I can think of no more well received topic amongst physicians than clinical quality metrics. Whenever I walk into a cafeteria or social event, quality metrics is one of my go to topics to lighten the mood and get everyone smiling.
OK, that’s a complete lie and all of you know it. However, that doesn’t diminish the importance of this topic. The number of metrics in healthcare has exploded over the past few years. They range from the essential to the absurd, and I’ve had a little fun on my Twitter account recently commenting on this.
The reality remains that metrics are not only increasing in our daily lives as clinicians, but they are starting to affect our wallets as well. I would venture to guess that a majority of you reading this now have some type of clinical quality metric that figures into your paycheck.
Once something starts affecting my paycheck, then you better believe it has my attention. As I’ve stated before, my goal is FIRN, so I cannot afford to have someone shaving pennies off my hard earned dollars.
My goal with this article is to give you some basic principles to apply whenever confronted with a clinical metric, not go through the ins and outs of all the different Medicare measures out there. I will readily admit that I am one of these weird physicians that enjoys this kind of stuff. Many of you are probably normal human beings that would be perfectly happy if this isn’t a part of your day. So, if you simply want to leave a snarky comment at the bottom as a means of taking out aggression, then please be my guest.
With that, let’s get started. I focus heavily on the mission whenever answering a question, so let’s start there.
The Purpose of Quality Metrics
So, why are we doing this stuff? No, it is not as a means to pay doctors less money, despite what many may think. The reason we follow metrics is to improve the quality of care we provide. No improvement happens without first measuring what you want to improve. Clinical quality metrics are the first collective step in that process.
Most clinicians want to improve healthcare quality. On average, physicians are honorable professionals that want to do their best for their patients. They would gladly put in the work to improve their patients’ blood pressures or lower their patients’ collective risk of surgical site infections.
The disconnect occurs, however, in how the measurement process works and whether measuring things really leads directly to improving them. Many physicians feel that the steps required to collect and report clinical quality data are too onerous and take up inordinate amounts of their time (they’re right by the way and we’ll discuss how to spread the work around later).
Healthcare is still in the process of determining whether all of this measurement is beneficial to patients on a broad scale. From my vantage point, this depends heavily on what metric you pick and what resources are available to improve it. I think we are often guilty of trying to hit home runs in this arena when singles and doubles can score runs.
You can get tangible results by improving the colon cancer screening rate. A solid single. Cutting the thirty day readmission rate by fifty percent may be a home run but is a much tougher goal. This leads me to my next tip…
Picking the Right Metric
If you want to meet a metric, then pick one you can meet. It doesn’t get more obvious than that, but many fail to understand this. If you are already a physician administrator, then this is where you come in. You need to be able to explain to your non-clinical team that setting the goal of 100% of patients having a systolic blood pressure less than 130 is flat out impossible. Just like goal setting in any other realm of life, picking the right metrics to focus on should involve shooting for something that stretches you but won’t break you in half.
In addition, try to pick metrics that are actually meaningful. Picking some meaningless goal like “we will check blood pressures on ninety percent of our patients” is easy. Professionals want to be challenged, however, and will revolt against pointless work.
For those of you not directly involved in picking the quality metrics that your organization focuses on, you have two options to provide input. One is find the physician that does have direct input in the process so your voice can be heard. The other is to become the physician that gives input into the process. As I said before, your paycheck probably depends at least in part on this process. I prefer to be sitting at the table when the meal is served, and I suggest you do the same. I have done both of the above tactics in my career, depending on what my position in the organization was at the time.
Know The Inputs
Once you have a metric picked, then you need to know exactly what the metric entails. Things seem very simple when sitting at a conference table, but they quickly become more complicated when you are back in the clinic seeing patients and trying to meet your goal.
Your electronic medical record (EMR) is intimately involved in this process, so plan to collaborate with your IT people or EMR vendor.
It’s probably easiest to use an example here so let’s suppose your clinic has decided to focus on your diabetic patients, and you want to get 80% of your diabetic patients to an A1c<9. Right off the bat, here are a few questions I would ask:
- Will ICD-10 codes identify diabetic patients or something else (i.e the EMR problem list)?
- If using ICD-10, which codes are we including (i.e what about the steroid induced diabetes folks etc)?
- Can patients be “cured” of diabetes? How will we figure that out?
- How do we track patients that have A1c’s done outside our healthcare system? Is someone going to manually enter these in the EMR or manually add them into the final calculations?
- Will both point of care A1c’s and serum A1c’s be included? Will the EMR capture both?
- Does the final A1c number of the year count or the average A1c?
- Will you be penalized if you go too long without measuring an A1c?
- Who are “your” patients? Is it the person that orders the A1c, the person that saw the patient last, or the person listed as the primary care?
- Do patients that move, change providers or get lost to follow up during the year still count?
- Do patients on hospice count?
A “simple metric” gets very complicated very fast, doesn’t it? Someone with a clinical background needs to be asking these questions, however, if you want to be successful. Knowing all of these details will allow you to take your next step in conquering a quality metric, building a systematic approach to success.
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Using Systems to Meet Metrics
Physicians cannot meet quality metrics by themselves. This concept is so important that I’ll say it again. Physicians cannot meet quality metrics by themselves. Systems of care meet quality metrics. Quality metrics are a means to improving systems of care at the end of the day. Physicians are essential to this system but are not the entire system.
This systematized approach happens at both an organizational level and an individual practice level. Let’s return to our A1c example from earlier. If trying to tackle this from an institutional level, I would address several items:
- Easy availability of A1c testing (lab availability or point of care testing)
- Technology transfer between health systems to obtain A1c data
- Working with EMR vendor to run periodic reports and ensure appropriate data capture
- Ensure appropriate diabetic referral resources available
As a provider in my daily practice, I would focus on different aspects of my individual system of care:
- Establish nursing staff protocol for nursing to test patient’s A1c’s automatically when due
- Establish or improve relationship with Endocrinology or clinical pharmacy to ensure quick patient access when needed
- Ask administration to give periodic updates on our numbers. Request real time data access if possible. Send the data to your staff so they can schedule appointments or deploy more resources for individual patients.
- Have front desk staff ask all diabetic patients if they have had labs drawn at other facilities. Get release of information on the spot for anyone that says yes.
As you can see, the scope of each approach is different but the concept is the same. You have to modify the system of care, not rely on one person (i.e the physician) to collect, analyze, and act on the data. The organization that can best implement systems at multiple levels instead of simply relying on doctors to do all the work will always win, and these doctors will not feel the onerous burden of meeting metrics by themselves.
The Evil Administrator Myth
Lastly, I want to tackle one common misconception that I constantly hear from physicians in regards to clinical metrics. I enjoy hearing physicians say things like,”This metric is just a way to cut into my paycheck,” or “I guess we’re not meeting the budget so they put in a few more metrics.” While I can’t speak for Uncle Sam’s motivation when it comes to implementing clinical quality metrics, I can tell you that the administration in your organization wants you to meet your metrics.
It is worth a lot more money to provide measurable, high quality care than to use metrics to deny doctors part of their salary. Number one, it makes for excellent marketing. If every primary care doctor you had controlled 100% of their diabetics, would you put that on a billboard if you were the CEO? You bet you would. More patients then come to your clinic, and everyone makes more money.
Second, meeting quality metrics produces improvements in staff morale.. There is a palpable improvement in the esprit de corps of a group when they meet a goal. Recognition for achievement will compound this effect even more in a group passionate about the cause. Healthcare professionals fit very well into this mold. Do these motivated groups then produce more? They do indeed. Every administrator on earth wants to improve the productivity of their people, so I promise, any administrator with sense is pulling for you (I hear you laughing back there!).
So, what do you think? Are you ready to conquer the clinical metric world? Do you still not care about this stuff at all? Does your boss need to read this article? Let me know what you think in the comments below. Remember that, at the end of the day, its still a great job to be able to take care of patients. Don’t let numbers on a page change that. But, if some numbers on a page can help you do a better job, then let’s do it!