Gregg S' Meyer, MD, MSc

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Quality Reporting and Its Effect On Promoting
Organizational Change

• Gregg S. Meyer, MD, MSc
• Medical Director, MGPO
• CMS Summit on Hospital QI and Public Reporting
• May 2005

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The Problem
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The Purchasers dilemma

• The cost of health benefits for employees gt the
  cost of steel in American cars
• We are not immune!
• MGH/MGPO pay nearly 70 million for healthcare
  for employees
• For other inputs purchasers are used to getting
  more when they pay more (value added)
• Not transparent in healthcare
• BUT, Levers for demanding added value have not
  existed
• Purchasers are asking payers to develop such
  levers

Effective and Efficient Utilization
OptimalQuality
Value Added
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The Providers Dilemma
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The 5 Stages of Getting Involved in Public
Reporting

• Denial
• Anger
• Bargaining
• Depression
• Acceptance
• We need help getting through the stages

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The Long View
High
Q 50 ppts 40 ppts
Chasm Crossing
Clinical re-engineering by MDs, hospitals
suppliers
Consumerism P4P
? Market sensitivity to hospital/MD quality TCO
Value of Health Benefits
Performance Disclosure
Performance comparisons for hospitals, MDs Tx
Q compliance with guidelines annual health
benefits cost
Low
Key Evolutionary Steps
2002
2012
Reproduced with permission of Arnold Milstein, MD
(Mercer)
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Uses of Quality Measurement
Improvement
THE NEW YORK STATE EXPERIENCE
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Physicians Quality Measures Wish List (what we
want)

• Transparent
• Sensible
• Meaningfully discriminates performance
• Stable
• Actionable

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C. P. Snow Redux The Two Worlds

• .claims data remains the only reliable source
  to verify the treatments doctors use and the
  drugs they prescribe. "It's imperfect, but it's
  better than being totally blind"
• Arnold Milstein
• Mercer Consulting

• "This is a very hard issueThe more quality
  measures, the better, but we don't want the
  information to be misleading. Without the
  appropriate statistical models, every time you
  start ranking doctors or putting a number of
  stars next to their name people are going to be
  misclassified
• Bruce Landon MD MBA
• Harvard Medical School

Quoted in Landro, L Doctor 'Scorecards' Are
Proposed In a Health-Care Quality Drive Wall
Street Journal March 25, 2004
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Report Card Authors Face Difficult Choices
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Transparent?Growth of Administrative Data Based
Websites
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How Do You Measure Quality?

• Ranked 1 overall, 2 in the nation for
  neurology and neurosurgery, 3 in cancer, 4 in
  heart and heart surgery
• No other Maryland hospital made the top 50
• Methodology Based on reputational ranking,
  actual-to-expected mortality (severity adjusted)
  and care-related factors (volume, technology,
  RNs-to-beds, trauma capacity, NCI designation)

2005 Ratings

• Did not earn clinical excellence award 4
  other Baltimore hospitals did
• Only award for specialty excellence was for
  stroke care
• Rated one of the worst hospitals in Baltimore
• Methodology Based only on Medicare data,
  mortality rate and complications. The better the
  documentation, the worse you look.

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Sensible?

• WHITE COAT NOTES NEWS FROM BOSTON'S MEDICAL AND
  SCIENTIFIC COMMUNITYA NEW WAY TO RANK HOSPITAL
  QUALITY
• Boston Globe, March 2, 2004
• Tops in Heart Attack Care
• Winchester Hospital
• Melrose-Wakefield Hospital
• South Shore Hospital
• Brockton Hospital
• Massachusetts General Hospital (5)
• Beth Israel Deaconess (23)
• New England Medical Center
• Brigham and Women's Hospital (3)
• Boston Medical Center
• Beverly Hospital

it's enough to get a patient thinking Am I
going to an outlier hospital?" -ManagerHealth
Share Technology
The picture painted for patients is often
confusing and contradictory
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Power to Meaningfully Discriminate?Tufts Health
Plan Physician Group Profile
www.tufts-healthplan.com
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Stable?
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Actionable?
Elements that are publicly reported will garner
the lions share of resources for improvement
Quality improvement programs aimed at issues not
subject to public reporting
Quality improvement projects aimed at issues that
ARE subject to public reporting
But, it also breeds resentment
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Taking small bites - Priority Areas (?)

• Asthma
• Care coordination (cross-cutting area)
• Children with special health care needs
• Diabetes
• End of life with advanced organ system failure
• Evidence-based cancer screening
• Frailty associated with old age
• Severe and persistent mental illness
• Stroke

• Hypertension
• Immunization
• Ischemic heart disease
• Major depression
• Medication management
• Nosocomial infections
• Obesity (emerging area)
• Pain control in advanced cancer
• Pregnancy and childbirth
• Self-management/health literacy (cross-cutting
  area)
• Tobacco-dependence treatment in adults

Choose, wisely
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New York State Cardiac Surgery Reporting
System The Media View
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Adjusted In-hospital Mortality Rates by Center
1987-2000 N37,599
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Consumer Effects of Public Reporting

• Is information available at the right time?
• Is information readily understandable?
• Is information presented in a manner which is
  statistically appropriate?

Public reporting alone may not do it
Source Harris Poll, 2002, http//www.harrisinter
active.com.
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Uses of Quality Measurement
Improvement
MOTIVATION
Motivation
THE NEW YORK STATE EXPERIENCE
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Iron Laws of Improvement

• B Teams with A Systems always beat A Teams with
  B Systems
• Its the systems stupid (recent papers on VA
  care)
• We need an A team, not A individuals and we need
  to provide that team A systems
• Its not the seed, its the soil
• Culture trumps all
• Innovation must be balanced with Spread
• The political is much more challenging than the
  technical
• TPS Order of change leaders -gt professionals -gt
  staff
• Data Anecdote Action
• You need both
• E.g. VA and bar-coding implementation
• Motivation from within is great, motivation from
  without is impossible to ignore

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Why Payment for Performance Is So Important

• There is a quality chasm between what is and
  what ought to be in healthcare
• We have programs that we know work to improve
  quality
• Patients have improved outcomes and quality of
  life (win)
• The savings accrue to the payers (win)
• The costs of the program are borne by the
  providers (lose)
• Payment for performance could make it a win win
  win
• This is a key additional motivator for
  improvement

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MGH scores as of February 2005
Examples Of Where We Are Participating In
Performance Disclosure
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Improving Care for Patients with Pneumonia
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Pneumovax intervention Winter 2004
Improving Care for Patients with Pneumonia
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Pneumovax Sticker Intervention MGH 2004
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High reliability QI tactics or Interventions
It Takes a Real System, Not Science Projects

• Level 1 (1 error in 10) prevent errors by
  standardizing care with algorithms, guidelines
• Design the implementation tactic to be as error
  proof as possible
• Level 2 (1 error in 100) mitigate errors by
  identifying failures promoting use of opt-out
  orders, making the best choice the default choice
• Even the best designed implementation plans have
  failures
• Level 3 (1 error in 1000) redesign the system in
  which the intervention operates eliminate
  work-arounds, use electronic records,
• Systems should perform 24-7 and be as error-proof
  as possible

Adapted from Institute of Healthcare Improvement
Innovation Series 2004 Improving the Reliability
of Health Care
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Pneumovax Opt-Out Intervention 2005
Patient will be screened for and given pneumovax
unless you opt out below
(Nursing will screen for patient / family
agreement and contraindications)
Literature suggests this should improve
compliance to 98 but it took time to prepare
the soil
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Dissemination of Innovation There is time for
digging Chunnels
We Are Here
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Recent Studies on Public Reporting and Hospital QI

• Mathematica National Hospital Voluntary Reporting
  Initiative review (KEY FINDINGS from 26
  hospitals)
• Most hospitals have experienced some difficulties
  in participating in the NVHRI to date, yet a
  majority of hospitals in the group that enrolled
  before the MMA was passed continue to strongly
  support the Initiative.
• Although the NVHRI is consistent with other
  quality reporting initiatives, hospitals report
  that the presence of multiple initiatives has
  resulted in a substantial cumulative burden.
• Checking their data and reconciling data
  differences is a substantial task for
  participating hospitals.
• To date, the primary effects of the Initiative
  have been to give higher priority to quality
  performance in the eyes of hospital leadership,
  to stimulate hospital efforts, to speed the
  collection of quality data, to spur new or
  enhanced quality initiatives, and to better
  document appropriate care. Some hospitals have
  diverted attention from other clinical areas to
  focus on those covered by the NVHRI.
• The NVHRI has stimulated more hospital
  improvement activity related to pneumonia, a
  condition newer to many hospitals as a focus,
  than it has for heart attack and congestive heart
  failure.

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Recent Studies on Public Reporting and Hospital QI

• RTI Review (Key Findings from 25 MD interviews)
• Although a number of factors influence hospital
  referrals, the physicians interviewed would not
  change their referral decisions based solely on
  public reports. Rather, they relied on the
  quality of services the hospital provides, the
  preferences of their patients, and the expertise
  of the referral physician.
• In responding to the patient scenarios,
  physicians expressed a willingness to discuss the
  hospital quality report. They would react by
  reassuring their patients about the care they
  would receive and by giving and requesting
  information.
• Interviewed physicians saw themselves as
  information intermediaries for their patients
  about public reports and, in general, would not
  want their staff to explain reports to their
  patients.
• Internal hospital reports are well recognized and
  well received by most of the physicians, who
  expressed interest in additional measures,
  frequent reports, and quality improvement
  updates.
• The characteristics of public reports that
  physicians looked for most often are a credible
  source of the data and a valid methodology used
  to collect and process the data.

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Conclusions

• Hospital quality reporting to date has been a
  failure as a driver of selection (? If this may
  change with more out of pocket cost at risk), but
  clearly focuses attention and fosters improvement
• Integrity in measurement, choosing targets
  wisely, and providing additional motivation (P4P)
  is a requisite balance to a plethora of reporting
  requirements
• Balancing musts and shoulds
• Promoters of public reporting for quality
  improvement motivation would do well to keep in
  mind the Iron Laws of Improvement and recognize
  the risk of diverting attention from what may be
  more important

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Be prepared for the long haul
Improving Quality and Safety is a commitment, not
a quick hit