To hear many hospital leaders talk, it seems quality is the new metric of success under healthcare reform. But that's oversimplifying, because quality has so many different definitions even within the hospital or health system. It means different things to patients, clinicians, and yes, even to the C-suite. Besides that, until recently, very little of a hospital's reimbursement or cost picture has been tied to quality. But that situation will change rapidly in coming years, many senior executives and boards believe.
Piedmont HealthCare in Atlanta, a four-hospital system, believes it has a handle on the one metric that, if it is addressed and improved, will also improve a variety of quality measures and make the health system stand out among its peers for high quality. Piedmont's ambitious goal is to be in the top 10 community health systems for quality based on CMS data, and patient satisfaction based on data from Press Ganey, in the next 10 years. Internally, they call it "Top 10 in 10." Driven by president and CEO Tim Stack, the initiative includes one simple factor that will help Piedmont reach the high quality scores that will be necessary to compete in the future: reducing mortality.
His board agrees, placing a significant share of senior executives' pay on that improvement. "Forty percent of my [and the rest of the C-suite's] pay incentives are based on mortality improving," he says. "I don't know many other CEOs where that is the case. As a result, our mortality has improved dramatically. We focus in on it."
Stack reasons that mortality, because it reaches across all other measures of patient safety, is that unifying metric. He believes that by reducing mortality, Piedmont will be on better footing as patients begin to shop for their healthcare based on quality measures as copays and high-deductible health plans rise. Stack says Piedmont's mortality focus will help bridge the gap as the federal government—the largest payer—transitions from a fee-for-service payment system to one based more on accountability for the patient's ongoing well-being.
At the center of Piedmont's quality push is Leigh Hamby, MD, a general surgeon and the system's executive vice president and chief medical officer. Hamby has been on a quest for higher quality scores at Piedmont since 2005, when he returned from a one-week stay at the Institute for Healthcare Improvement's Executive Quality Academy.
"A turning point for our organization was that the best sum-total quality measure is focused on reducing hospital mortality," he says.
Since that time, the health system has set institutional goals centered on a particular specific challenge—such as sepsis (2009) or hospital-acquired infections (2010)—for which targets on outcomes and processes are measured. Those targets are determined based on an analysis by the chief medical officer's team to identify the disease or condition that has recently contributed most to hospital mortality.
Hamby says Piedmont focuses on two measures of mortality. One, raw mortality, is simply the number of deaths that happen in the hospital divided by number of admissions. But a more important measure as it relates to quality is called risk-adjusted mortality, a way of standardizing patient acuity levels across all hospitals, developed by the institute.
"I upload our hospital's data every quarter and they give us back a risk-adjusted mortality rate," Hamby says.
The emphasis on quality is nice, he adds, but getting executives to really buy in to it as a business strategy involves not only the coming incentives associated with healthcare reform legislation, but also, until reimbursement begins to vary based on quality metrics, compensation. At Piedmont, more than half of at-risk executive pay is based on quality (40%) and patient satisfaction (20%), than on the bottom line (40%).
"That keeps the short-term interest of leaders, if you can dangle that carrot," Hamby says. "But patients choose their provider based on where their insurance company's network is and where friends and physicians tell them to go. Over time that will change and people will require us to have measurable results posted so they can make good decisions on their care."
Getting the statistics is the easy part. Tracking mortality's causes to the places where it occurs is much more difficult, Stack and Hamby agree. Two of Piedmont's hospitals have fully implemented physician order entry and nursing documentation technology. Such technology can be helpful in gathering data, but Hamby says it's important to start with standard expectations and checklists so that when a patient who has multiple illnesses or conditions is admitted, caregivers implement care protocols based on evidence of efficacy.
Building those alerts for clinicians into the hospitals' clinical information technology system is important, but not sufficient to improving quality, he says.
"Lack of technology should not be an excuse for not achieving the results, while having it doesn't guarantee results," he says. "Commitment and focus is what we're looking for."
For example, 2010 quality goals at Piedmont revolve around reduction of hospital-acquired infections as the key quality initiative. That focus of singling out one metric a year allows the system to attack the factors that affect quality systematically. Hamby says the hospital quality arena consists of so many different metrics that caregivers can suffer from information and process overload.
"You can spend time and energy on core measures, but only a couple of them really drive mortality," he says. "That's the management of patients with acute heart attack and heart failure. A lot of other things are important, but counseling people to stop smoking doesn't lead to reductions in mortality. My job is to keep that balance and focus on what really matters."
Many studies have shown that patients' perception of quality is at least as important as the data. Perception depends less on statistical calculations and more on the human touch, consideration of other problems the patient may be experiencing, and simple customer service issues.
"Service and quality go hand in hand, but patients don't necessarily look at infection rates or making sure patients get aspirin when they present for chest pain," says Susan Osborne, vice president of service excellence at Piedmont. "That's not what they're monitoring. They want people to listen, answer questions, and alleviate their concerns."
Patient satisfaction doesn't just happen, she says, it must be "coached." Piedmont has three "coaches" who work with physicians and other caregivers at each of its facilities, one on one.
"The focus on patient satisfaction, at 20% of variable pay, means physicians and other caregivers aren't so slavishly devoted to achieving the numbers that they forget about what helps patients agree they got excellent care," says Osborne.