Is an outcomes-based approach the best?
Surgical collaborative moving in that direction
An ongoing study of nearly 200 hospitals in a collaborative sponsored by the American College of Surgeons (ACS) appears to make a strong argument for outcomes-based QI programs such as the National Surgical Quality Improvement Program (NSQIP), described in an article published in the September issue of the Annals of Surgery.1 The results of the study showed that morbidity rates improved for 82% of the participants and mortality rates improved for 66% of the participants.
"NSQIP is a quality program that targets surgery, and the unique aspect is that it uses clinical data as opposed to administrative or claims data, and it is risk-adjusted with clinical data; that works a lot better to do the risk adjustment than claims data," explains Clifford Y. Ko, MD, MS, MSHS, FACS, director of the ACS division of research and optimal patient care, and one of the article's authors. "It is outcomes-based rather than process-based. Finally, within the program, there is data feedback to help target where improvement should happen and expertise providing guidelines, and case studies as well, so you can learn how others decrease length of stay, improve efficiency, and so forth."
Outcome vs. process
Ko notes that with a process-based approach, the belief is that, "if everyone can think of the right things to do and we all do them, that's good quality care." In an outcomes-based approach, he explains, "You send people to facilities that have good outcomes; it does not matter how many patients they see." This runs contrary to some current thinking that, for example, hospitals that perform the greatest number of open-heart surgeries are likely to have the best outcomes.
"The real kicker is that we found — and others are starting to report — that there's a lack of correlation between processes and quality," says Ko. "A lot our strategies are based on process — like giving aspirin and beta blockers. But we've started to find in surgery, for example, that there are a number of process measures like prophylactic antibiotics within an hour of surgery that have little or no correlation to outcomes. In other words, you'd expect those who are 99% compliant to have better outcomes than those that are 55% compliance, but there's not necessarily a correlation."
That doesn't mean, he emphasizes, that you should throw out process measures. "What probably happens is that we identify maybe five or six of the most important things to do, but there may be another 10, 20, 30, or 50 important things you have to do to get, for example, the rate of infections down. What has happened is that we are 'studying for the test' — the things on which we are measured, for example, for pay for performance. But we are not targeting other things that are important; we lose the big picture, which is helping patients with outcomes."
Improve processes?
Ironically, Ko says that once you learn that your outcomes are not as good as you'd like them to be, "You get better by improving processes." However, he adds, "It should not be just the six things; it may be 50 things."
It's up to each facility, he continues, to figure out what it's good at and what it is not good at, and how to improve. "The best way to do QI is to find out what went wrong and the best way to fix it in your hospital," he says. The case studies and guidelines provided by NSQIP, he notes, are designed to help hospitals do just that.
The key, he explains, is to maintain balance. For example, while many preach standardization, he is opposed to what he calls "cookbook" medicine. "Everything in moderation; you can't have the wild wild West, but you can't standardize everything," he asserts.
The same holds true, he continues, for tools such as Lean methodology. "Virginia Mason is one of the most advanced facilities when it comes to Lean methodology — it's amazing to see them," he says. "There are certain things to take from them — getting everyone on board and having that kind of culture is all great, but you have to tailor it to your medicine and your setting. Not all cultures or resources are the same."
In an effort to achieve that balance, ACS is now working with the Centers for Medicare & Medicaid Services (CMS). "The process way to improvement is the way CMS has done incentivized programs, but we are working on a contract with them to develop more outcomes measures," he shares. "We're trying to help the patients and also help the providers; if there are six or 10 or 15 process measures you have to collect data on, wouldn't it be easier to collect data on just a few outcomes measures?"
(Editor's note: For more information on ACS/NSQIP, go to: acsnsqip.org/login/default.aspx.)
Reference
- Hall BL, Hamilton BH, Richards K, Bilimoria KY, Cohen ME, and Ko CY. Does Surgical Quality Improve in the American College of Surgeons National Surgical Quality Improvement Program? An Evaluation of All Participating Hospitals. Ann Surg 2009; 250. DOI: 10.1097/SLA.0b013e181b4148f.
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