Quality Talk
Provider report cards: How helpful are they?
This month’s guest is Patrice L. Spath, a health care quality and resource management consultant. In addition to QI, her expertise includes utilization review, case management, clinical paths, and outcomes management. Spath’s latest book is Provider Report Cards: A Guide for Promoting Health Care Quality to the Public (AHA Press, Chicago).
Q. As you planned the book that you edited on provider report cards, what issues did you particularly want to explore for QI specialists?
A. I think a very important issue for QI specialists to remember is that there are really two classes of consumers: those people who need health care services regularly because of a chronic disease and those who need them just periodically. Periodic users are basically well people who have an occasional broken leg or something like that. When you create a report card for them, remember they have information needs that are different from people with chronic disease. When you are marketing to these two groups of consumers, give them what they want to know.
Q. Are provider report cards a cost-effective way for health care organizations to offer their consumers useful information?
A. Probably satisfaction data are the most useful to consumers. But, frankly, I think consumers use their neighbors’ opinion more than anything else to judge quality. On the other hand, I think that since consumers are most interested in the satisfaction components, providers should routinely measure satisfaction to see where they could improve quality — from a consumer standpoint.
Q.How would a well-conceived report card serve a provider?
A. Providers need to define what they want from the report card. In fact, one of the first steps in creating a report card is the planning phase: determining what your purpose is. Again, we come back to the two different consumers, the sick one and the well one. For each consumer group, you may have different purposes and information, and perhaps slightly different types of report cards.
For the sick people, for example, your purpose may be to reassure them that they won’t have to wait long to see their provider. Also, it’s important to those patients that providers have compassion. One way to show that might be to explain how well they manage pain. Well patients care a lot about whether they can pick their provider. They want to know whether you have preventive services and wellness care and classes. Once you know your purpose, you can pick a whole variety of objectives:
- Objective #1 — Marketing
You might say, for example, "We want that well person to come into our hospital when they get sick because they liked the classes they attended." However, if the people of the community don’t have a choice of hospitals, then I don’t know how effective that marketing will be unless you’ve lost market share to facilities a hundred miles away.
- Objective #2 — Consumer education
You might say, "We want our consumers to be more knowledgeable about how to measure quality." So, you share information with enough narrative to help them understand, for instance, that a high postoperative infection rate is not a good thing. You would want to include postoperative infection rates on your report card. Or you might want to inform them that a very high cesarean rate is not a good thing, and your rate is low. With that kind of report card, you would be helping the consumers define how to measure health care quality.
- Objective #3 — Fulfillment of public expectations
Your facility might put out a report card because there are so many organizations making a variety of performance measurements available. You could get to a point where your consumers say, "Everybody else has a report card, why don’t you?"
Q. In one chapter, written by a guest expert, the author describes some of the legal issues surrounding provider report cards. For example, she warns organizations against making absolute statements such as "Our doctors are the best." Are there any rules of thumb about reducing the legal risk involved in publishing a provider report card?
A. Subjective claims are going to haunt you more than sharing some kind of comparative data that show, for example, your CABG (coronary artery bypass graft surgery) mortality rate vs. some other hospital. It’s really the promises and guarantees that get you in trouble. But I still think that people are concerned about showing even comparative data because they feel it may increase liability. (For a reference to basic liability prevention tips with regard to provider report cards, see the editor’s notes at the end of Quality Talk.)
Q. In the past, you have expressed some doubt that consumers even use the report cards that providers so conscientiously put out — do you still believe that?
A. I don’t know if we’d have conscientiously put them out if somebody hadn’t made us do it. I have an opinion that those consumers who don’t have a whole lot of choices — in other words, they live in a town that has one hospital — are less likely to pay attention to any kind of report card data than those people who live where they have choices. Because if you don’t have choices, why even look at the data to see what your choices are?
However, I am beginning to see, in those well populations of patients, that they are willing to travel out of town to undergo elective surgery. Sometimes they’ll go 50 to 100 miles away because they think they’ll get better care in another hospital. But that decision is not usually based upon a report card. It’s usually about how prestigious the other hospital might appear.
For example, consumers tend to think that a university hospital provides better quality care just because it’s a teaching facility and it has the latest technology. It’s interesting, when you go into smaller communities and talk to the hospital administrators, they say that they are trying to change these attitudes. Consumers think that driving 100 miles to the university hospital gives them better technology when, many times, the community hospital has the same technology. A lot of it is consumer perception that if you put that "university" label on it, people think you somehow get better care.
Q. Are you saying that report cards don’t have much to do with that perception?
A. Not right now — but I think they can. Some of the community hospitals are now presenting their data to show that their outcomes are just as good or better than the hospital down the road.
Q. In your book, you included a chapter on measuring whether your health care organization is meeting the health needs of its community. Isn’t that a hard thing to sell to institutions that are struggling to contain costs?
A. Measuring whether or not you’re meeting the community’s needs and their satisfaction with your facility, I think, is an important component of an overall marketing effort. We tend to measure satisfaction by surveying people who have been to our facility. They are the population we ask, "How do you like it?" What we don’t do is ask someone who has never been to our facility, "How do you like it?" By doing that, a provider could find out what kind of community initiatives would meet the health care and wellness needs of their community.
Of course, if you’re in an urban setting, it becomes a little difficult to define your community. Let’s take Denver, for example. The hospitals’ communities overlap one another. When you get out into smaller suburbs and rural areas, you do have a defined community. If you’re meeting the needs of that community through your wellness program, they are going to view you as the provider of choice. They are less apt to drive 100 miles to another hospital when they view you as the primary provider of health care services.
I think it’s important, too, that we listen informally to what our community is saying. When you go to your dentist or your hairdresser, for example, ask the people who don’t know anything about health care which hospital they would go to and why. It gives you a perspective that I think we lose once we work for a provider.
Generally, you’re going to find that people who are just periodic users of hospitals tend to choose a facility based on very soft measures of quality. My dental technician, who is pregnant, said, "I’m going to go to Hospital A [actual name withheld] to have my baby."
I think that Hospital A is a high-quality provider, but it’s also an hour’s drive from her home. I asked her why she is going to Hospital A when there is another hospital 10 minutes away. She said, "I’ve just heard some bad things about this other hospital from my friends. And I heard that Hospital A has got a nice new facility and everything is clean and the nurses are so nice. People are really friendly and I want to go there."
Did she say she went to the Internet to find out what Hospital A looks like vs. this other hospital? No. Did she pick up some report card to see how their outcomes compare? No. She’s willing to drive an hour rather than 10 minutes — while in labor — because she perceives, through word of mouth, that Hospital A is better.
I would encourage people to have these types of conversations with the general public in their community when they have a chance to, especially if they don’t know that you work for a health care entity. See what they’re saying about how they choose providers. I would encourage quality managers to talk to the people in their community and then develop report cards that give them the information they most want to know.
[Editor’s notes: See Spath’s book, chapter four, "Recognizing the legal issues surrounding provider report cards" by Alice G. Gosfield, Esq.
To contact Spath, write to Brown-Spath & Associates, P.O. Box 721, Forest Grove, OR 97116. Telephone: (503) 357-9185. Fax: (503) 357-9267. E-mail: hc_quality@ msn.com. You may also visit her Web site, which is regularly updated with original articles on health care, news from the field, and links to related Web sites.]
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