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Quality metrics should be streamlined to focus only on those that truly affect the care provided to patients, a physician group says.
The medical community is slowly realizing that an overabundance of metrics is detrimental to the cause of improving healthcare, says Steven Green, MD, chief medical officer at Sharp Rees-Stealy Medical Group in San Diego, and secretary of the Council of Accountable Physician Practices (CAPP), a coalition of multispecialty medical groups and health systems based in Alexandria, VA.
One physician says “measurement mania” is bogging down efforts to provide quality care.
The challenge is getting physicians and other healthcare leaders to see the big picture and not just their own slice of healthcare, Green says.
“I hear from physicians that they want the measurements to be streamlined, but I’m not sure everyone is on board yet because there are a lot of people involved and they all have good intentions. People want to add just one more metric to the list because in their particular area of medicine, it would be a laudable metric that is worth tracking,” Green says. “They don’t realize that in the great scheme of things it just becomes too many. A health plan adds one, state organizations add one, and if this isn’t limited and coordinated, it can quickly get overwhelming.”
CAPP recently released a report noting that though the country has made progress in measuring quality of care, lack of coordination has produced an overabundance of measures that are confusing to everyone. Lack of coordination among quality measurement initiatives creates multiple parallel systems with hundreds of measures, the report says. It calls the current system of measures fragmented and redundant. (The report is available online at http://bit.ly/2nq3q0A. See the sidebar on pages 32 and 33 for excerpts from the report.)
Green notes that research has shown physicians spend an average of 785 hours per calendar year reporting external quality initiatives — time that could be better used caring for up to nine more patients per week.
Preventive care and chronic disease management are among the most useful metrics on which to focus, Green says. His medical group focuses on quality measures for conditions such as diabetes and blood pressure because there is substantial opportunity to improve patient health and avoid complications through interventions guided by metrics, he says.
“We put a lot of emphasis on getting patients to their goals, and on issues like hospital admission rates. About two-thirds of our patients are in managed care, so it’s important to us for our group’s finances and to our patients to keep hospital admissions down,” Green says. “We’ve managed to achieve a rate of 186 admissions per thousand senior patients, but that takes a lot of coordination with making sure patients have access to care in outpatient settings. It’s also a matter of keeping their chronic conditions under control so they’re just less likely to need hospitalization.”
The medical group also looks at service metrics, devoting a good deal of time and resources to educating staff about patient relations. Over 15 years, the group has raised its service metrics from the 15th percentile to the 85th percentile nationally.
“That is useful not just from the standpoint of being able to brag about it, but if patients and physicians have a good relationship it is much more likely that patients will bring up concerns to the doctor,” Green says. “Access to care is another metric we focus on, so that when patients have a concern they get help in the way that makes the most sense. In the past year we’ve increased the use of patient portal messages by 25%, and we’ve also increased the use of phone or video visits.”
Streamlining metrics and getting the most use from the ones you keep will require physician leadership, Green says.
“At department meetings, it is very common for us to be talking about these and we might have physicians with good measures share their best practices. It isn’t something you can impose on people,” Green says. “You have to work on the culture and get buy-in for it. Physicians have to recognize that this is good for the medical group as a whole and good for the patients.”
Technology infrastructure also is important in making a focused metric approach work, Green says. For instance, the patient portal and electronic health record should be linked so that the system can alert a physician to care gaps, such as the patient coming in for an appointment while not on the proper medication.
Clinicians are bogged down with “measurement mania,” says Amy A. Adome, MD, senior vice president for clinical effectiveness with Sharp Healthcare in San Diego. Green’s medical group is affiliated with Sharp Healthcare.
“Many of the metrics are not voluntary, so you’re just required to report them whether you think they yield anything useful or not. That is not a choice, and it can take considerable time and resources,” Adome says. “Nevertheless, you have to find time to partner with physicians to come up with meaningful metrics.”
The healthcare community generally agrees that there should be more focus on outcomes measurement than process measurement, but making that transition is not easy, Adome says.
“The struggle is that to get true outcome measurement, you have to be able to track patients across the continuum for an extended period of time. A physician who touches a patient in an outpatient clinic may not always know what the outcome of that patient is down the road,” Adome says. “You can find that so many physicians have touched that patient through the continuum of care that it is hard to attribute the outcome to one individual provider. So as we think about these measures, we have to be careful around attribution.”
Sharp Healthcare focuses on metrics that its physicians find useful in improving patient care, such as sepsis mortality, whether they are required or not. Physicians will engage best when they are involved in the decision-making, she says. Also, be sure to explain why a certain metric is being measured, particularly if it is one that is required and was not suggested by the physicians.
“Physicians are so busy during the day and may have no idea why a certain metric is required by the health system. Help them understand not just what is being measured, but why it is being measured,” Adome says.
“The measurement system in place today is not perfect but the intentions are pure. Helping them understand the ‘why’ is an important way to engage the physicians,” she adds.
The transition to outcomes measurement may have to come in small increments, she says.
“To manage the number of metrics means prioritization, taking on the challenge in slices. We agree on a couple of metrics per year that seem to make sense,” Adome says. “Hunkering down and working hard on those metrics helps you chip away at the elephant.”
Financial Disclosure: Author Greg Freeman, Editor Jesse Saffron, Editor Jill Drachenberg, Nurse Planner Amy M. Johnson, Editorial Group Manager Terrey L. Hatcher, and Consulting Editor Patrice Spath report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.
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