We are now knee deep in the quality revolution. In some ways, this should have been driven by the hospitals and doctors striving for continual quality improvement. It should have been driven by patients demanding better outcomes, more uniform processes, and the data to help them decide where to receive the best care. In reality it is being driven by those who pay for care—America’s businesses and our government, two entities that want better value for the increasingly dear dollars they spend on healthcare.
Hospitals and doctors have survived (and many have succeeded) by using the traditional compensation system, which rewards the performing of care without rewarding the best or even the better practice of medicine. Today you can do the wrong procedure and do it poorly and still get paid. The mantra of the entire performance and standards effort is to shift at least some of the rewards to those with better outcomes, to processes that are more in line with national practice standards, and to those who have the data to back that up. In marketing shorthand, this is pay for performance—or P4P—and while it seems natural in most of the rest of the American marketplace, it is somewhat revolutionary in healthcare.
While the concept of identifying best practices, measuring performance, collecting data, and then appropriately tying compensation or rewards to performance sounds clear and straightforward, many issues quickly surface to cloud any forward progress.
Decide What to Measure
Unfortunately, you can arrive quickly and efficiently at the wrong destination. Everyone knows that some of the hallmarks of physicians are that we can “perform for the test” and adapt to a new paradigm. It is important that we don’t just settle for what we can easily measure (knowing that most of our systems’ data collection efforts are geared initially to getting paid and not to measuring key performance indicators), but that we make sure that we are selecting performance measures that lead to better patient outcomes and improve care. Hospitalists must constantly examine their hospitals’ plans for data collection to ensure that achieving high marks will lead to better patient care.
Data, Data, Who Gets the Data?
There is no doubt that the by-product of the current P4P movement is that there will be more known about doctors and hospitals than ever before. Like nuclear energy, this volatile resource can be used for good or evil. It is not a trivial issue of who “owns” the data and who has access to it.
How valuable would it be to the pharmaceutical industry to know which doctors treat a lot of heart failure and which medications they use and why? How valuable would it be for insurance companies to see physician or hospital performance data not just for their insured, but for all of a physician’s or institution’s patients? Who will control access to all the data that will be collected?
This plays into another important question: Just how will individual or small independent groups of physicians pay for all this reporting? Very likely, data collection and reporting will be an additional cost of doing business for an already strapped profession. To succeed—or just to stay in the game—physicians will need to upgrade their systems with new hardware and software, while facing the prospect of having their payment diminished or of being cut off from certain patients. What if a hospital offered physicians free systems upgrades in exchange for a look at all the physicians’ data? What if pharmaceutical companies made the same offer? Would physicians potentially sell their information for a handful of beads?
Where to Be? What to Do?
For national professional societies, the greater issue may be how best to participate proactively in the P4P process and how to define their roles. Should SHM be involved in developing new standards of care for areas where we have crucial roles (e.g., transitions of care, end-of-life care) or should we simply critique the efforts of others? Is our role to be the patients’ advocate at any cost, or do we have a responsibility to stand up for the young and evolving discipline of hospital medicine? Is SHM’s main role to be a communicator to our nation’s hospitalists about what the new rules and standards will be, or should SHM develop educational resources to help hospitalists act as leaders in the implementation of the rules that flow out of this complex process?
Just as important is to try to understand where SHM can be most effective. As hospitals have seen a huge growth in the data they must collect and report on, so too has SHM observed a proliferation of organizations cropping up to take their place as key players in the P4P arena. SHM can’t be everywhere, so we have chosen to enter where we feel we can make the most impact.
Hospitalists’ Role in Improving Quality
First, SHM has created a working group on Performance and Standards to coordinate all of our relationships in this rapidly evolving and growing field. SHM has hired Jill Epstein to be the dedicated staff for this effort. SHM has decided to actively participate with the AMA Physician Consortium for Performance Improvement (PCPI) because this is where most of the specialties of medicine come together to develop and assess performance standards.
SHM is also becoming more active at the National Quality Forum (NQF), where groups such as the PCPI submit their standards for acceptance. SHM has nominated hospital medicine leaders for the NQF Steering Committee as well as for its Technical Advisory Panels on Patient Safety, Anesthesia and Surgery, and Pediatrics. The Centers for Medicare and Medicaid Services and Congress will look to NQF as a national clearinghouse for performance measurements.
SHM has had a good working relationship with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for years. Now, SHM looks to expand our work with JCAHO as their role in standard setting and accreditation evolves.
In this complex arena, SHM is constantly looking for other professional medical societies with similar interests and values with which to share information and strategies. SHM has found the American College of Physicians, the American Geriatrics Society, the Society of Critical Care Medicine, the American College of Chest Physicians (ACCP), and others particularly open and helpful.
But SHM won’t be content with just helping to set the standards. We believe hospitalists have a unique role in implementing change. Beginning with our Leadership Academies, which train those who can lead and manage change, SHM has also introduced a quality improvement precourse at our annual meetings, as well as the practical Resource Rooms on our Web site, which have 100-page detailed workbooks to guide hospitalist leaders in quality improvement projects in DVT and diabetes. Under the leadership of Greg Maynard, MD, of University of California at San Diego (UCSD) and Jason Stein, MD, of Emory University Hospital, Atlanta, with staff leadership by Kathleen Kerr of UCSF, SHM has just launched its DVT Mentored Implementation project, in which we will guide, support, and mentor 30 hospital medicine leaders to improve patient care at their local institutions.
SHM is actively partnering with the Institute for Healthcare Improvement (IHI) to train and support the hospitalists who will leverage IHI’s “100K Lives Saved” campaign. These hospitalist leaders will act as change agents for further quality improvements on a local level.
Not a Time to Stand Idly By
The status quo is not an option. This call for change is, in many ways, fueling the growth of hospital medicine. Change that was called for many years ago is now taking shape. SHM is playing a role in ensuring that the new standards of care that we will have to meet make sense to improve the care our patients receive. But SHM won’t just set the rules, line the field, and build the scoreboard. Spring training—a time when we will need to refine old skills and develop new ones—is upon us. Hospitalists are ready to play their part. Game on. Let’s go. TH
Dr. Wellikson has been CEO of SHM since 2000.