Measuring quality in hospitals in the United States
- Mark W Friedberg, MD, MPP
Mark W Friedberg, MD, MPP
- Assistant Professor of Medicine
- Brigham and Women's Hospital and Harvard Medical School
- Bruce Landon, MD, MBA, MSc
Bruce Landon, MD, MBA, MSc
- Professor of Health Care Policy and Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
- Section Editors
- Andrew D Auerbach, MD, MPH
Andrew D Auerbach, MD, MPH
- Section Editor - Hospital Medicine
- Professor of Medicine
- University of California, San Francisco
- Hilary Sanfey, MD
Hilary Sanfey, MD
- Section Editor — General Surgical Principles; Quality and Safety
- Professor of Surgery
- SIU School of Medicine
Since the early 1990s, health plans in the United States have been measuring and publicly reporting their performance on measures of quality of care. In part, this was a response to health care purchasers who sought better information about the quality of care they were purchasing. Performance measurement and reporting has now become commonplace in most health care settings.
Predated by regional efforts , national efforts to measure and report hospital performance on quality measures began with a pilot program of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, subsequently renamed "The Joint Commission") . Beginning in 2001, the Joint Commission, the Centers for Medicare and Medicaid Services (CMS), the American Hospital Association, and other organizations formed the Hospital Quality Alliance (HQA) as a mechanism through which hospitals could submit performance data to CMS [3,4]. Hospital participation in the HQA has been voluntary. However, the Medicare Modernization Act of 2003 made receipt of a hospital's full Medicare payment updates contingent upon reporting the initial 10-measure "starter set" to CMS. Consequently, the vast majority of acute care hospitals in the United States participate in this reporting.
Hospital-level performance data, which can be searched by geographic location, category of health condition (eg, general, medical, surgical), and quality measure are available to the public at the Hospital Compare website. The original "starter set" reported in 2004 reflected processes of care for only three health conditions (acute myocardial infarction, heart failure, and pneumonia), which are among the most common and clinically important reasons for hospitalization among Medicare beneficiaries [3,4]. The range of measures reported on Hospital Compare has been expanding and now includes measures of process quality for additional conditions, risk-adjusted mortality, patient experience, and utilization of health care, including utilization of imaging services and readmissions, and structural measures such as participation in a cardiac surgery registry and use of safe surgery checklists. While all of these measure types are important, this review focuses on process measures of hospital performance, as defined below.
QUALITY MEASUREMENT AND QUALITY IMPROVEMENT
Despite having higher health care spending per capita than the health care systems of other industrialized countries, compelling evidence accumulated over the last two decades suggests that the quality of care delivered by the United States health care system is suboptimal . A core principle of quality improvement is that what is not measured cannot be improved. Consequently, performance measurement and reporting has become ingrained in our health care system.
The ultimate goal of quality measurement and reporting systems is to improve care and outcomes. Efforts to improve documentation without changing the content of clinical care are unlikely to achieve this goal. For quality measurement and reporting efforts to be successful, hospitals and clinicians must engage in efforts to understand the root causes of poor performance and develop fundamentally better systems of patient care that will lead to improved performance across a broad range of potential measures.
- Rosenthal GE, Hammar PJ, Way LE, et al. Using hospital performance data in quality improvement: the Cleveland Health Quality Choice experience. Jt Comm J Qual Improv 1998; 24:347.
- Williams SC, Schmaltz SP, Morton DJ, et al. Quality of care in U.S. hospitals as reflected by standardized measures, 2002-2004. N Engl J Med 2005; 353:255.
- Landon BE, Normand SL, Lessler A, et al. Quality of care for the treatment of acute medical conditions in US hospitals. Arch Intern Med 2006; 166:2511.
- Jha AK, Li Z, Orav EJ, Epstein AM. Care in U.S. hospitals--the Hospital Quality Alliance program. N Engl J Med 2005; 353:265.
- McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003; 348:2635.
- Donabedian A. Evaluating the quality of medical care. Milbank Q 1966; 44:166.
- Friedberg MW, Damberg CL. Methodological Considerations in Generating Provider Performance Scores for Use in Public Reporting: A Guide for Community Quality Collaboratives. Agency for Healthcare Research and Quality, US Department of Health and Human Services. Rockville, MD: 2011. Available at: http://www.ahrq.gov/qual/value/perfscoresmethods/index.html (Accessed on October 03, 2011).
- Landon BE, Normand SL, Blumenthal D, Daley J. Physician clinical performance assessment: prospects and barriers. JAMA 2003; 290:1183.
- Physician Consortium for Performance Improvement. Measures Development, Methodology, and Oversight Advisory Committee: Recommendations to PCPI Work Groups on Outcomes Measures. American Medical Association. Chicago: 2011.
- Hays RD, Fayers P. Reliability and validity (including unresponsiveness). In: Assessing quality of life in clinical trials: methods and practice, 2nd ed., Fayers P, Hayes RD. (Eds), Oxford University Press, New York 2005. p.25.
- Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller ME, et al. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008; 358:2545.
- jama.jamanetwork.com/article.aspx?articleid=2084900 (Accessed on January 19, 2015).
- Risk adjustment for socioeconomic status or other sociodemographic factors. National Quality Forum. http://www.qualityforum.org/Publications/2014/08/Risk_Adjustment_for_Socioeconomic_Status_or_Other_Sociodemographic_Factors.aspx (Accessed on January 19, 2015).
- Werner RM, Goldman LE, Dudley RA. Comparison of change in quality of care between safety-net and non-safety-net hospitals. JAMA 2008; 299:2180.
- Adams JL, Mehrotra A, McGlynn EA. Estimating reliability and misclassification in physician profiling. RAND Corporation. Santa Monica: 2010.
- Hibbard JH. Engaging health care consumers to improve the quality of care. Med Care 2003; 41:I61.
- Schneider EC, Epstein AM. Use of public performance reports: a survey of patients undergoing cardiac surgery. JAMA 1998; 279:1638.
- Fung CH, Lim YW, Mattke S, et al. Systematic review: the evidence that publishing patient care performance data improves quality of care. Ann Intern Med 2008; 148:111.
- Faber M, Bosch M, Wollersheim H, et al. Public reporting in health care: how do consumers use quality-of-care information? A systematic review. Med Care 2009; 47:1.
- Berwick DM, James B, Coye MJ. Connections between quality measurement and improvement. Med Care 2003; 41:I30.
- Marshall MN, Shekelle PG, Leatherman S, Brook RH. The public release of performance data: what do we expect to gain? A review of the evidence. JAMA 2000; 283:1866.
- Hibbard JH. What can we say about the impact of public reporting? Inconsistent execution yields variable results. Ann Intern Med 2008; 148:160.
- www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/FY-2013-Program-Frequently-Asked-Questions-about-Hospital-VBP-3-9-12.pdf (Accessed on January 19, 2015).
- Damberg CL, Elliott MN, Ewing BA. Pay-for-performance schemes that use patient and provider categories would reduce payment disparities. Health Aff (Millwood) 2015; 34:134.
- Friedberg MW, Safran DG, Coltin K, et al. Paying for performance in primary care: potential impact on practices and disparities. Health Aff (Millwood) 2010; 29:926.
- Bradley EH, Herrin J, Elbel B, et al. Hospital quality for acute myocardial infarction: correlation among process measures and relationship with short-term mortality. JAMA 2006; 296:72.
- Morse RB, Hall M, Fieldston ES, et al. Hospital-level compliance with asthma care quality measures at children's hospitals and subsequent asthma-related outcomes. JAMA 2011; 306:1454.
- Wachter RM, Flanders SA, Fee C, Pronovost PJ. Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure. Ann Intern Med 2008; 149:29.
- Yu KT, Wyer PC. Evidence-based emergency medicine/critically appraised topic. Evidence behind the 4-hour rule for initiation of antibiotic therapy in community-acquired pneumonia. Ann Emerg Med 2008; 51:651.
- Meehan TP, Fine MJ, Krumholz HM, et al. Quality of care, process, and outcomes in elderly patients with pneumonia. JAMA 1997; 278:2080.
- Houck PM, Bratzler DW, Nsa W, et al. Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia. Arch Intern Med 2004; 164:637.
- Dedier J, Singer DE, Chang Y, et al. Processes of care, illness severity, and outcomes in the management of community-acquired pneumonia at academic hospitals. Arch Intern Med 2001; 161:2099.
- Silber SH, Garrett C, Singh R, et al. Early administration of antibiotics does not shorten time to clinical stability in patients with moderate-to-severe community-acquired pneumonia. Chest 2003; 124:1798.
- Lee SJ, Walter LC. Quality indicators for older adults: preventing unintended harms. JAMA 2011; 306:1481.
- Thompson D. The pneumonia controversy: hospitals grapple with 4 hour benchmark. Ann Emerg Med 2006; 47:259.
- Pines JM. Profiles in patient safety: Antibiotic timing in pneumonia and pay-for-performance. Acad Emerg Med 2006; 13:787.
- Pronovost PJ, Miller M, Wachter RM. The GAAP in quality measurement and reporting. JAMA 2007; 298:1800.
- Metersky ML. Measuring the performance of performance measurement. Arch Intern Med 2008; 168:347.
- Kanwar M, Brar N, Khatib R, Fakih MG. Misdiagnosis of community-acquired pneumonia and inappropriate utilization of antibiotics: side effects of the 4-h antibiotic administration rule. Chest 2007; 131:1865.
- Welker JA, Huston M, McCue JD. Antibiotic timing and errors in diagnosing pneumonia. Arch Intern Med 2008; 168:351.
- Fee C, Metlay JP, Camargo CA Jr, et al. ED antibiotic use for acute respiratory illnesses since pneumonia performance measure inception. Am J Emerg Med 2010; 28:23.
- Friedberg MW, Mehrotra A, Linder JA. Reporting hospitals' antibiotic timing in pneumonia: adverse consequences for patients? Am J Manag Care 2009; 15:137.
- Mitka M. JCAHO tweaks emergency departments' pneumonia treatment standards. JAMA 2007; 297:1758.
- Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27.
- Lee TH. Eulogy for a quality measure. N Engl J Med 2007; 357:1175.
- Chassin MR, Loeb JM, Schmaltz SP, Wachter RM. Accountability measures--using measurement to promote quality improvement. N Engl J Med 2010; 363:683.
- Werner RM, Bradlow ET. Public reporting on hospital process improvements is linked to better patient outcomes. Health Aff (Millwood) 2010; 29:1319.
- Elnahal SM, Joynt KE, Bristol SJ, Jha AK. Electronic health record functions differ between best and worst hospitals. Am J Manag Care 2011; 17:e121.
- Campbell DA Jr, Englesbe MJ, Kubus JJ, et al. Accelerating the pace of surgical quality improvement: the power of hospital collaboration. Arch Surg 2010; 145:985.
- Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med 2009; 150:178.
- Bradley EH, Herrin J, Wang Y, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med 2006; 355:2308.
- Bradley EH, Curry LA, Ramanadhan S, et al. Research in action: using positive deviance to improve quality of health care. Implement Sci 2009; 4:25.
- QUALITY MEASUREMENT AND QUALITY IMPROVEMENT
- MEASURING THE QUALITY OF HEALTH CARE
- RATIONALE FOR REPORTING PERFORMANCE
- ORGANIZATIONS GENERATING MEASURES OF HEALTH CARE QUALITY
- CURRENTLY REPORTED PROCESS MEASURES OF HOSPITAL QUALITY
- CONTROVERSIES IN QUALITY MEASURE REPORTING
- Validity of measures
- Unintended consequences
- Little opportunity for improvement
- IMPROVING PERFORMANCE
- SUMMARY AND RECOMMENDATIONS