As hospitals and health systems face growing financial pressures to maintain a certain level of clinical quality, executives are leaning on internal quality improvement programs to keep their care in check. However, having standards programs isn't enough. They have to be effective and that's where the challenges arise.
The focus on quality improvement kicked into overdrive after the passage of the Affordable Care Act, which tied payments to outcomes rather than volume. In turn, the Centers for Medicare and Medicaid Services now levies financial penalties for those who don't meet certain performance standards, But according to Elizabeth Mort, senior vice president of quality and safety and the chief quality officer at Massachusetts General Hospital, this culture shift took place much earlier.
Mass General began focusing on quality improvement around 2000 when the federal government decided doctors and hospitals should be more accountable for the quality of their care or else there would be high stakes financially. That's when the Boston hospital's leadership created its quality improvement infrastructure.
"The hallmark of a good infrastructure starts at the top," said Mort. "I've seen hospitals invest in their resources but not have the board of trustees establishing the accountability to make sure the right people are focused on the right things."
According to Mort, the hospital's a board of trustees needed education so, at the start of Mass General's program, consultants came in with a curriculum. "The main message was,'Guess what guys, you're not only responsible from a fiduciary perspective, but you're also responsible for the quality of care.' Most boards at that time felt that was something that was delegated to the medical staff," she said.
"Management structures are really important as well," she said. "If you're in a hospital or multi-specialty group practice, whoever is in charge needs to own quality and safety. They need to be educated about the importance of that."
An effective quality team may look slightly different depending on the hospital or system, but generally, there needs to be involvement from all levels of the organization. At Mass General, the quality team is comprised of about 55 full-time employees ranging from physicians, nurses, analysts and physician leads from all of the clinical departments. Mort sees it as a best practice.
But there are challenges, particularly at the policy level.
"There are enormous requirements from CMS and our commercial payers," said Mort. "Many hospitals I speak with are lucky if they can improve achievement in those areas, and they don't have enough left for other areas. It's a challenge -- the regulatory deal, the pay-for-performance. You spend a lot of time and energy on it. Some of it is extraordinarily important, but not all of it. You have to leave enough resources to get other clinical things done."
Also of prime concern is the implementation of a solid communication framework between health plans and providers -- one that allows for an easy flow of data. Bruce Carver, associate vice president of payer services at MedeAnalytics, has seen what happens when payers and providers aren't on the same page, and the results aren't pretty.
"The challenge is that in order to achieve high-quality outcomes, there needs to be a collaboration between health plans and providers," said Carver. "They need to be chasing the same stick. If they're not, that ends up with payers and providers fighting with each other."
To avoid that, there needs to be "a single strategy in how the workflow is aligned," said Carver. "You need to align which quality measures you're going to measure against. It needs to be critically important to the provider and the payer at the same time so they can manage that information strategically."
The most effective mechanisms through which to share data tend to revolve around a technology platform, either in-house or through a vendor, in which a provider can freely access and share information with the health plans. The health plan should then be able to share information back to the provider that's more broadly focused around a particular patient.
"For example, you're going to be able to identify a high-risk patient population and hone in on an algorithm, based on the demographics of the population, based on comorbidities," said Carver. "All of that stuff combined together can help establish a prioritized list -- which ones are going to close that gap in care."
A more proactive approach to quality management, according to Carver, involves interpreting the latest information from CMS and determining what kinds of conditions and processes the agency will be paying attention to most in a given year's measurement. That requires a deft handling of data.
"There's a lot of concentration on behavioral right now, on patient satisfaction, and as plans identify what's causing high costs and what CMS is measuring, health plans should be installing processes that specifically concentrate on improving those outcomes today," said Carver. "So when they become part of a value-based contract they're already ahead of the curve, and have that process in place."
Without a solid platform, clinical data is generally pulled from an electronic medical records system. But the EMR has hundreds of metrics and tons of fields, and it can become burdensome for a provider to understand what information they need. If a health plan can help to better articulate that, that makes it seamless for the provider and they can more easily access the right information. But it has to happen concurrently.
"To take that first step forward, you have to have a mechanism of upside payment to the provider to ensure they're going to take the extra step to get that clinical information and manage these clinical outcomes," said Carver. "It starts there at the clinical outcome measure."
One instance in which data can come in handy is when a quality improvement team is researching solutions to a problem -- reducing the rates of a certain condition, for example. Mort calls them "science projects." And they need to be a regular part of a system's culture in order for quality programs to be consistently effective.
"The challenge is taking a science project and developing it into an organizational change that has durable and lasting results," said Mort. "That's where a lot of organizations get stuck. There's a big focus on taking our organizations and making them highly reliable so it's not just science projects, so we have results that are durable and consistent. That way every patient gets what they need. Where organizations fall short is in getting a good start but not getting it across the finish line."