Wednesday, 01 July 2015 23:30

VBP and Quality: Time to “Start with the Sand?”

Written by

p nathansonIn 1989, a group of executives involved in hospital quality improvement met with Jamie Houghton, then CEO of Corning Incorporated. They wanted to know how Corning had managed to make capacitors at true Six Sigma – with fewer than four defects in a million capacitors – to compete with the Japanese company Kyocera.

“We realized that we had to go beyond what we could control directly – our own plant,” Mr. Houghton told the group. “We had to improve the entire manufacturing process. That meant that we had to start all the way back with the sand that provides the silica that eventually becomes the ceramic part of the capacitor. We worked with our supplier until the sand came in practically contamination-free. We then continued to work with our suppliers, engineers, plant workers, and the union to perfect each step in the process.”

 At the time of the Houghton visit, most in the healthcare industry still believed that quality only could be evaluated one chart at a time, by a clinician, to determine if the care met “the community standard of care.” In the 25 years between that visit and the era of value-based purchasing (VPB), there has been a lot of progress. But there has been little movement toward taking Corning’s Six Sigma insights to heart.

Let’s briefly review the accomplishments of healthcare quality improvement programs to date:

  • Most hospitals and physicians today agree that healthcare quality can and should be evaluated objectively – both for individuals and for populations.
  • A broad consensus has developed about what constitutes “quality” and what dimensions need to be measured: care and safety outcomes for individuals or for a defined population; conformance to evidence-based best practices; and patient experience of care.
  • Standardized quality measures sets made up of valid and reliable metrics have been developed and are in use by healthcare’s paying customers, regulators, accreditors, and interest groups.

Providers have plenty of legitimate complaints about quality programs, especially the measures. There are way too many of them. Some are topped out. Some are unconnected to patient outcomes. Some are duplicates of others with slightly different specifications. Tracking and reporting them can cost large institutions millions of dollars per year. But notwithstanding the complaints, it is beyond dispute that the use of quantitative quality measures has improved care dramatically. To cite just a couple of obvious examples, the Joint Commission and Centers for Medicare & Medicaid Services (CMS) measures of inpatient care for heart attack, heart failure, pneumonia, and stroke have lengthened countless lives. Ditto the National Committee for Quality Assurance’s HEDIS measures of the percentage of managed care populations that get preventive care, ranging from beta blockers for heart attack victims to flu shots for the elderly to annual eye tests for diabetics.

In spite of its achievements, however, the healthcare quality movement has not been able to do what Corning did with capacitor manufacturing – namely, to create collaboration among the participants in a set of interconnected sub-processes so as to ensure high-quality results for the process as a whole. The ability to do that is a hallmark of mature quality improvement programs across American industry. The Ford Motor Company’s’ Certified Supplier program pioneered in reaching deep into parts manufacturers’ processes. Disney’s Strategic Sourcing Partnerships give its suppliers “skin in the game” and linked Disney to firms as diverse as Bank One, HP, and Frito-Lay.

Is this approach relevant in healthcare? Certainly. Unhealthy lifestyles, poor living conditions, lack of access to primary or urgent care, lack of support systems in the home – all of these are the “sand” that must be addressed if the healthcare industry wants to keep people healthy.

There are lots of good reasons why outside of integrated delivery systems, this kind of starting with the “sand” hasn’t happened very much in healthcare. Payors and regulators haven’t required it. Unaffiliated caregivers working with the same patients may have no incentive to cooperate. Lack of electronic health record (EHR) interoperability can pose major data sharing challenges.

But with the advent of VBP programs, the incentives are starting to shift, especially for hospitals.  VBP programs like ACOs and bundled payments align the incentives of hospitals with providers, which see patients before and after they become hospital patients, may have close ties to community resources, and can work with patients themselves, relatives, schools, and other entities to support patients in embracing healthy lifestyles.

In addition, intentionally or not, some VBP measures require starting with the “sand.” A prime example is CMS’s readmissions reduction program. Experience with this program has made it clear that many of the factors driving readmissions have nothing at all to do with the quality of care given in the hospital:

  • For COPD patients, air pollution alone can trigger an exacerbation that requires an ED visit and, frequently, a readmission.
  • For hip and knee replacement patients, a recent study showed that more than half of readmissions are caused by surgical site infections contracted outside the hospital.
  • Another recent study showed that in one community, discharged patients who needed an immediate primary care physician follow-up visit often couldn’t get one because the overbooked primary care physicians had no incentives to give them priority. Result: readmissions.

In response, hospitals are beefing up their care management and care coordination staffs. They’re strengthening relationships across the spectrum of care and beyond. They’re establishing home visit programs that are sometimes almost as much social work as about instruction in how to use a nebulizer or maintain a catheter.

We can expect these outreach activities to continue to grow in scope and sophistication as more and more care is linked to value in years to come. We even can predict that healthcare organizations’ responsibility for quality will expand beyond the traditional continuum of care as the search for root causes of unhealthy behaviors and other factors that add to the population’s burden of illness goes deeper into the “sand.”

For a glimpse of what healthcare quality improvement might look like if current trends continue, consider the Institute of Medicine’s May 2015 report titled “Vital Signs: Core Metrics for Health and Health Care Progress.This 353-page document is the product of a 21-member committee of healthcare experts chaired by Commonwealth Fund President and former National Coordinator for HIT David Blumenthal, MD. The committee was charged by IOM to develop a “parsimonious set of measures for health and healthcare” to replace the huge and growing number of quality measures in use.

The committee decided that the best way to get to a “parsimonious set” – i.e. a set that provides the needed quality measurement in the fewest possible measures – is to imagine a future in which responsibility for improving the nation’s health outcomes is “assumed by … the full array of sectors and entities, from clinicians and hospitals to schools andfamilies, that influence the health of the population through their activities.” In other words, healthcare organizations must not only deliver healthcare; they must partner with each other, schools, families, and presumably community resources, religious institutions, and charities as well, to work together to create and maintain a healthy population.

As that goal is achieved, say the report’s authors, the current plethora of quality measures can gradually be replaced by only 15 "core measures." And here they are:

  • Life expectancy, measured by expectation at birth
  • Well-being, measured by self-reported health
  • Overweight and obesity, measured by body mass index
  • Addictive behavior, measured by addiction death rates
  • Unintended pregnancy, measured for teens
  • Healthy communities, measured by high school graduation rates (yes, there’s evidence that children who don’t finish high school are sicker than those who do)
  • Preventive services, measured by childhood immunization rates
  • Care access, measured by unmet care need
  • Patient safety, measured by hospital-acquired infection rates
  • Evidence-based care, measured by preventable hospitalization rates
  • Care matched with patient goals, measured by communication with clinicians
  • Personal spending burden, measured by high healthcare spending relative to income
  • Population spending burden, measured by per capita healthcare spending
  • Individual engagement, measured by health literacy rate
  • Community engagement, measured by levels of social support

That list is sure to cause serious heartburn for today’s healthcare quality managers. High school graduation rates? But who really knows where starting with the “sand” will take us?

To sum up: healthcare quality measurement and management have come a long way over the past three decades. But addressing some of the deepest causes of disease or injury has been outside the scope of most healthcare quality programs. Today’s VBP programs are helping to encourage healthcare institutions and organizations to “start with the sand.” Healthcare delivery may never reach true Six Sigma, as Corning Incorporated’s capacitors did. But by breaking out of their traditional facility- or practice-specific constraints, heathcare quality improvement programs can get us a lot closer.

About the Author

Philip Nathanson is the president of Nathanson Consulting LLC. Phil has held quality leadership positions at CMS, Aetna, and NCQA. His consulting clients include hospital systems, HIM firms, and biotech companies. His articles on quality and healthcare management have appeared in Becker’s Hospital Review, H&HN Online, Topics in Healthcare Financing, and other journals.

Contact the Author

This email address is being protected from spambots. You need JavaScript enabled to view it.

Comment on This Article

This email address is being protected from spambots. You need JavaScript enabled to view it.

Last modified on Thursday, 02 July 2015 06:38

Philip Nathanson is the President of Nathanson Consulting LLC.  Phil has held quality leadership positions at CMS, Aetna, and NCQA. His consulting clients include hospital systems, HIM firms and biotech companies. His articles on quality and healthcare management have appeared in Becker’s Hospital Review, H&HN Online, Topics in Healthcare Financing and other journals.