Critical Care Plus

Financial Incentives Need More Quality-Based Measures

Report calls for more outcomes standards

By Julie Crawshaw, CRC Plus Editor

According to a new study from Hewitt Associates, when it comes to financial incentives programs, most hospitals and health care systems link executive compensation to patient satisfaction. The study, sponsored by the National Committee for Quality Health Care, called for using more clinical care and outcomes-based measurements to determine financial rewards. The study reported that 71% of 63 groups polled had incentives plans in place, but only 62% said that they include specific quality and outcomes measures in their incentive plans. Only 29% measured specific patient safety factors such as medication errors, patient falls, use of restraints, and infection control.

Measuring clinical quality performance and outcomes is no easy task in critical care medicine, says Robert McCaffree, MD, chief of staff of the Veterans Administration Medical Center and professor of medicine in the pulmonary disease and critical care section of the Oklahoma University Health Science Center in Oklahoma City. He says that the complexity of illness has become so great, it’s difficult to develop measurements that help ICU physicians reflect accurately on what they are doing.

"In a critical care unit, you have an incredible heterogeneity of diseases with a lot of cofactors that might affect the outcome," McCaffree says.

McCaffree says the best measurements of medical performance are outcome-based but, in critical care units, it’s challenging to get meaningful and useful outcome measures. As an example, he points to VA-developed benchmarks such as counting the number of patients who receive influenza vaccine or smoking cessation counseling, which are straightforward and easy to measure. Even moving the bar up a notch to measure diabetes outcomes is doable because both the nature of the disease and the large population of patients allow for gathering significant data.

But assessing outcome-directed measures for ICU care involves more cofactors than most other medical models. For example, McCaffree points out that checking the nosocomial pneumonia infection rate in groups of patients on mechanical ventilation is more complex because of ICU mortality and length of time on ventilators. "Those measures generally require large numbers of patients to be significant," McCaffree says. "Otherwise, you fall into the tyranny of small numbers."

But an ICU may have only 5 patients with a disease that claims 2000 patients nationwide. "If 2 of those patients die," McCaffree says, "it becomes a matter of knowing whether your 40% mortality rate is significant in comparison with the national 2% mortality rate. Then you have to start stratifying patients."

Linking Quality of Care to Paycheck Works

Basing financial rewards on performance is hardly a new idea. It is, however, one that seems to be spreading rapidly across the health care horizon. In the past few months, Harvard Pilgrim of Boston, Blue Cross of California, and other HMOs began offering pay bonuses based on patient satisfaction and other quality standards to physicians who attend to their members.

Borges Medical Center in Kalamazoo, Mich, began tying money to quality improvement several years ago using goal-setting and outcomes-based measurements to determine financial rewards. Cindy L. Harvey, RN, MSN, Borges’ director of quality improvement, says her institution uses annual goal setting as a dual incentive/quality improvement tool. "We have a number of clinical excellence goals for the coming year," Harvey says. "All the senior leadership has those goals and they cascade through all levels of staff."

Borges’ physicians, nurses, and staff members work on goal teams set up by type of patient illness/care. Each team writes a list of goals at the beginning of the year targeting desired outcomes improvements and setting a minimum achievement level. At the end of the year, the percentage of the allowable pay raise team members can receive is determined by the number of goals the team achieves, with everyone on the team receiving the same score.

Achieving or exceeding the goal translates into a certain percentage of salary increase for the following year. "We’re finding that people do very well on the goals because they want to get their raises," Harvey says. Harvey says one specific Borges goal for critical care this year is improving outcomes of vent-assisted DRG 475 (diagnostic related group) cases. The critical care team began by stating the current rate per 1000 vent days, then set the lower rate desired and the rate at which the goal will be considered to have been exceeded. "Everyone on the DRG 475 team has the same financial incentive to achieve the goal," Harvey says. "We all sink or swim together."

Borges harvests its own outcomes databases to determine what issues need the most work, using any type of data available. "The task is choosing where you focus your efforts," Harvey says. "You can only have so many incentive goals—the challenge is to prioritize."