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From the Departments of *Quality Management and Anesthesiology, Stony Brook University Medical Center, Stony Brook, New York.
Address correspondence to Peter S. A. Glass, MB, ChB, Department of Anesthesiology, Stony Brook University Medical Center, HSC L4-060, Stony Brook, NY 11794-8480. Address e-mail to peter.glass{at}stonybrook.edu.
The article by Kanter et al. (1) appearing in this issue of Anesthesia & Analgesia is but one example of the pervasive trend in clinical medicine to measure and publish clinical performance and, where warranted, to use performance improvement methodologies to attain better "marks." The adoption of this approach has been substantially advanced by the decision of the Centers for Medicare and Medicaid Services (CMS) to proceed over the last several years with "core measures" and their publication on the "hospital compare" web site (2). Although CMS is the proverbial "gorilla" in the room, the use of performance measures with comparative outcomes has been championed by the Joint Commission on Accreditation of Healthcare Organizations ("ORYX"), by the Premier group of hospitals in collaboration with CMS (3), by various specialty or subspecialty societies, e.g., the National Surgical Quality Improvement Program of the American College of Surgeons (4), and by state governments such as Pennsylvania and New York which are or will be requiring the reporting of hospital-associated infections.
Although most of these initiatives have stressed the mandatory reporting and publishing of quality data, only few have been directly tied to payment. Of the ones cited above, only the Premier demonstration project with CMS was related to higher reimbursement for better performers. However, CMS is late to this aspect of performance measurement. It has been preceded by the private insurers in the form of "consumer directed heath care" in which patients are directed to higher quality and/or, more efficient providers by scaled copayments and deductibles (5). Similarly, employers as members of Leapfrog (6) have also tied higher payment to providers that conform to quality criteria related to the Donabedian triad of structure, process, and outcomes (7). This trend is certain to accelerate with the entry of CMS into this phase with what it euphemistically calls "value-based purchasing," i.e., pay for performance (8).
Until now CMS has provided the full annual payment update to Medicare for hospitals that 1) choose to report the core measure data; and 2) do so with an 80% validity, i.e., 4/5 of the data elements submitted are verified by CMS contract reviewers. Failing either of these penalizes hospitals by a 0.4% reduction in the annual payment update regardless of whether the institution’s core measures performance was in the top or bottom deciles by comparison with others. These same criteria apply in fiscal year 2007 (beginning October 1, 2006), but with a potential 2% penalty. However, for fiscal year 2008, it seems very likely that CMS will begin to exact penalties (or offer rewards) based on achievement rather than just submission. The precise nature of that program remains to be specified but may well be similar to the Premier demonstration project or some variation of it (3).
The Kanter et al. study is a timely example of how institutions should go about responding to this onslaught of reporting requirements. It is timely because with federal fiscal year 2007 (but with data collection as of July 1, 2006), CMS is now requiring submission of pre and postoperative antibiotic timing data (antibiotic choice is for now not required) for all hospitals desiring their annual payment update including those that, for more than 2 yr submitted only the "starter set" of 10 measures for congestive heart failure, acute myocardial infarction, and community-acquired pneumonia. Even more timely is the illustration provided of how a group of performance improvement principles might approach the goal of providing "perfect" care, i.e., the ability to deliver every measure (in a set of measures) to every eligible patient.
The authors emphasize the rapid-cycle plan, do, study, act approach. Although this methodology is commonly used, it is but one of a number of potential approaches including Six Sigma, Toyota lean production methods and others. Common to all the effective programs are: the use of data pre and postchange to describe the problem and measure success (or lack); collaboration with stakeholders who best know the processes underlying the data and therefore how best to change them; the use of frequent, real-time specific feedback of the data to the stakeholders; and, ultimately, minimization of clinically unjustified variation. Insufficiently emphasized but vitally important are three additional elements: the availability of forums (either created or standing) that incorporate leadership and allow for information and data sharing; the rewarding of excellent performance by recognition, acclaim, tangible incentives; or in academic medical centers, the realization that performance improvement effort with achievement is a legitimate endeavor for those in the clinician/educator tracks. The recent change allowing for the awarding of Category I continuing medical education credits is also welcome and should be built into many such projects.
The final element that bears greater emphasis is crucial to acceptance of the legitimacy of these endeavors: the measures for improvement must be evidence-based and tightly (or at least soundly) linked to improved outcomes. CMS was wise to choose process rather than outcome measures for its initial forays because the latter get into the risky jungle of risk adjustment, the favorite discussion (and dissension) point concerning public report cards for mortality, complications, etc. that are exemplified by HealthGrades (9) or the New York State Cardiac Advisory Board reports (10). By defining numerators and denominators carefully and by choosing process measures thoughtfully, one can avoid the "my patient is sicker than your patient" dialogue. One can only hope that future required measures will continue to reflect evidence-based medicine.
What is in store for the future? Certainly more of the same. But institutions and practices should be endeavoring to measure the quality of their care not because it is required, but because it is the right thing to do. How else would one know whether you are truly applying the best practices to your patients? How many "Centers of Excellence" have been formed without much evidence of excellence? Also certain is the aforementioned idea of "perfect" care, that all measures are delivered to all eligible patients with a resultant "score" no higher than the lowest score for any one of the elements. Finally, where on the horizon is "pay for safety?" Although effectiveness of care is expected and economy of care is desirable, safe care is mandatory. The next frontier is to find ways to measure patient safety and to combine that with measures of cost and quality. When that is accomplished, measured, and expressed, only then we will be truly "pursuing perfection," as the Robert Wood Johnson Foundation has named their initiative (11).
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