NCQA explores patients as valuable resource for information to add to their unworkable metric set

So the NCQA would like public comment on adding patient experience measures to its measure set.  This is a good thing and I'm glad they are doing it, but on the other hand this is adding more dials and metrics to a dashboard that is so broken as to be unusable.

Let's say we're all about gas mileage.  We know from studies that tire pressure effects mileage.  We know that tire temperature effects tire pressure.  We know oil viscosity, gas flow to the engine, spark delay, age of spark plug are all important factors in ultimate mileage.

Imagine a dashboard on your car with:

• Right front tire pressure
• Right front tire temperature
• Left front tire pressure
• Left front tire temperature
• and on
• and on
• and on

I can defend each and every one of these metrics, but the sum total has long ago past the point of absurdity.  We spend our time worrying the multiplicity of dials while we're driving the car off the road.

The approach to quality measurement has gone past the point of absurdity.  How about an approach that works for primary care.  Primary care is effective when it delivers care above a reasonable threshold on four key elements:

• Access - I can get care when and how I need it
• Relationship over time - I have a PCP who knows me as a person
• Comprehensive services - my PCP takes care of the bulk of my needs
• Coordination - my PCP coordinates any care I need in the health system

Patients who receive care in practices that deliver care at or above national benchmarks on these measures are:*

• Less likely to
• • End up in the hospital
  • End up in the emergency room
  • Miss days from school or work
• More likely to
• • have preventive care needs met
  • good control of their chronic conditions
  • say they understand their conditions and receive good help from their practice

I love that the NCQA is looking to recognize that patients know something about the care they receive but enough with the boatload of metrics.  Enough with the myth that solo and small practices can't or won't participate in quality.  In the Ideal Medical Practices project we demonstrated that solo and small independent practices can and will stand up for quality and demonstrate terrific results when given an approach that makes sense.

Let us get the car back on the road and steer it straight.  Let's start with a focus on our practices as effective systems of care delivery.  High performing systems have as their foundation effective primary care, effective primary care is defined by threshold improvement on these key metrics.  This can be achieved with a handful of metrics addressing the broad systems noted above.

Once our car is back on the road we can discuss refining other metrics and attend to the individually defensible but cumulatively absurd approach.

*Wasson, J. H., Johnson, D. J., Benjamin, R., Phillips, J., & MacKenzie, T. A. Patients report positive impacts of collaborative care. Journal of Ambulatory Care Management, July-September 2006 29(3), 199–206

Comments

[Donald T. Stewart, MD]

There is a literature on this, which has been alluded to in previous posts. I like your proposals for metrics more than I like NCQA's current metrics. But, I would suggest we build on what is known about patient experience and outcomes, rather than create something totally new.

[Joe Heinowski]

I also agree on the need for metrics. What do think of the idea of using the following four metrics, Efficacy, Efficiency, Loyalty and Environmental? To expand on the words - Does the service have impact? Is the service delivered in the proper time frame? Does it have meaning to the customers? Does the physical environment enhance the service? It has been my experience that these metrics have been looked at in isolation - or as separate silos based on areas of expertise. This begs the need for not only co-creation between care givers and patients but between key “designers” of an experience. By looking at these metrics in a “star plot” chart comparing current state and future state the “experience design team” could move towards the desired experience. Offering a better understanding of ROI for all involved. Any thoughts?

[Donald T. Stewart, MD]

"As you can see, my take is that it’s not about the metrics at this moment in time. It’s the need for a healthcare experience that is : direct, informed, actionable, collaborative, transparent, empathetic, designful, engaging."

I fully agree with your conception of how healthcare experience needs to change. But, how will we know we are making progress toward such a healthcare experience unless we have some way of measuring it?

[Joe Heinowski]

Number of successful heart surgeries vs Reduction of heart surgeries?

I would like to expand on Dr. Moore’s “patient experience” and back up a bit to find out what should be measured. We have to start with the transitions of our economy from commodities to goods to services to experiences as described in The Experience Economy (1999) by Joe Pine and Jim Gilmore. After their book it became apparent that many customers were not just looking for experiences but transformations in their lives. So as a patient and physician interact a co-created transformation is taking place. I would emphasize that co-creation is required for maximum value creation, based on the idea that co-ownership supports sustained transformation (not just an experience)

IDEO’s Tim Brown’s recent book Change by Design picks up were The Experience Economy left off. Moving beyond market understanding to models for innovation in response to the market based on design thinking. The book’s paradigm shift for healthcare is that caregiver’s will need to learn the principles of design thinking and apply them themselves. Bridging the chasm between thinking and doing.

As you can see, my take is that it’s not about the metrics at this moment in time. It’s the need for a healthcare experience that is : direct, informed, actionable, collaborative, transparent, empathetic, designful, engaging.

I hope this sparks some ideas - no pun intended as related to Mayo clinic’s design thinking SPARC program.

[Donald T. Stewart, MD]

I posted a link to this survey on the Ideal Medical Practices listserv this morning, and asked the group to comment on it. Here are the comments of some excellent doctors who have supurb quality measures in their micropractices:

JA, from Maine: "...in typical NCQA fashion this survey asks one to put, from a limited list, the five items one thinks of as the highest priority and the 5 of the lowest. NONE were low priority but you HAD to put 5 in DUMB DUMB:)"

LH, from Rhode Island: " so if you distill this list this is what you get:

1,2,3 are access
4 efficiency
5,6 information
7, 9, 10 are patient centeredness (paternalism vs collaborative approach)
8 continuity
11 problem solving
12 a weird turned around view of confidence (the writer of this survey thinks/wants to know if it's important for the doctor to have confidence in the patient's ability?! yeah this one is way off, I don't think they get it)
13, 15, 17, 18 office process related
14 coordination of care
16 just wrong this is for kaiser/mayo models but this is not primary care, this is health care delivery system stuff
19 important but not applicable to me = ?rate the staff type question

So, are they asking which ones they should be evaluating to judge a practice to be a 'patient centered medical home?'

Are they asking which of these they can ditch in evaluating a 'patient centered medical home?'

. . .

Most of this stuff comes right off the HYH survey, except 7,9,10 sound like CAPHS survey questions
Funny how HYH doesn't really have spots for 7,9,10. hmm wonder if it is at all correlated to outcomes such as chronic care ER visits or hospitalizations. Need to ask Wasson about that.

The format that NCQA is using to take public comment is as Jean says, restrictive and not helpful - 5 goods and 5 bads
yeah really dumb
Should we - as an organization? - tell them that ? maybe they will modify the format before they get a lot of useless stuff dribbling in?"

My response was: "I agree completely with your assessment. My impression is that they don’t really understand what patient-centeredness is, so they are fumbling around trying to find a way to make their large-organization-centric, protocol-and-administrative-policy-driven, disease-and-process-focused, medical hotel model appear to have some qualities of patient centeredness, probably to appease the critics who point out that what they offer provides very little value to the majority of patients or physicians.

I hope you (and JA) put your comments in the comments section.

If they respected us as an organization, they wouldn’t have designed their model the way they did. They as an organization make their money by dealing with 'politically correct' useless stuff, so I don’t see why they would want to make their PCMH model or recognition process any more useful than the rest of the stuff they do. If they simplified it, anyone could do it and they couldn’t charge for it.

Am I cynical today, or what?"

LH's response: "JA you are right I think we are back to DEVO
WHO are these people?
Don I am right there with you, cynicism is probably too nice a term for where I am.
Yah, crabby and cynical is moving in the right direction.

why should we even care what they do, they are so out of touch....
WHY would NCQA ask the PUBLIC for comment on this, unless the Journal of Ambulatory Care Management is being broadcast onto FOX "NEWS", people will have no clue what they are asking or why. Is this just an organizational PR move so that they can say, 'we asked and this is what they the people wanted?'

And why don't they KNOW that the conclusion is already out there, if you JUST read John Wasson's papers. So WHY are they even asking what is important? WHY DONT THEY JUST USE THE DATA it is already right there! Aren't they supposed to be a health care focused organization, maybe it is too much to ask that they read the current literature? 'F' for evidence based for them. RARGHH!!!!!

Unless they really would take the HYH survey results as an alternate cert path to the 'medical home' (Now I can't believe they would do anything as downright smart as that, why would they? It doesn't make them any money.)

Nope, it is looking hopeless.

Yes I did send in my comments. Probably useless. "

[L Gordon Moore]

Well, in this post I'm not talking about patient satisfaction but about how patient experience of care can be used as indicators of the office as an effective system of care delivery.
My comment about practice size was to counter the oft stated myth that solo small practices are incapable or lack interest in measuring reporting on quality. The problem is that most of the approaches held up as standards have unacceptable large practice bias.

To the question about how satisfaction varies by practice size I dimly recall a study by Dana Safran (Tufts) addressing this. I think this is the one, and the second Safran study helps differentiate patient satisfaction from patient experience measures.

Safran DG, Karp M, Koltin K, et al. Measuring
Patients’ Experiences with Individual Primary Care Physicians Results of a
Statewide Demonstration Project J GEN INTERN MED 2006; 21:13–21.

Safran DG. Defining the future of primary
care: what can we learn from patients? Ann Intern Med.
2003;138:248–55.Gordon

[Juliet Mavromatis]

Interesting. Certainly it is not patient-centered to ask patients to fill out countless surveys. I agree that fewer metrics are better. You highlight the important categories. However, it would be interesting to know if and how different medical home structures: small private offices versus large health care systems differ in terms of patient perception, and to compare patient satisfaction amongst medical home designees.