As healthcare systems shift from the fee-for-service model to managing health across a population of patients, hospital quality managers’ work using quality indicators and other data is moving to front and center of the evolution.
“From a payers’ standpoint, there are initiatives underway where their payment is based on the ability to reduce utilization and keep a population healthier,” says Ken Gross, PhD, MPH, principal at Quantitative Innovations in Pennington, NJ, and an adjunct lecturer at the University of Pennsylvania in Philadelphia.
“That’s a different focus for hospitals when, in the past, their population was anyone who walks through their doors,” Gross says.
A technological change that likely will come of this evolution is that electronic tools soon will be able to do the work of collecting and analyzing data, which now is being done by quality managers and preventionists. When this shift occurs, quality managers and preventionists will be able to use their time in quality improvement projects and prevention work, says Richard Platt, MD, MSc, professor and chair of the Department of Population Medicine at Harvard Medical School in Boston, MA. Platt also is the executive director of Harvard Pilgrim Health Care Institute in Boston.
The role of quality managers will change in the near future — in three-to-five years — with much more emphasis on the health of populations and keeping people healthy, says Keith Kosel, PhD, MHSA, MBA, vice president of VHA-UHC Alliance, director of the Center for Applied Health Services Research, UHSC, in Dallas. Kosel, Platt, and Gross will be speaking about turning raw data into effective action at the National Association for Healthcare Quality (NAHQ) National Quality Summit, held May 11-12, 2016, in Dallas.
“Someone has to say, for example, ‘There’s a high incidence of asthma in the community, and here are the things we need to do to keep asthma patients from coming into the emergency room,’” Kosel explains. “That’s a natural function for a quality person: They understand that kind of data; they understand what you need to do to keep people healthy.”
This focus is a slight shift for quality managers because it moves them from considering only data in the hospital to paying attention to what’s happening in the community — both before and after patients are hospitalized, he adds.
“There is a need for quality people to pay attention to things — not abandoning quality, but to start seeing them shift emphasis and spend more time looking at quality in outpatient and ambulatory settings and keeping people healthy in the community,” Kosel explains. (See story on quality managers’ role in population health focus later in this issue.)
Platt, Kosel, and Gross offer the following practical suggestions for how quality managers can prepare for the population health shift while managing their current roles:
• Narrow down focus in data collection. The information quality managers collect should be relevant, sufficiently timely, and complete enough to guide some kind of action, Platt says.
“I’m very respectful of the fact that quality managers have a long list of items that people tell them are high priority,” he says. “But there are a couple of ways to slice this: For things that are the highest priority, do you currently have the appropriate tools to identify areas where you invest resources, and if you don’t, what would it take to create them?”
Once you have your high priority list, determine the most efficient way to collect these data, Platt adds.
“Is it possible to use a single platform?” he says. “This is much more appealing than creating or gaining access to a separate set of tools.”
• Offer data collection for the hospital’s community health needs assessment. Under the Affordable Care Act (ACA), nonprofit hospitals are required to do a community health needs assessment to report on what needs are uncovered, Gross says.
This requirement is necessary for the hospital to maintain its tax-exempt status, and it must be conducted at least once every three years, or there will be financial penalties.1
“Most hospitals don’t know where to begin,” he says. “So they leave it to their legal departments or their marketing departments to hold focus groups, talking with people about health in the community.”
A better and more useful solution would be to take a data-driven approach, and this is where a health system’s quality manager can help, Gross says. “Hospitals have lots of data that reflects the health of the community population, and it’s all in their claims data.”
For instance, many people go to the emergency room for asthma treatment, and a quality manager could collect claims data on where these patients live, identifying any geographic hotspots for asthma, Gross suggests.
Since the sole purpose of claims data is collection for billing purposes, it is free from the open-ended text and notes found in electronic health record data. Plus, every hospital collects claims data the same way and it’s not vendor specific, Gross explains.
“Claims data contains demographic information, including date of birth, address, clinical information, and financial information — all in one place,” he says. “All of these together shed a lot of insight on population health.”
• Understand financial implications. While financial implications generally are viewed by hospital leadership, it’s important for quality managers to connect the dots behind safety and quality measures and financial outcomes, Kosel suggests.
For example, the Centers for Medicare & Medicaid Services (CMS) penalize hospitals with high rates of poor outcomes and rehospitalizations on an increasing list of indicators. “Quality folks are in the best position to understand those trends and to identify data of what’s going on,” Kosel says.
“They can recommend alternative practices to put in place to reduce patient falls and those kinds of things, and that’s the most important role for hospital quality managers,” he adds.
Here’s an example of how this can work: A California hospital’s data showed high numbers of people admitted to the emergency department (ED) for acute alcoholism, Kosel says.
Hospitals EDs often can be so overcrowded with non-emergency patients that ambulances carrying people with serious conditions are diverted to other facilities.2
Even worse, from a financial and quality perspective, ED crowding leads to higher rates of patient morbidity, mortality, and readmissions.3
“When they looked at community data and broke it down by ZIP code, they realized a lot of cases were coming from around sports venues,” he explains. “People were getting inebriated to the point of requiring some medical attention, and they were brought to the ER, which is an expensive stop versus taking them home and giving them a cup of coffee.”
So the hospital opened up a half-way shelter where EMS could bring drunken patients to be seen by a nurse and nurse practitioner until they were sober enough to return home. The entire solution cost a fraction of the cost of taking the same people to the emergency department and left ED beds available for seriously ill and injured patients, Kosel adds.
Quality managers can use data to find similar causes and possible solutions for pediatric asthma cases and other health problems within their communities.
“In today’s world, quality is about treatment: We want high-quality care and to make sure patients are not being harmed,” Kosel says. “But the longer-term role of quality management is trying to understand the health of the community and to focus more on prevention.”
REFERENCES
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Kasprak J. Federal health care reform – hospitals and community health needs assessments. OLR Research Report. May 10, 2011: https://www.cga.ct.gov/2011/rpt/2011-R-0222.htm.
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Barish RA, Mcgauly PL, Arnold TC. Emergency room crowding: a marker of hospital health. Am Clin Climat Assoc. 2012;123:304-311.
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Hostetter M, Klein S. Quality Matters. 2013:October/November issue: http://bit.ly/1TBlGMU.
SOURCES
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Ken Gross, PhD, MPH, Principal, Quantitative Innovations, Pennington, NJ. Telephone: (215) 574-5800. Email: [email protected].
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Keith Kosel, PhD, MHSA, MBA, Vice President, VHA-UHC Alliance; Director, Center for Applied Health Services Research, UHSC, Dallas, TX. Email: [email protected].
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Richard Platt, MD, MSc, Professor and Chair, Department of Population Medicine, Harvard Medical School, Boston, MA. Telephone: (617) 509-9971.
