Some hos­pi­tals say the pro­posed new mea­sures will be tough to im­ple­ment

Modern Healthcare - - Cover Story -

Aslew of newly pro­posed qual­ity mea­sures have providers clam­or­ing for clar­i­fi­ca­tion and won­der­ing about the bur­dens that ad­di­tional re­port­ing re­quire­ments may place on their or­ga­ni­za­tions.

The CMS in­cluded the new mea­sures for its Re­port­ing Hos­pi­tal Qual­ity Data for An­nual Pay­ment Update pro­gram in its pro­posed changes to the in­pa­tient prospec­tive pay­ment sys­tem, pub­lished April 19 (See re­lated story, p. 10). If the rule is fi­nal­ized, hos­pi­tals will be re­quired in Jan­uary 2011 to be­gin re­port­ing on 10 ad­di­tional mea­sures to re­ceive the full mar­ket­bas­ket update for 2012.

Eight of those new mea­sures are from the agency’s list of hos­pi­tal-acquired con­di­tions and the two re­main­ing mea­sures are pa­tientsafety in­di­ca­tors from the Agency for Health­care Re­search and Qual­ity (See chart). The CMS also pro­posed delet­ing one mea­sure—mor­tal­ity for se­lected sur­gi­cal pro­ce­dures (com­pos­ite) — which would bring the to­tal num­ber of mea­sures re­quired for the full 2012 update to 55.

The pro­posal from the CMS at­tracted some crit­i­cism over the mea­sures it se­lected.

“We em­brace re­port­ing and be­ing mea­sured for the care we pro­vide to our pa­tients, but a lot of these mea­sures are weakly linked to sci­ence and are sub­ject to a lot of vari­a­tion,” said Alex Hover, se­nior vice pres­i­dent of clin­i­cal ex­cel­lence at St. John’s Health Sys­tem, a six-hos­pi­tal sys­tem in Spring­field, Mo. “We’re go­ing to need a lot of clar­i­fi­ca­tion.”

For in­stance, Hover said, the CMS’ pro­posed re­quire­ment that hos­pi­tals re­port all falls that re­sult in mi­nor in­jury could prove dif­fi­cult with­out clearly out­lined pa­ram­e­ters.

Some called for elab­o­ra­tion from the CMS. Re­port­ing re­quire­ments on man­i­fes­ta­tions of poor glycemic con­trol should be made clearer be­cause con­trol is af­fected by many dif­fer­ent fac­tors, said Shawn Stin­son, vice pres­i­dent of clin­i­cal qual­ity and pa­tient safety at Palmetto Health, a three-hos­pi­tal sys­tem based in Columbia, S.C. “Glu­cose con­trol de­pends on Among the re­port­ing mea­sures is one on for­eign ob­jects re­tained af­ter surgery. co-mor­bidi­ties and sever­ity of ill­ness, and while we have spe­cific blood sugar tar­gets for some con­di­tions, we don’t for oth­ers,” he said. “When you start to tighten con­trol, it can re­sult in an in­creased num­ber of hy­po­glycemic events, which can be even more dan­ger­ous.”

Stin­son said he will also be look­ing care­fully to see how the CMS han­dles re­port­ing of deep vein throm­bo­sis. Specif­i­cally, he said he is hop­ing to see a method to in­di­cate whether all steps of care were prop­erly fol­lowed. “Some­times we can do ev­ery­thing right and a pa­tient will still have a DVT,” he said. “We need to be able to re­port that.”

And the qual­ity changes may not stop with the 10 new pro­posed mea­sures. The CMS is propos­ing 35 more mea­sures that providers would need to be­gin re­port­ing on in 2011, but which would not be used in de­ter­min­ing an­nual pay­ment update un­til 2013. Most of the data on those qual­ity mea­sures would come from reg­istries.

For in­stance, 15 mea­sures re­lated to car­diac surgery, in­clud­ing post-op­er­a­tive re­nal fail­ure and beta block­ade at dis­charge, would come from a car­diac surgery registry. The pro­posed changes also in­clude registry-based mea­sures for stroke care and nurs­ing sen­si­tive care.

Ad­di­tion­ally, the CMS pro­posed four more mea­sures—two re­lated to emer­gency depart­ment through­put and two re­lated to im­mu­niza­tions for re­port­ing in 2012 that would be used for 2014’s an­nual pay­ment update.

Fi­nally, the agency also in­cluded 28 other mea­sures that would not be re­quired for re­port­ing, but would likely be used in fu­ture rule­mak­ing.

The steep vol­ume of the changes also caught the at­ten­tion of qual­ity ex­perts. “The real con­cern for us is how they are go­ing to take this on­slaught of new data and use it to drive bet­ter per­for­mance,” said Nancy Fos­ter, vice pres­i­dent for qual­ity and pa­tient safety for the Amer­i­can Hos­pi­tal As­so­ci­a­tion. “Are these re­ally the right mea­sures? Do they have the ca­pac­ity to drive im­prove­ment? I don’t think we know that, and it’s also pos­si­ble CMS could get bet­ter re­sults with a leaner set of mea­sures.”

An­other worry is the pro­posed rule’s re­liance on registry-based re­port­ing, said Blair Childs, spokesman for the group-pur­chas­ing and qual­ity-im­prove­ment or­ga­ni­za­tion Premier. Many providers al­ready sub­mit qual­ity data to reg­istries such as the So­ci­ety of Tho­racic Sur­geons’ Adult Car­diac Surgery Data­base or the Amer­i­can Heart As­so­ci­a­tion’s Na­tional Registry of Car­dioPul­monary Re­sus­ci­ta­tion, and that par­tic­i­pa­tion is a good thing, Childs said.

The prob­lem, he ar­gued, is a govern­ment man­date that re­quires providers to par­tic­i­pate in pro­pri­etary pro­grams—a pol­icy that would re­sult in “govern­ment-cre­ated mo­nop­o­lies,” he said. Some hos­pi­tals have data ware­houses that en­able them to ac­cess qual­ity data for these mea­sures, he said, but un­der the pro­posed rule and with­out ac­cess to the right al­go­rithms, they would still be ob­li­gated to sub­mit to reg­istries.

“There are ter­rific reg­istries out there, and I’m glad that hos­pi­tals who want to par­tic­i­pate have the op­tion to do it,” Childs said. “The is­sue is that hos­pi­tals shouldn’t be forced to do it as part of pub­lic pol­icy.”

For most hos­pi­tals, the ad­di­tional re­port­ing

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