Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

Creating Constructive Urgency Around Quality Metrics

6/7/2016 3:08:02 PM | 5 comments

A very respected hospital in my region recently asked CEP America to take over its hospitalist program. Their existing group had been there for 20 years, but lately they hadn't been hitting their quality benchmarks. Administrators were frustrated. "We tried to help," they said. "They don't listen."
 
I met with the hospitalists. They seemed like caring, competent professionals who took very good care of their patients. Nurses kept telling me how wonderful the doctors were. What was going on?
 
Finally I met the head of the group. When the subject of quality came up, a cloud crossed his face.
 
"Core measures," he said. "They’re silly. Maybe they matter to the hospital, but they certainly don't matter to us."
 
It was like I'd stepped back 20 years in time. But he's certainly not the only physician who feels this way.
 
Quality? Bah Humbug.
 
Making quality measures relevant is a perennial headache for healthcare leaders.
 
Four years into healthcare reform, many providers still feel little urgency around quality improvement. When pressed, they say things like:
 
  • There's little to no correlation between clinical quality measures and great care.
  • Patient satisfaction is counterproductive. Patients don't know what care is best for them.
  • Because I care about my patients, I refuse to practice "cookbook medicine."
  • Administrators/legislators/bureaucrats shouldn't be telling clinicians how to practice medicine.
 
The irony is that clinicians have a lot to gain from quality programs. As leaders, we need to show them what's in it for them. Here's a cheat sheet to help you deliver the right messages through optimal channels.
 
1. Cultivate champions who can help spread your message.
 
Healthcare reform is all about asking people to go beyond their training and perform tasks they might not be expert at. Such requests are always a tough sell.
 
I recall a quality initiative in which I was practically turning backflips trying to gain buy-in from the nursing staff. "Whatever, doc," I imagined them thinking. "Don't tell nurses how to do their jobs. You're probably just asking us to do this so the physicians can make more money, right?"
 
Then our Practice Management Consultant (who was a RN) arrived. She explained the rationale for the project using virtually the same words I had. But because she was a nurse, credibility was on her side. Within minutes, the majority of the nurses were on board.
 
Whether you're an administrator or clinical leader, cultivating likeminded "champions" pays off. Clinicians will generally be more receptive to messages that are voiced and backed by one of their own.
 
2. Quality equals job security.
 
If hospital-based providers want to continue working and hold onto their contracts, the hospital needs to survive. In this era of ever-shrinking hospital profit margins, that means maximizing outcomes while containing costs.
 
Some facts to drive home the gravity of the situation:
 
  • These days, 2 percent is a good profit margin for a hospital. At those margins, little things make a big difference.
  • If every inpatient in a 400-bed hospital stays half a day longer than necessary, the hospital loses 200 days worth of patient care costs. That could add up to tens of millions of dollars per year.
  • If a provider doesn't document all of a patient's comorbidities, the hospital will get paid for only a fraction of what they otherwise would have received for the hospitalization. If that patient subsequently dies in the hospital, they might get inappropriately dinged for an unexpected death. This is publicly reported information.
 
When it comes to value-based reimbursement, relatively small missteps can put a hospital in the red and harm their reputation. When physicians and groups take quality metrics seriously and work with the hospital to improve them, they become an asset to administrators — and their contract security skyrockets.
 
3. Perfect shouldn't be the enemy of good.
 
Many providers resist quality initiatives by playing the validity card. They argue that the measures they're accountable for don't relate logically to outcomes. They may go the extra mile and insist that the measures actually hurt patient care.
 
Whoa. Let's step back.
 
It's true that no metric can be universally applicable. However, CMS metrics are chosen by a panel of clinical experts to represent the lowest common denominator of quality care.
 
They're also evidence based. It's demonstrable that septic patients generally do better when they receive aggressive fluid hydration and early, appropriate antibiotics. They do significantly better when we eliminate unnecessary tests that could expose them to discomfort, higher costs, and potentially harm them. Providers need to realize that if they do what’s best for their patients, they're already going to be in compliance with the quality measures the overwhelming majority of the time.
 
4. Numbers matter to patients.
 
Hospitals that perform well on quality metrics aren't necessarily superior to those that perform poorly. Scores are often based on a relatively small number of cases. A hospital that forgets to give aspirin to a couple of its heart attack patients may still be a great hospital.
 
As healthcare professionals, we know this. But imagine that an acquaintance of yours needs a hip replacement. She checks Hospital Compare to see how the local hospitals stack up on surgical quality.
 
As a layperson, she's not thinking about validity and correlation and clinical significance. If a hospital's quality numbers don't stack up to the competition, she's going to assume it's inferior and cross it off her list.
 
Providers want to work at hospitals that have great reputations. They'll have more patients, more reimbursement, and their jobs will be more secure. And fairly or not, hospital reputation is increasingly tied to quality scores.
 
5. Hospital quality bolsters provider quality.
 
If quality metrics don't tell the whole story about a hospital, they probably tell even less about an individual provider.
 
Many providers have seen their PQRS scores vary wildly between reporting periods. And the current metrics don't encompass several key physician competencies (e.g., diagnostic ability).
 
That being said, physicians need to care about quality for the same reason hospitals do. Soon patients will be able to compare physician quality scores online.
 
It's also feasible that physician quality scores could impact career advancement and even malpractice risk. A doctor with low quality scores might be more difficult to defend, even if the scores have nothing to do with the case.
 
Here's the rub: for hospital-based providers, quality scores probably depend more on organizational processes than individual efforts. A good provider is going to be at a disadvantage in a dysfunctional system. Conversely, when hospital quality rises, it tends to help the lower-functioning providers the most.
 
6. Clinical pathways aren't "cookbook" medicine.
 
Each clinical case has unique considerations. Quality doesn't mean prescribing a cookie-cutter solution. It means having the basics in place so the provider can focus on the details.
 
Say an ED patient screens positive for sepsis. The provider clicks a single box in the EMR. The requisite fluids, antibiotics, and labs are instantly ordered — despite the fact that it's extremely busy and the provider just ran a code.
 
Building standardization into the system provides a safety net so that busy docs working in chaotic environments with frequent interruptions don’t miss basic things while freeing up the provider to attend to any unusual aspects of the case. That's not cookbook medicine. It's common sense.
 
7. Deep down, we all want satisfied patients.
 
When providers question the relevance of patient satisfaction metrics, I walk them through this exercise.
 
Think about a day you came to work, and your patients had already been waiting six hours to be seen before you arrived. They vented their anger and frustrations at you — despite the fact that you just came in early or on your day off to help them.
 
The problems weren't your fault. Maybe your department's processes were inefficient or ineffective. But the patient couldn't see that. They were in pain and having one of the worst days of their lives. And as a representative of your department and hospital, they were taking it out on you.
 
It's no surprise that there's an almost universal correlation between patient satisfaction and provider and nurse satisfaction. Most of us went into healthcare to help people. It's meaningful when a patient says, "Wow, thanks! You saved my life." It reinforces why we became healthcare providers.
 
I end with patient satisfaction, because I think it's the common theme that runs through all of these suggestions.
 
At the end of the day, what's best for the patients is generally what's also good for providers and hospitals. As you lead change, keep this idea at the center of your intentions and interactions. The results may surprise you.


Comments
David Birdsall
Great article Jeff. It really brings home the importance of the metrics. I think your advice will help our site leadership convince all med staff docs to get on the quality train.
6/13/2016 8:03:48 AM

Cyndy Flores
Thanks Jeff - great way to bring it back around as to the "why"
6/10/2016 8:31:57 PM

Dan Culhane
Great comments Jeff. I agree with all of your points.
6/8/2016 9:56:15 AM

Jon Brummond
Wow!!! Excellent insight concisely presented. Will be passing this along.
Thanks for contributing.
6/8/2016 9:22:09 AM

Rick Newell
Thanks for sharing. Great Piece Jeff!
6/8/2016 9:06:34 AM