Yet quality measures continue to be created, espoused, and studied. Payments to accountable care organizations (ACO), hospitals, and individual providers are being tied to performance on quality measures. Medicare is considering quality measures that can be applied to PHM, which might affect future payments to children’s hospitals. Paciorkowski and colleagues recently described the development of 87 performance indicators specific to PHM that could be used to track quality of care on a division level, 79 of which were provider specific.5 A committee of pediatric hospitalists led by Paul Hain, MD, recently proposed a “dashboard” of metrics pertaining to descriptive, quality, productivity, and other data that could be used to compare PHM groups across the country.6 Many hospitalist groups already have instituted financial incentives tied to provider or group-specific quality measures.7 Pay-for-performance has arrived in adult HM and is now pulling out of the station: next stop, PHM.
The Rest of the Cost Story
Like any labor-intensive process in medicine, defining, measuring, and improving quality has a cost. A 2007 survey of four urban teaching hospitals found that core QI activities required 1%-2% of the total operating revenue.8 The QI activity costs fall into the category of the “cost of good quality,” as defined by Philip Crosby in his book, Quality is Free (see Figure 1).9 Although hospital operations with better process “sigma” will have lower prevention and appraisal costs, these can never be fully eliminated.
Despite our attempts at controlling costs, most ongoing QI efforts focused on improving clinical quality alone are doomed to fail with regard to providing bottom-line cost reductions.10 QI efforts that focus on decreasing variability in the use of best practices, such as the National Surgical Quality Improvement Program (NSQIP), have brought improvements in both outcomes and reduced costs of complications.11 Not only do these QI efforts lower the “cost of poor quality,” but they may provide less measurable benefits, such as reduced opportunity costs. Whether these efforts can compensate by reducing the cost of poor quality can be speculative. Some HM authorities, such as Duke University Health CMO Thomas Owens, have made the case, especially to hospital administrators, for espousing a more formulaic return on investment (ROI) calculation for HM QI efforts, taking into account reduced opportunity costs.12
But measured costs tell only part of the story. For every new quality measure that is defined, there are also unmeasured costs to measuring and collecting evidence of quality. Being constantly measured and assessed often leads to a perceived loss of autonomy, and this can lead to burnout; more than 40% of respondents from local hospitalist groups in the most recent SHM Career Satisfaction Survey indicated that optimal autonomy was among the four most important factors for job satisfaction.13 The same survey found that hospitalists were least satisfied with organizational climate, autonomy, and availability of personal time.14
As many a hospitalist can relate, although involvement in QI processes is considered a cornerstone of hospitalist practice, increased time spent in a given QI activity rarely translates to increased compensation. Fourteen percent of hospitalists in a recent SHM Focused Survey reported not even having dedicated time for or being compensated for QI.
Which is not to say, of course, that defining and measuring quality is not a worthy pursuit. On the contrary, QI is a pillar of hospital medicine practice. A recent survey showed that 84% of pediatric hospitalists participated in QI initiatives, and 72% considered the variety of pursuits inherent in a PHM career as a factor influencing career choice.15 But just as we are now focused on choosing wisely in diagnosing and treating our patients, we should also be choosing wisely in diagnosing and treating our systems. What is true for our patients is true for our system of care—simply ordering the test can lead to a cascade of interventions that can be not only costly but also potentially dangerous for the patient.