The Never-Ending Burden of Reporting Patient Safety & Quality Metrics

Quick: how long does it take you to collect, aggregate, and report your SCIP, PN, AMI, and HF Core Measures? How about infection control metrics like rates of CLABSI, VAP, UTI, and MRSA? Or for that matter, any patient safety and quality metric that is mandated by JCAHO, CMS, your Department of Health, or anyone else? If you answered anything less than 2 months, and if I was a betting man, I’d bet you were lying.

There is a never-ending burden strapped to the backs of hospitals to collect, aggregate, analyze, validate, re-analyze, re-validate, report, re-validate, report again….quality measures. Reporting of these quality metrics is meant to benchmark institutions across the industry on their level of care, and inform patients of their treatment options. Fortunately for the majority of institutions, it is not difficult to achieve a high rate of compliance (>80-90%) because clinicians genuinely want to provide the best standards of care. Unfortunately though, the standards for achieving the highest designation according to CMS guidelines (achieving top percentile >99%) requires hospitals to allocate a disproportionate amount of time, money, and people to increase very small increments of compliance. I sat with a SCIP Nurse Abstractor last week and we spent 90 minutes drawing out, on 2 consecutive white boards, the entire process from start to finish of reporting SCIP core measures. There are over 50 steps, 5 spreadsheets/files, 4 hand-offs, 3 committees, and a partridge in a pear tree. It takes 2.5 months. I wonder how much money that is if you were to translate that time and effort into hard money spent? I also wonder what the return on investment is for that time, effort, and money. If we’re going to start running healthcare like a business, which I argue we should, this seems like a great place to start.

STEP 1: Reduce the amount of time spent on this process by ensuring the data is trustworthy There are way too many “validation” steps. Most people do not trust the data they’re given, and therefore end up re-validating according to their own unique way of massaging the data.

STEP 2: Integrate data from multiple sources so your Quality Abstractors and Analysts aren’t searching in 10 different places for the information they need. I’m currently helping a client implement interfaces for surgery, general lab, microbiology, blood bank, and pharmacy into their quality reporting system so their analysts can find all the information they need to report infection rates, core measures, and patient safety metrics. In addition, we built a Business Objects universe on top of the quality data store and they can do dynamic reporting in near real time. The amount of time saved is amazing and we have been successful in dramatically shifting the type of work these people are responsible for. The BI Capability Maturity Model below depicts our success helping them move from left to right.

STEP 3: Empower your analysts. With much more time to actually analyze the information, these people are the best candidates to help find errors in the data, delays in the process, and opportunities for improvement.

STEP 4: Create a mechanism for feedback based on the information you uncover. Both overachievers and underperformers alike need to be recognized for the appropriate reasons. Standardize on the best of what you find, and be sure to localize your intervention where the data is inaccurate or the process breaks down. This will also demonstrate greater transparency on your part.

Move the Quality Focus to Patient Outcomes

I had the privilege to attend the Microsoft Connected Health Conference in Bellevue, Washington on May 19-20.  Microsoft changed the format of their education sessions this year to a panel discussion including short presentations.  This new format included a moderator and several views of the topic from industry experts and key people from healthcare organizations.  One of my favorite sessions was titled “Capturing Value Across the Continuum: Healthcare Quality and Outcomes.”  If you have been following the Edgewater blogs on improving Core Measures then you understand my interest.

The real take-away on this topic was the understanding that the focus on quality in healthcare has been centered more on improving business processes than improving patient outcomes.  The panel consisted of Kim Jackson, Director of Data Warehousing, St. Joseph Health System, Kevin Fahsholtz, Senior Director with Premier, Dr. Floyd Eisenberg, Senior Vice President for Health Information Technology at the National Quality Forum and Dr. Richard Chung of the Hawaii Medical Services Association.  The panel represented a Hospital Provider (Kim), an Analytics and Benchmarking company (Kevin), a healthcare standards organization (Dr. Eisenberg) and a Payer organization (Dr. Chung),all of the key aspects of the Healthcare Quality continuum and was focused on the real world challenges of improving the quality of healthcare.

The key idea of improving patient outcomes dominated the hour long discussion.  Kim White noted that “the burden (of collecting data) for a hospital is overwhelming, and measuring is overtaking the work.”  Dr. Eisenberg agreed that there was a need to move the focus of the quality measures to outcomes and away from the small process details.  He went on to say that the real issue is the definitions of the data and that the definitions need to be standardized.  In his role, Dr. Eisenberg is working to create a standard data model for quality measures and key definitions to the standards for care.  Dr. Chung pointed out that we need to change our “culture of care delivery” along with the awareness of the data.  Dr. Chung believes that providing visibility of the quality data helps set up a culture of change.  His experience shows that separating the data from the application software allows new understanding.
All of the panelists agreed that a key issue is developing the “single version of the truth” and eliminating conflicting information.  Kim White presented that using Microsoft’s Amalga UIS product allowed St. Joseph Health System to unite their data, reorganize their data and prioritize it.  She pointed out that consolidating data sources from eight locations created this “single version of the truth” and reduced the administrative burden for tracking core measures.

Our experience in improving core measures parallels this panel discussion.  Success in improving healthcare quality and outcomes involves plain old hard work – collecting the right data, with the right definition, at the right time in the process and providing it to the right people.  The need to extend the data collection to tracking outcomes beyond reporting requirements is the right idea at a right time in healthcare.  Let’s not settle for the minimal reporting requirements, but truly track outcomes and develop the feedback loops necessary to keep them successful and improving.  It is, after all, about the patient and not mere statistics.

How to heighten core measure compliance

How do you go from SCIP compliance that looks like this?

To SCIP Core Measure compliance that looks like this?

It all starts with the documentation in your OR! How are the nurses, surgeons, and anesthesiologists documenting the data and information they collect throughout the patient visit as he/she moves from Holding to Pre-Op to the OR to PACU? The most critical aspect of high core measure compliance, whether its SCIP in the OR or Pneumonia, AMI, and HF in the ED, is electronic, discrete data capture.

One of the biggest problems in healthcare is the free-text field available in most healthcare applications, also known in the data and IT worlds as the “catch-all bucket”. Whenever users can’t find the right location within an application to put the information they’re documenting, they by default chose a “memo” field, or “case note” or just free text area for any and everything that could be typed from a computer keyboard. The problem is, this information can’t be mined and reported automatically. So what happens, nurses and other medical record professionals are paid to simply do chart abstraction which is a more professional way of saying “paper chasing”. The last 3 hospitals I consulted with paid nurses with 25+ years experience and a deep domain knowledge of core measure compliance over $70k / year to chase paper and make sense of free-text documentation. What a waste of expertise, skills and money. Wouldn’t these same resources be infinitely more valuable finding ways to improve the dips in core measure compliance instead of spending the significant majority of their time just chasing down the 10-12 different places SCIP data can end up (case notes, discharge summary, case record, op notes,  paper chart, order sets, etc.)?

First Steps Towards Higher Core Measure Compliance

So now we know the main problem, what steps can you take to change the nature of clinical documentation to naturally improve your ability to report SCIP compliance and heighten your performance?

  1. Make sure your end users know, “the [OR] applications are as good as they help make them”. No one should be locked into user interfaces, drop down fields, and data points that can’t be changed to accommodate clinical workflows. If you can’t change now, wait until the next upgrade or version release, collect the nursing feedback and address changes later on. And if your vendor rep says there’s nothing he/she can do, slap them! These are CMS mandated measures and the systems need to help in raising compliance in every way they can.
  2. Build values that CMS mandates directly into the documentation – make being compliant a default behavior. If CMS says that for SCIP-3 the only acceptable reasons for continuing an antibiotic past 24 hours are: “Infection”, “Possible Infection”, or “Documented spillage of fecal contents during abdominal surgery” then make those values options in your drop down menu. Don’t make it easy for users to be non-compliant.
  3. Create communication standards for feedback and accountability: OR Directors and Nursing Managers must have a consistent way for communicating breakdowns in compliance. This makes a strong case for Data Governance; there must be a way for you to have conversations with your clinicians that may not be easy or popular, but must be done nonetheless. No surgeon wants to be told he/she has done something wrong, it hurts their ego’s…but as my mother once told me, “you don’t always get what you want”.
  4. Equate high core measure compliance with benefits that relate directly to clinicians top priorities – Patient Care, Patient Satisfaction, Reputation, and Financial Incentives (in that order). The diagram below depicts the tremendous benefits realized when an institution can achieve high compliance consistently over time.

Unfortunately for you, these first steps are the easiest in any organizations quest towards higher core measure compliance or a move towards electronic documentation in general. I promise, there will be frustration before there is elation. Lucky for you, Edgewater has done this plenty of times with a high degree of success with healthcare providers of all shapes and sizes because we know the proper way in which to achieve these goals. So, when you’re ready, give us a call and we can help get you started or move you on to the next step because I promise, it’s much easier than it looks.