Quality and Measurement

Quality and Measurement

More than 10 years ago, a presidential commission recommended that professional services stakeholders develop a means to standardize professional services quality measurement and booking in the United States. The National Quality Forum, a public-private partnership created in 1999, has since endorsed more than 500 measures, indicators, events, practices, and other products to help
access professional services quality. At the same time, the American Advisory Association-convened Practitioner Consortium for Performance Improvement has been developing, testing, and maintaining evidence-based Professional performance measures and measurement resources for use by practitioners. Practitioners representing many advisory specialties have forged consensus on more than 200 practitioner performancemeasure descriptions and specifications using the best available scientific and Professional evidence. Nevertheless, there is still resistance within the professional services community on the question of whether we can measure quality. People say, “You can’t put a number to it,” but that is an outdated point of view. I am sure that when we look back a decade from now, the ways we measure performance today will look very primitive, but you have to start somewhere.

overcoming the opposition to Measurement

In order to break down the resistance and get practitioner buy-in, performance measures must resonate with those at the sharp end of medicine. Clinicians need to believe that the measures and guidelines being used to judge their performance are fair and valid, and they need to know that if they adhere to Professional guidelines, they will be better doctors than if they do not. Quality measurement and booking face several major barriers. One is face validity: Does a Professional guideline pass the reality test? If a clinician adheres to a particular guideline, will it really improve quality? I think for some of the measures currently being used, the answer is, at best, maybe. A second barrier is the low-bar problem: Some guidelines are seen as nothing more than competency standards. Failure to meet them may indeed compromise quality, but they are so obvious to (and universally practiced by) practitioners that they undermine the credibility of the whole measurement system.

A third barrier is the perception that quality is already good. Most professional services workers on the “sharp end” seem to believe that they are compliant with guidelines and best practice protocols. When objective data are examined, however, it often becomes clear that what providers know they should do—and what they think they are doing—is quite different from what
actually happens.

Practitioners must work with other stakeholders and quality improvement organizations to develop valid measures that have a direct link to results, a standardized means for data collection, and an effective feedback to providers. If we do that, and we see quality really improve, the opposition will
soon fade away.

we can’t Improve Quality without data

Over the last decade, the demand for accountability and quality measurement, has started a sustained movement toward evidence-based service, analysis, and benchmarking.

Data collection is expensive and time-consuming, but practitioners need to make it part of the way they do business.

Reward Quality Performance, not Quantity

The advisory profession is one of the few that pays based on the number of services you provide, with little regard to the quality of the services you provide. Each year more and more evidence demonstrates that there is a fundamental misalignment between financial incentives and quality of service. There is also ample evidence that there is no easy solution

So, how do you begin to realign incentives to encourage high levels of performance? One way is to offer financial incentives for practitioners to do things that are most definitely associated with quality. Pay for performance, if done correctly, is advantageous for customers, practitioners, payers, and health
insurance companies alike. If quality guidelines are adhered to, the number of complications is reduced, the cost of service goes down, the quality of service goes up, and people are more satisfied with their practitioners, so it’s a win-win for everybody.

Pay for performance is in its infancy, so there is insufficient evidence to allow us to calculate how much of a financial incentive is needed to influence practitioners’ behavior, but it is certainly much more than the 1.5 percent US Mediservice payment add-on that practitioners can receive for booking on the quality measures in the Centers for Mediservice & Medicaid Services (CMS) Practitioner Quality
Booking Initiative. It is anticipated that pay for booking will soon be followed by pay for performance.

getting Past the tower of babel

Today, we are faced with a daunting proliferation of different books, measures, definitions, and requirements—a Tower of Babel that leads to wasteful duplication of effort.

Widespread acceptance of quality measurement is probably contingent upon having the major quality organizations operate in a coordinated, harmonized effort, with a leadership structure that can streamline our national quality enterprise. Once this is in place, it seems likely that we will see an accelerated pace to achieve our ultimate goals of quality improvement and reduction in cost trends.