How managing the quality cycle can help the healthcare industry provide superior care now and in the future
Written by Susan DeVore
As an industry, healthcare is fraught with risks. Every therapeutic decision has a ripple effect on an individual’s life and livelihood, and there are risks associated with negative outcomes. Providers who make the clinical decisions are exposed to liability risk. By their nature, clinical encounters generate volumes of sensitive information, introducing the risk of potential data breaches. And increasingly, providers are being held accountable for quality outcomes and the total cost of the care they provide, presenting them with new levels of financial risk.
Although data security and liability concerns are longstanding challenges that many healthcare providers have extensive experience managing, performance-based reimbursement is a relatively new phenomenon. Largely ushered in by the Affordable Care Act, there are at least 10 separate federal programs that require public reporting, in many cases tying reimbursement directly to outcomes.
While the overarching goal of these programs is advantageous to consumers who have long sought transparent data to hold providers accountable for quality, these programs are challenging to implement because the list of measures grows every year. Moreover, not only does poor performance carry specific payment penalties of up to six percent of Medicare revenue, but the public disclosure of this data means that consumers also may use it to make decisions about their provider of choice.
Central to success in this environment is a holistic approach to performance measurement, with well-defined metrics, a firm culture of accountability, and deep executive engagement. In essence, providers need tools to manage their quality cycle as fervently as they do their revenue cycle, lines that become increasingly blurred as more and more outcomes measures tie to payment.
To effectively manage the quality cycle, providers need real, actionable intelligence on their performance across a range of measures down to the individual physician level. This may seem easy enough to do in an era of big data and electronic medical records, but it’s far more of a challenge than it would seem on the surface.
For one, electronic medical records systems are proprietary, and up to 95 percent of providers report that interoperability across systems is a major challenge. So, for a hospital, pulling outcomes data across affiliated physician practices, all of which use a different vendor’s systems, can become a frustrating and complicated exercise.
Moreover, it can be difficult to extract data from medical records because there are few common standards for documentation, and many terms vary in their meaning. The quality of the data may also be an issue, particularly across different sites, practices or organizations. And lastly, many measures require a manual review of the record, using expert staff to interpret findings and determine whether a particular care process was conducted or not. Accordingly, the quality cycle is much more labor intensive than the revenue cycle to manage, since in the latter, it’s common practice to standardize around common accounting processes, terms, and billing technologies.
Another challenge within this era of accountability is presented by the nature of the measures themselves. Each of the federal programs evaluating performance uses a unique set of measures that may overlap or, in some cases, conflict with one another. Commercial insurers may layer on additional pay-for-performance programs that include homegrown measures or differing methodologies for calculation, all of which adds more complexity. Tracking measures quickly becomes an additional work stream for health systems focused on the care process. As one physician recently remarked to me, “I spend more time doctoring to the charts and the measures than I do doctoring to the patient.”
In addition, quality cycle management isn’t just about measuring where you are today; it’s about anticipating where you will be tomorrow as measures evolve and the amount of at-risk revenue increases for a healthcare system. In several of the pay-for-performance programs, penalties are assessed to the bottom quartile of participants. In other words, Health System A may rank as a top performer in 2015, but if all providers nationwide improve dramatically and Health System A doesn’t keep pace, they could easily find themselves in the bottom quartile and subject to penalties the next year. As such, quality cycle management is much more of a marathon than a sprint. It’s a continual process that demands ever higher levels of performance in order to remain out of the penalty box.
Mitigating all of these risks is contingent upon a few success factors. The first is focus. We need a national strategy for measurement to avoid a proliferation of competing and contradictory measures that place an unnecessary burden on providers and result in only limited utility for consumers. To get there, federal policy is needed to develop and test measures to determine if they are valued and understood by consumers, as well as their ability to assess functional health, risk, patient experience, and total costs.
Only after measures are proven should they be used in the commercial and federal pay-for-performance programs. In following a more deliberate course, we can be assured that measures in all pay-for-performance programs work toward a consistent goal, across the care continuum, to incent the better patient outcomes we desire. Simply put, the old model of defining metrics because “the data is available” must give way to a longer-term and patient-centered approach.
The second change is cultural, demanding an ever-upward focus on quality improvement. Measurement is not enough; change comes through focused action and a culture of high accountability. Yes, measures must matter, but so, too, must process and ownership. No competent health system leader would leave to chance the management of hospital revenue and proceed without a clear process of measurement and accountability. It is becoming increasingly clear that the same can be said of managing the cycle of quality within the organization going forward.
Lastly, fostering the right level of executive engagement in quality improvement is important. An essential tenet of effective quality cycle management is providing healthcare executives with an optimal level of visibility across their quality performance measures and translating that into actionable information they can use to make management decisions. This requires more than just a “data dump” of performance measures. Instead, information needs to be parsed to uncover root causes that can be acted upon.
Becoming a “high-accountability organization” is not an easy task, nor can it be accomplished without significant investment. But only within a culture of high accountability can consistently excellent care be delivered to patients and families. Pay-for-performance programs are moving us in the right direction by aligning the incentives for a greater focus on outcomes. But with those incentives come risks that must be managed with the tools and discipline that total quality management can deliver.
Author Biography:
Susan DeVore is President and CEO of Premier, Inc., a leading healthcare improvement company. With approximately 30 years of experience, Susan is an industry-leading thinker who has been named to Modern Healthcare’s 100 Most Influential People in Healthcare and Top 25 Women in Healthcare lists. Under her leadership, Premier has been recognized for building an industry-leading code of ethics, has been named eight times as one of the World’s Most Ethical Companies by Ethisphere, won the Malcolm Baldrige National Quality Award, and has been named four times to the InformationWeek 500 list of the top technology innovators in the nation.
