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Unprecedented access to data: Disaster in the making or golden opportunity?
A patient is about to be admitted to your hospital but first goes on-line to the Joint Commission on Accreditation of Healthcare Organizations’ new Quality Check web site. Upon learning that you’re ranked far lower than your competitors in compliance with the National Patient Safety Goals, the patient decides to go to another hospital instead — and lets your CEO know exactly why.
Sound far-fetched? This actually occurred at one hospital recently, and you can believe it had a strong impact. "Just based on reading that data, a patient said they didn’t want to go there. That was the thing that finally got the CEO of this organization on board in terms of having more of a commitment to quality," says Judy Homa-Lowry, RN, MS, CPHQ, president of Homa-Lowry Healthcare Consulting, based in Metamora, MI.
The public initially was slow to access publicly reported data but is catching on quickly, she explains. "When the public data first started hitting, I don’t think the public responded as quickly as many organizations feared," Homa-Lowry says. "But people are becoming more astute in terms of obtaining that information."
There is no question that the amount of data being publicly reported will continue to increase, with current requirements from the Joint Commission, the National Committee for Quality Assurance, and the Centers for Medicare & Medicaid Services (CMS), which announced recently that nearly all the nation’s eligible hospitals have begun reporting quality data.
A pivotal development is the Joint Commis-sion’s Quality Check web site (www.qualitycheck.org), launched in August 2004, which allows consumers to compare patient care at 3,357 hospitals statewide and nationally. Consumers can find out quickly how your hospital ranks in the care of patients with heart attack, heart failure, pneumonia, and pregnancy and related conditions.
Although CMS’s National Voluntary Hospital Reporting Initiative (Go to www.cms.hhs.gov and click on "Quality Initiatives.") provides similar data to consumers, the new JCAHO site is more user-friendly, making comparisons easier.
The JCAHO site also allows patients to see how your hospital compares with others in complying with the National Patient Safety Goals. "Now that there is information about the safety goals in addition to the public information about surgeries that has been available for some time, the public is paying more attention," says Homa-Lowry. "The public is reading those. So obviously, compliance with the safety goals is huge."
As consumers assume more responsibility for their health care choices, they want information they can understand to guide these decisions, says Karen Pietrodangelo, executive director of quality management for Tallahassee (FL) Memorial HealthCare. "Payers — both private and governmental — want quality to guide their purchasing decisions, and providers of care want information to improve their clinical practices," she says. "The quality manager is now challenged to meet all these needs, whereas in the past, the primary focus was on institutional quality alone."
Third-party payers are jumping on the bandwagon, says Patti Higginbotham, RN, CPHQ, FNAHQ, vice president of quality management and medical staff services at Arkansas Children’s Hospital in Little Rock. "In our state, Blue Cross/ Blue Shield is very active in working with hospitals to identify measures of performance that can be reported and made available to their clients and customers," she says. "I think it’s coming down the line — certainly other states have already seen it."
As a proactive approach, the organization is considering completing the Washington, DC-based Leapfrog Group’s Hospital Quality and Safety Survey. "We believe we probably do meet a lot of those standards already," Higginbotham says. (For more information, go to www.leapfroggroup.org.)
Comparing apples to oranges?
While it’s clear that publicly reported data is a top priority, health care administrators are hampered by a lack of agreement on which measures are true indicators of quality care and how the data can be used to accurately compare one hospital to another, Pietrodangelo says.
The main concern is that publicly reported data, though prevalent, may be misleading and even dangerous. "It’s concerning, because it’s not an apples-to-apples comparison," Higginbotham notes. She gives the example of her own organization, a pediatric hospital that cares for infants requiring quaternary care. "The care and management of those babies and their outcomes are shakier from the day they are born," she says. "Comparing outcomes for neonates in neonatal intensive care with outcomes of infants in the newborn nursery of a general hospital may be confusing to the public."
Likewise, if your organization has a mortality rate within your cardiovascular service that is higher than your competitor’s, that may be due to the fact that the competitor operates only on patients with a better chance of recovery, notes Homa-Lowry. "So, if you are one of those organizations that turns away patients, your mortality rate is going to be lower," she says.
The standards are too generic to take into account the different populations served by different organizations, Higginbotham adds. "It’s hard to look at two numbers and compare them, unless you can do some acuity adjustment."
The other problem is the definitions used at individual organizations, which she argues are not well-defined. For instance, one hospital may count near-misses as medication errors, and another hospital may count them only if the error reaches the patient. "That hasn’t all been worked out, either."
Higginbotham’s facility currently is working with pediatric organizations to develop consistent pediatric measures of care, and she has given presentations to the quality improvement committee about public reporting requirements.
If the comparisons were truly accurate and consistent definitions were used, she says that publicly reported data would be very beneficial. "If it’s an apples-to-apples comparison, I think we compare well for pediatric care — and if we don’t, I want to know it."
Your biggest concern should be that publicly reported data accurately reflect the services and care provided at your organization, advises Pamela R. Voss, FACHE, FASHRM, director of risk management at Round Rock (TX) Medical Center.
"You need to be certain that your data are as good and clean as possible," she says. "You should do that at any point in time, whether it’s published or not — but if you’re going to be in the spotlight, you want to look your best."
Leverage for changes?
Publicly reported data potentially can give you a lot of leverage when asking administrators to invest resources in specific quality projects, says Voss. "For instance, if there is a target area in nursing or the laboratory that needs improvement, the data might display this in clearer terms than previously and get greater attention than before," she explains.
Many quality professionals feel that the pay-for-performance trend is a positive development, arguing that the transparency that comes from requiring hospitals to publicly report data in-evitably will lead to safer care. That’s because in addition to the financial incentive, the reputation of the organization is at stake, emphasizes Janet A. Brown, RN, BSN, BA, CPHQ, FNAHQ, president of JB Quality Solutions, a Pasadena, CA-based consulting firm.
"If leaders tell the medical staff, We’re in the 10th percentile for getting antibiotics to pneumonia patients on time. That’s hurting our patients and our reputation in the community; that’s a great incentive. Patients are going to improve; the data are going to improve; and the hospital will be better off."
If the numbers are not good and the public now knows it, you have a strong incentive for caregivers to make necessary practice changes, Brown adds. "I think that getting performance measures linked to accreditation and Medicare reimbursement, with mandatory public reporting, is one fix," she says.
The JCAHO/CMS set of National Hospital Quality Measures, with its specifications manual of common data definitions and collection specifications does provide a legitimate comparative data set for public reporting, as long as like facilities and, as much as possible, similar patient populations, are compared, Brown says. "Of course, acuity and clinical risk-adjustment are always issues that may be the basis for a rebuttal of less-positive data results," she adds.
Quality professionals can’t make practitioners provide better care, Brown acknowledges, but data are a strong incentive. "Physicians and nurses want to do what’s right, but they need to see the data," she says. "It’s a matter of helping them understand the value of performance measurement and the organization’s goals for improvement of patient care and outcomes. That understanding is now being quickened by the need to be responsive to what the public knows."
PR and quality team up
The link between public relations staff and quality professionals has become more important due to publicly reported data, says Voss. "When JCAHO came out with publicly reported data on hospitals, we made sure that our marketing staff were knowledgeable and knew how to respond," she adds. "It’s critical to have their involvement, to help us all look the best that we possibly can."
Too often, there has not been a drill-down analysis done for data that are publicly reported, Homa-Lowry warns. "So when you start presenting the numbers, sometimes that public data can be somewhat misleading," she says.
Before bragging about your results, be sure to do the analysis so you can let the data speak for themselves, says Homa-Lowry. "If you have done the drill-down and feel they are credible and reliable, then you may want to use them as a marketing tool," she says.
You also need to make sure the data are the most recent available, says Homa-Lowry. "In some of the reports, they are using MEDPAR data that could be old, and recent results may be much better," she explains, adding that organizations might not want to wait for the next run of the Medicare data if the results suggest problems.
For example, the results of the MEDPAR data can be the result of coding issues, which may result because the coders are dependent upon the documentation contained in the medical record to code. "Therefore, the data do not always indicate a quality-of-care issue, and the organization might want to show the improvements they have made or explain the data," Homa-Lowry says.
The organization may participate in other databases with different information and results concerning the issues reported in the MEDPAR data. This information can be used in response to the MEDPAR data reported, and in addition, the organization may have an opportunity to use data from previous years to show incremental improvement, Homa-Lowry says.
Regardless, there is a definite need for a strong relationship between marketing and quality staff, Homa-Lowry says. "I would certainly start having regular meetings with them and also get them more involved in the process," she says.
Tallahassee Memorial’s web site (www.tmh.org) features a press release stating that the organization is rated by JCAHO as "above the performance of most accredited organizations" for heart attack care and ranked in the top 10% for inpatient mortalities for heart attack victims both statewide and nationally. Quality leaders were instrumental in putting together this campaign, says Warren Jones, the organization’s chief communications officer.
"We worked very closely with the organizational improvement department," he says. "We look at this as an extension of our internal communications and how we celebrate successes, and transfer that outside the hospital."
As more information becomes public, you clearly want to have your marketing people involved so they are aware of the requirements and also keep current regarding potential risks, Homa-Lowry says. "For example, if the quality department becomes aware of a patient complaint from the Joint Commission or Medicare, eventually the marketing people will hear about it, but it would be better if there were an ongoing relationship so they can get together and discuss it beforehand," she says, because in many organizations, these are the individuals who prepare statements for the public in response to inquiries from the media.
Often, marketing people have access to data sources that aren’t necessarily consistently used in quality, such as the demographics of your community, changes in market share based on competitors, and planning information, Homa-Lowry says.
"Usually, the quality people will get the DRGs in rank order and so forth, but it would be interesting to see how the community is changing — are you getting an influx of young people? What about physician practices in terms of competitors or new markets?" she says. "It’s always helpful for the quality people to know that, because it can have an impact on how to prioritize quality issues."
[For more information on publicly reported quality data, contact:
• Janet A. Brown, RN, BSN, BA, CPHQ, FNAHQ, President, JB Quality Solutions Inc., 2309 Paloma St., Pasadena, CA 91104-4926. Phone: (626) 797-3074. Fax: (626) 797-3864. E-mail: email@example.com.
• Patti Higginbotham, RN, CPHQ, FNAHQ, Vice President, Quality Management and Medical Staff Services, Arkansas Children’s Hospital, 800 Marshall St., Little Rock, AR 72202-3591. Phone: (501) 364-4394. E-mail: firstname.lastname@example.org.
• Judy Homa-Lowry, RN, MS, CPHQ, President, Homa-Lowry Healthcare Consulting, 560 W. Sutton Road, Metamora, MI 48455. Phone: (810) 245-1535. Fax: (810) 245-1545. E-mail: email@example.com.
• Karen Pietrodangelo, Executive Director, Quality Management, Tallahassee Memorial HealthCare, 1300 Miccosukee Road, Tallahassee, FL 32308. Phone: (850) 431-2522. E-mail: Karen.Pietrodangelo@tmh.org.
• Pamela R. Voss, FACHE, FASHRM, Director, Risk Management, Round Rock Medical Center, 2400 Round Rock Ave., Round Rock, TX 78681. Phone: (512) 341-5286. Fax: (512) 341-5364. E-mail: firstname.lastname@example.org.]