Top watchdogs vow to coordinate, simplify quality reporting systems

Accreditors promise action but give no deadline for results

The country's leading accreditation organizations have rolled out a plan to coordinate their quality measures in an high profile effort to eliminate duplication and to standardize reporting methods and measures. But if you are looking for some immediate relief from the growing burden of collecting and reporting quality data, don't hold your breath.

Responding to consumer, payer, and provider criticisms of inconsistent and irrelevant reporting requirements, The American Medical Accreditation Program (AMAP) of the American Medical Association, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA) say they will attempt to make reporting more useful to everyone. But representatives from these groups say they haven't set any timetable for results.

Each organization is selecting five representatives to serve on a Performance Measurement Coordinating Council (PMCC). After its initial meeting, the PMCC will convene three to four times a year. At this writing, the date of the initial meeting is set for August or early September. As for when concrete results will trickle down to health care facilities, "I couldn't hazard a guess," concedes Brian Schilling, spokesman for the Washington, DC-based NCQA, "but it's a top priority initiative for all three organizations."

Will these three behemoths make the compromises required for genuine coordination? Al Buck, MD, executive vice president of Performance Measures and Research at JCAHO in Oakbrook Terrace, IL, says he is hopeful. "The coordination council itself is a remarkable achievement," he observes. "One of the most important things that will come out of this group has already come - the building of consensus from our parent organizations in creating the consensus document," he adds. (For highlights from the consensus document, see "Key points from consensus statement," at right.)

Buck expects the group to focus on two main areas:

1. standardization of data element definitions and measures to be reported;

2. improvement of data quality through risk adjustment and standardized measures of effective care.

Schilling, however, hints at little change in the fundamental power bases of each body. He warns, "We're not looking at one set of [accreditation] measures for facilities; that would not be realistic. Each organization will maintain its own set of measures, but with a lot of fine-tuning and tweaking, not a complete overhaul. There will be complimentary measures that make the data mesh better." Schilling cites otitis media as one example of the challenges faced by the PMCC. While everyone agrees it's important to track the treatment, he says, the flow of information for multiple uses is not possible because some organizations report how often they give antibiotics and others track how often they implant tubes to drain infection-prone inner ear fluid.

While it might be unrealistic to expect the accreditors to merge their measures into one all-purpose set, there is plenty they could do to better serve their constituents, quality executives say. QI/TQM asked several quality managers how they would direct the 15 members of the PMCC. Here are their responses:

The coordination effort is good news to employers who struggle with inconsistent and incomplete data in trying to match providers and health care organizations with their employees needs, says Stephan Rodgers, program leader for health care programs at the Fairfield, CT, General Electric office. He's frustrated with the quality measures on which he's expected to base buying decisions. "There are problems with the reliability and consistency," he contends. And each accreditor has plenty of room for improvement, Rodgers adds.

· NCQA reports provide only some of the answers needed to support purchasing decisions.

"We want to know how a health plan would deliver health benefits to meet our specifications. We and our employees need to know how a plan resolves customer problems and pays claims. Those haven't been tracked well," he says.

· "JCAHO's ORYX program is a good start, but far from anything that's useable on a day-to-day basis," adds Rodgers.

The problem is twofold. Providers have too wide a choice in outcomes to report. "As a purchaser," he points out, "if I'm looking at two health care organizations, and one reports cardiac and diabetes outcomes and the other diabetes and mental health outcomes, it's difficult to compare one to the other."

The second problem, Rodgers says, is the huge choice in outcomes reporting data systems allowed by JCAHO. The data systems are not uniform thus complicating comparisons. (For background on ORYX, see QI/TQM, January 1998, p. 1.)

· The next evolution in quality assessment must emerge at the provider level - how an individual provider delivers care based on a standardized set of measures.

"Then that would be rolled up as to how they deliver care within a health plan," he adds. "And that would be rolled up as to how providers compare with others in delivering quality care. If a medical group delivers care under two health plans, Plan X or Plan Y, for example, we should be able to look at how that group measures up quality-wise under both plans. Maybe there are [external] factors that impact whether a provider delivers better care under one plan or the other."

If providers sat down with the PMCC, they would plead a case for practicality and thrift in quality measurement. Robert Klint, MD, president and CEO, and Henry Anderson, MD, chief quality officer of SwedishAmerican Health System in Rockford, IL, voice the frustrations of providers who often wonder whether their real customers are their patients or their accreditors.

· "We need a common severity adjustment system," stresses Klint.

"Our data should be as current as possible, and they should be benchmarked with other organizations. Data on their own are fairly useless." Acknowledging the grass-roots discontent typified by Klint's remark, Buck notes that simplification of data reporting is technically doable at this time. But progress stops where consensus begins. "As a country, we must resolve some very specific data issues: In which instances must data be risk adjusted? And, we have to agree on the basis for standardizing data," Buck says.

· In the interest of thrift, "I would ask them to consider how wonderful it would be if we could use the Internet to send data back and forth to the accrediting agencies," Klint says.

He notes it would be a cost-effective way to solve some of the incompatibility problems with information management systems. The Internet allows different operating systems to communicate with each other, making it possible to share data across systems that would otherwise have to be made compatible by linking them with expensive hardware or software.

· Simplify your accreditation feedback.

Klint describes one section of the performance report card from SwedishAmerican's 1996 JCAHO accreditation report. "It's 7/16 of an inch thick," he notes, "Now how do we as managers and directors of boards react to this much data?"

· Providers are concerned about how the data they report will be exploited.

"These are external accrediting bodies," Klint says, "They set the standards; we meet them. We give them our information free, and we pay them to accredit us - so they can sell it? What happens to our data?"

· Is this initiative going to streamline the reporting process?

Klint contends that while nobody is trying to avoid quality improvement, reporting requirements can detract from the patient care goal. He's concerned that excessive standards will reduce health care providers to automatons so compliance driven that patient care gets lost.

And to Anderson, that's precisely the sort of issue the council should tackle. If given his say, he would warn them that "sooner or later, hospitals or purchasers are going to say `That's enough!' There needs to be uniform quality data, and it might take legislative action to enforce it."

Ellen Gaucher, MPH, MSN, vice president for Quality and Customer Satisfaction at Wellmark Inc. Blue Cross/Blue Shield of Iowa and South Dakota in Des Moines, IA, says she would advise the coordinating council to ask itself what it is trying to help health care organizations achieve.

· The group needs to decide whether to refine the existing minimum accreditation standards or set stretch goals.

"I'd like to see stretch measures instead of easy-to-reach standards. An example of a stretch goal would be effective counseling on osteoporosis through the life span," she explains.

· We also need to be asking what's the best way to achieve the right results so we can produce better quality with fewer resources.

To that end, she would suggest to the accrediting bodies that they appoint to the council "out-of-the box thinkers who can be innovative and futuristic."