Quality Metrics: 7 Guidelines For Deciding What to Measure

So your organization is implementing a gainsharing strategy and you have been selected to oversee the program.    Gainsharing can be a stand-alone program or be an integral part of other initiatives, such as ACOs and Bundled Payments.  Identifying the common elements to all these initiatives is critical – especially if you want the goals and objectives to mesh together into a cohesive organizational strategy.  Quality measures are a key component to all these initiatives.

Quality metrics assist in measuring or quantifying processes, outcomes, patient perspectives and organizational structure or systems.  But where to start?  That is a frequent comment we hear.  Typically people rely on their intuition to choose metrics – they look at their objective and decide whether the metric will help achieve it. (Mauboussin, M. J. 2012)  You must bear in mind that it is relatively easy to analyze data; deciding what matters is more difficult.  These are some basic guidelines we suggest:

1. Ensure the integrity of the data: Perhaps more important than everything else, you must be able to show that the data gathered is good data.  In gainsharing programs, as well as others, data is used to determine and condition the incentive paid to physicians.  So you will need to be able to justify the results to them.  Using automated sources may make this process easier, replicable and defensible.  However, if there are metrics that are not tied to an electronic source, you may still want to use them, provided that you have an established system to collect and verify results.
2. Decide what you want to look at – process versus outcome: Process indicators that you might choose are specific actions and they measure compliance with standards or procedures that the organization or other agency (e.g. The Joint Commission, CDC, etc.) has set. Examples might include administering a prophylactic antibiotic within 1 hour of surgical incision, discontinuing antibiotics within 24 hours post-surgery or surgical patients with appropriate hair removal, 2014) Surgical Care Improvement Project Core Measure Set).  Conversely, outcomes can be monitored and these assess the effectiveness of a program in producing change.  An example here would be the number of infections in surgical patients – this measures whether the individual steps (i.e. antibiotic within 1 hour of incision, etc.) that were taken have resulted in a decrease in infection rates.  It is typically easier to measure process indicators than outcomes however outcomes may be more important.
3. Don’t re-invent the wheel: There are so many programs for which you report metrics (as of December 2014 the CMS list totaled 329 pages), 2015) Health Industry Washington Watch), creating new ones just makes more work. Instead, look at what your hospital is going to work on and compare that to the measures that are already being monitored.  Chances are, there will be at least one measure that will match your plans.  For example, if you are focused on the care of heart failure patients, there are probably several Committees within your organization that are reviewing a variety of issues related to the care provided to these patients.  So you should tap into these groups to augment your activities.  Much like the proliferation of alarms in the ICU can lead to alarm fatigue, an explosion of additional measures may become a distraction to practitioners.  This can undermine your intentions so choose judiciously and look to existing metrics to avoid disengagement.
4. Determine where you would be able to make the most impact: Where to start is often people’s biggest concern.  Chances are, the Finance Department can provide information of those cost centers and departments where cost is out of line with budget.  This can help identify opportunities waiting to happen.  Benchmarking, especially to outside metrics, can also be a source of prospects for a variety of metrics, from costs to readmission rates to infection rates.  For instance, Virginia Mason Medical Center (Letourneau, R. (2014)) was able to increase the time nurses spent with patients from 35% to 90% by reassigning non-skilled tasks to other personnel.  The outcome of redesign was that overtime decreased, per diem staff utilization dropped and patient experiences improved.  In this case, a relatively simple redesign resulted in decreased costs, improved satisfaction and may have an impact on the transition from hospital to home possibly decreasing readmissions.
5. Talk to your physicians: The physicians who provide care in your institution see a lot and they hear a lot, especially from patients and their families.  As we continue to move towards higher percentages of employed physicians, the opportunity to change physician behavior will also increase.  Remember, physicians are intelligent people, and while some suggestions may be off the charts, often they have very viable observations and suggestions that can streamline processes, enhance patient satisfaction and improve care.
6. Talk to the clinical staff: In addition to physicians, there are a host of other people within the hospital who may have great ideas but no one to listen to them. From the respiratory therapist (who questions daily blood gas testing for stable vent patients) to the ICU nurse (who questions why hand sanitizing stations are located inside the patient room) to the Diabetic Educator (who questions the need for HgB A1Cs more often than every 3 months) to the pharmacist who notices that several physicians are prescribing an expensive antibiotic when a less costly generic alternative is available, there are numerous individuals that can provide insight and direction to choosing metrics.
7. Focus on Improvement: In health care, we love to measure things, from vital signs to infection rates to lengths of stay.  The list is seemingly endless.  But when you are looking at quality metrics, an individual measurement may not tell the whole story.  There are three things you need: where you started (the baseline); where you want to get to (the goal); and how you are doing (interim measurements).  Sometimes, for a variety of reasons, there may be a backslide in the path to the goal, which is when you might need to revise the actions that are being taken.  Some hospitals we work with were marching along the route of redesign, achieving cost reductions, reductions in length of stay and improved patient experiences.  And then – Super Storm Sandy hit the region and much of the progress was washed away in a few days.  But the important issue was that they still knew where they were aiming for and were able to get back on course.

As you undertake one or more of these new programs and have the need to monitor the impact on care, choose the least bumpy road – the one that entails less new work, provides correlation with process and outcome, makes significant impact, enlists the help of your physicians and clinical staff, focuses on improvement and is reliable .  These may be the keys to ensuring success.

References

 Mauboussin, M. J. (2012) The True Measure of Success.  Harvard Business Review, October 2012

(2014) Surgical Care Improvement Project Core Measure Set. The Joint Commission.

(2015) Health Industry Washington Watch.  MedPAC Voices Concern about Growing Volume, Burden of Medicare Quality Measures.

Letourneau, R. (2014).  Process improvement initiatives designed to create better patient experience and bolster outcomes can have downstream effect of decreasing costs, Virginia Mason Medical Center finds.  Health Leaders Media.