How hospitals measure up: focusing on ways to evaluate performance, hospitals are following the lead of managed care by issuing report cards - includes related article on national hospital standards

Focusing on ways to evaluate performance, hospitals are following the lead of managed care by issuing report cards.

The report card movement is spreading. Just as HMOs are facing pressure from consumers and employers to report on their efforts to measure and report on quality, hospitals, too, are feeling a need to demonstrate that they deliver quality care.

Also like the fledgling report card movement in managed care ("Are Health Plans Making the Grade?" June), the current efforts among hospitals are varied and widespread. The result is a patchwork quilt of attempts to account for quality.

"If we're all collecting data differently, we are creating a mishmash of incomparable data," says Gordon Smith, president of the Ozarks Area Business Group on Health, in Springfield, Mo. "What we really need are national definitions that allow us to say, 'This is the quality of care in the United States."' National report card standards for hospitals are still years away (see "The Movement Toward National Hospital Standards" page 24). Nonetheless, Smith and others who represent employers acknowledge that the current efforts are encouraging.

"Report cards will transform the health care market," says Patrick Casey, executive director of the Health Action Council of Northeast Ohio, an employer coalition in Solon. Employers and providers agree that public scrutiny of health care services is well deserved given unexplained variations in mortality and utilization rates at hospitals nationwide.

Inappropriate procedures, overuse of high-tech tests, needless cardiac surgery, hysterectomies, Cesarean sections, and longer than average lengths of stay are often cited as shortcomings of hospitals. Report cards that measure the frequency and quality of such procedures would enable payers and consumers to hold hospitals accountable for their results.

Thus, the report card movement is a dream come true for employers and employer coalitions. Indeed, some employers are collaborating with hospitals in efforts to publish report cards. Others are informing hospitals of the need for a national quality measurement system. And, state health departments, employers, and hospitals are working together to ensure that report cards deliver the information consumers and payers want when choosing a hospital or service.

But to date, the reports are few in number and unsophisticated.

SELF-REPORTING

Here are two examples: Mercy Hospital Medical Center in Des Moines, Iowa, and Methodist Hospital of Indiana Inc., in Indianapolis. In publishing their first report cards themselves, these hospitals are engaged in "self-reporting." They are grading their own facilities based on the competency of their physicians, and they are measuring consumer satisfaction.

Traditionally, such reports have been the staff of confidential internal reviews because hospitals have been sensitive about reporting their findings publicly, says Betsy Lee, director of quality and utilization management, at the 1,120-bed Methodist Hospital. "Report cards are a complete culture shock," she says. "It's going to be a difficult transition for some hospitals. Until now, quality assurance, which is what this is about, has been hidden behind a veil of peer review and avoidance of malpractice suits. But that's all changing."

In February, Mercy Hospital Medical Center, a 555-bed, acute-care facility, published an eight-page report card that has generated much interest from hospitals nationwide, says Scott Harrison, Mercy's corporate vice president.

The report compares Mercy's charges, lengths of stay, results of treatment, and patient satisfaction with those data for other area hospitals. Because Iowa requires all hospitals with more than 100 beds to use Medisgroups, a quality measurement system developed by MediQual Systems Inc., in Marlboro, Mass., the data were already available from the Iowa Hospital Association.

Mercy is establishing a physician hospital organization and plans to use report cards to generate business. "We know that anyone thinking of buying health care services will need the information we've put into our report card," Harrison says.

In Indianapolis, Methodist Hospital has spent three years developing 20 quality measures. In January, Methodist drafted a report using 1992 data and then asked area employers for their views about the utility of the information. Encouraged by their response, Methodist published the report and mailed copies to consumers and health care buyers. But Lee cautions, "We're not calling it a report card. People's expectations are automatically heightened if you call it a report card." Officials at other hospitals offered similar complaints, saying the term oversimplifies their efforts to measure quality.

"Right now it's not severity adjusted or comparative but it is a step in the right direction," Lee comments on Methodist's efforts. The hospital's quality measures include clinical outcomes for coronary angiography, C-section rates, cataract surgery, and hospital system efficiency measures, such as how soon patients with severe head injuries get a CAT scan. Length of stay and patient satisfaction also are included.

Many Indianapolis employers agree that the report card is useful. Among the 70 employers surveyed by Methodist, 70% said the quality measures and the report card in general were either very helpful or somewhat helpful when making health care quality and purchasing decisions. All of the responding employers said they would be interested in seeing further reports, Lee says.

STATE INITIATIVES

Prompted by legislation requiring hospitals to use specific performance measuring systems, some state health departments are collaborating with hospitals to publish consumer reports and buyers' guides.

These reports are enabling consumers and employers in New York, Pennsylvania, and Missouri, for example, to make statewide comparisons of specific hospital services. The most well-known examples of such efforts are the reports published by the Pennsylvania Health Care Cost Containment Council. Based in Harrisburg, PHC4 is an independent state agency established at the urging of employers and providers in 1986 to address the cost and quality of Pennsylvania's health care system.

Today, PHC4 collects and publishes data on coronary artery bypass graft (CABG) surgery at 35 hospitals using Medisgroups to gather the data and adjust for the illness of patients. The reports list 176 cardiac surgeons and 35 hospitals in Pennsylvania that perform CABG surgery. Included in the report is information allowing consumers to compare each hospital's and surgeon's actual number of patient deaths to the expected number of deaths. The report also includes the average charges for CABG surgery at each hospital.

Consumers have quickly become avid readers of the reports and some are reading the information for assurance about the skills of their surgeons. Others want to know if they are using the best hospital. "We've had calls from people facing CABG surgery who wanted to check on a hospital and surgeons, even people who literally were going to be operated on the next day," says Joe Martin, a PHC4 spokesperson.

The Pennsylvania report cards also have been controversial. While most hospitals and surgeons see value in delivering such information to the public, some dispute their ratings. They also complain that the data are too old and do not accurately portray the quality of care currently provided.

In a similar effort, the New York State Department of Health began publishing reports about cardiac surgery for patients and consumers four years ago. Heart disease is the leading cause of death in New York state. The reports list all 31 hospitals and surgeons performing at least 200 operations in New York. They rank the surgeons and hospitals by the quality of care they deliver, such as survival rates after surgery. The ratings are based on risk-adjusted patient mortality statistics. Risk adjustment allows a fair comparison of hospitals and surgeons because it involves such factors as complications presented by each patient, says Peter Slokum, a health department spokesperson.

In its latest report, published in December, the department says its report cards are forcing hospitals to improve services. The statewide risk-adjusted mortality rate for cardiac surgery fell to 2.5% in 1992 from 3.5% in 1990. For 1992, however, the risk-adjusted mortality rates for hospitals ranged from 1.38% to 8.78%.

One hospital, the New York University Medical Center, was ranked well below the statewide average for 1992. Another hospital, St. Peter's Hospital, in Albany, was rated above the statewide average.

St. Peter's provides a good example of how hospitals that were once disappointed with their ratings are improving service. Long before their ratings were published in the report card, medical chiefs at St. Peter's consulted the data transmitted by the health department for them to verify.

Focusing on why the hospital's mortality rate was higher than average, they discovered problems in emergency cases. After reviewing emergency room procedures and comparing them with those of best practices elsewhere, St. Peter's instituted a policy allowing doctors and nurses to spend more time stabilizing patients before moving them to surgery. In December, the hospital said it admitted more patients in 1993 than it had in 1992, but not one emergency cardiac bypass surgery patient had died.

Like New York and Pennsylvania, Missouri is shaking up health care delivery with report cards. The Missouri Department of Health has published five consumer report cards about the quality of obstetrical services in five regions of the state. The report cards are based on quality indicators for average charges, newborn deaths, ultrasound rate, vaginal birth after C-section, very low birth weight, and patient satisfaction.

Five separate report cards are issued, one in each of five regions. These regional report cards give readers information about why charges vary among facilities and advice on how they can use the data. The department does not intend the reports to be used as a rating system but rather as a guide to obstetrical services. "Our hope is that this report gives credit to those facilities that successfully provide obstetrical care and encourages others to upgrade their programs," notes Barbara Hoskins, chief of the Bureau of Health Resources Statistics.

The guides were produced with information provided by the hospitals. Each hospital reviewed and corrected the data before the report was published, Hoskins says.

AN INDEPENDENT EFFORT

Apart from campaigns led by state health departments, other groups, such as businesses, hospitals, and physicians, are forging independent report card initiatives. Ohio is a prime example. Five years ago, employers, hospitals, and physicians in Cleveland formed a voluntary partnership to bring about health care reform using report cards.

Called Cleveland Health Quality Choice (CHQC), the group has developed and published objective measures of patient outcomes and satisfaction for 29 area hospitals. Two reports of comparative data are published annually. The reports measure the quality of medical, surgical, and intensive care outcomes, and patient satisfaction with 11 hospital services.

Clinical service quality is measured by death rate, length of stay, and complications. The outcomes are analyzed to see how patients at each hospital with the same condition fared after treatment. These outcomes are then compared with outcomes predicted by using a statistical model based on a sample of patients with similar conditions.

A separate quality measurement tool, called Cleveland Hospital Outcomes Indicators of Care Evaluation (CHOICE), developed by consultants for Cleveland hospitals, is used to predict surgery and general medicine outcomes. Data from hospital charts are analyzed using statistical models to see how each hospital actually performed compared with expected performance based on the severity of patients' illness.

To measure the quality of care provided to patients in intensive care, CHQC relies on a system called the Acute Physiology and Chronic Health Evaluation system (APACHE), developed by Apache Systems Inc., in Washington.

LOOKING FORWARD

Report cards will become increasingly important given pending health care reform and the growth of managed competition. Emboldened by their experience with managed care report cards, health care buyers and consumers are becoming more willing to ask questions about hospital procedures and performance.

Indeed, the report card movement itself will no doubt have a sentinel effect on health care in general. Once patients begin to see how hospitals and physicians compare with others in their community or nationally, many people believe educated consumers and purchasers will gravitate toward facilities that provide high quality care. Such market reform will encourage hospitals that and physicians who perform poorly to improve the quality of care they provide. They will be forced to do so if they want to compete for business and survive, says Casey of the Health Action Council of Northeast Ohio.

The Movement Toward National Hospital Standards

Hospitals will be unable to report quality data using sophisticated national standards for many years, but there are moves in that direction.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), in Oakbrook Terrace, Ill., accredits hospitals and health plans, and is working on a quality measurement system involving 204 hospitals. Called the Indicator Measurement System (IMSystem), it is intended to produce a yardstick for rating hospitals nationwide.

Designed to complement the standards on which JCAHO has based accreditation decisions traditionally, the IMSystem focuses on patient outcomes-the results of hospital care--and other direct measures of hospital performance, says JCAHO President Dennis O'Leary, M.D.

To qualify for accreditation, hospitals eventually will have to report data according to IMSystem specifications, which are now being developed and tested, O'Leary says. The information will be gathered quarterly and entered into a national data base, enabling each participating hospital to compare its performance with that of others, O'Leary says. Participation is voluntary, but JCAHO is hoping all 5,300 hospitals it currently accredits will participate. That means JCAHO will produce report cards ranking all 5,300 hospitals. The first report cards are scheduled for release in 1997, O'Leary says.

  What Hospital Report Cards May Tell You

Patient discharge rates
Number of discharges in total and by specialty
Prices
Highest and lowest average charge per discharge and per procedure
Severity of illness
Per patient upon admittance
Average length of stay
For patients under and over 65 years of age
Morbidity
Clinical outcomes one week after admission
Mortality
Actual versus expected number of deaths
Inpatient care
Surgical infection rate; unplanned readmission; unplanned return to
operating room; Cesarean-section rate
Outpatient care
Unplanned return to emergency room; patient waiting time in ER
of six hours or more; X-ray discrepancy; number of ambulatory
procedures canceled
Patient satisfaction
Percentage of patients who think overall service is very good,
good, average, or poor

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