The first half of 2020 was an extraordinary time for the United States. Quality leaders are beginning to assess how the COVID-19 pandemic response will affect the quality metrics of hospitals for months after the emergency subsides. What will those metrics look like?

They may not look great, and accreditors might be prompted to use a form of “compassionate surveying” when it comes to revelations of noncompliance during this period.

Even after the pandemic winds down, the experience is likely to leave a significant and lasting effect on quality metrics, says Lauren Patrick, founder and president of Healthmonix, a healthcare analytics company based in Malvern, PA.

There are several components to the effect on quality metrics, she says. First, what will the quality metrics show in terms of quality of care? Will quality, measured via the clinical quality measures that are reported, remain at the same level?

“Changes in the performance of clinical quality metrics may be affected in a variety of ways. Chronic care management and preventive care measures may suffer due to missed appointments, clinical transformations, and providers’ focus on immediate issues during the initial period,” Patrick says. “Focus on urgent care, first and foremost, may impact the focus on nonemergent care.”

Metric Effects Uncertain

Secondly, there will be two factors that contribute to a change in the metrics, Patrick says. Depending on how well the quality protocols and standards of care are embedded in a practice at the beginning of the pandemic, there may be a temporary or longer-term decrease in those numbers, she explains.

“A decrease may be due to high-priority urgent care needs that cause a lack of focus on the quality actions that are normally included. A decrease may also be temporarily seen by physicians who are transforming their clinical practices to accommodate new strategies and protocols so swiftly,” Patrick notes. “As physicians quickly move to telehealth or shift roles due to layoffs or urgent care needs, workflows may need to be redesigned to accommodate the changes and ensure that outcomes continue to be achieved and documented.”

Credit for Trial Participation

The Centers for Medicare & Medicaid Services (CMS) has not released revisions to the quality measure reporting requirements for 2020, Patrick notes. CMS issued guidance for completing 2019 reporting since it was due at the onset of the pandemic. Still, even in Registry Kick-Off meetings with CMS, there was little guidance as to what changes may occur for 2020, Patrick says.

“So far, we have heard that there will be one new addition to the quality payment program [QPP] for 2020, which is credit for participating in clinical trials connected to COVID-19. We do know that CMS is considering changes for 2020 reporting,” Patrick says. “To date, CMS has remained tight-lipped on what those changes may be. When we have asked them directly, the response is that we will hear something ‘very soon.’”

In the addition to the QPP, CMS announced clinicians may earn credit in the Merit-based Incentive Payment System (MIPS), the performance-based tracker that incentivizes quality and value, for participation in COVID-19 clinical trials.

To receive credit, CMS says clinicians must participate in a COVID-19 clinical trial using a drug or biological product and report their findings through a clinical data repository or clinical data registry.

“The new improvement activity provides flexibility in the type of clinical trial, which could include the traditional double-blind, placebo-controlled trial to an adaptive or pragmatic design that flexes to workflow and clinical practice. It also carries a high weight from a scoring perspective,” CMS announced. “This means that clinicians who report this activity will automatically earn half of the total credit needed to earn a maximum score in the MIPS improvement activities performance category, which counts as 15% of the MIPS final score.”

Patrick says the fact that CMS is not requiring reporting of some metrics for a while could produce negative effects. The saying “what gets measured gets done” may apply here.

“If we are not requiring the metrics to be tracked and reported, many may not receive the attention they have in the past, and the outcomes and processes that are being measured could decrease,” she says. “If we essentially give a two-year pass to providers — 2019 and 2020 — and then attempt to reinstate the program again after that, we may lose the gains made over the program’s history. Providers could be less likely to participate in the process of quality reporting.”

‘Compassionate Surveying’ Needed

Similar concerns about what quality data will look like when surveyors look back on the pandemic period months from now come from Patrick Horine, chief executive officer at DNV GL Healthcare in Milford, OH, which offers hospital accreditation integrating ISO 9001 with the Medicare Conditions of Participation.

“One of the things I’m really concerned about when we go back out and do our on-site surveys, in light of the waivers and the concentrated focus on COVID-19 — there are going to be a lot of issues that are demonstrated noncompliance in a lot of different areas,” Horine says. “It’s probably going to require some level of compassionate surveying because there is going to be a lot of noncompliance issues that hospitals might otherwise have been more strict in following. We’re going to want to see that there are corrective action plans put in place in short order to address immediate concerns, and then plans for long-term correction.”

In particular, Horine is curious to see the effects on infection control during the pandemic. With the increased use of personal protective equipment, heightened awareness of hand hygiene, and the reduction in patient volume in many hospitals, some facilities could see a reduction in infections, he says.

“One would think their overall infections would be reduced in light of the enhanced practices, but it could be the opposite if all those precautions were just keeping their heads above water while the infection rates were going up,” Horine offers.

Horine also wonders about the impact on value-based purchasing programs. CMS is providing waivers that ease the burden during the pandemic response, he says, but what is going to happen later when hospitals do not meet the expectations of value-based purchasing agreements?

“There are going to be a lot of challenges for hospitals and for CMS. Are they going to look at a different data collection period for assessment of that value-based purchasing?” Horine asks. “Will they forgo any penalties during this time with the hospitals so impacted? I don’t think there is an easy answer, but it is going to have an impact no matter which way they go.”

On a positive note, Patrick says hospitals and providers have done a tremendous job of adapting. Facilities have rapidly and aggressively adopted telemedicine, changed hospital and provider protocols to address COVID-19 needs, and prioritized urgent care while re-engineering a significant portion of the standard way they deliver healthcare services, she says.

The number of eligible cases for quality metrics will be down for this period, Patrick notes. Elective surgeries and procedures have been suspended. There has been a dramatic decrease in office visits, and routine care and preventive testing have taken a back seat to more urgent needs. That will mean lower populations are included in the measures. “While we may pause capturing some outcomes [as] we adapt to the new normal, hospitals should ensure that as the crisis subsides, we pick these back up. There may be new workflows that need to be created, and we may need to ensure that documentation is up to date,” Patrick says. “New tools that have been adopted during this time will need to incorporate the quality metrics so that we don’t place undue burden on physicians as we move forward.”

Patrick suggests this is an opportunity to assess how ingrained the quality practices are within any organization. Consider an audit moving forward to ensure there are no lost processes in the urgency and transition. Assess gaps that have arisen, and institute appropriate improvement processes to bridge any gaps.

“Reviewing quality metrics from this period will show the extent to which quality practices are ingrained into the workflows, even at a time of crisis and change,” Patrick says. “Comparing metrics and root cause analyses of these changes, or lack of changes, will certainly inform our practices going forward.”


  • Patrick Horine, Chief Executive Officer, DNV GL Healthcare, Milford, OH. Phone: (866) 523-6842.
  • Lauren Patrick, Founder and President, Healthmonix, Malvern, PA. Phone: (888) 720-4100.