• Transparency Leads to Better Quality Scores at Two Health Systems

    May 30, 2012

    By Maggie Van Dyke

    By sharing their quality scores online, Alegent Health and Spectrum Health motivated staff to aggressively improve patient care and branded themselves as quality-oriented providers.

    This infographic highlights Alegent's and Spectrum's quality transparency approaches.  

     Breakthrough Map-Page 48-49 spread

    If you have trouble reading this jpg file, download a PDF of this infographic.

    The phone did not ring off the hook as expected. In September 2005, Alegent Health thought it was making a dramatic move by posting its quality scores on its website and in the local Omaha, Neb. paper. "We thought it was an enormous deal. We thought we'd get all kinds of questions and start discussions in the community," says president & CEO Richard A. Hachten II, FACHE. "But most of the questions came from our competitors who wondered why we were doing this," he added with a laugh. 

    However, one very important contingent-Alegent physicians and employees-took the publicly posted metrics very seriously. Unhappy with their performance on nationally recognized quality measures, they committed to meeting aggressive improvement targets. Within a year, Alegent's scores rose to 94 percent on average, from below 90 percent. Today, the health system scores 97 percent or better on 40 quality metrics.    

    Alegent has successfully achieved one of its transparency goals: "This is about delivering the very best care that we can for our patients, and continually challenging ourselves to improve," says Rick Miller, DO, senior vice president & chief quality officer. The health system is also inching toward its second goal of giving patients useful information that can help them make educated decisions when selecting a hospital. More than 5,000 people a year now visit Alegent's online quality scores.

    Nationally, patients have been slow to make use of healthcare quality reports. Only 12 percent of adults who responded to a 2011 Pew Internet survey have consulted online rankings or reviews of providers. "We're still very early in the process of educating the public about quality," says Miller. "And we're continually challenged about how we present and explain quality information. Patients are beginning to try and dig in and understand things. But we have a responsibility in that process and in helping educate people." 

    Ask Patients

    Like Alegent, Spectrum Health saw a significant improvement in quality scores after the Grand Rapids, Mich. health system posted results on its website in 2008. "We have a lot of internal incentives that motivate our staff to continuously improve quality," says John Byrnes, MD, senior vice president of quality. "But when staff know data is going to be shared publicly, it provides an additional motivation. Some of our teams really got to work and made improvements very quickly."

    Spectrum posts scores on all the core measures, or the metrics reported on Medicare's Hospital Compare website. It also shares scores on additional metrics for cardiac and orthopedic care, which are two of the health system's key service lines.

    Before posting its scores, Spectrum consulted patients for advice. "We worked with our Patient and Family Advisory Committee and held numerous patient focus groups for more than a year to try to determine how we could present the quality scores in the most understandable way," says Byrnes. The key messages from patients included the following:

    • We don't understand the importance of the measures (e.g., ACE inhibitors for left ventricular systolic dysfunction) that you are using
    • We don't understand the language you are using 
    • It would help if you explained this graphically with comparisons that are meaningful

    Spectrum staff used this feedback to develop quality reports for six conditions or procedures, including community-acquired pneumonia and heart attacks. Plus, there is a separate quality report for the Surgical Care Improvement Project.

    Many of these reports graphically compare national readmission and mortality rates against Spectrum's rates (see the exhibit below).  

    pg49_exhibit breakthrough-spectrum-1

    The reports also graphically highlight and explain Hospital Compare metrics. For example, on the community-acquired pneumonia report, patients can see what percentage of Spectrum pneumonia patients received a pneumococcal screening and/or vaccination-compared to the national and Michigan averages (see the exhibit below).

    pg49_exhibit breakthrough-spectrum-2

    Three elements help make this Spectrum graphic more meaningful to patients:

    • A short explanation of why pneumococcal screenings/vaccinations matter to pneumonia patients
    • Easy-to-understand comparative data
    • An arrow explaining that a higher score on this metric is better than a lower score

    Spectrum also includes additional information on its website (under the banner "Quality") that educates patients and other visitors on How to Evaluate Quality and Resources for Quality.   

    A lot of what Spectrum has done in creating its quality reports follows best practices laid out by the Agency for Healthcare Research and Quality (AHRQ). For instance, AHRQ recommends that organizations use color, symbols, and simple words to help consumers process and interpret data quickly.

    See the sidebar: Tips for Designing and Promoting Quality Reports

    Consider a Composite

    Alegent took a somewhat different approach to simplifying quality information for consumers than Spectrum. When visitors click on "Quality" on Alegent's website, they are brought to a single scorecard, or composite report, entitled Alegent 40.

     pg48_exhibit breakthrough-alegent-1

    "We roll the scores up into composites for the various disease states that we measure," says Angela Ward, quality and ancillary services executive. "To make it personal for us, we rebranded the scorecard as the 'Alegent 40' because we want it to be about the care that Alegent provides and show that it is important to us to continually improve that care."

    The Alegent 40 includes:

    • The 25 core measures for heart attack, pneumonia, and heart failure that are currently tracked by Hospital Compare
    • Five measures that Hospital Compare will soon require hospitals to report
    • Nine measures that are tracked by the Surgical Care Improvement Project
    • A hand washing measure aimed at preventing healthcare-acquired infections

    "The difficulty with quality and safety measures is that the things we are measuring are fairly technical in nature," says Hachten. "For example, the measure 'how many patients got a beta blocker after an MI' means something to me, but it doesn't necessarily mean anything to the average person on the street."

    To get around that problem, the Centers for Medicare & Medicaid Services (CMS), as well as some consumer organizations and payers, have put together aggregate scores. "For CMS' Hospital Compare, a hospital is at the national average, above the average, or below," says Hachten. "I think that approach is helping the public understand an organization's overall quality."

    For website visitors who are interested, Alegent also posts more granular reports on how each of its hospitals is performing on all the Hospital Compare metrics. 

     pg48_exhibit breakthrough-alegent-2

    Link to Comparative Information

    Neither Spectrum nor Alegent list the quality scores of their competitors or even noncompetitive peers on their public quality reports. On Spectrum's reports, patients can compare Spectrum's performance against the national and Michigan hospital averages. But only Spectrum facilities are singled out on the health system's quality reports.

    Alegent doesn't even provide national or regional averages-only the scores of Alegent facilities. "This is not about marketing," says Miller. "The motives are very pure."

    "This is truly about feeling a clear sense of responsibility to be transparent about all the aspects of care that we are providing to the public," adds Hachten. "It not only holds us accountable to our patients but it hold us accountable to ourselves to provide the kind of care to patients that we like to think we provide to them."

    Interested consumers can easily compare the performance of Spectrum or Alegent hospitals against other hospitals via the Hospital Compare website-and both Spectrum and Alegent do link to Hospital Compare from their websites. "It's all nationally reported data," says Miller.

    Drive Improvement

    On their quality reports, both Alegent and Spectrum purposely detail how well each of their hospitals is performing on various metrics to inspire internal improvement. "We initially got some push back from some of our physicians about publishing these scores," says Miller. "But it set up a competition of sorts among our physicians and employees, and the scores started significantly improving."

    One score that has improved dramatically is hand washing. "I remember when we first started talking about handwashing, our scores were in the 60th percentile," says Miller. "Now we report this metric every month for all of our campuses. We use secret shoppers who go out and actually observe whether staff is washing their hands when they should be."

    Now handwashing scores at all Alegent hospitals are in the 98th percentile. Most important, healthcare-acquired infections have gone down. "As our hand washing went up, our rate of Methicillin-resistant staphylococcus aureus (MRSA) went down-directly proportional to the amount of hand washing," says Hachten.

    Communicating the linkage between process measures (such as handwashing) and outcome measures (such as lower MRSA rates) helps further motivate staff to improve, says Ward. "It's really important for staff to see the 'so what'? Everyone wants to do best thing for our patients."

    Alegent furthers drives continuous improvement across the health system in two ways. First, all leaders and frontline staff have performance incentive goals around the Alegent 40 quality metrics, as well as patient satisfaction. "We take this seriously," says Hachten. "It's everybody's job."

    Second, Alegent has developed formal approaches to sharing best practices with the goal of creating the same standard of care across the health system. "We have a care redesign process that involves all our campuses," says Hachten. "Each team takes a diagnosis and redesigns that diagnosis to meet national best practices and guidelines. We take waste out of system using Lean techniques, and we redesign for cost, quality, safety, and patient satisfaction. So we have regular meetings, which we call decision accelerators, which bring people together from across the system to learn from each other and continuously redesign."

    Look to the Future

    Asked how he hopes to improve Spectrum's quality reports, Byrnes says he hopes to add more metrics and more conditions. Specifically, he's hoping to beef up Spectrum's heart surgery quality report with additional metrics from cardiac specialty organizations as a way of drawing more attention to the health system's center of excellence. "When I looked at how well our vascular surgeons are performing compared to others, I'm excited to share this data with patients."

    Spectrum sees its quality reports as part of its brand, says Byrnes. "Quality is a leading factor in our strategic plan-and it is central to a lot of the work we do in our primary and secondary service areas. We lead on quality and cost, and those are the main messages of our marketing plan."  

    Hachten believes more work is needed on a national level to develop and report on quality metrics that matter more to patients. "When I think about what patients really care about, I think they want to know if they will get better quicker, how much discomfort they are going to have after surgery, or what level of health they can reasonably expect to attain as a result of a surgery, procedure, or a therapy."

    The National Quality Forum and others are beginning to develop these types of patient-centered measures. For instance, an Apr. 9, 2012 post on the Health Affairs blog highlights efforts in Sweden and the United Kingdom to collect data on health gain and patient satisfaction after orthopedic surgery (Lansky, D., Public Reporting Of Health Care Quality: Principles For Moving Forward).   

    However, it may be years before providers can report on these types of measures. "Collecting this type of data is very dependent on the IT systems we have," says Hachten. "Today, we don't have the ability to track patient-centered outcomes, but as we get more clinical data systems, better electronic health records, we will be able to report on metrics that are much more meaningful to patients."  

    Another challenge is getting more patients to use quality reports to make healthcare provider choices. "Many patients don't even know these reports are out there," says Hachten. "The more we report these scores and expose patients to them, the more familiar they will become with them."

    He urges other hospitals and health systems to post their quality metrics. "You need to get over your fear of putting your information out there-even if it's not good. Posting your scores demonstrates to your patients that you really care enough to tell them what they need to know-and that you are willing to work to improve quality."

    Access a related article on how Alegent and Spectrum are communicating prices: Lessons Learned from Hospital Transparency Pioneers

    Maggie Van Dyke is managing editor of HFMA's Leadership publication (mvandyke@hfma.org).

    Interviewed for this article:

    John Byrnes, MD, senior vice president of quality, Spectrum Health, Grand Rapids, Mich. (John.Byrnes@spectrumhealth.org).

    Richard A. Hachten II, FACHE, is president & CEO, Alegent Health, Omaha, Neb.

    Rick Miller, DO, is senior vice president & chief quality officer, Alegent Health.

    Angela Ward, FACHE, is quality and ancillary services executive, Alegent Health.