To pro­vide bet­ter-qual­ity care, let’s mea­sure what re­ally matters, not what’s easy

Modern Healthcare - - Comment - By Dr. Cather­ine Ma­cLean

If “qual­ity” is the most im­por­tant thing we pro­vide in health­care, I be­lieve the way we mea­sure it is equally im­por­tant. But I also know that be­lief and prac­tice are very dif­fer­ent things. To­day, met­rics of con­ve­nience con­tinue to win out over mea­sures that truly mat­ter, blur­ring our view into how true qual­ity in care is evolv­ing—or if it is evolv­ing at all.

There is an ur­gent need to put bet­ter qual­ity mea­sures into prac­tice.

A newly re­leased study in the New Eng­land Jour­nal of Medicine by the Amer­i­can Col­lege of Physi­cians’ Per­for­mance Mea­sure­ment Com­mit­tee found there are se­ri­ous flaws in physi­cian per­for­mance met­rics. Of 86 per­for­mance mea­sures as­sessed, only 37% were found to be valid. Bad mea­sures are a waste of time and money—and worse, they can be harm­ful to pa­tients.

U.S. physi­cian prac­tices spend, on av­er­age, more than $15.4 bil­lion and 785 hours per physi­cian re­port­ing qual­ity mea­sures each year. That’s over $40,000 per physi­cian per year, and more than the cur­rent bud­get re­quest for the In­ter­nal Rev­enue Ser­vice in the ag­gre­gate. But what are we mea­sur­ing through those ef­forts?

Met­rics of con­ve­nience—like ones based on easy-to-col­lect ad­min­is­tra­tive data—have be­come stan­dard due to pres­sures for “more mea­sures” while re­duc­ing the “bur­den” on the delivery sys­tem. While they may be accurate, they of­ten do not mea­sure what’s most im­por­tant in terms of im­prov­ing health and achiev­ing pa­tient safety goals— and the cur­rent ap­proach is in­deed bur­den­some to the delivery sys­tem.

Qual­ity re­port­ing should fa­cil­i­tate qual­ity im­prove­ment ac­tiv­i­ties within the care delivery sys­tem and af­ford trans­parency to con­sumers so they can select high-qual­ity providers or avoid low-qual­ity providers. Some qual­ity re­port­ing sys­tems do nei­ther. For ex­am­ple, while the CMS’ “five-star” hospi­tal rat­ings sys­tem is a wor­thy con­cept, the roll-up scores across con­di­tions and pro­ce­dures end up ob­scur­ing qual­ity at the level of the con­di­tion or pro­ce­dure— ex­actly where we could make sig­nif­i­cant gains in qual­ity.

An­other prob­lem is the scale we use for re­port­ing. In the U.S., the health­care in­dus­try gen­er­ally mea­sures qual­ity on a rel­a­tive scale. For ex­am­ple, it looks at the num­ber of com­pli­ca­tions at a hospi­tal com­pared with the num­ber of com­pli­ca­tions at other hos­pi­tals. In this rating sys­tem, half of hos­pi­tals will al­ways be rated as bet­ter than the other half—re­gard­less of whether any or all of the hos­pi­tals are per­form­ing at a level that would be con­sid­ered high qual­ity.

In con­trast, the Na­tional High­way Traf­fic Safety Ad­min­is­tra­tion mea­sures new-car safety on an ab­so­lute scale, mean­ing it looks at a car’s safety against a set stan­dard—not against an­other car’s per­for­mance. The NHTSA has de­fined a set of mean­ing­ful safety stan­dards and re­ports whether or not they are met. Car­mak­ers strive to achieve these goals, and con­sumers fac­tor these rat­ings into pur­chase de­ci­sions. This rating sys­tem has helped im­prove auto man­u­fac­tur­ing qual­ity im­mensely, mak­ing to­day’s cars the safest in his­tory.

Defin­ing health­care qual­ity in terms of mean­ing­ful mea­sures that pro­mote health will not be quick or easy. We’ve seen this in our own re­search at the Hospi­tal for Spe­cial Surgery, where we iden­ti­fied a need for greater con­sen­sus around stan­dard­iz­ing meth­ods used to cal­cu­late pa­tient-re­ported out­come mea­sures for hip and knee re­place­ments. The rea­son? Even though most would agree that pa­tient-re­ported out­comes should be key per­for­mance met­rics, the cal­cu­lated scores var­ied sig­nif­i­cantly depend­ing on which method was ap­plied.

Thought­ful work is needed to sort out how mean­ing­ful mea­sures in health­care should be used to as­sess qual­ity. Qual­ity mea­sure­ment should be an in­te­gral part of real-time care delivery. Let’s re­di­rect the cur­rent ad­min­is­tra­tive costs to col­lect mea­sures that mat­ter and reimag­ine care delivery ac­tiv­i­ties that in­clude rou­tine col­lec­tion and re­port­ing of mea­sures that mat­ter at the point of ser­vice.

By re­fo­cus­ing on mea­sures that truly mat­ter to­day, we have a defin­ing mo­ment to make mea­sur­ing qual­ity more mean­ing­ful and be of greater ser­vice to our pa­tients—now and far into the fu­ture.

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Dr. Cather­ine Ma­cLean is chief value med­i­cal of­fi­cer at the Hospi­tal for Spe­cial Surgery in New York City and chair of the Amer­i­can Col­lege of Physi­cians’ Per­for­mance Mea­sure­ment Com­mit­tee.

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