Lessons from high-risk industries offer additional lessons on organization culture
With all the challenges that frontline health care providers have faced this year, from Ebola and the Middle East Respiratory Syndrome (MERS) to the sweeping implementation of the Affordable Care Act, news from The Joint Commission (TJC) that hospitals are continuing to make significant strides on key quality measures was certainly welcome.
In TJC’s annual report, summarizing 2013 performance data for more than 3,300 accredited hospitals, the agency noted that 1,224 of these facilities were recognized as top performers on a range of quality measures, representing key evidence-based care processes that have been linked to positive patient outcomes. In a news conference announcing these results on November 13, Mark Chassin, MD, FACP, MPP, MPH, president and CEO of TJC, said that it is clear that the agency’s approach to quality improvement is working.
“When the core measure program began in 2002, only 7% of hospitals registered performance of greater than 95% on the accountability measures that were in the program at that time, and there were only eight of them,” he said. “Fast forward to 2013, and fully 81% of hospitals are at over 95% performance on all of their accountability measures, which total 44 measures.”
Chassin noted that the data show the hospitals are delivering improved care for pneumonia, children’s asthma, surgical care, heart failure, and other common conditions represented in the accrediting agency’s measure sets. Further, as an example of the progress that has been made, Chassin pointed out that less than 10 years ago many heart attack patients did not receive recommended percutaneous coronary intervention (PCI) treatment to open a clogged heart artery within a 90-minute window of arrival at the hospital.
“In 2005 national performance on this scientifically evidence-based measure of quality was a disappointing 68.3%. Today that figure has drastically improved to 96%, and the composite rate for the heart attack care measure set, which PCI is a part of, was at 99% in 2013,” said Chassin. “That means that hospitals provided seven different evidence-based treatments for heart attack patients 990 times for every thousand opportunities to do so.”
To be recognized as a top performer, TJC stipulates that hospitals must achieve a cumulative performance of 95% or greater on all reported accountability measures, achieve a performance of 95% or greater on every accountability measure where there are at least 30 denominator cases, and have at least one core measure set that has a composite rate of at least 95% — and all metrics within that measure set must rank at 95% or above as well.
Chassin explained that when TJC first launched its top performers on the key quality measures program in 2010, only 405 hospitals or 14% qualified for the recognition. Today more than a third of accredited hospitals or 37% are recognized as top performers. (See TJC bar graph, Fig 1, on p. 10.)
“In addition, another 718 Joint Commission-accredited hospitals are on track to achieve top performer recognition because they missed this year by only one measure,” observed Chassin. “That means that well over half of Joint Commission-accredited hospitals — fully 58% — are top performers this year or are on track to become one soon.”
Devote resources to quality
Breaking down the data further, Chassin pointed out that the number of academic medical centers recognized as top performers grew from 24, recognized in last year’s annual report, to 35 in the 2014 report, now representing 29% of all accredited academic medical centers. However, he also acknowledged that only 11% of the top performers were public hospitals, designated as “government owned” in the annual report.
“I think it has been difficult for some hospitals, particularly those that may be feeling under-resourced, to devote the attention to this quality improvement effort,” said Chassin. “But you know academic medical centers said the same thing a few years ago and they figured out how to do this, so I think this is a challenge for some hospitals to find the resources to do it, but they should be focusing on this and prioritizing it, in my view.”
Elaborating on this point, Chassin explained that in the early years of the core measures program, academic medical centers clearly did not prioritize trying to get consistent excellence on the identified measures. Only four academic medical centers were recognized as top performers in the first year, but priorities changed for a high number of these facilities, as the number of top performing facilities in this group has grown markedly, observed Chassin.
“We want to see more resources devoted to quality and quality improvement, and this recognition program was designed to encourage that kind of priority setting,” said Chassin. “I think with the substantial increases year over year that we are seeing in hospitals achieving top performer status, the program has been successful in reaching that objective.”
Chassin also noted that in this year’s report TJC provided special recognition to a group of hospitals that went beyond the reporting requirements to achieve top performer recognition. “We required hospitals to report quality data in only four measure sets [for 2013], and the vast majority of top performers reported on four measure sets, but 44 went beyond the minimum requirements, reporting on five or more sets of measures, and achieved top performer recognition on that expanded set of measures,” he explained.
Some metrics remain challenging
While performance in the core measures program has steadily increased, there are some metrics that continue to be quite challenging for hospitals. For instance, Chassin noted that antibiotic selection for some non-ICU patients in the pneumonia measures set is the most often missed metric, followed by urinary catheter removal, and he noted that many hospitals continue to struggle to achieve 95% performance levels on delivering PCI within 90 minutes in appropriate heart attack patients. However, while TJC can compile a list of the most-often missed metrics, Chassin stressed that it is a very individual phenomenon that can vary quite a bit depending on the patient population and other factors.
Chassin advised hospitals that are struggling with particular metrics to make use of TJC’s “solution exchange,” a database that includes information from hospitals that have had success in sustaining high levels of performance. “Every accredited hospital has access to that database to look up measures [administrators are] having trouble with to see examples of hospitals that have succeeded and understand exactly how they were able to achieve that success,” he said. “That is an important tool that hospitals can use to continue to get better.”
Pay attention to culture
While this year’s report offered good news about the quest for continued improvement on specific quality and patient safety metrics, Chassin noted that it is important to emphasize that the 14 measure sets that are part of this program do not capture all aspects of quality care.
“The evidence is very clear that variations in quality within individual hospitals [are] quite strong and very consistent,” said Chassin. “This program has shown that, in fact, it is possible to get to very high levels of performance on these very strong, evidence-based measures over the entire country, but that … does not address everything a hospital does. And the hospitals that are starting to address that problem seriously are turning to the lessons from, for example, high reliability industries that recognize that the organizational culture of a high-risk industry is critical to improving across a wide array of different quality and safety areas.”
Consequently, Chassin noted that while attention to the evidence-based metrics in the core measures program is important, hospital leaders also have to focus on organizational culture to find unsafe conditions so that they can be corrected before they do harm. “High-reliability [industries] are showing hospitals how to do that,” he added.
The bar for performance measurement will keep going up, not just in the core measures program, but also in TJC’s certification and accreditation programs, promised Chassin. For instance, he noted that in January of 2014, all hospitals with 1100 or more live births per year had to start reporting perinatal measures to TJC, and the total number of measure sets that TJC requires of accredited hospitals increased from four to six [in 2014]. “That increased level of activity will be reflected in our 2015 annual report,” he said. “You will see a lot more measures reported in the annual report for next year, and we may see a decline in the number and percentage of hospitals making top performer status because it may be more difficult for them to achieve top performer status next year.”
Further, Chassin acknowledged that heightened standards are coming even as hospitals face added challenges from changes in the way health care providers are reimbursed for care. “As more hospitals find more of their payments either tied to risk-based arrangements where they are taking on more risk for populations, or bundled payments for different kinds of services, it is even more important for them to focus on getting it right the first time and making sure that evidence-based care is always provided, which this set of [core] measures talks directly to,” he observed. “The stakes are even higher now with the different kinds of payment schemes that are out there, and [the core measures program] helps hospitals provide accountable care for improving population health as well as being successful in the new payment arrangements.”
Editor’s note: To access The Joint Commission’s (TJC) 2014 Annual Report, visit TJC’s website at jointcommission.org.
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Mark Chassin, MD, FACP, MPP, MPH, President and CEO, The Joint Commission, Oakbrook Terrace, IL. E-mail: [email protected].
