The Top 7 Outcome Measures and 3 Measurement Essentials
The healthcare industry is riddled with administrative and regulatory complexities that make it difficult for health systems to achieve the Triple Aim of healthcare (improving the patient experience, improving the health of populations, and reducing costs). Complexities in outcomes improvement are particularly challenging, as health systems measure and report on hundreds of outcomes annually.
We can manage this complexity by taking a closer look at outcome measures—defining them, understanding their nuances, reviewing real-life examples, and proposing three essentials for successful outcomes measurement.
Outcome Measures Defined
The World Health Organization defines an outcome measure as a “change in the health of an individual, group of people, or population that is attributable to an intervention or series of interventions.” Outcome measures (mortality, readmission, patient experience, etc.) are the quality and cost targets healthcare organizations are trying to improve.
Outcome measures are frequently reported to the government, commercial payers, and organizations that report on quality, such as The LeapFrog Group—a national nonprofit that evaluates and reports U.S. hospital safety and quality performance. LeapFrog’s work centers on “increasing transparency among health care providers in order to reduce the estimated 440,000 annual deaths from hospital errors, accidents, and injuries.”
Why Measuring Outcomes Is Important
The ultimate goal of measuring, reporting, and comparing health outcomes is to achieve the Triple Aim of healthcare:
- Improve the patient experience of care.
- Improve the health of populations.
- Reduce the per capita cost of healthcare.
The organization behind the Triple Aim—the Institute for Healthcare Improvement (IHI)—is dedicated to outcomes improvement. IHI describes measurement as “a critical part of testing and implementing changes. Measures tell a team whether the changes they are making actually lead to improvement.” Healthcare organizations, motivated by the Triple Aim, measure outcomes for many reasons:
- Reveal areas in which interventions could improve care.
- Identify variations of care.
- Provide evidence about interventions that work best for certain types of patients under certain circumstances.
- Compare the effectiveness of various treatments and procedures.
Outcome Measures Are Driven by National Standards and Financial Incentives
Outcome measures are primarily defined and prioritized by national organizations, including CMS, The Joint Commission (TJC), and the National Association for Healthcare Quality (NAHQ). Health systems target outcome measures based on state and federal government mandates, accreditation requirements, and financial incentives.
Although outcomes and targets are defined at the national level, health systems might set more aggressive targets. Meeting and exceeding national targets benefits not only quality of care, but also marketing and contracting.
TJC is a regulatory body that accredits health systems and has national standards for quality measures that are “developed with input from healthcare professionals, providers, subject matter experts, consumers, government agencies (including CMS) and employers.” New standards must meet strict requirements:
- Relate to patient safety or quality of care.
- Positively impact health outcomes.
- Meet or surpass law and regulation.
- Can be accurately and readily measured.
Reporting and accreditation entities have processes in place to normalize outcomes data to account for context, which is key when it comes to reporting. It’s easy to take data out of context. Using fall rates as an example, if a small, 10-bed hospital sees ten patients in one month and one patient falls, then their fall rate is high (10 percent).
CMS uses outcome measures to calculate overall hospital quality. In a recent report, CMS explained how it arrived at its 2016 hospital star ratings. CMS grouped outcome measures into seven categories weighted by importance:
- Mortality (22%)
- Safety of care (22%)
- Readmissions (22%)
- Patient experience (22%)
- Effectiveness of care (4%)
- Timeliness of care (4%)
- Efficient use of medical imaging (4%)
The Top Seven Outcome Measures Explained
There are hundreds of outcome measures, ranging from changes in blood pressure in patients with hypertension to patient-reported outcome measures (PROMs). The seven outcome measures CMS uses to calculate hospital quality are some of the most common in healthcare:
#1: Mortality (life expectancy)
Mortality is an essential population health outcome measure. For example, MultiCare Health System’s initiative to improve the care, cost, and experience of pneumonia patients, reduced the pneumonia mortality rate by 28 percent.
Readmission following hospitalization is a common outcome measure. Readmission is costly (and often preventable). For example, MultiCare Health System reduced pneumonia readmissions by 23 percent by building evidence-based order sets, assigning a team of social workers to improve patient follow-up and communication, and deploying an analytics application to provide near real-time feedback on compliance and performance while offering a single view of patient-specific data (medication, readmission histories, etc.) across multiple visits and care settings.
#3: Safety of Care (i.e. skin breakdown, hospital-acquired infections, etc.)
Safety of care outcome measures pertain to medical mistakes. Skin breakdown and hospital acquired infections (HAIs) are common safety of care outcome measures:
- Skin breakdown happens when pressure decreases blood flow to the skin. A skin assessment tool can be used to reduce skin breakdown. Patients with skin breakdown are at a higher risk of infection. Patients’ risk scores go up if they’re diabetic, for example, because their circulation is poor.
- HAIs are caused by viral, bacterial, and fungal pathogens. For example, Texas Children’s identified evidence-based bundles to reduce HAIs in children through their partnership with the Solutions for Patient Safety National Children’s Network. Using an enterprise data warehouse (EDW) and analytics applications to identify vulnerable patients and monitor clinicians’ compliance with best-practice bundles, Texas Children’s decreased HAIs by 35 percent.
#4: Patient Experience
Patient-reported experience measures (PREMs) fall within the patient experience outcome measure category. According to the Agency for Clinical Innovation (ACI), PREMs “assess the patient’s experience and perception of their health care. This information can provide a more realistic gauge of patient satisfaction as well as real-time information for local service improvement and to enable a more rapid response to identified issues.” For example, a patient might be asked to complete a satisfaction survey (on a scale of 1-5) about the care they received.
#5: Effectiveness of Care
Effectiveness of care outcome measures evaluate two things:
- Compliance to best practice care guidelines.
- Achieved outcomes (e.g. lower readmission rates for heart failure patients).
Given the rapid changes that occur within healthcare practice, making sure best practice care guidelines are current is critical for achieving the best care outcomes. It’s important to track clinician compliance to care guidelines. It’s equally important to monitor treatment outcomes and alert clinicians when care guidelines need to be reviewed.
Failing to adhere to evidence-based care guidelines can have negative consequences for patients. For example, according to The Dartmouth Atlas of Healthcare, “even though it is well established that beta-blockers can reduce the risk of heart attack in patients who have already had one heart attack, many heart attack patients are never prescribed beta-blockers.”
#6: Timeliness of Care
Timeliness of care outcome measures assess patient access to care. For example, a health system working to design a more efficient and accurate system for assessing sepsis developed an analytics platform to track the timeliness of care delivery, including several interventions: lactate tests, blood cultures, antibiotics, and central venous pressure (CVP).
#7: Efficient Use of Medical Imaging
The efficient use of medical imaging is an increasingly important outcome measure. According to the European Science Foundation, “Medical imaging plays a central role in the global healthcare system as it contributes to improved patient outcome and more cost-efficient healthcare in all major disease entities.”
For example, during Texas Children’s efforts to improve asthma care it discovered a high volume of chest X-rays being administered to asthma patients. Using its EDW to examine real-time X-ray data, it realized physicians were ordering chest X-rays for 65 percent of their asthma patients—evidence-based practice calls for X-rays in only 5 percent of cases. Texas Children’s IT team traced the problem to a faulty order set within the hospital’s EHR, and rewrote the order set to reflect the evidence-based best practice.
Process Measures Are Equally Important
Achieving outcomes is important, but the process by which we achieve outcomes is equally important. Process measures capture provider productivity and adherence to standards of recommended care. For example, if a health system wants to reduce the incidence of skin breakdown, then it might implement the process measure of performing a risk assessment using the Barden Scale for reducing pressure ulcer risk in all the appropriate units in the hospital. If health systems are too focused on an outcome, then they lose sight of the process.
The following outcome and process measures illustrate how health systems improve outcomes by improving processes:
- Conducting a medication reconciliation system check with heart failure patients at the time of discharge (process measure) can reduce heart failure readmission rates (outcome measure).
- Performing a fall risk assessment on a patient at the time of admission (process measure) can reduce fall rates (outcome measure).
- Using a skin assessment tool (process measure) can prevent skin breakdown (outcome measure).
Three Essentials For Successful Outcomes Measurement
Health systems’ ultimate goal is to improve patient outcomes. But outcomes improvement can’t happen without effective outcomes measurement. As health systems work diligently to achieve the Triple Aim of healthcare, they need to prioritize three outcomes measurement essentials: transparency, integrated care, and interoperability.
Used in tandem, these essentials improve and sustain outcomes measurement efforts by creating a data-driven culture that embraces data transparency (essential #1), an integrated care environment that treats the whole patient and improves critical care transitions (essential #2), and interoperable systems that enable the seamless exchange of outcomes measurement data between clinicians, departments, and hospitals (essential #3).
The healthcare industry is on a journey to outcomes transparency. Patients want outcomes data so they can make educated decisions about their healthcare. Quality reporting organizations, such as The LeapFrog Group, evaluate and report U.S. hospital safety and quality performance. Patients want reassurance they’re receiving the best care for the lowest cost—publicly reported outcomes help.
#2: Integrated Care
The industry is also shifting toward integrated care—we aren’t just treating a hip anymore; we’re treating the whole person. A key component of integrated care is helping patients with transitions; easing patient transitions from the ER, to surgery, to inpatient care, to rehab, and, ultimately, back to a steady, normal state. Transitional points of care are critical for managing consistency of care and providing the right care in the right setting at the lowest cost.
Sharing data between departments within an integrated system is another important component. Outcomes measurement and improvement depends on the system’s ability to share data across clinicians, labs, hospitals, pharmacies, and other staff, departments, and settings. EDWs improve interoperability by integrating data and providing a single source of truth.
Improving critical care transitions through integrated care and seamlessly exchanging data through interoperability are essential ingredients for better outcomes measurement. For example, as heart failure patients are discharged (depending on the risk stratification), it’s critical for them to see a cardiologist or primary care physician as quickly as possible. Otherwise, they are discharged and have a higher risk of being readmitted.
The Triple Aim: The Ultimate Goal of Outcomes Measurement
Outcomes measurement should always tie back to the Triple Aim (improve the patient experience, improve the health of populations, and reduce costs) so we’re not just reporting numbers. The focus should be on quality and improving the care experience at the lowest cost. We don’t want to become so obsessed with numbers that we forget our Triple Aim goal.
We measure outcomes to ensure we’re delivering the best care. Making sure patients receive the best care at the right time at the lowest cost so we can get them back to a steady, normal state—that is outcomes nirvana.
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