To improve quality, whom we measure is as important as what.
by Joe Rotella, MD, MBA, FAAHPM
The growing awareness in America that our healthcare system is unaffordable and fails to deliver consistent quality has led us to healthcare reform, mandatory quality reporting, pay-for-performance, and Accountable Care Organizations (ACOs). We need good measures of quality healthcare so we can direct our limited resources where they provide the most value. We would do well to pay particular attention to the quality of care near the end of life. As Ellen Goodman noted in her recent Harvard Business Review article “Die the Way You Want To”, 25% of Medicare expenditures are incurred by the 5% who are in their last year of life. Surely we can deliver more value by increasing quality of life and decreasing futile medical interventions for these patients.
It makes sense that we should measure quality in order to improve it, but figuring out exactly how can be a real devil. We often focus on what we should measure—the numerator, but whom—the denominator—is just as important. Working on the AAHPM Quality and Practice Standards Task Force this past year has been an eye-opening experience for me. Wading through ponderous technical documents describing a host of proposed national quality measures, I was struck with how hard it is to design a really good one. The National Quality Forum (NQF) recently recommended a set of quality measures for hospice and palliative care. The NQF only recommends measures with well-defined methodologies validated for the specific populations under consideration. Many employ a narrow denominator, e.g. hospice patients rather than dying patients. It’s a good start, but I hope policymakers and payers will be careful in how they incorporate them into mandatory quality reporting systems. Measuring only hospice patients in order to improve the quality of end-of-life care is like searching for a lost dollar bill only where the light is good. The real payoff may be lurking in that dark corner.
For example, the best set of quality measures we have for end-of-life care so far, the Family Evaluation of Hospice Care (FEHC), has only been validated for hospice patients. When we apply the FEHC to hospices, we can compare the quality of Hospice A with that of Hospice B. That might be good enough if most dying patients received hospice care, but the National Hospice and Palliative Care Organization reports in its 2011 Facts and Figures that only 42% of those who died in 2010 were enrolled in hospice. So what about the quality of end-of-life care for the majority of patients who die in hospitals, skilled nursing facilities and homes without the benefit of hospice care? How can we measure that?
Current and proposed mandatory quality reporting programs perpetuate the silos in our healthcare delivery system. Since hospitals are designed for treating acute, potentially-reversible problems, they report post-discharge, patient-rated satisfaction surveys that totally miss the experience of the many patients who die during their stay. Likewise, we see skilled nursing facilities as places for rehabilitation, so we require a Minimum Data Set that focuses on restoration of function, even though many patients languish and die there. Since hospice is the place for dying, that’s where we’ll mandate reporting of end-of-life quality measures, but that’s not going to improve the quality of dying where most of it happens.
The Medicare final rule creating ACOs requires them to report on 33 quality measures linked to how much they can share in any savings. Despite the striking disproportion of Medicare dollars spent in the last year of life, none of these measures has anything to do with comfortable dying or the appropriate utilization of hospice or palliative care. In the original 127-page proposed ACO rule, the word “hospice” appeared once and “palliative” not at all. Comments from the AAHPM and others must have been heard, because the terms appear about a dozen times in the final rule. It’s a step in the right direction, but we have a long way to go. We need researchers to develop and validate quality of life and quality of dying measures for all relevant care settings. Once available, we should push for their inclusion in all mandatory quality reporting and pay-for-performance systems. We’ll never get the maximum value for the Medicare dollar without it.
Charles V. (Chuck) Wellman, MD FAAHPM, is Chief Medical Director of Hospice of the Western Reserve in Cleveland, OH, and chair of AAHPM’s Leadership and Workforce Strategic Coordinating Committee
It is with great pleasure that we can finally announce the availability of the AAHPM Physician Compensation and Benefits Survey Report. Two years ago a poll of AAHPM’s members indicated a strong interest in such a survey. Earlier surveys, while helpful, suffered from a low rate of participation and from a lack of depth and refinement in the data. Consequently, the Academy’s Board of Directors charged the Business Practice Task Force to select a vendor who could help to design and implement such a survey. As a co-chair of the Task Force at the time and as current chair of our Leadership and Workforce Strategic Coordinating Committee, I can attest to the many hours that Task Force members spent on this process and the challenges we faced in dealing with the complexity and variability in our field.
The complexity is and will continue to be a challenge. HPM practitioners come from many different backgrounds. We work fulltime and part-time. We work for hospices, hospitals, the Veterans Administration, or as independent practitioners. Some of us are on salary while others have productivity-based compensation. We measure productivity in different ways. Some of us are in academic settings, and many of us have administrative, research, and teaching responsibilities. We have great variability in titles with no consistent agreement on chief medical officer, medical director, associate medical director, and team physician. As you might imagine, each iteration of the survey resulted in further discussion, and we realized a constant tension between designing a thorough, comprehensive survey versus a survey that might be too complex or time-consuming. In the end we find ourselves very pleased and grateful that nearly 800 of us were willing to complete this survey.
One will find that there is a wealth of data in this survey. It tells us a lot about who we are in this relatively young field. It will help to establish ranges of benefits and compensation, which will be increasingly important as we strive to attract residents and mid-career physicians to our field. The survey will give us greater flexibility in negotiating work hours, time off, productivity expectations, and CME benefits. There were also questions about job satisfaction, and it is exciting and gratifying to know 96% of us are satisfied or very satisfied with our profession and 93% of us are likely or very likely to recommend a career in HPM.
The survey will continue to be a work in progress. As we review the current survey results, it is expected that additional questions will arise, and there will be recommendations on how to further refine the survey questions. The unique and evolving arrangements in our field will challenge our future revisions, but we invite your feedback and encourage dialogue on how we can make future surveys more helpful and accurate. Comments can also be sent to the Academy at firstname.lastname@example.org, (Subject: Comp Survey Feedback.) It is an exciting start.
As hospices and palliative care services evolve into advanced palliative care organizations with greater scope and influence over late-life care within their communities, a “new” physician executive role is emerging along the career path for HPM physicians. This role is broader than the traditional senior medical director or chief medical officer positions, and is progressing toward what we refer to as the “chief community palliative care officer”.
These physician executive positions have proven to be instrumental in shaping late-life care practices by applying management competencies to:
-build and sustain relationships that evolve into community-wide palliative care networks
-disseminate throughout a community the use of metrics and evidence-based practices to hold practitioners to high standards of performance
-inspire referring physicians and HPM medical staff members to meet clinical outcomes and family satisfaction metrics
-envision and stimulate a change process that coalesces the community around new models of late-life care
Daunting challenges, to be sure. As hospice executives and HPM physicians come to grips with impending rules around face-to-face recertification requirements, and other day-to-day operational issues, we would all do well to remain mindful of the strategic leadership objectives that will ultimately determine how successful we are in transforming late-life care in the US. We’ve seen the importance of the role of HPM leadership in exemplar communities across America. To “spread the science ” of HPM is our next challenge.
I had the privilege to represent AAHPM at the 18th Annual Liaison Network Forum at The Joint Commission (JC) headquarters in Oakbrook Terrace, Ill. I suspect many of us, in our professional career, have some hesitancy when approaching the JC but the “newer and friendlier” JC have some progressive, visionary work for the future of healthcare. It was a two-day conference and networking opportunity for 70 invited representatives from a diverse healthcare contingent representing a variety of organizations from the American Hospital Association, to the CDC to the Undersea & Hyperbaric Medical Society, Inc. All a friendly lot and it was very nice to see the AAHPM represented.
The JC enterprise actually has three divisions: the Joint Commission is the certification and accreditation company which is most familiar to us as the auditors showing up at our institutions doorsteps, The Joint Commission Resources which addresses safety and quality, nationally and internationally ( 41 countries so far) through provisions of education, publications , consultations and evaluation services, and the Center for Transforming Healthcare, a newer 501 C3 company which serves to offer solutions through setting up collaborative performance improvement projects with healthcare organizations in order to disseminate effective, durable solutions to the world.
The keynote plenary for the conference was given by Mark Chassin MD, MPP, MPH, President of the JC. In a nutshell, he set the stage for the future vision of the JC which is to transform healthcare into a “High-Reliability Industry” much like nuclear power and commercial air travel, which have highly effective process improvement and fully functional safety cultures. So a “simple” formula:
Robust Performance Improvement (RPI) + Safety Culture = High Reliability.
RPI involves systematic, highly effective strategies and tools for solving complex problems. Sort of a dynamic, continuous “root cause analysis” over time. RPI’s work to solve both routine processes like hand washing AND rare adverse events like wrong site surgery. Jerod M. Loeb, PhD the JC Executive VP for Quality Measurement and Research, points out that organizations must understand specific causes of problems they are trying to fix and then target interventions to those causes. He goes on to say the real challenge is the solutions (“Best Practices”) developed through this process may not work for all organizations across the board. Therefore the JC is suggesting “re-tooling” (the new buzz word) already established measures. Their newly published NEJM article (see reference below) summarizes this concept well.
Developing a Safety Culture involves trust, reportable, and appropriate use of RPI’s. The JC pointed out it’s not about developing a “blame-free “message but developing a culture that can separate small errors (blameless) from egregious(blameworthy)ones. The “Swiss Cheese Model”of assessing errors in healthcare that lead to harm was discussed extensively with emphasis on institutions assessing errors systematically, and establishing one code of behavior for all.
With all the “Big Picture” discussion at the conference as noted above, where did Hospice and Palliative Medicine fit in?
1) All issues mentioned above are important to HPM including RPI and Safety.
2) The attendees networking opportunity reinforced the support we have from a multitude of groups including the AHA, Critical Care Nurses, Critical Care Medicine, Pediatrics, the ANA, Physician Executives, Healthcare Executives, Nurse Practioners, Professional Chaplains, Women’s Health, the VA, Oncology Nursing, National Association of healthcare Quality.
3) The JC supports hospice care essentially by reinforcing the Hospice Medicare Benefit Conditions of Participation. They had no comment on the potential COP’s for face-to-face physician/NP visit mandates.
4) The JC supports palliative services and noted they were involved in standards development in the past but stated after this summer’s board meeting, they are still reluctant to develop a certification/accreditation process because they do not see any “ownership in the service” referring to funding support like CMS, Private Insurer, etc. They noted needing more “proof of sustainability” in order to move forward with certification. They agreed to listen to any input on this issue.
5) “Hand-off” communication in hospitals as patients move through different services was a hot topic and one HPM can make impact through a continuum of care model.
6) Unlike hospitals, long term care currently has no universal, comprehensive pain assessment standards.
7) The JC is reluctant to establish standards for chaplaincy services in hospitals due to fear of “creating a demand that can’t be filled by workforce”.
Maternal Mortality is increasing in the US and got a lot of attention especially related to future development of prenatal care standards. This also coincided with NICU and prenatal discussions.
9) The JC is just now starting to write standards for Children’s Hospitals. Input desired
10) The JC plans on writing standards for Long Term Acute Care Hospitals (LTACH) in 2011 which are an important population of patients for HPM.
11) The JC was embracing CMS COP’s for Telemedicine but CMS has momentarily stopped any work in this area and the JC does not know what will happen but reinforced their position that it is important for the future.
12) Health Information Technology is a complex integration program for the next few years. On example given is SNOMED-CT has no eMeasure code for “hospice care” in the comfort care section.
Overall, the meeting was very productive and interactive. The JC continues to emphasize their desire to collaborate with other organizations. With a growing number of competitive enterprises like the JC, we should expect more outreach, dialogue, and ability to contribute to their activities.
Chassin MR, Loeb JM, Schmaltz SP, Wachter RM, “Accountability Measures- Using Measurement to Provide Quality Improvement”, NEJM, June 29, 2010.
The first piece of education reviews the basic Center for Medicare & Medicaid Services (CMS) requirements for authentication of services provided or ordered. When CMS reviewed numerous examples of CERT signature denials, they found in almost every instance that the documentation was acceptable. Services were denied because of one of four “not acceptable” signature reasons, including
1. Illegible, unrecognizable handwritten signature or initials
2. Unsigned “typewritten” progress notes with a typed name only
3. Unverified or unauthorized electronic signatures
4. No indication of the rendering physician/practitioner
The Palmetto GBA Medical Directors strongly encourage the following improvements
1. Be sure a handwritten signature is a mark or sign by an individual on a document to signify knowledge, approval, acceptance or obligation
2. Records should clearly indicate they have been “electronically signed by” and include a date/time, including verbiage that makes this clear
3. Establish a protocol to ensure valid signatures are affixed to every order, record, or report within a reasonable time frame (i.e., customarily 48-72 hour after the encounter – but certainly before the claim is submitted to CMS for payment)
Additional information about the CERT program is available on the Palmetto GBA website under the CERT link. This focus is likely to apply to other intermediaries soon, so watch for additional educational updates and start looking into your current processes.