Cover Story
An H&HN exclusive: Insights from the 5 top hospitals
Pay for performance is no passing fad. It’s real and it’s here to stay. Private payers, employers and the federal government are all devising ways to pay hospitals to improve patient care. The 800-pound gorilla in payment policy, the Centers for Medicare & Medicaid Services, under congressional mandate, is devising a plan to deploy pay for performance on a broad scale by fiscal 2009. Hospital leaders involved in the nation’s most ambitious pilot project say the bonus money doesn’t even come close to covering the administrative costs that the project imposes on their institutions. Where it does pay off is helping leaders and staff focus on continuous improvement.
Under the Hospital Quality Incentive Demonstration, a joint effort between CMS and Premier Inc., quality indicators for 260 participating hospitals rose by 11.8 percent over two years. The hospitals are scored on their adherence to 30 nationally standardized measures in five clinical areas: acute myocardial infarction (AMI/heart attack), congestive heart failure, coronary artery bypass graft (CABG), pneumonia, and hip and knee replacement. A composite quality score is used to determine how large a payment bonus they’ll get from CMS—2 percent of the patient load for hospitals in the top 10 percent; 1 percent for hospitals in the second tier.
But the program is hard work. It involves getting buy-in from clinicians. There’s an enormous data collection burden. And there’s the fact that the project’s measures are slow to keep pace with advances in clinical guidelines.
In an exclusive roundtable discussion, officials from the top scoring hospital in each of the project’s five clinical areas spoke with H&HN Senior Editor Matthew Weinstock about their experiences in the program and the challenges hospitals will face as pay-for-performance programs become the primary way that providers will be reimbursed by public and private insurers.
Does pay for performance work?
Diane Ryckman: Yes. Pay for performance helped improve our quality. We asked ourselves, “Did we improve quality or just improve documentation?” In fact, we did both. We reduced the variability of care and increased our accountability. We went from the sixth decile in year one to the first decile in year two. We also reduced our infection rate by 75 percent from year one to year two and our readmission rates improved 2 percent. Our most significant improvement was in administering the antibiotic within 24 hours. That improved by 52 percent.
This project helped us focus on the target. We were somewhat surprised when we began this project to see that we needed to make improvements, specifically on the antibiotic measure.
Lorrie Boenhke: In terms of CABG, we started at the first decile and remained there over the course of the last two years. The project helped us sharpen the arrow or spear, making sure that we were doing things appropriately and documenting appropriately. It gave us that extra incentive to go up an extra notch.
Was it hard getting physician buy-in?
Christopher Hansen: We have 65 physicians who are involved in treatment of heart failure in any given year, and so to have 100 percent of those physicians be compliant is always a surprise … to get that kind of buy-in is tough.
Dave Moen, M.D.: I’m an emergency physician. We all recognize that there is a move toward transparency in health care and these types of results are going to say something to the outside world about our organization. Our physicians and really all of our staff are concerned about how they are viewed by the community we serve. So I think the move toward transparency is a very good thing. Staff realize that we have to do these things.
There is a lot of data collection and administrative work on this project. How do you stop from being overwhelmed by that?
Candy Fincke: You can, at times, be overwhelmed. It can seem that as soon as you get one rolled out and get a cadence with it about how we are going to approach each of these measures, there’s another one behind it. So it is a never-ending thing. We understand it as a patient safety factor, so that helps a little bit.
Moen: You also have to think through how to do these things so that it doesn’t make the clinical work more difficult. Our best success, we found, was when we were able to require less work of the clinicians having to do the care. When we first started talking about this, the physicians talked about cookbook medicine, protocols and standardization. It just was not viewed positively. But as physicians have gotten used to standardization and using protocols, they make fewer errors. The work of doing the care goes faster and smoother because the team knows what to expect in these situations. So it’s not a hard sell once you get going. It would be a hard sell if you made it onerous or difficult because the work is already onerous and difficult.
Pamela Warner: It is really important to remember that this is evidence-based medicine and the physicians know that and they do, at least in our case, treat according to that, at least most of the time. There is a documentation issue. We have to stay on top of that all of the time. We are constantly reminding physicians, especially when we finally got them used to documenting why they don’t give an ACE and now it’s an ARB. They know in their heads why they aren’t doing this, but oftentimes, in their busy schedules, the documentation needs reminding. That is one of the biggest things that we found.
So do you do that in face-to-face meetings, through e-mail?
Warner: We do face-to-face reminding. And anytime I see a physician in the hallway, I thank him or her for remembering to do this and for constantly keeping it on the forefront. I bring it up at every meeting and reinforce that we have to document these things.
Fincke: We share these measures with all of our staff. They are posted each month and we do talk about them. They understand the importance of their role in these projects. It’s something that is in conversation with everyone in the hospital and we also talk about what measures are coming up because of participating with IHI or what the Joint Commission is bringing in.
What’s the role of nurses in all of this?
Moen: It’s critical. They are often the ones who are documenting certain aspects of this and administering medications. They are also a great check in the system. If they know what to expect, they can be a check on the physicians’ work. What you need is a culture where nurses questioning care that is being administered in the interest of safety and quality becomes the norm.
Fincke: At Mariners, it really became a team approach. It’s everybody from the nurses to the techs down in the lab. They became very involved in making sure the blood is drawn in a certain amount of time, bringing the patient up to the floor, the imaging, educating—it’s a huge team approach.
Are the financial incentives enough to compensate for the resources you put into this?
Ryckman: I don’t think the money, most would agree, is the real incentive here. That’s not going to pay for the time and effort. What it has allowed us to do is actually improve our outcomes.
Warner: I totally agree. The financial incentive doesn’t come anywhere near covering the resources that need to be put into it. However, the outcomes and the reduction in complications and readmissions make it very much worthwhile.
Boenhke: It gives you the incentive to go the extra step, but it truly isn’t the motivating factor. You would do that eventually, but it’s a way to improve your focus.
What needs to be tweaked in the program?
Moen: We need a more rapid feedback loop into the evidence and changing measures. A good example of that would be the use of beta blockers in acute AMI. They’re required to be used in every case. There’s now literature saying that in the case of elderly hypertensive patients it’s probably not the best thing to be doing. So now we have a measure that is running in conflict with what is becoming evidence-based medicine. There doesn’t seem to be a feedback loop. What I’m concerned about is that pretty soon this project is going to be disconnected from the evidence. If you want to lose physician buy-in—and other clinical staff—to projects like this, disconnect it from the evidence and make it not authentic.
What I would like to see are measures that don’t get stale and I’m not seeing a lot of movement from the project leaders to adjust the measures that are in place. That is a critical component going forward. High-performing institutions are going to do what the evidence says and we need to continue to reward high-performance institutions.
What do you do when the clinical evidence runs counter to the measure?
Moen: You do what the evidence tells you to do. The patient in front of you is what matters. You document to the best of your ability. It will create work on the back end—justifying why you didn’t do something.
If measures run counter to what the evidence tells us to do, the project will wither quickly. We’ve forwarded concerns to Premier. I’m hoping that there will be change on the horizon, but at the moment there are times when the measures are incongruent. I hope people realize how damaging that is to the project going forward.
Warner: We find that, too. Our physicians are encouraged to practice the best evidence-based medicine no matter what. It’s not to meet a certain criteria, it’s to give the patient the very best care. If we ask physicians to do something different than what they think is in the patient’s best interest, that could very much take away from the program’s credibility.
How would that feedback loop work?
Ryckman: When we went through this project, we realized we had to get to concurrent monitoring and data in real time. In the ideal world, we’d have our computerized documentation system that would dump our data into our outcomes system, provided we were doing all of the right documentation. We had to get to daily information in order to make changes. If we had it one month later, it didn’t do us any good. We’ve had to speed up our whole process. It would be ideal if we had a system on a national level to do that.
The measures focus on process, not outcomes. Is that something that needs to change?
Ryckman: I would say that the processes fuel the outcomes as we reduce variability and have more accountability with our processes, whether it be with the nurse or physician. For example, we’re getting patients with hip and knee replacement up the day of surgery. That early mobility is going to help reduce deep vein thrombosis. We want to look at all those clinical processes.
Hansen: I don’t think most institutions have the numbers where outcomes can be measured that easily. And even if you have those numbers for a given year or quarter, you aren’t sure if they are statistically significant. So as long as we are doing things that the entire field of medicine agrees is the right thing to do, we should continue to look at process.
How do you ensure continuous improvement?
Ryckman: One of the things we’ve done, is we started doing benchmarking. You can be the highest rated in, say, Ohio by Health Grades—which we were for three years—but we did some benchmarking. We took our whole team out and we saw some other total joint programs. We came back and did a gap analysis. We are actually working on a whole new set of clinical process improvements. You can always learn, you can always improve.
Matiana Vala: Ownership is vital. You have to have someone who owns that process. Through [Six Sigma], owners are responsible for tracking a measure and reporting it monthly. The other thing that is very powerful is to be transparent with our outcomes. The patient outcomes are reported through the key management meetings and to staff and on our Web page.
How involved does the executive team need to be in pay for performance?
Boenhke: They’ve worked to ensure that the right practices are in place. It’s very important that leadership becomes involved in our processes, or have ownership or oversight of our efforts to continuously improve.
Is it the financial incentive that gets them involved at that level of detail?
Joyce Dombrouski: The financial incentive wasn’t a buy-in factor at all. I sit on the executive team. We clearly understood that the end point was for the patient and for quality. We understand exactly what is being asked of the clinician—from the physician to OR staff to the bedside person. Because we have that level of understanding, we are able to support the individuals who need to do the work. Without that level of understanding and interest, it is hard to reach a high level and sustain it. So from my position on the executive team, it is staying very engaged in what is being asked of the individuals doing the work.
What do you tell your peers who are just now looking at pay for performance?
Dombrouski: Don’t remain at a 30,000-foot level and then assume that you are going to be able to make the strides you need to and then sustain them. As executives, we often want to function at that level. For these initiatives, you really have to understand the nuts-and-bolts grassroots effort that you are asking of individuals and you have to be willing to champion that and be willing to break down barriers so that they can do their work on a daily basis. So you cannot stay removed and expect to gain success.
This article first appeared in the March 2007 issue of H&HN magazine.
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