515741
other2013
AJMXXX10.1177/1062860613515741American Journal of Medical QualityJames
Commentary
Is It Time to Change Directions of Quality Measures?
American Journal of Medical Quality 2014, Vol. 29(6) 555–556 © 2013 by the American College of Medical Quality Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860613515741 ajmq.sagepub.com
Thomas James III, MD1 Current sets of measures of clinical quality were not designed to adequately describe trends in the overall health of individuals and of populations. There is no definition of “health” in the 2013 National Quality Strategy (NQS) provided in the Annual Report to Congress by the Secretary of Health and Human Services (HHS).1 A purpose of the report “is to build a national consensus on how to measure quality.” The focus of the NQS is largely on measures of health care rather than on measures of health. On the other hand, the Centers for Medicare and Medicaid Services has set national goals with its Triple Aim of better health for the population, better health care for individuals, and lower cost of care.2 Although existing measures are intended to describe health care, they do not provide metrics for the population. Measures of “systemness” and well-being of both individuals and populations should be developed to better serve all 3 elements. Existing measures of quality used in the NQS report have been based largely on the quality model described by Avedis Donabedian, MD, MPH. This framework, based on measures of structure, process, and outcomes, has been adopted for the development of quality measures by organizations such as the National Committee for Quality Assurance, the American Medical Association Physician Consortium for Performance Improvement, and the Agency for Healthcare Quality and Research (AHRQ), among others. Measures developed by these and other organizations may be reviewed by the National Quality Forum (NQF) for endorsement. Those measures endorsed by NQF are frequently adopted as accountability measures by payers, consumer groups, employers, and others. NQF-endorsed measures also may be reviewed by the Measurement Application Partnership, a multi-stakeholder organization established under the Affordable Care Act to advise the Secretary of HHS on quality measures for use in HHS programs. These NQF-endorsed measures have been used to assess the variations among providers and between geographic regions. With variations between physicians on performance measures, assumptions have been made that variation reduction will lead to improvements in quality of care. A second assumption is that improvements in quality of care result in greater health. This may be true for some individuals but has not been demonstrated at a population level where other factors such as behaviors,
genetics, safety, environment, and social determinants have greater impact on health.3 Hospitals and physicians have raised concerns about accountability for health care quality outcomes measures when much of the outcomes are dependent on factors beyond the control of medical care providers. Additionally, consumer groups, employers, and payers have voiced concerns that current process measures do not address well-being. Furthermore, studies are not clear as to the impact of public reporting or of financial incentives on physician-directed performance measures.4 In medicine, we may have made false assumptions about the impact of measures. In other industries, measures are used as part of a checklist to stop a process should a defect be found. This use of measures is common on the manufacturing assembly line or in the airline industry. The use of measures as part of checklist is still relatively uncommon in medicine. Anesthesiologists and surgeons increasingly use checklists for operative procedures to improve the safety of the surgery. For reductions in central line infections, the checklist advocated by Peter Pronovost, MD, PhD, and popularized by Atul Gawande, MD, MPH, represent recent use of the checklist. These are examples of the few quality control measures in medicine. But much of health care is based on a series of complex decisions that cannot easily be put into algorithmic checklists. Frequently the number of inputs exceeds the ability to make a meaningful series that could be placed into a checklist. Furthermore, jet planes and assembly lines are inanimate and do not provide their own volitional input into decision making. People are complex creatures from biologic, social, and emotional points of view. Current process and outcome measures consider only disease prevention or control and not the other myriad variables. Although these measures are based on evidence or consensus standards for a typical population, they do not consider the variability of individual comorbidities and genetic backgrounds let alone preferences, values, and cultures. 1
AmeriHealth Caritas, Philadelphia, PA
Corresponding Author: Thomas James III, MD, AmeriHealth Caritas, 200 Stevens Drive, Bldg 200, Philadelphia, PA 19113. Email: [email protected]
Downloaded from ajm.sagepub.com at GEORGIAN COURT UNIV on May 11, 2015
556
American Journal of Medical Quality 29(6)
All of this raises the question of whether we are measuring the important elements if the goal of measurement is to help improve the health of the population. Conway, Mostashari, and Clancy have called for a realignment of measures to better describe quality outcomes.5 Current measurement systems define quality based on results of structure, process, and outcomes measures. Those provider entities with higher scores are judged to deliver higher quality care. The scores define the determinants of quality. That is a self-defining determination of quality. Rather than assess the quality of care provided by physicians or medical care systems by the composite of individual points, we need a broader process that is based on the global tenants as our society defines quality of care: •• Care that promotes well-being: treating disease appropriately and teaching healthier practices for the patient and community •• Care that is consistent with the values of the patient and engages the patient and family with respect •• Care that improves the health of the population while treating the individuals •• Care rendered with the personal and societal limitations on resources These goals encompass the elements of the Triple Aim. Measures of how well a physician, group practice, or community does in providing quality of care must go beyond individual measures of points of quality, and more to broad constructs of measurement. Heuristics may be an important tool to arrive at better measures of quality. This tool is used in engineering and in the social sciences but has not been widely deployed in health care. Heuristics has been used for assessment of patient safety in design of durable medical equipment.6 The AHRQ Patient Safety Network defines heuristics as “loosely defined or informal rules often arrived at through experience. . . . Heuristics provide cognitive shortcuts in the face of complex situations, and thus serve an important purpose.”7 To measure the total health of the individual or of the population requires thinking beyond just the current clinical measures of elements of prevention and disease management and requires the leap to systems thinking. The system, in the case of well-being for individuals and for populations, must involve the overlapping influences of the medical care system, the employer and educational system, community resources, and the family/social support systems. All of these play roles in the total wellbeing of the individual and of the unique population. There are no existing measures that are representative of the final overall goal of maximizing well-being. Heuristics allow the development of such measures through a consensus process that identifies those medical,
social, and community systems that most closely achieve the highest states of well-being for the greatest percentage of people, using a risk-adjusted methodology. Those systems identified should be studied to ascertain the characteristics held in common. Once common characteristics have been determined, testing measures of those characteristics on other systems can validate the proposed measure. This systems approach to identification of common characteristics and measure development does not come from the tradition of current measure development that relies on controlled clinical trials. This proposed use of heuristics to achieve measurement sets is more likely to be predictive of health care outcome improvement for individuals. This can be achieved by a better understanding of the factors more likely to be associated with health outcome goals for individual patients and for populations of individuals. It may be that the relatively simplistic heuristic methodology may give us more information on the quality of care provided by individual doctors, group practices, communities, or other entities than a complex set of individual measures. This approach is gaining traction in medical education and may be worthy of greater review for quality measurement.8 By using heuristics to identify characteristics of health and community systems, it may be possible to move to the next generation of health measurement that will better align with the Triple Aim. References 1. US Department of Health and Human Services. 2013 Annual progress report to Congress: National strategy for quality improvement in health care. http://www.ahrq. gov/workingforquality/nqs/nqs2013annlrpt.htm. Accessed September 7, 2013. 2. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27:759769. 3. McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood). 2002;21:78-93. 4. Scott A, Sivey P, Ait Ouakrim D, et al. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Database Syst Rev. 2011;(9):CD008451. 5. Conway PH, Mostashari F, Clancy C. The future of quality measurement for improvement and accountability. JAMA. 2013;309:2215-2216. 6. Zhang J, Johnson TR, Patel VL, Paige DL, Kubose T. Using usability heuristics to evaluate patient safety of medical devices. J Biomed Inform. 2003;36:23-30. 7. Agency for Healthcare Research and Quality. PSNet glossary: heuristics. http://www.psnet.ahrq.gov/glossary. aspx?indexLetter=H. Accessed September 7, 2013. 8. Wegwarth O, Gaissmaier W, Gigerenzer G. Smart strategies for doctors and doctors-in-training: heuristics in medicine. Med Educ. 2009;43:721-728.
Downloaded from ajm.sagepub.com at GEORGIAN COURT UNIV on May 11, 2015
other2013
AJMXXX10.1177/1062860613515741American Journal of Medical QualityJames
Commentary
Is It Time to Change Directions of Quality Measures?
American Journal of Medical Quality 2014, Vol. 29(6) 555–556 © 2013 by the American College of Medical Quality Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860613515741 ajmq.sagepub.com
Thomas James III, MD1 Current sets of measures of clinical quality were not designed to adequately describe trends in the overall health of individuals and of populations. There is no definition of “health” in the 2013 National Quality Strategy (NQS) provided in the Annual Report to Congress by the Secretary of Health and Human Services (HHS).1 A purpose of the report “is to build a national consensus on how to measure quality.” The focus of the NQS is largely on measures of health care rather than on measures of health. On the other hand, the Centers for Medicare and Medicaid Services has set national goals with its Triple Aim of better health for the population, better health care for individuals, and lower cost of care.2 Although existing measures are intended to describe health care, they do not provide metrics for the population. Measures of “systemness” and well-being of both individuals and populations should be developed to better serve all 3 elements. Existing measures of quality used in the NQS report have been based largely on the quality model described by Avedis Donabedian, MD, MPH. This framework, based on measures of structure, process, and outcomes, has been adopted for the development of quality measures by organizations such as the National Committee for Quality Assurance, the American Medical Association Physician Consortium for Performance Improvement, and the Agency for Healthcare Quality and Research (AHRQ), among others. Measures developed by these and other organizations may be reviewed by the National Quality Forum (NQF) for endorsement. Those measures endorsed by NQF are frequently adopted as accountability measures by payers, consumer groups, employers, and others. NQF-endorsed measures also may be reviewed by the Measurement Application Partnership, a multi-stakeholder organization established under the Affordable Care Act to advise the Secretary of HHS on quality measures for use in HHS programs. These NQF-endorsed measures have been used to assess the variations among providers and between geographic regions. With variations between physicians on performance measures, assumptions have been made that variation reduction will lead to improvements in quality of care. A second assumption is that improvements in quality of care result in greater health. This may be true for some individuals but has not been demonstrated at a population level where other factors such as behaviors,
genetics, safety, environment, and social determinants have greater impact on health.3 Hospitals and physicians have raised concerns about accountability for health care quality outcomes measures when much of the outcomes are dependent on factors beyond the control of medical care providers. Additionally, consumer groups, employers, and payers have voiced concerns that current process measures do not address well-being. Furthermore, studies are not clear as to the impact of public reporting or of financial incentives on physician-directed performance measures.4 In medicine, we may have made false assumptions about the impact of measures. In other industries, measures are used as part of a checklist to stop a process should a defect be found. This use of measures is common on the manufacturing assembly line or in the airline industry. The use of measures as part of checklist is still relatively uncommon in medicine. Anesthesiologists and surgeons increasingly use checklists for operative procedures to improve the safety of the surgery. For reductions in central line infections, the checklist advocated by Peter Pronovost, MD, PhD, and popularized by Atul Gawande, MD, MPH, represent recent use of the checklist. These are examples of the few quality control measures in medicine. But much of health care is based on a series of complex decisions that cannot easily be put into algorithmic checklists. Frequently the number of inputs exceeds the ability to make a meaningful series that could be placed into a checklist. Furthermore, jet planes and assembly lines are inanimate and do not provide their own volitional input into decision making. People are complex creatures from biologic, social, and emotional points of view. Current process and outcome measures consider only disease prevention or control and not the other myriad variables. Although these measures are based on evidence or consensus standards for a typical population, they do not consider the variability of individual comorbidities and genetic backgrounds let alone preferences, values, and cultures. 1
AmeriHealth Caritas, Philadelphia, PA
Corresponding Author: Thomas James III, MD, AmeriHealth Caritas, 200 Stevens Drive, Bldg 200, Philadelphia, PA 19113. Email: [email protected]
Downloaded from ajm.sagepub.com at GEORGIAN COURT UNIV on May 11, 2015
556
American Journal of Medical Quality 29(6)
All of this raises the question of whether we are measuring the important elements if the goal of measurement is to help improve the health of the population. Conway, Mostashari, and Clancy have called for a realignment of measures to better describe quality outcomes.5 Current measurement systems define quality based on results of structure, process, and outcomes measures. Those provider entities with higher scores are judged to deliver higher quality care. The scores define the determinants of quality. That is a self-defining determination of quality. Rather than assess the quality of care provided by physicians or medical care systems by the composite of individual points, we need a broader process that is based on the global tenants as our society defines quality of care: •• Care that promotes well-being: treating disease appropriately and teaching healthier practices for the patient and community •• Care that is consistent with the values of the patient and engages the patient and family with respect •• Care that improves the health of the population while treating the individuals •• Care rendered with the personal and societal limitations on resources These goals encompass the elements of the Triple Aim. Measures of how well a physician, group practice, or community does in providing quality of care must go beyond individual measures of points of quality, and more to broad constructs of measurement. Heuristics may be an important tool to arrive at better measures of quality. This tool is used in engineering and in the social sciences but has not been widely deployed in health care. Heuristics has been used for assessment of patient safety in design of durable medical equipment.6 The AHRQ Patient Safety Network defines heuristics as “loosely defined or informal rules often arrived at through experience. . . . Heuristics provide cognitive shortcuts in the face of complex situations, and thus serve an important purpose.”7 To measure the total health of the individual or of the population requires thinking beyond just the current clinical measures of elements of prevention and disease management and requires the leap to systems thinking. The system, in the case of well-being for individuals and for populations, must involve the overlapping influences of the medical care system, the employer and educational system, community resources, and the family/social support systems. All of these play roles in the total wellbeing of the individual and of the unique population. There are no existing measures that are representative of the final overall goal of maximizing well-being. Heuristics allow the development of such measures through a consensus process that identifies those medical,
social, and community systems that most closely achieve the highest states of well-being for the greatest percentage of people, using a risk-adjusted methodology. Those systems identified should be studied to ascertain the characteristics held in common. Once common characteristics have been determined, testing measures of those characteristics on other systems can validate the proposed measure. This systems approach to identification of common characteristics and measure development does not come from the tradition of current measure development that relies on controlled clinical trials. This proposed use of heuristics to achieve measurement sets is more likely to be predictive of health care outcome improvement for individuals. This can be achieved by a better understanding of the factors more likely to be associated with health outcome goals for individual patients and for populations of individuals. It may be that the relatively simplistic heuristic methodology may give us more information on the quality of care provided by individual doctors, group practices, communities, or other entities than a complex set of individual measures. This approach is gaining traction in medical education and may be worthy of greater review for quality measurement.8 By using heuristics to identify characteristics of health and community systems, it may be possible to move to the next generation of health measurement that will better align with the Triple Aim. References 1. US Department of Health and Human Services. 2013 Annual progress report to Congress: National strategy for quality improvement in health care. http://www.ahrq. gov/workingforquality/nqs/nqs2013annlrpt.htm. Accessed September 7, 2013. 2. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27:759769. 3. McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood). 2002;21:78-93. 4. Scott A, Sivey P, Ait Ouakrim D, et al. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Database Syst Rev. 2011;(9):CD008451. 5. Conway PH, Mostashari F, Clancy C. The future of quality measurement for improvement and accountability. JAMA. 2013;309:2215-2216. 6. Zhang J, Johnson TR, Patel VL, Paige DL, Kubose T. Using usability heuristics to evaluate patient safety of medical devices. J Biomed Inform. 2003;36:23-30. 7. Agency for Healthcare Research and Quality. PSNet glossary: heuristics. http://www.psnet.ahrq.gov/glossary. aspx?indexLetter=H. Accessed September 7, 2013. 8. Wegwarth O, Gaissmaier W, Gigerenzer G. Smart strategies for doctors and doctors-in-training: heuristics in medicine. Med Educ. 2009;43:721-728.
Downloaded from ajm.sagepub.com at GEORGIAN COURT UNIV on May 11, 2015
