The healthcare industry is riddled with administrative and regulatory complexities that make it difficult for health systems to achieve the Triple–or better yet, the Quadruple–Aim of healthcare. The complexities found in outcomes improvement are particularly challenging, as health systems measure and report on hundreds of these outcomes annually. Health systems can manage these complexities by taking a closer look at outcome measures—understanding their definitions and nuances, reviewing real-world examples, and integrating three essentials for successful outcomes measurement.
The goal of measuring, reporting, and comparing healthcare outcomes is to achieve the Quadruple Aim 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.” The fourth aim may vary depending on the organization.
Healthcare organizations–motivated by the Quadruple Aim–measure outcomes for several reasons:
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.” While initial measures focused on inpatient care, they have since expanded to include most aspects of care delivery.
Outcome measures are primarily defined and prioritized by national organizations, including CMS, The Joint Commission, 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 healthcare outcomes and targets are defined at the national level, health systems might set more aggressive targets. Meeting and exceeding these national targets, benefits not only quality of care, but also healthcare organizations’ marketing and contracting efforts.
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 10 patients in one month and one patient falls, then their fall rate is high (10 percent).
The Joint Commission 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 the following strict requirements:
CMS uses outcome measures to calculate overall hospital quality. In a 2018 report, CMS explained how it arrived at its 2018 hospital star ratings. CMS grouped outcome measures into seven categories weighted by importance:
There are hundreds of outcome measures, ranging from changes in blood pressure in patients with hypertension to patient-reported outcome measures (PROMs). The seven groupings of outcome measures CMS uses to calculate hospital quality are some of the most common in healthcare:
Mortality is an essential population health outcome measure. For example, Piedmont Healthcare’s evidence-based care standardization for pneumonia patients, resulted in a 56.5 percent relative reduction in the pneumonia mortality rate.
Safety of care outcome measures pertain to medical mistakes. Skin breakdown and hospital-acquired infections (HAIs) are common safety of care outcome measures:
Readmission following hospitalization is a common outcome measure. Readmission is costly (and often preventable). In fact, researchers estimate that in one year, $25 to $45 billion is spent on avoidable complications and unnecessary hospital readmissions. After increasing efforts to reduce their hospital readmission rate, the University of Texas Medical Branch (UTMB) saw a 14.5 percent relative reduction in their 30-day all-cause readmission rate, resulting in $1.9 million in cost avoidance. UTMB reduced their hospital readmission rate by implementing several care coordination programs and leveraging their analytics platform and advanced analytics applications to improve the accuracy and timeliness of data for informing decision making and monitoring performance.
Patient-reported outcome measures (PROMs) fall within the patient experience outcome measure category. According to the Agency for Clinical Innovation (ACI), PROMs “assess the patient’s experience and perception of their healthcare. 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.
Patient experience may also be used as a balance metric for improvement work. For example, a care delivery process may decrease the LOS, which can be a positive outcome, but result in a decreased patient satisfaction score if patients instead feel they are being pushed out.
Effectiveness of care outcome measures evaluate two things:
Given the rapid changes that occur within healthcare, making sure best practice care guidelines are current is critical for achieving the best care outcomes. It’s important to track clinician compliance with 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.”
Timeliness of care outcome measures assess patient access to care. Overcrowding in the emergency department has been associated with increased inpatient mortality, increased length of stay, and increased costs for admitted patients.
A community hospital system implemented an improvement process to address overcrowding in its ED after determining that approximately 4,000 patients were leaving its ED each year without being seen. They leveraged their analytics platform to develop an ED analytics application that provided actionable, timely ED performance data to focus improvement efforts on four areas: staffing patterns, registration, triage assessment by the registered nurse, and early access to a qualified medical provider. They achieved significant performance improvements, including an 89 percent relative reduction in the rate of patients that left without being seen, with current performance at 0.4 percent.
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 Hospital’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 clinicians were ordering chest X-rays for 65 percent of their asthma patients—evidence-based practice calls for X-rays in only five percent of cases. Texas Children’s Hospital’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.
Achieving outcomes is important, but the process by which health systems 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 systems can improve healthcare outcomes by improving processes:
Among every health system’s goals is to improve patient outcomes. But outcomes improvement can’t happen without effective outcomes measurement. As health systems work diligently to achieve the Quadruple Aim, 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, an integrated care environment that treats the whole patient and improves critical care transitions, and interoperable systems that enable the seamless exchange of outcomes measurement data between clinicians, departments, and hospitals.
Healthcare is on a journey to outcomes transparency. Patients rely on outcomes data to make educated decisions about their healthcare. Quality reporting organizations, such as The LeapFrog Group, evaluate and report on U.S. hospital safety and quality performance. Patients want reassurance that they’re receiving the best care for the lowest cost. Publicly reported healthcare outcomes help do just that.
The industry is also shifting toward integrated care—hospitals aren’t just treating a hip anymore; they’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, clinics, 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 have a higher risk of being readmitted.
Outcomes measurement should always tie back to the Quadruple Aim, so healthcare organizations aren’t just reporting numbers. Health systems shouldn’t become so obsessed with numbers that they forget their Quadruple Aim goal. Instead, they should focus on quality and improving the care experience at the most efficient cost.
Health systems measure outcomes to ensure they are delivering the best care for patients and providing a transparent, efficient, and accessible environment for all healthcare providers. That is outcomes nirvana.