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Monday, May 11, 2015

So-called CQMs: They're "Process Indicators," not "Clinical Quality Measures"

Last week I attended an online webinar conducted by Dr. John Toussaint. The content went to material in his soon-forthcoming new book "Management on the Mend."

Five years after his debut book, On the Mend, showed how a large, cradle-to-grave health system revolutionized the way care is delivered, Dr. John Toussaint returns with news for healthcare leaders. There is a right way to go about such a transformation. And senior leaders need to be far more intimately involved.

While studying and assisting hundreds of organizations transitioning to lean healthcare, Dr. Toussaint witnessed many flaws and triumphs. Those organizations that win – creating better value for patients while removing waste and cost in the system – have senior managers that lead by example at the frontline of care. The best health systems have also discovered ways to engage everyone in solving problems and embracing change.

Management on the Mend is the result of years of investigations by Dr. Toussaint and dozens of healthcare organizations around the world. Using their collective experiences, he has built a model for lean transformations that work. This book describes the model, step by step, through people in 11 organizations who are doing the work. It is the story of many journeys and one conclusion: lean healthcare is not only possible, it is necessary.

As senior leaders look ahead to a future that includes radical changes in patient populations, the economics of healthcare, and patient expectations, everyone knows that health systems must be agile to survive. In order to thrive, they must be able to continuously improve. Here is the roadmap for that future.
During the post-presentation Q and A, someone asked about the much unloved CQM compliance. Dr. Toussaint responded by calling them what they really are -- "process indicators." e.g., what percentage of the time did a provider or clinical organization do x, y, or z. (A multitude of x's, y's, and z's actually.)

Whether doing so contributed to improved individual patient outcomes at the point of care or not.

The CMS web page spiel on CQMs:
Clinical Quality Measures Basics

Clinical quality measures, or CQMs, are tools that help measure and track the quality of health care services provided by eligible professionals, eligible hospitals and critical access hospitals (CAHs) within our health care system. These measures use data associated with providers’ ability to deliver high-quality care or relate to long term goals for quality health care. CQMs measure many aspects of patient care including:

  • health outcomes
  • clinical processes
  • patient safety
  • efficient use of health care resources
  • care coordination
  • patient engagements
  • population and public health
  • adherence to clinical guidelines
Measuring and reporting CQMs helps to ensure that our health care system is delivering effective, safe, efficient, patient-centered, equitable, and timely care.

To participate in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs and receive an incentive payment, providers are required to submit CQM data from certified EHR technology.

To participate in the Medicare and Medicaid EHR Incentive Programs and receive an incentive payment, providers are required to submit CQM data from certified EHR technology.
Gotta love how they position "health outcomes" at the top of their bullet list. In the actual current CQM tables documents for both EP's (Eligible Providers - pdf) and EH's (Eligible Hospitals - pdf), however, you only see these:
  • Patient and Family Engagement
  • Patient Safety
  • Care Coordination
  • Population/Public Health
  • Efficient Use of Healthcare Resources
  • Clinical/Process Effectiveness
    "Clinical/Process Effectiveness?"

    Like Dr. Toussaint said, they're "process indicators," and the "effectiveness" part goes mostly to "what % of the time did you do these?" "How 'effective' is your compliance?" Calling them "quality measures" is a stretch (as they pertain to individual health outcomes).

    Just like "interoperability" is a misnomer (my "interoperababble" rant). Just like "Meaningful Use" is a misnomer -- what we really need is 'Effective Use," from the POV of the patient.

    The obvious intent and big-picture expectation is that by doing x, y, and z (and the voluminous additional "a" through "v" of CQMs), aggregate/statistical patient outcomes will eventually improve.

    Critics of CQMs (including critics of those process indicator cousins in the equally unloved PQRS initiative) complain that these compliance measures are actually detrimental to individual patient care, given the additional workflow burdens they impose -- that the paltry "incentive" funds are a net loser. Time and money and staff are finite; resources spent obsessively fiddling with process indicators compliance are resources not accorded the patient on the exam table or in the acute care bed.

    I remain conflicted about these things. A lot of smart, experienced people had their learned and lengthy say in the promulgation of such initiatives. And, while I sometimes irascibly call things like CQMs and other compliance measures "Quadrant Three" activities ("urgent, but not important"), even that is simplistic. ("All models are wrong; some models are useful.") Urgency and importance are continuous-scale, dynamic, contextual phenomena (that pesky "variation" that dogs all QI efforts). Nonetheless, we must always ask "urgent for whom?" "important to whom?" "meaningful to whom?"

    Moreover, inexorably, "he who pays the piper calls the tune." You don't want to do this stuff? Go Direct-Pay / Concierge (not that doing so will totally absolve you of all regulatory compliance, all your griping about "autonomy" notwithstanding).

    Dr. Toussaint was unfazed by the webinar participant's question. Implicit in his response was more or less "All the more reason to go Lean. You'll free up time for process compliance measures that aren't going away anytime soon."

    I'm looking forward to getting and reading (and reporting on) the new book. I was all over his first book "On the Mend" five years ago on this blog in my second post.

    I've closely studied everything he's put out ever since. Enter "Toussaint" in the upper left search cell atop this blog. You'll be scrolling for quite some time.

    I'll be covering the 2015 Lean Healthcare Summit in Dallas in early June, where Dr. Toussaint will be keynoting.

    From last week's webinar deck.

    "Courage to speak the truth." "Lead with humility." Music to these ears. "Talking Stick," anyone? "Just Culture," anyone? See also, specifically "Physician, Health Thy System."

    And, "Doctors and nurses in the trenches." to wit:
    Their hard-won, sophisticated, indispensable clinical skills aside, nurses and physicians are just people like the rest of us, people more or less beset by all of the frailties, foibles, insecurities, and neuroses that typically dog us all across the breadth of our lives. The fractious, high-stakes, irreducibly high cognitive burden organizational environments within which they must function are neither of their design nor under their control, and can (and unhappily do) exacerbate interpersonal difficulties that are counterproductive to optimal patient care. I call the syndrome "psychosocial toxicity," and have blogged about it at some length in prior posts.

    It's hardly confined to healthcare, to be sure, but organizational cultural dysfunction in healthcare is ultimately a patient safety issue. To the extent that we continue to view clinical co-workers through "transactional/instrumental," "superior/subordinate" lenses, our improvement efforts will be significantly hampered.


    Started a new blog, wherein I've collated for convenience a bunch of disparate posts on a different topic. See "Western U.S. Drought." I'll be adding resource links as I have time.

    More to come...

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