How FAACT measures what consumers want to know
(David J. Lansky, PhD, is the president of FACCT, the Foundation for Accountability in Portland, OR. FACCT is a not-for-profit organization whose board of trustees represents consumers, corporate, and government health care purchasers. All told, the trustees represent 80 million Americans. FACCT is dedicated to creating tools that help people understand and use quality information in making health care decisions.
Before joining FACCT, Lansky was regional director of clinical information for the Oregon-based Providence Health System, an integrated system including hospitals, ambulatory, and home health services. His team was responsible for outcomes research, measuring consumer satisfaction, and for developing electronic records.)
Q. What sets Foundation for Accountability measures apart from other types of consumer satisfaction measures?
A. FACCT measures are intended for a particular purpose, which is to support the ability of consumers and purchasers to make decisions in the health care marketplace. We design the measures with a strong emphasis on what patients and consumers tell us they care about.
We are trying to build a comprehensive profile of the quality of care provided by health care organizations. Within that goal, consumer satisfaction is an important piece, but only one of several elements we think constitute a complete picture of quality.
Our measures are intended to cover the breadth of health care experience — both consumers’ experience of interacting with the health system and their experience of illness, and hopefully, recovery as well as their experience of receiving necessary care. So, we’ve tried to develop measures that address three different types of health care:
1. The steps to good care, or process measures, tell you whether the right things are done.
2. The experience of care (which is where we put satisfaction measures) is how people experience their interactions with health care professionals and organizations.
3. The results of care show whether the intended benefits of health care are actually achieved.
Q. Could the results measures that FACCT uses substitute in some instances — or maybe all instances — for the outcomes measures drawn from hospital association reports or from medical records?
A. I wouldn’t say our measures replace them. I would say we capture clinical outcome measures where they are available and appropriate. In the example of diabetes, the most important intermediate outcome is the maintenance of good blood sugar control, typically measured through the blood test for hemoglobin A1C level. That’s really a concrete measure. To us, it’s an appropriate results measure.
It reflects a lot of input to achieve that goal: good testing and good advice to the patient about diet and lifestyle. And where appropriate, good medications have to be made available and have to be used by the patient. All those things have to come together to achieve the results, so the lab test is a very elegant way of assessing health care performance by looking at an outcome. In our diabetes measures, we definitely capture that kind of indicator.
Q. What are some questions a consumer might answer on the FACCT survey?
A. For a patient with asthma, we would ask if he or she had been observed by the doctor or nurse using the inhaler, to make sure the patient is using it correctly. Almost every patient says, "Yes, I have an inhaler. Yes, I have been given a brochure on how to use it." But only about half the patients have ever been watched by a professional while using it to make sure that they are doing it right. Put another way, about half the patients with moderate to severe asthma don’t really know how to use the inhaler correctly.
Similarly, we ask patients if they know what to do when they have a severe asthma attack, if they know how to adjust their medications when their asthma gets worse, or if they know how to care for themselves when they have an acute asthma problem. Again, about half to a third of the severe asthma patients around the country don’t know what to do when they have a severe flare-up. Which, of course, relates to unnecessary hospitalizations and other problems people encounter when they have asthma attacks.
Q. What questions would you ask consumers to assess process measures?
A. With diabetes patients, for example, it’s easier to ask them directly if the doctor examined their feet to look for effects of vascular problems at their last visit. That information is more reliably obtained from the patient than it is from a medical chart review where it may or may not be noted specifically in the chart.
Our concern with the outcomes approach we have is to see whether the patients ultimately received benefit — if the asthma patients know how to take care of themselves, if heart patients take their aspirin.
Q. How have you been involved in the measures coordination program announced last year by the Joint Commission on Accreditation of Healthcare Organizations, the American Medical Coordination Program, and the National Committee for Quality Assurance?
A. We have had no involvement with them at all, and we were not contacted about it. That’s really all I can tell you about that. (See editor’s note, p. 62.)
Q. Who uses the measuring guides that FACCT has developed and tested so far?
A. We originally set out to develop measurements primarily for public accountability. For that purpose, the users tend to be groups of purchasers who want to get this information into their own hands and potentially into the hands of their employees or the population they are responsible for.
For example, the federal employee benefit program has been using our asthma measures in a pilot project. They are now thinking they want to get that data on a broader basis. The program contracts with a large number of health plans that cover 10 million people. Our efforts have been to work with specific regional or national purchasing organizations.
However, the more frequent use is not the one we intended. Health care organizations, integrated systems, and health plans have used the measures as an externally developed benchmark with some basis in scientific review and consumer input, to get a handle on their own asthma care, or breast cancer care, or whatever it might be.
Q. What is FACCT’s next objective?
A. What is next for us is a stronger emphasis on helping consumers get information and make decisions. One thing we’ve learned is that the structure of American health care and the mix of purchasers in this marketplace don’t lend themselves to public accountability or broad information collection and disclosure. Therefore, we’re turning our attention more to the question of how to support individual consumers and consumer organizations. We have a library of measures that we think is a starting point. The question is how to get that information into the hands of the public.
If we have no information on quality in this marketplace, we are doomed to cost competition. I don’t know anyone who wants that as an outcome for American health care. Until we have some quality competition to balance cost competition, we’re going to have a very unfortunate situation.
We think we need to build public demand for quality competition, so that’s the direction we’re going to be exploring for the next couple of years.
Q. How can QI managers promote quality-based competition when they operate under so much pressure to contain costs?
A. At a recent meeting of thinkers in QI, I heard a lot of doubt and frustration about getting continued support from both the administrative and clinical people in their organizations. While everyone believes that improving quality is important, and morally right, and will ultimately lead to more appropriate health care, making a case for that in a business sense is getting more and more difficult, whether in a hospital or an HMO.
One theme that came up at this meeting is that we all need to work together to build an external demand for quality and quality information. We won’t get very far until we build a public expectation of accountability. Only then will quality be a competitive advantage, not a competitive disadvantage — which now it tends to be. If we could build that external expectation, it will permit greater resources and attention to go into the quality of work.
What I’m hearing is unless those of us on the external advocacy side are more successful, it’s going to become more difficult to sustain a commitment to internal improvement.
(Editor’s note: The August 1998 QI/TQM cover story, "Top watchdogs vow to coordinate, simplify quality reporting systems," announced the accreditation agencies’ plan to develop a common measurement agenda to promote greater accountability and ease the reporting burdens on health care facilities. A recent update notes that the coordinating council has met several times. No project completion date has been announced.
The April 1999 QI/TQM cover story, "Consumer-based quality measures gain support from buyers, accreditors," describes the framework on which FACCT’s measures are organized and the reactions of a few purchaser groups who are piloting them.)
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