More alignment of measures on horizon — but not soon enough for many QPs
Slight differences in many measures causes 'waste and inefficiency'
When performance measures required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare & Medicaid Services (CMS) were completely aligned, many quality professionals breathed a sign of relief. Staff no longer had to collect data for two different measurement sets. But for many in the quality field, non-harmonization of measures is still a major headache.
Many hospitals report quality data to dozens of different entities in addition to CMS and JCAHO, including state organizations, QIO data warehouses, health insurers, vendors, and others. In many cases, measures are very similar but not identical. "It is really getting difficult with the data demands and the multiple and sometimes contradictory reports," says Joanne Lee, director of case management and quality improvement at Sacred Heart Hospital in Allentown, PA.
For example, in addition to CMS and JCAHO requirements, the hospital is required by the state to report demographic and clinical data to the Pennsylvania Health Care Cost Containment Council on a quarterly basis on mortality, readmissions within 31 days, infections, length of stay, and charges.
"What I see happening right now is that data are getting reported in various formats. This is confusing to both hospitals and consumers," says Lee. "I am currently seeing this with the core measures versus the JCAHO ORYX reports. They have the same numbers, yet the reports do not look a bit alike and almost appear contradictory at times."
Measures that are slightly different mean that data have to be collected twice or several times. "There is always just a little bit of difference, but the bottom line is, it's the same patient," says Jerod M. Loeb, PhD, JCAHO's executive vice president for research. "It really does represent incredible duplication of efforts, and you can read that as waste and inefficiency from the hospital's perspective."
The goal is to collect data once in a standardized manner to be used by any entity that needs it for whatever purpose, whether accountability, public reporting, or pay for performance. "The word of the day is harmonization," says Loeb. "The thing we're all looking to avoid is chaos. The key message here is that we understand the problem, and we are all working together now to address this."
Added to the problem is data being presented through various companies, based mostly on claims or public data which is usually several years old, says Lee. "Worse than the redundant data collection is the redundant data analysis that QI departments must do when these reports are published," says Lee. "I believe that optimal organizational quality can only be achieved through integration — and that includes data integration."
Efforts are in the works to reduce redundant data collection. The AQA alliance/Hospital Quality Alliance steering committee, formed to better coordinate quality measurement and transparency programs pertaining to hospitals, physicians, and other health care providers, now has a measure harmonization workgroup. The group is looking at various physician and hospital measures that address the same aspect of quality, such as health care-acquired infections, but have slightly different measure specifications.
"Where alignment of specifications and definitions is desirable to reduce burden and produce more actionable information for quality improvement purposes, the workgroup is facilitating discussions between the various measurement stewards to achieve harmonization," according to Janet M. Corrigan, PhD, MBA, chair of the measure harmonization workgroup and president and CEO of the Washington, D.C.-based National Quality Forum.
The workgroup already has identified alignment of measures that can be accomplished over the next three to six months, as well as longer-term alignment to occur over the next 18 to 24 months.
For instance, definitions were aligned for the terms used in the numerators of the smoking cessation measures that mean essentially the same thing across the various hospital and ambulatory measures, including "intervention," "strategy," "medication," and "advice or counseling." In the longer term, to harmonize with the outpatient approach, CMS and JCAHO have discussed developing a measure on smoking cessation that would include all hospitalized patients.
"As hospital- and physician-level measurement continues to evolve and mature, quality professionals will benefit most from this alignment activity occurring as early in the process as possible," says Corrigan.
However, having a multitude of measures specified differently has been a significant problem for some time and will not be solved quickly. In the short term, there will be modifications made to some measures to bring them into better alignment, but significant changes are also coming.
"The harmonization effort is trying to ask, 'How do we fix a problem looking backwards, which was created by siloed efforts?'" says Loeb. "There is easy stuff that can be done very quickly and harder stuff that will take a lot of complex thought and negotiation."
The concept of harmonization transcends the hospital setting and is being looked at across the continuum of care. "What has happened is, as the hospital and ambulatory arenas have both blossomed in measurement, in many cases the same clinical condition is being addressed," says Loeb. "The problem is that the patient doesn't really care what setting he or she is in — they are looking for good care, and we are looking to measure the quality of care." He gives the example of heart failure, which is treated in both the acute care and ambulatory setting.
For real progress to occur, there will need to be some compromise. "Ultimately, there is no perfect measure. At the end of the day, somebody is going to have to say, you know, it's probably okay to leave it like this even if that means we have to retrofit something," says Loeb. "The argument is often 'Don't make me change this because it will cost money.' But if you don't change it, the money being wasted right now is going to continue to pour down the drain. It's more costly not to change it."
A second dilemma is how to avoid this problem in the future, as new measures continue to be developed by various groups. When measures are developed, a single expert panel representing the whole continuum of care needs to be involved, as opposed to "dueling expert" panels for ambulatory and inpatient care, says Loeb. "That is a whole separate issue, to make sure that we don't create more of the problem downstream," he says. "We need to be sure that any future expert panels are appropriate for presentation to all the relevant parties."
What you can do now
Clearly, alignment of existing quality measures is going to take time to sort out. In the meantime, some quality professionals are developing tools to present these data more clearly to administrators. "Quality's role is to analyze and present these multiple formats to the hospital and medical staff and explain the differences," says Lee.
To do this more effectively, Lee is developing an external data report card showing requirements of the various agencies, the hospital's rates, and the actual format that the data are reported on by these multiple agencies, to present to the hospital's medical executive and quality committees. "I hope that it gives hospital and medical leadership an overview of our performance, indicating the areas that we excel in and those areas that we need to focus on," says Lee. "Our data are used by at least six agencies that we know of."
In addition to the CMS and JCAHO measures, Lee is including data from the New Jersey Quality Report in her report card. "I have a section that compares our state data to the state and region averages, by diagnosis," she says. "I also have data from a third party payer that includes core measure compliance as well as specific quality indicators. Again, I compare our results to their state and national network numbers."
Right now, the smartest thing for quality professionals to do is prepare for the measures "coming down the pike" that you'll soon be required to report, advises Denise Remus, RN, PhD, vice president for clinical informatics of Premier Inc., based in Charlotte, NC.
"One of the best gauges for measures that will be used nationally is to watch the work of the Hospital Quality Alliance," Remus says.
The Deficit Reduction Act of 2005 requires CMS to implement a value-based purchasing plan beginning fiscal year 2009, and commercial payers already are linking payment to quality in regional and national initiatives, notes Remus. "Hospitals need to be focused on increasing their quality, not only to better serve their communities, but to adhere to government legislation," says Remus. "The current health plan environment includes more consumer-directed health plans and increasing accountability. The current quality measures only cover a small subset of inpatient services, so additional measures are being encouraged."
She points to initiatives like the Surgical Care Improvement Project and the Hospital Care Quality Information from the Consumer Perspective Survey, which will broaden the quality information available to purchasers, payers, and consumers.
But quality professionals should consider going a step further and actually become involved in the research activities and review of proposed new P4P measures, advises Remus. "There are several opportunities for input into national policy and measurement programs," she says. She recommends the following:
- Pay attention to calls for public comment from JCAHO, CMS, and NQF. These organizations often issue requests for comment in response to proposed measure sets and proposed rules.
- Serve as a member of a technical advisory panel or committee.
- Shadow P4P projects such as the CMS/Premier Inc. Hospital Quality Incentive Demonstration, the first national project of its kind designed to determine if economic incentives to hospitals are effective at improving the quality of inpatient care. "In this instance, inclusion in the project is no longer available and they won't be eligible to obtain reimbursement from CMS," says Remus. "But any hospital can shadow the project as if they were participating, and gain valuable insights and information from over 250 participating hospitals regarding P4P."
Quality professionals have an opportunity to not only proactively scan the national environment regarding new measures, standards and practices, but directly impact the overall outcome by consistently responding on behalf of their organizations when public comment or hospital-specific feedback is requested, says Cheri Throop, RN, MHSA, RHIT, CPHQ, director of measures, standards and practices at the Texas Medical Institute of Technology.
This means organizations already have assessed their key strategic priorities, populations served, and percentage of those included within their approved standardized care guidelines or pathways, says Throop.
Always provide comments or feedback to national organizations' request for public comment as it relates to your organization's strategic priorities and impact to populations served, advises Throop.
"Embed nationally endorsed or approved measures into your hospital's existing performance improvement program as a proactive approach ahead of a national requirement," recommends Throop.
"You can also strategically launch or re-energize improvement strategies focused on care systems in these particular areas," Throop says. "This helps the organization move from focusing on measuring and monitoring, to meeting requirements for proactive care management."
Along with providing feedback when measures or standards are being field-tested, consider participating in regional, state, national, or systemwide collaborative initiatives focused on improving quality and reducing harm. "The output from these efforts includes standardized measures with targets for improvement," says Throop. Many of these measures ultimately are submitted to national organizations for their consideration for endorsement or approval.
"Take advantage of opportunities to engage in research activities offered by organizations as a field-tester or testbed," says Throop. "Hospitals engaging in these activities have a head start on what may ultimately be required."
[For more information, contact;
Joanne Lee, Director, Case Management/Quality Improvement, Sacred Heart Hospital, 421 Chew St., Allentown, PA 18102. Telephone: (610) 776-4886. E-mail: jlee@SHH.ORG.
Cheri Throop, RN, MHSA, RHIT, CPHQ, Director, Measures, Standards & Practices, TMIT. Telephone: (816) 283-3622. E-mail: cheri_throop@tmit1.org. Web: www.safetyleaders.org]