Are we there yet? Quality quest continues
Report highlights areas for improvement
There are two ways to look at the top-line piece of information in The Joint Commission’s annual quality report for 2013: Either a third of the hospitals it surveys achieved top performer status, or two-thirds of them didn’t. Given that the achievers — 1,099 — were joined by a large number — 673 — who missed top performing status by a single measure, the news is pretty good. "We are very pleased at the progress," says Margaret Van Amringe, MHS, executive vice president for public policy and government relations at The Joint Commission. "We had a significant increase in the number who made it this time, and there was another large number just a measure away. There is a lot of attention being paid to the core measures; the practices around them are being embedded so that they are a part of daily practice and routine. You can see that in these numbers."
Top performers have to achieve cumulative performance of 95% or above across all reported accountability measures; reach 95% or above on each and every measure with at least 30 cases; and have at least one core measure set with a composite rate of 95% or above and, within that measure set, all individual measures have a performance rate of 95% or above. And they have to do that on four different measure sets. Most of the top performers chose heart attack, heart failure, pneumonia, and surgical care. Other options include children’s asthma, venous thromboembolism (VTE), stroke, immunization, and hospital-based inpatient psychiatric care.
For 424 of the hospitals, this was the second time they achieved top-performer status; for 182, it was the third year in a row. Of those that missed by one measure last year (583), 253 made it this year.
It’s not easy to make the list — and perhaps there is a good argument for it being hard to be a top performer — but Van Amringe says that if hospitals take these measures seriously, "there is no reason why they shouldn’t make the list."
Here’s where The Joint Commission says it can see room for improvement. There is a composite result score it calculates by combining all the individual accountability measures. Last year, accredited hospitals achieved a 97.6% composite accountability measure on 18.3 million opportunities to perform care. As a comparison, a decade earlier, the score would have been 81.8% on 957,000 opportunities.
But while there was a 95% or better score on most measures, the report noted that providing care plans and discharge instructions for asthma patients (86.7%), continuing care plans for psychiatric patients (86.1%), and providing discharge instructions for VTE patients taking warfarin (82.2%) are among individual results that need to improve.
Van Amringe says that the top performers program is a "great equalizer" because you "don’t have to be a great center of one thing or another to do well, or not do well. With a lot of the other report cards out there, they are based on reputational data, like what doctors think about other doctors or where they would go for care. That’s not to say they don’t have a place. But this is based on data. We are not looking at overall hospital performance on everything — just narrowly focused points where science has proved that it is justifiable to say these things must be done by everyone, no matter what size your organization.’"
She was pleased to note that the Healthcare Association of New York State’s rating of report cards (http://www.hanys.org/quality/data/report_cards/2013/docs/2013_hanys_report_card_book.pdf) ranks Joint Commission methods higher than any other — because of its use of data.
Most of the top hospitals haven’t chosen to use VTE and stroke as measure sets, something Van Amringe says might be because they are newer measures. However, starting next year, to be a Top Performer, hospitals will have to excel in six measure sets, including stroke and VTE. (For a list of measure sets, see box, page 137.) In addition, hospitals with more than 1,100 births will have to add perinatal care measure sets. "It takes a couple years to get Top Performer status on new measures. You have to learn to embed those practices in your daily routine," she says.
Urban and rural make the grade
Among the Top Performers are more than a dozen Kaiser Permanente hospitals, about 18 of them in California alone. Patti Harvey, senior vice president for Patient Safety and Quality, says that being a connected system helps make consistent care possible, thus giving Kaiser hospitals a bit of a leg up on providing the best care every time. Every part of the system is designed to foster doing the right thing the right way every time, she says.
Still, most of those hospitals that hit Top Performer for Kaiser focused on those first four measures, not stretching to stroke or VTE or immunizations yet. That will change next year, Harvey says. "We are looking to become stroke certified in our California hospitals, so you will see that, and we are already above 90% in the majority of our Southern California hospitals for VTE." A couple of years ago, that would have earned Top Performer status for hospitals who included VTE in their measure sets, but the requirements were increased to 95% this year to reflect the higher performance most Joint Commission-accredited hospitals were achieving.
The hospitals are measuring and collecting data on issues such as perinatal care, VTE and stroke; they just haven’t started reporting it yet, Harvey says. "That does take resources," she says. "For now, we are spending those resources on other things."
In Northern California, Kaiser is actively reporting on some measures that Southern California isn’t. And across other states, there are different priorities at other hospitals. Happily, the regions cooperate, communicate, and coordinate, she says. "We learn and share across those regions, whether we are top hospitals or not."
And that learning is vital. Being a Top Performer isn’t something that allows you to sit back and relax, Harvey says. "We have systems, but they are not always 100% reliable," she says. "You can have a 95% reliability in a report to the commission, but if you are one of the five patients out a hundred that doesn’t get that care and is harmed, what do you care? Ninety-five percent isn’t good enough; 98% isn’t good enough. As complex as this system is, with competing and compelling priorities, the focus has to be on taking care of this patient here today. Translating that across a whole system is an art. We are trying to make it a science, but it is still an art."
So when something bad happens, they review — in every region, not just in the one where the bad thing happened — to see if something needs changing. That keeps the fire burning, Harvey says. It’s great to be a Top Performer, but there is no destination in quality. It’s all a journey.
In Wyoming, the quality concerns often revolve around how to provide timely care for folks who are coming from vast distances, says Carol Solie, MD, chief medical officer of Wyoming Medical Center in Casper, another Top Performer.
Next year, the 200-bed facility will have to start reporting perinatal data, and she wonders if distances will keep her off the list. One of the measures is about not inducing labor before the 38th week. But imagine this scenario, not uncommon in rural Wyoming: A woman lives far away, and a blizzard is forecast for tomorrow. She is 37 weeks, 5 days pregnant. The best option is to get her to Casper before the storm. The ideal, according to the folks who make the rules, would be to have the patient pop herself into a hotel or with a friend and hole up until she hits that magic 38-week mark. Then you could induce. Or maybe the storm would pass and she’d go into labor naturally. But for many patients, says Solie, that’s not an option. They don’t have the money for a hotel, they don’t have friends in town, and you can’t admit her and have her hang out in a hospital bed. So the best alternative has been to induce at 37 weeks, six days.
Solie says the realities of rural life — the isolation preferred by many, the extreme difficulty some providers have getting people to agree to follow a plan of care — don’t always match what "measures" say you have to do. Still, thus far, the hospital has been able to be a paragon of quality and safety. It is a "Gold Plus" stroke achiever. It has gone as many as 400 days without any safety event — "it’s just devastating to go back to zero on the board after that long," she says — and while they don’t report on stroke and VTE to The Joint Commission (as a way to save money), they have been collecting and reporting that data as part of Meaningful Use, and of course, using it for the benefit of quality improvement projects.
"The challenge for leadership in any industry that engages in quality improvement is sustaining the game," Solie says. "It’s easy to slip into complacency. You build a wall. You stand on it. You say it’s there. But quality is a wall you have to build every single day with every patient."
She says that getting behaviors hard-wired into staff is great, as long as you continue to have those people doing those things continually. If someone moves onto something else — another project focusing on another task to be hard-wired, or another job that doesn’t use that skill — then eventually, the "hard wiring" will be more like that French class you took in college 20 years ago that left you feeling sure you were fluent.
Solie says it wouldn’t surprise her to see fewer top hospitals next year — six measures is a lot, and there are hospitals like hers in rural areas that will have a hard time figuring out how to meet the requirements of some measures and still meet the needs of patients. But she knows that hospitals will still reach for that level of achievement and feel good if they meet it. She hopes Wyoming Medical Center is one of them.
The complete annual report is available online at http://www.jointcommission.org/assets/1/6/TJC_Annual_Report_2013.pdf. It contains the list of the 1,099 Top Performer hospitals by state.
For more information on this topic contact:
- Margaret Van Amringe, MHS, executive vice president for public policy and government relations, Joint Commission, Oakbrook Terrace, IL. Email: firstname.lastname@example.org.
- Patti Harvey, MPH, Senior Vice President, Patient Safety and Quality, Kaiser Permanente, Los Angeles, CA. Email: email@example.com.
- Carol Solie, MD, Chief Medical Officer, Wyoming Medical Center, Casper, WY. Telephone: (307) 577-2130.