, which are attended by board members, with presentations to underscore the importance of quality initiatives. "I think most lay board members understand finances, marketing, and strategic planning, but looking at quality and patient safety data are a challenge for them," says Rahman. "Often, they don't know what questions to ask. We have to help them, because ultimately they are the ones who are going to drive the organization's patient safety and quality performance."
Next year, the organization will link compensation of senior executives to measures including mortality, patient satisfaction, financial targets, and associate satisfaction.
In addition, teams at all the individual facilities, comprised of the chief medical officer, chief nursing officer, and quality professionals, will be asked to submit plans for how to get core measure compliance at the 95% target range. "At some point in time, the federal government is going to put the hospital's compensation at risk based on core measures. So in a sense, we are just getting ahead of the curve," says Rahman.
Is quality affected?
An important question is still unanswered: Are public reporting programs really improving the quality of care that patients receive? "The jury is still out," says Pham. "And no one has done the science to help hospitals decide which programs would work the best."
When tied to dollars, reporting has spurred compliance with public reporting requirements, acknowledges Virginia Bynum, PhD, senior vice president at Sioux Valley Health System in Sioux Falls, SD. "But I am not sure a case can yet be made that the reporting improves quality of care, outcomes for patients, or the ability to obtain quality resources," she says.
The first indicators for reporting were mostly process measures, and it is only recently that the measures have related to outcomes, Bynum adds. "Process measures are much easier to achieve and also less controversial than outcome measures, where physicians often argue that the required outcome is not best practice," she says.
Several factors affect the ability to obtain quality resources in addition to reporting, including location of facility, size, readiness of physicians, the "quality savvy" of the CEO, the abilities of and confidence in the quality leadership team, and dollars available for expansion of any resources including quality, says Bynum.
"The way to be more respected by health care leaders is to provide good, solid data," advises Bynum. "Give comparisons that make sense to your facility, and stay abreast of everything that is happening in the field."
Quality professionals should consider asking for additional data from sponsors of public reporting programs, argues Pham. "Quality leaders should really 'push back' a bit, to demand that program sponsors put forth some real data on whether reporting is actually affecting the level of quality of care," she says.
This point is more relevant for programs that are not as "voluntary," such as some state reporting programs, CMS, and Joint Commission, says Pham. "When there's the threat of payment cuts or loss of accreditation, hospitals don't have much of a choice in terms of deciding to participate or not, based on evidence that doing so will improve quality of care," says Pham. "So it seems reasonable to ask these types of sponsors what analyses they are doing to assess impact on quality over time."
Documenting that scores improve is not enough; you have to control for factors such as temporal trends and interactions with other reporting programs. "The latter, in particular, has not been done by anyone, to our knowledge," says Pham.
Disconnect between quality and IT
"Obviously, quality is not capital intensive, but there has been a greater degree of conversation and support relative to purchasing items such as computerized physician order entry [CPOE] and electronic health records," says Rahman.
One hospital in the system has CPOE with bar-coding that's up and running, and other larger hospitals are in the early phases of implementation. "For our critical access hospitals, we are trying to find an economic solution so they can have electronic health records for their inpatient side," says Rahman.
Still, there is a major "disconnect" between quality measures and information technology (IT) systems, says Pham. "I can't overemphasize the importance of this," she says. "It is important to understand that this shouldn't be viewed as just inadequate IT systems — although that's clearly part of the story at many hospitals."
Quality measurement professionals also should take on responsibility for creating measures that are feasible and practical to collect data for, given the real physical constraints of even the best available IT systems, Pham stresses. "As long as this disconnect exists, hospital quality leaders will catch the brunt of bridging the gap," says Pham. "That's costly in both dollars and time, especially with the paucity of available medical informatics experts to consult. And, in some cases, it may just not be doable."
- Pham HH, Coughlan J, O'Malley AS. The impact of quality reporting programs on hospital operations. Health Affairs 2006: 25(5);1412-1422.
[For more information, contact:
Jan Brewer, PhD, RN, Director of Quality Improvement, Mission Hospital, 27700 Medical Center Road, Mission Viejo, CA 92691-6426. Telephone: (949) 364-1400 ext. 5642. E-mail: Jan.Brewer@stjoe.org
Virginia Bynum, PhD, Senior Vice President, Sioux Valley Health System, 1305 West 18th Street, Sioux Falls, SD 57117-5309. Telephone: (605) 333-6657. E-mail: firstname.lastname@example.org
Hoangmai H. Pham, MD, MPH, Senior Health Researcher, Center for Studying Health System Change, 600 Maryland Avenue, SW, Suite 550, Washington, DC 20024. Telephone: (202) 554-7571. Fax: (202) 484-9258. E-mail: email@example.com.
Jon Rahman, MD, Chief Medical Officer, St.Vincent Health, 8425 Harcourt Rd., Indianapolis, IN 46260. (317) 338-7073, Indianapolis, IN 46260. E-mail: firstname.lastname@example.org.]