Tag Archives: management

Pay-for-Performance

Challenges in Developing  Standards

The U.S. health care industry is contemplating the implementation of pay-for-performance reimbursement schemes in order to increase quality and safety in the delivery of health care. Pay-for-performance is a business model that combines reduced compensation for those who fail to meet standards and bonus payments for those that meet or exceed the stated expectations, but the results of such programs, thus far, is mixed (Baker, 2003; Campbell, Reeves, Kontopantelis, Sibbald, & Roland, 2009; Lee & Ferris, 2009; Young et al., 2005). The introduction of pay-for-performance models is primarily to provide relief from other, more extreme, reimbursement models, such as fee-for-service (which rewards overuse) and capitation (which rewards underuse), and with rising health care costs, a diminishing economy, and the increasing number of Americans lacking adequate health insurance, its introduction to the U.S. health care system could not be more timelier (Lee & Ferris, 2009).

The impetus of contemporary pay-for-performance schemes is derived from a report from the Institute of Medicine (2001). This report argued that current reimbursement schemes fail to reward quality in health care and may possibly create a barrier to innovation (Baker, 2003; Young et al., 2005). There are many international supporters of health care pay-for-performance, especially in England where the National Health Service employs pay-for-performance to keep costs under control while attempting to provide for quality and safety in the delivery of primary health care (Baker, 2003; Campbell et al., 2009; Young et al., 2005). However, the adoption of pay-for-performance seems to face many challenges.

One challenge to pay-for-performance implementation concerns the effectiveness in the overall continuity of care. Campbell et al. (2009) conducted an analysis of the effect of pay-for-performance in England and found that, although implementation of pay-for-performance in 2004 resulted in short-term gains in the quality of care, the improvements receded to pre-2004 levels. Beyond the pay-for-performance standards, though, the quality of care in areas not associated with incentives declined. Cameron (2011) reports on a recent study of the effectiveness of pay-for-performance on hypertension – the study shows no improvement in any measure including the incidence of stroke, heart attack, renal failure, heart failure, or combined mortality among the group (Lee & Ferris, 2009). McDonald and Roland (2009) describe these effects on other aspects of care as unintended consequences detrimental to health care quality and safety as a whole.

Another significant challenge to pay-for-performance implementation is ensuring that certain patient populations continue to be able to access appropriate care (McDonald & Roland, 2009). Under some pay-for-performance schemes, practices with a sicker patient demographic (i.e. geriatrics, oncology, neonatology, etc.) will suffer economically despite providing a higher level of care than their counterparts in family medicine or other more generalized practices. Specific concerns address a physicians ability to choose not to treat patients due to their non-compliance with medical orders (McDonald & Roland, 2009). Equity and access cannot suffer under a just reimbursement model, just as physicians with a sicker demographic should not suffer.

Identifying a reliable standard of measure in health care quality proves difficult. Earlier methods, such as those developed by Campbell, Braspenning, Hutchinson, and Marshall (2002), initially appeared sound, but ineffective methods and unintended consequences were soon identified (Cameron, 2011; Lee & Ferris, 2009; McDonald & Roland, 2009). More recent work by Steyerberg et al. (2010) shows that new approaches are on the horizon and that pay-for-performance may still remain a viable scheme, providing the measures and standards are, in fact, legitimate and accurately identify improved quality without detracting from other aspects of heath care. Steyerberg et al. identifies novel approaches to prediction models that may help to standardize measures in pay-for-performance schemes to be more realistic and reliable without causing many of the unintended consequences of earlier plans.

As we become more technologically advanced and find ways, albeit expensive, to cure and treat diseases that until now were intractable, we must address the ethics surrounding the provision of this care as a system of management. By combining the whole of health care into the ethics discussion, we opt to leave no one wanting for care, but we now have to address the problem of paying for the expensive care that we have all but demanded. Pay-for-performance, though not perfect, shows much promise in keeping health care costs manageable. However, we must strive to identify those patients and practitioners that lose out under this system of reimbursement and strive to identify just and ethical means of repairing the scheme. Though, we should first answer the question: is health care a right or a privilege?

References

Baker, G. (2003). Pay for performance incentive programs in healthcare: market dynamics and business process. Retrieved from http://www.leapfroggroup.org/media/file/Leapfrog-Pay_for_Performance_Briefing.pdf

Cameron, D. (2011, January 27). Pay-for-Performance does not improve patient health. Harvard Medical School News. Retrieved from http://hms.harvard.edu/public/news/2011/ 012611_serumaga_soumerai/index.html

Campbell, S. M., Braspenning, J., Hutchinson, A., & Marshall, M. (2002). Research methods used in developing and applying quality indicators in primary care. Quality and Safety in Health Care, 11(4), 358–364. doi:10.1136/qhc.11.4.358

Campbell, S. M., Reeves, D., Kontopantelis, E., Sibbald, B., & Roland, M. (2009). Effects of pay for performance on the quality of primary care in England. New England Journal of Medicine, 361(4), 368-378. doi:10.1056/NEJMsa0807651

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Retrieved from http://www.iom.edu/reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx

Lee, T. H. & Ferris, T. G. (2009). Pay for performance: a work in progress. Circulation, 119(23), 2965-2966. doi:10.1161/CIRCULATIONAHA.109.869958

McDonald, R. & Roland, M. (2009). Pay for performance in primary care in England and California: comparison of unintended consequences. Annals of Family Medicine, 7(2), 121–127. doi:10.1370/afm.946

Steyerberg, E. W., Vickers, A. J., Cook, N. R., Gerds, T., Gonen, M., Obuchowski, N., … Kattane, M. W. (2010). Assessing the performance of prediction models: A framework for traditional and novel measures. Epidemiology, 21(1), 128–138. doi:10.1097/EDE.0b013e3181c30fb2

Young, G. J., White, B., Burgess, J. F., Berlowitz, D., Meterko, M., Guldin, M. R., & Bokhour, B. G. (2005). Conceptual issues in the design and implementation of pay-for-quality programs. American Journal of Medical Quality, 20(3), 144-50. doi:10.1177/1062860605275222

Challenges Developing Measurement Tools

Common sense would dictate that a person should want to purchase quality when choosing any product or service, and as health care costs soar in the United States, we also want to ensure that we, as consumers of health care and taxpayers who subsidize health care, are reaping maximum quality for that cost (Buck, Godfrey, & Morgan, 1996). According to McGlynn (1997), the costs for health care in the U.S. have been rising dramatically causing disruption in the manner of which professionals provide care and patients seek it out. It is important to realize the impact that these increasing costs and other changes have on the delivery of care, and, as McGlynn points out, assessment of quality measures are the means of evaluation. Unfortunately, McGlynn and others at the time have found quality measures to be lacking the requisite data needed to make an accurate evaluation of the delivery of health care (Brook, McGlynn, & Shekelle, 2000; Grimshaw & Russell, 1993; McGlynn, 1997).

Over the past decade, many efforts have been made to develop quality measures in order to direct quality improvement; however, these efforts, though effective, have been disjointed and ad hoc at best. McGlynn and Asch (1998) cautions that careful attention to methodology is essential when developing these measures. Accurate methodologies can be reproduced and used to effectively compare efforts between institutions. This leads to a best practices continuum of health care provision.

Recently, researchers have studied teamwork behaviors and their influence on patient and staff-related outcomes, but many of the discussions were institution-centric and may not have applied in the macro environment of U.S. health care. Reader, Flin, Mearns, and Cuthbertson (2009) recently attempted to organize these studies and develop a portable and robust framework which would lead to the development of effective team performance and provide means of further testing and improvement of team dynamics. Their findings suggest that effective teamwork is crucial to providing patient care in critical settings. Reader et al. shows one of the shortcomings of recent quality measure development but also illustrates a manner in which to overcome the limitations.

Developing methods for measuring and evaluating performance in health care have been challenging, overall. Campbell, Braspenning, Hutchinson, and Marshall (2002) identify three component issues to addressing these challenges: “(1) which stakeholder perspective(s) are the indicators intended to reflect; (2) what aspects of health care are being measured; and (3) what evidence is available?” (p. 358). This addresses the qualitative concerns of capturing indicators, while efforts like those of Steyerberg et al. (2010) concern themselves with quantitative abstraction and portability, as well as predictive value. Steyerberg et al. promotes the use of reclassification, discrimination, and calibration when using statistical models to develop valid prediction models and novel performance measures.

Performance indicators that are an accurate reflection of health care provision can lead to development of best practices, lower overall health care costs, and improve the delivery of care which will decrease mortality and morbidity. When considering these performance indicators, especially during development, researchers and administrators need to ensure the validity of the measurements. Approaches to developing quality improvement measures are constantly evolving, and new and novel methods are being designed to standardize the instruments, the application, and the reporting. Quality improvement is still, however, a challenge to many health care providers.

References

Brook, R. H., McGlynn, E. A., & Shekelle, P. G. (2000). Defining and measuring quality of care: a perspective from US researchers. International Journal of Quality in Health Care, 12(4), 281–95. doi:10.1093/intqhc/12.4.281

Buck, D., Godfrey, C., & Morgan, A. (1996). Performance indicators and health promotion targets (Discussion paper No. 150). York, UK: Centre for Health Economics, University of York. Retrieved from http://www.york.ac.uk/che/pdf/DP150.pdf

Campbell, S. M., Braspenning, J., Hutchinson, A., & Marshall, M. (2002). Research methods used in developing and applying quality indicators in primary care. Quality and Safety in Health Care, 11(4), 358–364. doi:10.1136/qhc.11.4.358

Grimshaw, J. M. & Russell, I. T. (1993). Effect of clinical guidelines on medical practice: A systematic review of rigorous evaluations. Lancet, 342(8883), 1317-1322. doi:10.1016/0140-6736(93)92244-N

McGlynn, E. A. (1997). Six challenges in measuring the quality of health care.Health Affairs, 16(3), 7-21. doi:10.1377/hlthaff.16.3.7

McGlynn, E. A. & Asch, S. M. (1998). Developing a clinical performance measure. American Journal of Preventive Medicine, 14(3), Supp. 1, 14–21. doi:10.1016/S0749-3797(97)00032-9

Reader, T. W., Flin, R., Mearns, K., & Cuthbertson, B. H. (2009). Developing a team performance framework for the intensive care unit. Critical Care Medicine, 37(5), 1787-1793. doi:10.1097/CCM.0b013e31819f0451

Steyerberg, E. W., Vickers, A. J., Cook, N. R., Gerds, T., Gonen, M., Obuchowski, N., … Kattane, M. W. (2010). Assessing the performance of prediction models: A framework for traditional and novel measures. Epidemiology, 21(1), 128–138. doi:10.1097/EDE.0b013e3181c30fb2

Quality and Safety Measurement

In regards to the incident surrounding the death of Josie King (Josie King Foundation, 2002), there have been many great improvements in the delivery of care at Johns Hopkins (Niedowski, 2003; Zimmerman, 2004). Those aside, and if I was faced with having to develop performance measures of quality and safety in the context of such a tragedy, I would strive to ensure that my measures were accurate and valid to identify areas of grave concern where Johns Hopkins would do good to improve.

First, I would consider measuring the structure of the care delivered. In Josie’s case, a medical response team responded when it was identified that she was in the midst of a medical crisis. The first measurement would serve to identify the availability of such teams and the adequacy of the team’s staffing. The measure would indicate the response time of the team and the licensing and certification level of each team member.

Second, I would consider measuring processes that might have contributed to the death of Josie King. In this instance, Josie was administered a narcotic while suffering acute dehydration. The administration of this medication was contrary to the physician’s orders regarding pain medication for this patient. This measure would indicate the appropriate use of narcotic analgesia in patients faced with contraindications, such as acute dehydration or shock. This measure would be a cross tabulation of recent vital signs and laboratory results.

Third, I would consider measuring outcomes. In cases where pediatric patients are downgraded from the pediatric intensive care unit (PICU) to a general ward, any adverse condition should prompt an upgrade back to the PICU. This measure would identify the number of cases in each reporting period that any recently downgraded patient was upgraded back to the PICU. This measure should account for the time between a crisis and upgrade along with a statement indicating the cause of the crisis and resultant upgrade. This measure should be augmented by a mortality and morbidity subset involving any patients who were downgraded from PICU.

My considerations for these processes are to determine if general ward nurses should be administering any medications on standing order or if there should be a requirement to ensure that any medication administered to a general ward patient is explicitly written in the patient’s chart at the time of administration. Also, nurses should be acutely aware of the contraindications of any medications that they are administering. The process measure will, hopefully, identify misuse of narcotic analgesia and any failure to assess the patient for other possible causes of distress before assuming the distress is in response to pain. Ultimately, a more timely and efficient use of medical response teams should result, which would avail physicians and more experienced nurses to the original patient care team. This should lead to an open discussion of how to better manage the patient post crisis. Also, a greater understanding of medication administration concepts should result, benefiting all patients.

References

Josie King Foundation. (2002). About: What happened. Retrieved from http://www.josieking.org/page.cfm?pageID=10

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from http://teacherweb.com/NY/StBarnabas/Quality/JohnsHopkinsErrors.pdf

Zimmerman, R. (2004, May 18). Doctors’ new tool to fight lawsuits: Saying ‘I’m sorry’. Wall Street Journal, pp. A1. Retrieved from http://www.theoma.org/files/wsj%20-%20medical%20error%20-%2005-18-2004.pdf

The Patient Perspective: Patient Safety

The Speak Up materials provided by The Joint Commission (2011a, 2011b) do a great service in succinctly illustrating the need to be educated about health care issues. Patients and their families have a unique perspective to understanding their (or, their family member’s) health (Vincent & Coulter, 2002). Although physicians, nurses, and allied health providers are responsible for providing quality care, it remains the domain of the patient to express uncertainty or provide additional information to guide the provider. Ultimately, the patient or surrogate decision-maker must provide consent for treatment and must do so with full understanding. There are times, however, that the scope of treatment is so drastic, emergent, or specialized that the patient may not have the facilities to gain a full understanding of care needing to be rendered (Vincent & Coulter, 2002). This is the exception.

In the case of Josie King (Josie King Foundation, 2002; Niedowski, 2003; Zimmerman, 2004), which I elaborated on last week, Sorrel King, Josie’s mother, was educated about her daughter’s condition and spoke up as The Joint Commission recommends. Unfortunately, this case turned into tragedy not because Sorrel King did wrong but because the nurse disregarded her apprehension. This was tantamount to malpractice and no patient or family member could have prevented this, save for using force to physically prevent the administration of medicine. According to MacDonald (2009), there are nurses that believe “[patients] have no say and that medications are the domain of doctors, leaving the nurse and the patient to trust that the doctors would do the right thing” (p. 29).

Perhaps things were slightly different, however. As MacDonald (2009) explains, patient’s who are knowledgeable of their illness and take an active role in their health care decisions add another layer of safety, especially when considering medication action, reaction, and interaction. Medication prescription errors are numerous within health care, and as in the case of Josie King, improved communication between the physicians, nurses, and Sorrel King might have prevented Josie from being administered the narcotic and instead receiving the fluid she so desparately needed (Vincent & Coulter, 2002).

Health care should be patient-centric as it remains the responsibility of the patient to be educated about the care they receive and to provide consent for that care and treatment to be rendered. An uneducated patient does add risk, but sometimes this is unavoidable. It is in these instances that special care should be taken until a full medical history can be attained.

References

The Joint Commission. (2011a, March 7). Speak up: Prevent errors in your care [Video podcast]. Retrieved from http://www.jointcommission.org/multimedia/speak-up-prevent-errors-in-your-care-/

The Joint Commission. (2011b, April 5). Speak up: Prevent the spread of infection [Video podcast]. Retrieved from http://www.jointcommission.org/multimedia/speak-up–prevent-the-spread-of-infection/

Josie King Foundation. (2002). About: What happened. Retrieved from http://www.josieking.org/page.cfm?pageID=10

Macdonald, M. (2009). Pilot study: The role of the hospitalized patient in medication administration safety. Patient Safety & Quality Healthcare, 6(3), 28-31. Retrieved from http://www.psqh.com/

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from http://teacherweb.com/NY/StBarnabas/Quality/JohnsHopkinsErrors.pdf

Vincent, C. A. & Coulter, A. (2002). Patient safety: what about the patient? Quality & Safety in Health Care, 11(1), 76–80. doi:10.1136/qhc.11.1.76

Zimmerman, R. (2004, May 18). Doctors’ new tool to fight lawsuits: Saying ‘I’m sorry’. Wall Street Journal, pp. A1. Retrieved from http://www.theoma.org/files/wsj%20-%20medical%20error%20-%2005-18-2004.pdf

“Disaster Response and Management – IT” (DRAM-IT)

With the growing focus of disaster mitigation, response and recovery, companies that rely on information systems need to prevent and minimize the impact of disasters (whether natural or man-made) to their infrastructure. Society’s focus is to regain a sense of normalcy which requires a functioning economy, thereby increasing the need for companies to recover quickly.

By providing expert philosophies, procedures, systems and tools, DRAM-IT can ensure that the client will transition seamlessly from pre-disaster to post-disaster with no negative long-term effects.

We start with employee-focused health, safety and security. We believe that the employee is the first defense against failure. Employees should be healthy and not have their minds occupied by other domestic problems (e.g. family welfare) which is why in times of a disaster affecting the community, we contract with armed security agencies to provide force security for key employees and their families. This focus allows other employees to take care of their own before returning to work. The same security force will provide on-site perimeter security allowing employees to feel safe while aiding in recovery efforts. But, before the incident occurs, we will create processes to assist each employee in staying healthy and fit, both physically and mentally, including the creation of medical response teams to manage on-site medical emergencies until EMS can arrive.

Data loss can be immeasurable and therefore cannot be tolerated. After performing a forensic analysis of current IT practices, DRAM-IT will offer methods of securing data with redundant distributed arrays with cryptographic and hashing intelligence ensuring the data has not been and cannot be manipulated. Along with distributed storage, we can offer distributed processing to ensure the business keeps running without a need for direct input by employees.

During a disaster, the focus needs to be on initiating recovery processes and requires interfacing with local authorities to be part of the solution. We will provide the internal Incident Command structure which will integrate with the local, State, and Federal efforts to ensure pooling of resources. We are also committed to the community. The faster the individual entities of a community can recover, the faster the community as a whole can heal.

With DRAM-IT Systems Mitigation, Response and Recovery, we can ensure that you can concentrate on what is important… we’ll take care of the rest.

By providing an all-encompassing approach to disaster management, our clients can be assured of continuous critical systems processing, ensuring business continuity throughout the disaster.

Table Title: Examples of Structure and IT needs
Functional Area (See Figure 7.23) Supporting Information Systems (See Figure 1.6)
Example: Human Resource Management Example: Transaction Processing Systems
Command Executive Information Systems
Operations Decision Support & Strategic Info Systems
Tactical Knowledge Management & Expert Systems
Logistics Specialized / Transaction Control Systems
Finance Specialied / Transaction Control Systems

Subject: Investment Opportunity – “Disaster Response and Management – IT (DRAM-IT)” 02/25/14
To Whom it May Concern

I am writing you as an entrepreneur in support of the community. We have faced a number of disasters recently and our economy continuously suffers. I hope to provide a host of services to companies which are key to the community infrastructure. My goal is to be able to assist these key companies in recovering from the disaster internally and allowing the economy a maximized benefit in a minimal amount of time.

As a critical care paramedic who has worked with FEMA response teams in the past years, I have the experience and education to know what is crucially important during a disaster. As a computer programmer and IT professional, I know how to apply my knowledge to critical business systems ensuring a smooth transition during the various phases of a disaster, whether large or small, internal or external.

I wish to be able to provide mitigation training, on-site employee health programs, redundant communications, secure data storage and retrieval with distributive data processing, personal and protective security and adaptive processes and philosophies that can overcome even the most destructive of forces. We will initially be focused on consulting with the promotion of best-practices in mind. During the disaster phase, we will respond directly as Incident Command Teams that will be fully self-sufficient for over 72-hours to ensure the response and recovery are as smooth as possible.

The unfortunate reality is that this endeavor will require a large amount of start-up capital. We must first hire and train appropriate personnel who can then consult to client companies and ensure they can operate effectively during and after a disaster. We also need access to distributive networks with which to operate. These will undoubtedly be fee-based services, but initial investments of processor-time and storage would be invaluable. Investing in this opportunity is investing in the community.

Sincerely,

Michael Schadone