By Anne-Marie J. Audet, M.D, M.Sc., S.M., and Shreya Patel, M.P.H.
The Centers for Medicare and Medicaid Services (CMS) has begun publishing data on new measures assessing the quality and safety of hospital care—providing a more complete picture of hospital care and thus furthering the nation's ability to assess health care performance and foster improvement. The new data, which look at hospital-acquired infections, certain surgical complications, and avoidable deaths, are being reported on the CMS Web site Hospital Compare, which enables consumers to compare hospitals on measures of quality.
When CMS launched Hospital Compare in 2005, standardized measures of hospital quality became available to the public for the first time, enabling comparisons across the nation. What began with 415 hospitals reporting on a starter set of 10 measures has grown to more than 4,400 hospitals reporting on 65 measures of health care quality, safety, outcomes, and patient experiences.
Six years later, the benefits of this national public reporting program are indisputable. Because the measures are standardized and reported every year, it is possible to track trends—helping policymakers and hospital leaders target areas in need of improvement. Another benefit is that, over time, measures that prove not to be useful are uncovered and withdrawn (e.g., those assessing oxygen monitoring, beta-blocker at arrival, and currently under consideration, smoking cessation instructions). Decisions to withdraw may be triggered by new scientific evidence, by consistent achievement of high performance by nearly all hospitals, or by new measures that are better indicators of quality.
The fact that this information is public is also important. Everyone has access to the same data, which can prompt healthy discussions among providers, patients, and those who pay for care. The Commonwealth Fund's benchmarking tool, WhyNotTheBest.org, which brings together data from Hospital Compare and other public sources, is being used by health care systems, health care coalitions and communities, and researchers to explore important issues such as the quality of care provided by rural hospitals and for vulnerable populations.
Perhaps the greatest value of the national public reporting program is the role it plays in spurring improvement. Evidence suggests that transparency garners providers' attention and leads them to make changes that can translate into better performance. In the October issue of Hospital Medicine, Schmaltz et al. reported on positive trends in performance between 2004 and 2008, and several of the measures examined align with those reported by CMS. The Commonwealth Fund's new National Scorecard also demonstrates improvement on the process-of-care measures publicly reported by CMS Hospital Compare and trended on WhyNotTheBest.org (see figures). For example, the performance gap on the overall composite measure of quality for patients with heart attack, heart failure, and pneumonia continued to narrow between 2004 and 2009. Most striking is that the worst performers in 2009 (those in the 10th percentile) are now doing as well or even better than the best performers in 2004 (those in the 90th percentile, Figure 1). On the other hand, performance on some of the Hospital Compare measures—for example those related to patients' experiences—has not improved. Clearly, improving patients' experiences is more complex than achieving compliance with a process such as prescribing the appropriate drug. Still, what patients tell us about the health care system cannot be ignored.
What's the Value of the New Measures?
Many hospitals are now reaching close to optimal performance on several of the measures reported for the past six years on Hospital Compare. But most would agree that those measures sketch out a limited view of quality. To help fill in the picture, the new measures focus on patient outcomes, shedding light on complications and conditions that should be preventable with appropriate care. Specifically, the measures focus on: 1) hospital-acquired conditions, serious and preventable conditions such as severe pressure ulcers, falls and trauma, and blood transfusion mismatches; 2) serious complications such as post-operative deep vein thrombosis and collapsed lung as a complication of medical procedures; and 3) deaths from certain conditions (e.g., among surgical patients with serious, treatable complications).
Although the measures are not perfect, their release will initiate a process of public vetting, similar to the one that occurred when CMS published mortality rates over 25 years ago. As the data are released, many eyes will be looking at them, probing their implications, comparing, and conducting root cause analyses. This attention can only lead to improvement—both in the measures themselves and in the care delivered.
Our national hospital quality reporting program is an essential tool to support the Department of Health and Human Service's National Quality Strategy, the CMS National Strategy for Quality Improvement in Healthcare, and the Partnership for Patients. Over time, more measures will be added to achieve a comprehensive view of health system performance. Although many of the measures reported on Hospital Compare are based on all patients admitted and treated in the hospitals profiled, some measures, such as mortality rates and readmission rates, apply only to Medicare beneficiaries. In the future we should make sure that all measures reported represent all patients, including those with private coverage or Medicaid, to gain a true picture of quality for all of the patients served by our health care system. In addition, our knowledge and measurement of health care performance is still hospital- and health plan–centric. We should seek to profile the quality of care in all settings where patients receive care. With these steps, the value of national performance measurement will be attained and the information made available will truly be relevant and meaningful to providers, payers, and patients.