Ann Lennarson Greer
A. L. Greer, Embracing Accountability: Physician Leadership, Public Reporting, and Teamwork in the Wisconsin Collaborative for Healthcare Quality, The Commonwealth Fund, June 2008.
The Wisconsin Collaborative for Healthcare Quality (WCHQ) is a voluntary consortium of health care organizations whose mission is to improve the quality and cost-effectiveness of health care in Wisconsin. WCHQ reports comparative measures of performance in ambulatory and hospital settings using data submitted voluntarily by provider organizations. Its ability to gain the voluntary cooperation of providers in public reporting rests on its self-definition as:
[A] learning organization whose members continually expand their capacity to create the quality improvement results to which they aspire. Its members do so by working and learning together to foster new and expansive patterns of thinking that drive improvement in our healthcare institutions (Wisconsin Collaborative for Healthcare Quality, www.wchq.org).
As part of WCHQ's mission, public reporting is used as a tool to jumpstart the learning and quality improvement process. Toward this end, member organizations collaborate in several activities, including: 1) development of scientifically valid ambulatory care measure specifications and an attribution method that enables physician groups and health systems to collect quality data on all patients in their care; 2) open sharing of quality performance data through public reporting; and 3) identifying and sharing of best practices to improve all members' performance. Although WCHQ prides itself on a scalable infrastructure that permits expansion to any number of reporting entities and conditions, early efforts in the area of ambulatory care have focused on conditions that are common, treatable, and costly: diabetes, uncomplicated hypertension, preventive cancer screening, and postpartum care.
The fact that WCHQ is a physician-led effort is critical to its success. Founded in 2003 by chief executives of several large multispecialty practices and their partner hospitals, it has grown rapidly from nine initial members to a membership in 2007 that includes 28 physician groups, hospitals, and health plans. Currently reporting data for more than 50 percent of Wisconsin primary care physicians, WCHQ has set a goal of including 75 percent of the state's physicians by 2010.
Membership consists of medium as well as large physician groups, as neither performance reporting nor participation in improvement efforts require sophisticated data systems, electronic health records, or extensive quality improvement staff. While most members are large organizations, they incorporate diverse practice structures. WCHQ also includes business partners whose participation is a vehicle to maintain direct lines of communication with purchasers of health services in the hope that the measures reported can serve multiple audiences.
This case study relies on 31 lengthy personal interviews conducted from June through September 2007 with persons closely involved with WCHQ. The project sought to interview the universe of persons who lead participating organizations, some of whom also serve on the WCHQ board. Interviews were successfully completed with top executives of 25 medical practices, hospitals, and health systems and 20 of 21 board members. Also interviewed were business partners who serve on the board, chief executives of the state medical and hospital associations (who serve on the board ex officio), and WCHQ executive staff.
WCHQ shows great promise as a means to successfully address two problems that have intractably bedeviled efforts to bring community practice into closer alignment with accepted indicators of evidence-based practice. First, it has achieved public performance reporting for ambulatory delivery sites where reporting depends on voluntary submission of clinical data. Second, WCHQ has put into place a dynamic model for translating evidence-based medicine into community practice.
The specific mechanisms by which WCHQ has achieved these goals include: 1) development of performance measure specifications and an attribution method that are accepted by physicians as accurate representations of the quality of care delivered; 2) use of motivational strategies that accord with physicians' desire to practice high-quality medicine, and 3) creation of a multi-level collaborative network that harnesses the knowledge and creativity of frontline professionals.
WCHQ begins with nationally endorsed guidelines and measures but uses grassroots involvement to address crucial barriers to the adoption and development of measurement specifications. One barrier is that current claims-based ambulatory care measures are viewed by physicians as scientifically inaccurate, punitive, and insensitive to actual delivery of care. A second is the common situation where physicians are unable to review, revise, or constructively use the data to achieve improvements. WCHQ's solutions, shaped by physicians familiar with these problems, involve adherence to the standards that physicians demand of data, transparency of measurement methods as well as results, and placement of the entire enterprise into the context of improving practice.
In response to physicians' demand for data that meet scientific standards and for results viewed as accurate benchmarks, WCHQ avoids sampling bias, generates sample sizes sufficient to draw valid conclusions, and reports at level appropriate to a "unit of analysis." Additionally, to be actionable in terms of comparing performance and deficiencies, results must be timely and as well as revisable in light of new evidence, and must encompass contextual diversity.
Failure to accord with these criteria may be seen as the sine qua non of the opposition by many physicians to standards, guidelines, and targets. WCHQ also has a philosophy regarding the use of its performance results: it avoids tactics that blame individuals and encourages a focus on systemic problems, such as failures of communication, teamwork, resources, or system design.
Interviewees agree that these interlinked elements have been successful in achieving a process in which participation in measures development and application leads to 1) acceptance of measures as valid indicators of performance; 2) "apples-to-apples" comparisons with colleagues practicing in similar settings for reliable performance benchmarks; and 3) opportunities to meet with peers to share strategies and practices employed by the high-performing organizations.
Strong leadership was indisputably a crucial element in launching and defining the organizational culture that guides working relationships within WCHQ. The founders rallied member organizations and their staffs with a few simple rules that resolutely defined public reporting as a means to high-quality health care for all patients in all settingsnot as a vehicle to eliminate practice sites. The code of ethics also defined behavior that was proscribed due to its potential to disrupt the honest sharing of data and knowledge across organizational boundaries (e.g., using results for marketing purposes).
Around these simple rules, a coherent, powerful, quality-focused culture coalesced that members report to be very satisfying. Leaders believe the observed performance improvement is attributable to participation in WCHQ. They also believe the approach is sustainable and self-generating because it is premised on valid, professional goals and standards.
A key principle has been WCHQ's intention to "lift all boats." To lift all boats is to reassert a goal consistent with the medical profession's traditional norms of collegiality and knowledge-sharing against the contrary influences of market competition. Other recurrent phrases are "bottom-up rather than top-down" (to characterize the basis for professional ownership and identification) and "the truth lies in the middle" (to describe collaboration with business partners).
Interviewees have agreed that WCHQ's model of physician-led voluntary reporting has delivered quality improvement to their organizations. They believe that the collaborative sharing of knowledge within the WCHQ model is conducive not only to improvement by lower-performing teams, but also to much-valued peer recognition of higher-performing teams.
One of the important findings from WCHQ's experience that may dispel fears of public reporting is that published scores did not naturally reveal a hierarchy of organizations. Instead, the reported data revealed many points of excellence scattered among the reporting organizations. This discovery affirms the idea of a bottom-up approach that learns from, as well as seeks to direct, community practice.
As with the publication of scores showing performance shortfalls in comparison to peers, the engagement with business is reported to have unsettled traditional patterns of thinking and acting. This new perspective has led to scrutiny of practices and to innovative solutions. At the same time, business partners and health care providers differ on appropriate levels of reporting. Business partners advocate reporting data for individual physicians as a means to enable consumer selection and economic credentialing by purchasers. But WCHQ's provider members argue that this practice paints a false picture of the quality of care that patients actually receive within the system, and could encourage individual solutions to poor scores (such as patient cherry-picking) that are harmful to teamwork and efficiency. Nonetheless, the debate within WCHQ is viewed as one of "constructive tension."
In sum, WCHQ's ability to enlist and sustain the involvement of medical groups rests on both avoiding strategies that elicit the resistance of physicians and supporting the achievement of professional patient care goals. The primary limit of this study is its dependence on reports of key executives not only for the model's theory and intent but for data on its actual workings. The consistency of reports across state organizations suggests accuracy, but this needs confirmation and elaboration. Also, generalizations about the transferability of WCHQ's model to new sites require additional research, including interviews with affected clinicians and members of the collaborative networks.