New studies examine the impact of performance measures
Do comparisons, financial incentives really impact quality?
With ever-increasing data collection burdens for performance measures and a growing emphasis on linking this quality data to reimbursement, you may wonder how they actually impact patient care at your organization.
A growing body of research is answering that question, with studies showing that performance measures do have a significant impact on quality. A recent report from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) examined data from 3,087 hospitals from 2002 to 2004 for various performance measures and found evidence of significant improvements.1
"There was a steady indication of progress over the two-year period, which was of course, very positive from our perspective," says Scott Williams, PsyD, one of the study’s principal authors and project director in JCAHO’s division of research.
Researchers found that hospitals ranged from 3% to 33% in improvement. "This has certainly reinforced the goal and the mission that we had set forth 10 years ago, which was to use data to drive performance improvement," says Williams. "It’s very consistent with JCAHO’s mission to improve care, that we can work both as an accrediting body and provide data to the general public to make informed choices."
There already was ample research evidence showing that if hospitals are provided with comparative feedback they will use it to improve their performance, but studies were small and never done on a national scale, she says.
The researchers were surprised to find that the poorest-performing hospitals improved at a faster rate than their peers. The theory was that hospitals starting on a lower performance level had significant problems with quality and therefore wouldn’t be likely to take the needed steps to make improvements.
"We had every reason to expect that they wouldn’t do anything to improve their performance, but that wasn’t what we saw. We saw them improve at a faster rate than hospitals that started at a higher level of performance," says Williams.
Poorly performing hospitals may have been embarrassed by how they measured up against their competitors, Williams theorizes. "They had a greater opportunity for improvement because they started out at the very lowest levels and may have been most sensitive to the comparative data," he says.
Leadership is an essential ingredient to achieve results in improvement of performance measures and quality, adds Williams. "The impetus is on hospital quality professionals and medical staff and administration to lead the way," he says.
The performance measures used by JCAHO and the Centers for Medicare & Medicaid Services are evidence-based and well supported in the literature, he says. "There is consensus on almost all of them that these are things that should be happening in hospitals. So these are things that are relatively easy to get behind when performance isn’t as it should be," he says. "But it requires leadership to make it happen. Quality professionals must use the data that they have available to them now, in a positive way."
Another study looked at data for 10 quality indicators at 3,558 hospitals and found poor or spotty compliance for many performance measures, even within the same hospital. "The implication for health quality professionals is simple," says Ashish Jha, MD, MPH, the study’s lead author and assistant professor of health policy and management at Harvard School of Public Health in Boston.2
"Given the tremendous variation we observed in quality of care, it is possible to reach high levels of performance. But too many hospitals are just not there," he says. "Organizations that prioritize quality assessment and quality improvement can ensure that their patients receive the right care consistently."
Performance measures represent a double-edged sword, says Jha. "If we continue to pick good measures that are clinically relevant, then focusing on them will clearly improve the care and outcomes for our patients," he says.
One challenge is for organizations to continue to pay attention to the aspects of health care that are not being measured. "Most of the things we do in health care are not measured in these performance measurement programs. For example, there are no measures for a vast majority of diseases that we manage in the hospital," says Jha.
Staying focused on all aspects of quality will become especially important as the number of performance measures continues to multiply, he says. "The role of the quality professional is to create an environment for providers to improve processes being measured, without distracting the providers from their day-to-day activities," says Jha.
Pay-for-performance impact unclear
The impact of tying performance measures to reimbursement is still unclear, says Williams. "It’s happening more frequently and it seems like a good idea. Certainly when you tie money to these things you expect an impact. But we don’t know for sure yet what that will be."
Research suggests a positive impact on quality, with the first study to assess the effects of a pay-for-performance program in a large health plan finding significant quality improvement in a physician group with an incentive program.3
However, many unanswered questions remain, according to a new report from the National Quality Forum. The report argues that scientific evidence is weak and doesn’t compare costs of effectiveness with other strategies for improving quality, and also that there is potential for adverse consequences with pay-for-performance.4
Still, many quality leaders report that pay-for-performance has had a positive impact on the care they provide. "We think this is a very positive movement, that started with the transparency of quality data," says Sam Flanders, MD, senior vice president of medical quality for Clarian Health Partners in Indianapolis. "Having that data available is a good thing. It’s put more pressure on all of us to excel in those areas. It has helped us to focus on those items that are going to make the biggest impact on patient care."
Although the pay-for-performance movement hasn’t been as rapid in Indiana as some other states, it is growing steadily, reports Flanders. "Right now, it doesn’t affect too many of our contracts. We are seeing that already in other parts of the country, and it is just a matter of time before it hits our market," he says.
Currently, the organization has only the CMS program and one large payer with a program. "But we really have jumped in with both feet to maximize performance, particularly on the publicly reported data elements," says Flanders.
Instead of adding more quality resources to handle increased data collection burdens, the organization has redirected its resources, says Flanders. "If I look back 10 years ago compared to now, we haven’t really added many people to our quality department per se. But the way we have it organized, quality is the job of everyone here."
The central department’s role is the "orchestra conductor" for quality, whereas hundreds of people are involved in quality as part of their jobs, says Flanders.
For example, a recent project for improving blood sugar control in the intensive care unit has had a major impact on patient care, with front-line staff implementing the new protocol. "We have seen our infection rates after heart surgery drop to almost zero as a result of doing that," he says.
The organization already has increased its reimbursement as a result of pay-for-performance. "We have gotten our bonus from one payer as a result of meeting quality targets, and it is a significant bonus," Flanders says.
Indirect financial gains come from preventing infections and shortening length of stay, adds Flanders, since most reimbursement in hospitals is fixed. "Every case of pneumonia you prevent not only benefits the patient but also benefits the hospital’s bottom line," he says.
References
- Williams SC, Schmaltz SP, Morton DJ, et al. Quality of care in U.S. hospitals as reflected by standardized measures, 2002-2004. N Engl J Med 2005; 353:1860-1861.
- Jha AK, Zhonghe L, Orav J, et al. Care in U.S. hospitals—the Hospital Quality Alliance program. N Engl J Med 2005; 353: 265-274.
- Rosenthal MB, Frank RG, Zhonghe L. et al., Early experience with pay-for-performance: From concept to practice, JAMA 2005; 294(14):178893.
- Wu HW, Nishimi RY, Kizer KW. Pay-for-performance programs: Guiding principles and design strategies. National Quality Forum 2005: Washington, DC.
[For more information, contact:
Sam Flanders, MD, Senior Vice President of Medical Quality, Clarian Health Partners, I65 at 21st, P.O. Box 1367, Indianapolis, IN 46206. Telephone: (317) 962-2475. E-mail: [email protected].
Ashish Jha, MD, MPH, Assistant Professor of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave., Boston, MA 02115. Telephone: (617) 432-5551. E-mail: [email protected].]
With ever-increasing data collection burdens for performance measures and a growing emphasis on linking this quality data to reimbursement, you may wonder how they actually impact patient care at your organization.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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