Helping Boards Have Productive Discussions about Quality of Care
Taking a broader view of “quality” can lead to better performance assessment
By Gary R. Yates, M.D.
There are a handful of metrics that boards, both health care and non-health care, commonly use to monitor and assess the high-level financial performance of organizations.
One question that occasionally comes up in discussions among health care board members is, “How can we get the same view of quality performance?”
Unfortunately, a small group of consensus measures that robustly assesses the multiple dimensions of performance we commonly think of as “quality” does not exist today. This leaves it for each health system to select its own set of measures, which can be challenging, especially given the growing number of quality measures from which to choose. Regrettably, there is no “easy” button for this process.
In this environment, some organizations elect to track only “national” measures approved by the Centers for Medicare & Medicaid Services or provided by payers. While there are good reasons to track these, including their link to reimbursement, relying on them exclusively invites the risk of measuring “what can be measured” rather than “what should be measured.” In addition, it can contribute to a short-sighted focus on measures that are important today but miss areas that are important for future success. This is particularly true as the continuing movement toward value-based care raises the question of whether existing quality metrics have the capacity to truly meet our evolving needs.
Finding the “Right Measures”
An important starting point for selecting an “optimal” set of quality measures for board review is to have an explicit, robust conversation among senior leaders, medical staff leaders and board members about what measures are important to track. These measures should encompass a broad and inclusive view of quality that reflects the dynamic health care environment with its growing focus on the experience of care and value from the patient’s and community’s perspective. The objective is not to track “more measures” but to focus on the “right measures” to meet the unique needs of each organization and the community it serves.
This conversation should lead to identifying system measures that help the board answer the following questions:
- How effective and patient-centered is our care from the patient’s point of view?
- Is the range of services we provide meeting the needs of our patient population?
- How effective are we at being a good steward of health care resources?
- How effective are we at meeting the needs of our community and promoting community well-being?
- How effective are we at meeting the needs and promoting the well-being of our workforce?
Focusing Board Deliberation
Important areas that should be included as part of a productive conversation include:
Patient experience of care. Patients and families expect (and deserve) care that is safe, high-quality and patient-centered. There is an interdependency among these dimensions, and we need to deliver effectively across all three to truly meet patients’ needs. Therefore, in addition to evaluating the technical quality of the clinical care and progress towards the goal of Zero Harm, it’s important to assess how patients and families perceive the care experience. Health equity should be an area of focus for every health system. Collecting and analyzing data by race, ethnicity and other diversity categories provides a foundation for identifying and tracking measures to ensure that care and outcomes are equal for all patients.
Workforce engagement and safety. We can only deliver on the promise we make to patients for safe, high-quality care if we have a highly engaged workforce. There is a growing body of evidence demonstrating that workforce engagement is associated with organizational performance in quality, patient and workforce safety, and patient experience of care. Given the growing concerns across the field about clinician burnout and workplace violence, this is an important area for focus.
Continuum of care. As more care is transitioning to settings outside of the hospital, quality assessment requires looking beyond hospital-centric metrics to include those that assess care across the full continuum, including ambulatory, office-based and post-acute care (including home health care). As this shift occurs, boards must be able to assess how effectively care is being coordinated across the continuum, looking both at system-owned entities and their connection with community partners. Readmission rate is one example of a measure that can provide a window into how well this is being done.
Value. It is important to examine how effectively the care we provide leads to improved health outcomes. This means looking beyond the cost of individual care events to consider the costs and outcomes associated with full episodes of care. The areas of focus might vary depending on the organization and local market. For example, an organization that has a health plan or accountable care organization might focus on the total cost and trend for those at-risk lives. Others might begin by looking at their employee population. Areas of focus might be the cost and health outcomes associated with specific procedures such as joint replacement across the entire episode of care or looking at patients with a specific chronic illness such as asthma or heart failure over a specified time interval.
Community health. Although measures of community health have not traditionally been considered quality measures, we know that social, environmental and economic factors influence what makes people healthy. Social determinants of health also play a major role in driving utilization of resources. Data from local community health needs assessments may provide important information about important community needs. Areas of focus might include access to medical and mental health services as well as issues such as food insecurity, social isolation and loneliness. Leading organizations are beginning to look at measures of health-related quality of life in addition to traditional measures of illness. One example is the “Healthy Days Measures” developed by the CDC.
Health care boards across the country are beginning to take a broader view of what encompasses “quality” and incorporating measures that reflect this understanding as they decide which performance measures to track. This approach can help them better meet their fiduciary responsibilities and assess performance in the right areas based on the unique current and future needs of the organizations and the communities they serve.