The Centers for Medicare and Medicaid Services (CMS) has a set of “Compare” websites – Hospital Compare, Nursing Home Compare, Home Health Compare, etc.; consumers and policymakers can compare physicians, long-term care hospitals, inpatient rehabilitation facilities, hospice care, and dialysis facilities today, and other settings may follow. Together with their associated health care quality measurement initiatives [PDF] and the Star Ratings programs, these sites are used to promote consistent standards of care. Quality improvement initiatives also provide valuable quality performance tools to providers.
These quality reporting programs use economic forces to encourage quality improvement, including monetary incentives and market mechanisms. Economic paths by which publicly reported quality of care data can influence care are complex. Determining how to react to quality reporting to gain the competitive advantage may prove challenging for providers. Focusing instead on the factors that already influence quality within the clinical care delivery systems may be an intuitive way for providers to make the most of their quality data.
Encouraging individual and organizational change is challenging. Psychology, sociology, institutional sciences, health policy management, and economics all attempt to describe processes that inspire change. Recently, research from many of these fields has been synthesized to produce a conceptual framework describing how performance information can lead to care improvement. Broadly speaking, change can be deliberate or reactive and its catalyst may be external or originate within an individual or organization.
Even the most well-thought quality evaluation/improvement plan does not occur in a vacuum. Applying a multidisciplinary model could help researchers and providers understand outcome data in the context of the environments were clinical practice occurs and leverage existing avenues and supports for change. Providers may be able to take immediate advantage of these insights by identifying what encourages change within their existing care structure and connecting their interpretation of quality reports with these factors.
Quality Reporting Process
Evidence suggests that reporting programs can improve care quality. But in order for public reporting to influence market forces, both patients/consumers and providers must act.
Consumers need the tools and capacity to process available quality reports in a context that allows them to take full advantage of their influencing role. Using publicly reported quality data available on Compare websites and armed with those tools, patients and families can be empowered to make informed decisions about the selection of care providers. Informed patients then take a discerning approach to selecting providers, inspiring market competition. The power of patient choice can be limited. For example, a patient may not be able to select a highly rated facility because there are no available beds.
Providers require access to their quality data and relevant market data. Even when providers can readily access data, determining their economic and practice implications takes effort. Routinely reviewing quality reporting data and translating results into actionable information may cause provider fatigue.
Decision-making research advises that a perceived lack of control can impede behavior change. If care providers are not confident that reacting to quality reports provides an advantage they may be reluctant to act. On the other hand, as described in this Medical Care article from 2009, there is evidence that providers involved in quality improvement initiatives experience significantly less isolation, stress, and dissatisfaction.
Care experts play a key role in the development of successful quality measures through their involvement in technical expert panels and committees, and through active participation in the public comment phase of federal rule-making. The valid and reliable quality measures produced by this process can be directly influenced by providers.
Applying an Interdisciplinary Approach
Providers are often considered to be intrinsically motivated to maintain a high quality of care. Clinical professionals and administrators engage in intentional behaviors that make their intrinsic motivations observable, including involvement in continuing education and voluntary adoption of new evidence-based practices. Mentoring and clinical collaboration support these quality maintenance and improvement activities.
Providers demonstrate their commitment to existing quality reporting programs by accessing and using continuing education and support resources, such as program manuals and dedicated help desks. Within this context of preexisting, intrinsic motivation to deliver the highest quality care, tailored quality reports — such as review-and-correct reports [PDF] — may serve as a monitoring tool, confirming the trajectory of a plotted course to predefined quality targets.
Progress reports describing a single provider’s performance can also inform a more urgent intrinsically motivated change through the identification of quality gaps or unexpected trends. When provider-specific quality data are delivered within a larger context — where providers can compare their performance with the performance of other similar providers — higher-performing peers may facilitate further change.
Contextualized quality data may become even more salient when paired with examples of top-performing providers’ successful care models. For example, providers working within a care network or with professional collaborators often share lessons learned. This type of detailed information can build upon providers’ intrinsic motivation to meet or exceed the performance of their peers. In this case, quality reports can be used to provide insight into the providers’ quality performance, the target they set for quality performance, and how they could achieve this goal.
Best practices become defined standards of care when they are formally codified by medical associations and professional organizations. Continued adherence to these accepted standards is a form of externally motivated, planned change. In this framework, publicly reported quality outcomes could document adherence to defined quality norms if tied to agreed-upon benchmarks of success.
Limiting Factors
Capacity for change can be limited or enabled by external structural forces such as the physical and organizational context in which care occurs. Examples of structural forces include the floor plan of a care facility, facility-level quality improvement initiatives, or staffing constraints. Considering these factors can facilitate quality improvement. Identifying and building on existing structural strengths can make reported quality data more applicable to practice implementation. Acknowledgement of structural factors restricting change allows administrators to focus on realistic ways to influence quality improvement.
What Next?
The influence of economic forces on improving care quality cannot be ignored, but the complexity of these interactions means that economic factors may not be the most intuitive way to motivate immediate behavioral change. To take full advantage of quality reporting resources, providers and administrators may wish to leverage existing structural supports and motivators within their practice to contextualize quality data, identify appropriate quality goals, develop quality maintenance and improvement strategies, and quickly synthesize results.
Further information is needed about how this approach to interpreting quality data works in practice, in the form of case studies or formal research, so we can identify how care providers can use regular quality reporting to their greatest advantage.
Erin Dobbins
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