Richard P. Dutton, MD, MBA
Turning Data into Dollars: How To use Quality Management information To Create Value for your Practice
The Anesthesia Quality Institute (AQI) was founded in 2009 to promote patient safety and quality management efforts across the specialty. The primary mission of the AQI is development of the National Anesthesia Clinical Outcomes Registry (NACOR), a repository for anesthesia case-specific data from across the country. NACOR is populated by transmission of electronic information from participating anesthesia practices and hospitals, including administrative (billing) data, Anesthesia Information Management System (AIMS) data, elements from the hospital’s electronic healthcare records, and purpose- gathered patient outcome information. The AQI began recruiting practices a year ago, and began accepting case data from
January 1, 2010. To date, the AQI has contracts with more than 40 anesthesia practices (including several ABC clients)ï»¿ and is working with more than a dozen anesthesia software vendors to format, transmit and translate their data into NACOR. Although few AQI sites have all of the desired data in electronic form today, all are working toward a future state that is 100% digital. In the meantime, the quantity of data that is available is truly astounding: NACOR will include a million anesthetics by the end of 2010, representing the work of thousands of anesthesiologists and CRNAs at hundreds of surgical facilities. But data collection, by itself, does not produce value. Value arises when the data is put to work.
This article will discuss the ways in which the data collected by the AQI—and reported back to participating practices— can be turned into tangible benefits for both patients and providers. I will cite examples that apply today using the relatively limited data now in NACOR, and I will suggest some examples that will apply in years to come. One of the first lessons of quality management, after all, is that the process is like peeling an onion: there is always another layer of understanding and improvement beneath the current one. The AQI and NACOR are just getting started, but will grow by incremental improvement in each year to come. More practices will be included, and more and ‘denser’ data will be gathered from the groups that are already signed up.
Benefits Provided by the Data
The purpose of quality management (QM) is to improve patient outcomes from their healthcare. ‘Improvement’ can take many forms, ranging from hard science (reduction in morbidity and mortality) to highly subjective (improvement in satisfaction scores). Improvement can also take the form of achieving identical outcomes at lower cost, or in higher- risk patients. Improved outcomes have direct value to the patients and practice, of course, but the data collected along the way can be applied for many other purposes. These are summarily listed in Table 1 and discussed in more detail below.
Let’s start with a straightforward example. One QM measure is “central- line associated blood stream infection,” or CLABSI. The rate of occurrence of this complication is provided by the AQI to the contributing practice, along with the national rate in similar hospitals. As a serious complication, the local rate would be ‘adjusted’ for known risk factors: age, ASA class, case mix, and others as available. The rate is reported only for those groups contributing all of the necessary data. Groups with a higher rate than their peers (“high outliers”) would be empowered to address the issue, and adopt new local policies to reduce the incidence of this complication, perhaps using guidelines or standards developed by ASA and promulgated by AQI. In the end, patient care is improved. And a considerable financial benefit is realized: each CLABSI prevented will save the hospital as much as $80,000, and perhaps more than that if current federal plans to dock payment for this so-called “Never Event” reaches fruition. For the anesthesia practice, reduction of the CLABSI rate begins as an opportunity to benefit patients, but ends up generating an important financial return. While this is just one example, the generic observation is equally true. Complications cost money. Reducing complications saves money. Everyone wins. And there are indirect benefits as well.
Improved QM data, with national benchmarks from AQI, will have value to the practice even before addressing specific outcomes. The core activity of QM is collection of data that documents a business, and the first result of most QM programs is simply a better understanding of how that business works. What activities consume the most time? What brings in the highest revenue? What just isn’t worth doing? These administrative endpoints, descriptions of process rather than outcomes, are nonetheless important for practice management. How many ORs should be staffed, and for how long each day? Which procedures take longer than they should? How much does it cost to perform an average anesthetic?
More particularly, QM data can be used to make decisions regarding hiring and firing, OR staffing, and contracts with hospitals and surgeons. Documentation of improved outcomes can feed directly into ‘gain-sharing’ discussions with the hospital. Trends over time can be examined to determine which portions of the business are growing, and which are not. Increased quantity and specificity of data is also useful to meet regulatory requirements, and facilitating this use is one of the AQI’s goals. Reporting of practice outcome data in comparison with national benchmarks will meet many overall requirements for anesthesia department QM activity, while data available on a per-practitioner basis will be of use for Joint Commission Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE), and for the Maintenance of Certification requirements of the American Board of Anesthesiology – as well as to the practitioner seeking to understand his or her own performance.
The bottom line is that QM data equals business data. The numbers are the same, but the application is different. Putting the data to work for the practice is driven by the questions that need to be answered, and many times new questions can be answered by a different look at existing data. One of the goals of the AQI is to present data back to participating practices in such a way that they can make these new uses themselves. Rather than a static 2-dimensional stack of paper, the AQI practice report will be a web-based tool that allows the participating group to combine and manipulate the data in ways that are of most use to them, based on local circumstances. This includes specific reports for individual facilities and providers, specific looks at certain procedures, and detailed examination of outcomes data. As an example, consider the use of data surrounding the rate of post-operative nausea and vomiting in a given facility. Perhaps a question has been asked in the PACU Committee suggesting that the rate is too high. Practice data reported by the AQI could be used to confirm or deny this suggestion by comparison to national benchmarks. Even more important, AQI data could then be used to take a focused look at the problem, by showing which patients appear to have the greatest risk, based on provider, procedure, age, gender, specific anesthesia medications used, time of day, and combinations of all of these variables.
Future Measures Will Include Patient Satisfaction
Because they are hard to make perfectly objective, measures of patient satisfaction are under-represented in anesthesia QM at the present. Looking at the future state of regulation, however, it is hard to imagine that patient-focused outcome measures aren’t going to be important. These can range from obvious elements like the rate of postoperative nausea and vomiting or the quality of pain relief to more complex and synthetic measures such as the Net Promoter Score (e.g. “on a scale from one to ten, how likely would you be to recommend this anesthesiologist to a friend or relative?”).
Working to improve patient satisfaction, based on benchmarks from the AQI or other sources, might involve a variety of different tactics targeting everything from standardized orders for postoperative analgesia to changing the magazines in the Surgicenter waiting room. As patients become more empowered to choose their own healthcare, including physicians, treatments and hospitals, attention to providing the patient what they want will have increasing value. Odds are that your hospital is already putting substantial effort into improving the so-called “hotel services,” and odds are that the OR is an important portal of entry for patients and their families. How long will it be before the anesthesia practice is ‘invited’ to participate in customer service training? Wouldn’t there be value in getting to this first?
The Hawthorne Effect and Incidental Positive Outcomes
In addition to improved clinical outcomes and enhanced patient satisfaction, there are cultural benefits to the use of QM data. Quality management is strongly sensitive to the Hawthorne Effect, which states that close examination of outcomes tends to affect them. While this is a source of bias in scientific research, it is an important benefit in QM. Knowing that outcomes data is being collected, and seeing evidence of this in periodic reports will lead to improvement in the measured outcomes over time, even without overt changes in department practice or procedures.
There is also a ‘pull through’ effect, where focus on one outcome (e.g. PONV rate) may improve other seemingly unrelated outcomes (e.g. rate of satisfactory postoperative analgesia). Even without considering these subjective benefits of QM data reporting, the ability to present and discuss real numbers can make the process of implementing changes more digestible for members of the practice. Knowing the exact rate of inadequately documented procedures, for example, provides a powerful lever for making changes in the billing system.
Tracking QM outcomes over time, which AQI data will facilitate, allows practice leadership to develop success stories that will meet regulatory needs externally and can help to improve culture internally. Being able to walk a surveyor or hospital executive or board member through a QM project from start to finish (see Table 2), using real data from real patient care is the most powerful possible illustration of the practice’s commitment to continuous improvement. Internally, being able to describe victories in tangible terms will help snap colleagues out of their normal cynicism towards increasing bureaucracy.
Working for a practice that takes QM seriously will improve the morale of individual practitioners, and will enhance recruitment and retention efforts. Done right, QM helps to put the emphasis on evidence-based improvements in care, and encourages a team and systems approach over individual blame. Self- reporting is enhanced. Anesthesia providers feel empowered when they can see tangible improvements in outcomes developing over time. This facilitates participation in further effort and further change.
External to the Department, the use of QM data to guide decisions and make improvements will create an important perception of the group as interested in patient outcomes, driven by data and committed to continuous improvement. Even beyond the use of specific pieces of data and QM stories to influence particular decisions, the reputation for collecting and acting on objective information will benefit the group in contracts with surgeons and hospitals, relations with other departments and service contractors and even with public advertising. One reason that the AQI has a licensing program for our preferred vendors and participating practices is that we believe that commitment to data- driven QM is the mark of an efficient, future-oriented practice, one that can be trusted to take good care of its patients.
Benefits to the Specialty of Anesthesiology
On the national level, the contribution of practice data to the AQI will bring benefits to the specialty as a whole. Aggregated data will have scientific purposes, of course, but it will also empower the advocacy efforts of ASA and its leaders. In an ever-changing landscape of healthcare reform the ability to help shape the regulations that we will live under is priceless, and there is no better way to influence discussions with regulators than to bring data from real clinical practice to the table.
The practice of medicine is changing rapidly in the United States, and its final shape remains uncertain. One thing that is likely, though, is that every provider— hospital, practice and individual—is going to face an increasing need to demonstrate in a tangible way the value they bring to patient care. The AQI is committed to meeting this need on behalf of anesthesiology, and with the help of practices and practitioners across the country we will find many future ways to do so.