Comparative performance data can be change agent

Identify and correct near fatal flaws’

One of the major challenges facing case managers is what to consider when selecting comparative performance data. But that is just the first of several questions that must be addressed, says Patrice Spath, BA, RHIT, a consultant in health care quality with Brown-Spath & Associates in Forest Grove, OR. It also is important to identify and correct serious flaws in utilization and outcome data, she adds.

Deborah Hale, president of Administrative Consultant Service in Shawnee, OK, says case managers then must learn how to create data presentations that answer common questions posed by physicians and administrative leaders. One key to success will be understanding why comparative data may not motivate physicians and other caregivers to action and how to change that, she points out. Another is what to do after you’ve captured people’s attention with the data.

According to Spath, the following questions are a good starting point for organizations to use when investigating comparative measurement options. It’s important to keep in mind that no one system is likely to meet all of these performance measurement requirements, she says.

Here are eight questions that can help begin the assessment:

1. Are the measures standardized at the national level? Do all organizations participating in the system report the same kind of data in the same way?

2. Are the measures adjusted for factors that could make your organization’s performance appear better or worse than it really is (e.g., patient age, gender, health status, severity of illness)?

3. What resources will your organization need to gather the data?

4. Will the measurement results be available in time for you to produce and distribute reports within a reasonable time following the end of the reporting period?

5. Have the measures been tested adequately to ensure that they consistently and accurately reflect the performance they are intended to measure?

6. Are you confident that the measures reflect actual performance and not shortcomings in the data and/or information systems?

7. Will the measurement results allow your organization to identify significant differences in performance as compared to other organizations with similar characteristics?

8. Does the performance system include an audit or quality-control function to ensure reliability of the measurement results?

In addition, each system should be evaluated based on its ability to meet the clinical information needs of its physicians and professional staff, as well as its ability to support its strategic performance improvement goals, Spath says.

The next step is to identify and correct near fatal flaws in utilization and outcome data, Hale says. "It is a near fatal flaw’ in the outcomes data if we are not accurately reporting the diagnoses and the procedures that were performed for the patient. That requires comprehensive physician documentation as well as coding accuracy."

This can be the most significant flaw in utilization and outcome data, she adds. "I have also seen any number of hospitals use mortality data indicating that they had a much higher than expected mortality rate." In those cases, investigating the problem often reveals that they were in the wrong DRG, she points out. When the DRG assignment is corrected, data typically fall within expected parameters.

As case managers prepare the data presentation, they must be certain to trace that back to the medical records and know the data are accurate based on accurate DRG assignments, Hale says. "You want presentations that draw clear pictures." That means avoiding spreadsheets or any very complex graphic display, she says. "I have found that physicians and administrative leaders do the best with very simple graphics that illustrate one or two points. It is best when they are colorful and very easy to read."

Another important consideration for case managers is why comparative data may not motivate physicians and other caregivers to action and what steps can be taken to change that. "Data quality is more than accuracy and reliability." Spath adds that high levels of data quality are achieved when information is valid for the use to which it is applied, and when decision makers have confidence in the data and rely upon them. "Data-based decisions must be made with confidence, at least confidence in the data," she explains. The final criterion upon which to judge the quality of data is whether decision-makers who rely upon the data have confidence in them, she explains.

Spath says case managers can help people feel confident in the quality of the data through two key steps. The first is to confirm as much as possible the accuracy and reliability of the data in the information system before preparing reports. The second is to know the questions that will be asked or the decisions that are to be made to ensure that the right data are presented and the appropriate analyses are conducted.

Beyond the more "mechanical" levels of data quality, she says it is important to keep the goal in the mind. "The true test of data quality is whether the information is useful, usable, and used for decision making," she asserts.

Hale says the last step in this process is to meet with a select group of physicians and staff who comprise a performance improvement team to examine not only financial data but clinical information as well. That includes high mortality rates and high potentially avoidable complication rates. "These are the other things in the data that raise questions rather than answering them," she adds.

Once that presentation is completed, Hale says case managers must examine the processes to determine what needs to be improved. These teams must "take apart the data," brainstorm, and hypothesize why the data look the way they do, she says. According to Hale, that means case managers must determine what the key performance measures are that must be captured from chart review. "You never want to collect more data in chart review than you think you might use," she cautions.

At that point, the team can begin to develop solutions using quality improvement principles. They may decide that a way to improve the overall performance is as straightforward as education for the staff, developing protocols, or redesigning the process, Hale says. "The important thing is that people with ownership in the diagnosis of the procedure in question determine what the strategies and procedures are."

The team may find very high costs for managing a particular diagnosis, but the care is consistent with professionally recognized standards of care and no improvements can be made. However, in most instances there is at least some opportunity for improvement including the chance to educate physicians, she says.

The team becomes the framework for disseminating information and developing improvement strategies, Hale says. "The thing that most people overlook is that they do not follow through by evaluating the effectiveness of the action that they have taken," she says. "They may have even made the situation worse. If they don’t go back and collect data and re-measure, they will never know." They will also have nothing to celebrate, Hale adds.

[Spath and Hale will conduct a presentation, "Using Comparative Performance Data as a Catalyst for Positive Change" at the 2003 Hospital Case Management Conference, to be held April 27-29 in Atlanta. For more information about the conference or to register, call (800) 688-2421.

In From Quality to Excellence: Using Comparative Data to Improve Health Care Performance, a new book by Patrice Spath and Aggie Stewart, quality managers and health care practitioners can learn how to incorporate comparative measurement data into their organization’s quality and patient safety improvement strategies.

The book includes examples of comparative data from many sources and sites of patient care and a discussion of relevant regulatory and accreditation requirements. Readers learn how JCAHO and Medi-care surveyors interpret comparative data and what is expected when the organization’s performance varies significantly from other facilities.

For more on From Quality to Excellence, call (503) 357-9185 or visit www.brownspath.com. A complete table of contents for this book is available on the product page of the web site.]