Looking at Care Quality Progress

April 10, 2013
The Premier health alliance's enterprise-wide chief medical officer, Dr. Richard Bankowitz, shares his thoughts on what's working in the remarkable QUEST initiative, and why what's being learned needs to be replicated health system-wide. Not surprisingly, data is at the center of the progress being logged in this program.

On Jan. 18 in Washington, D.C., executives and leaders of the Charlotte, N.C.-based Premier Health Alliance held a live-plus-telephonic press briefing to announce three years of results from the organization’s ongoing QUEST High-Performing Hospitals Collaborative program and to showcase the comments of several senior executives from Premier member hospitals participating in the QUEST program.

In its announcement to the healthcare press the day before about the upcoming press conference, Premier’s media relations team offered the marquee headline results thus: “Join hospital and healthcare experts for a briefing on how 157 hospitals saved 25,000 lives and $4.5 billion in three years.” (Since then, the program has expanded to include 293 hospitals in 40 states.)

As Healthcare Informatics reported on that date,
 the results coming out of QUEST have been truly noteworthy, including a mortality rate among QUEST hospitals that was 29 percent lower than the national averages; the averting of several thousand deaths related to sepsis, respiratory conditions, and cardiac conditions and shock; and a 73-percent point increase in hospitals meeting the top performance thresholds established by the program.

Richard Bankowitz, M.D., enterprise-wide chief medical officer at Premier, has been deeply involved in all of Premier’s quality-related initiatives, including the QUEST program. He shared his perspectives on the clinical and cost-effectiveness progress made by QUEST participant hospitals in a recent interview with HCI Editor-in-Chief Mark Hagland. Below are excerpts from that interview.

Richard Bankowitz, M.D.

What are your top takeaways from three years’ worth of progress within QUEST?

For me, looking back at the first three years of QUEST, I think there have been three important takeaways. The first is the need for hospitals to compare and benchmark their performance and set targets for best practices. And that sounds simple, but in order to do that, you need to have a group come together and create a consensus on what you want to achieve. And that took a little time, but the time was well-invested, because once we’d taken a little time to talk over what would be in the measurements, we had everyone’s buy-in, because everyone knew what we were looking for, and what they needed to achieve. The second thing is that transparency of results is easier to achieve than you might think. We had a group of hospitals that were fully transparent on their results on mortality, on patient experience, patient safety, on use of evidence-based care. And you might think people might be reluctant to share their data, but everyone wants to do better for their patients. And we knew that once the data was out there, it would accelerate progress, because no one wants to be at the bottom of a list on patient safety. And it was a little bit of a risk, but it went forward because there was trust in Premier.

And I think the third lesson is that healthcare systems need to find ways to share best practices and what works and what doesn’t. And right now, we just don’t have time to reinvent the wheel; we’ve got value-based purchasing upon us, and to try to blue-sky things is very difficult, so to be able to share best practices was very valuable.

What would your reaction be to people who say that the tools we’re using to benchmark performance are still very primitive? You have to start somewhere, right?

Absolutely. And it is very true that tools are still relatively early in their development. And QUEST came into existence, because we decided to measure mortality, to measure the patient experience, to measure patient safety, which is a difficult thing to do, and it’s a process, and it’s a journey, and we’re not perfect. We want to move beyond cost and look at waste, etc. But if you wait for the perfect measurement, you’ll never get started. And we had a lot of discussions early on in the collaborative around not knowing precisely what the 32 measures of harm would be, or what the benchmark would be.

And I would remind participants that the goal was to reduce harm, so figure out opportunities, and go for it—don’t wait for perfect measures. And while it’s true that we don’t have perfect measurement, it should be incumbent on the providers to define what is important. Too often, providers have waited for CMS to define measures; I think the unique thing about QUEST was that the providers themselves came together and decided what was important to measure. I think that’s a good model that could be adopted more widely.

And the third observation is that, unlike some of the payment measure being adopted elsewhere, within QUEST, everyone can win; it’s not a zero-sum game where one organization’s loss is another one’s gain. We set a threshold in every area, and the aim was to get over that threshold, and that really made sharing easier, because it’s fundamentally good to get everyone’s care better.

Has QUEST replaced HQID [the CMS/Premier Hospital Quality Incentive Demonstration project, co-sponsored by the federal Centers for Medicare and Medicaid Services and Premier]?

They ran concurrently for a while; but at a certain point in time, though it was being developed concurrently, HQID ended, and QUEST is moving forward, and we’re planning for the third iteration soon.
Will the various factors around trust in Premier that might be missing in other settings, such as lack of trust, be barriers in other contexts?

There might be some barriers. I think the most important thing is for hospitals to be engaged with their hospital associations or other entities; it’s important to find a partner with whom you can create best practices to accelerate action. So any way you can do that, with whatever trusted partner you have, is the way to go. I think inevitably, we’ll have to look at the entire continuum of care. And it won’t be enough to provide good enough inpatient care; sometimes, it will require keeping people out of the hospital and emergency rooms. And right now, that data is lacking among providers unless they own their own plans.

That data typically resides at CMS or with the commercial payers, because they can see the whole claims history. And historically, there’s been a lack of trust there, and it’s required a negotiation in terms of getting the pieces of the pie in terms of the payment dollar. So it’s going to be important to establish that trust. And we’ve now seen forward-thinking institutions engaging with payers, and it’s called the Partnership for Care Transformation. It’s a Premier program, explicitly set up for systems that want to test different payment models. So we have a number of institutions that will be going after the Medicare Shared Savings Program; some that will go into the bundled payments program; some that will go in with employers and payers in their market to collaborate; some that are working to improve their medical home programs or resource utilization. That program is fairly new and fairly broad, and really represents the forward-thinking institutions.

How can CIOs and CMIOs be facilitators and leaders in their organizations, in working with programs like this one?

That’s a very good question. The advice, I would say, is to lead by example. And what we’ve found in all successful organizations is that the leadership is fully engaged. And for CIOs CMIOs, that would mean being very strong proponents of finding out what is important to measure; and if they can lead by that example, the successes will build on each other. And CIOs play a very big role in terms of the planning of this. And some institutions may be in denial about this, and believe that change will blow over. But forward-looking CIOs should be very involved in looking for partners and trying to find where they can collaborate, and not waiting to where they can be compelled by the federal government or whoever, because if you wait that long, you’re often too late.

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