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A Word From the President: Measuring This, Measuring That: Measuring What Is Important

AAMC Reporter: March 2014

Recently, I participated on a panel to discuss the parameters of a federal government proposal to create and implement a system to rank colleges and universities. We discussed key foundational topics, including how such a system should be constructed and which benchmarks should be included. While the participants had many questions, it all boiled down to the need to craft a system that really gives students and parents the information they require to make informed decisions when choosing a school.

The experience reminded me of where we were nearly a decade ago when the federal government applied a similar system to the health care sector to launch Hospital Compare in 2005. Along with existing gauges in the private sector, such as the U.S. News & World Report’s Best Hospitals ranking and Healthgrades, these measurement systems seek to evaluate health care providers and provide information to help people choose hospitals.

Prior to my tenure at the AAMC, I served as an academic health system leader at a time when demands for accountability were growing in health care. Qualitative measures to meet that demand grew as well. As a result, chief quality officers, once uncommon, are today regular members of a hospital’s team. You can find them with capable staff members gathering data and quality measures, and using the data to achieve meaningful improvements in care. In recent years, the number of organizations issuing and posting reports on hospital and physician quality performance only has increased, with the unfortunate result that these reports sometimes present conflicting conclusions.

Interest in hospital quality measures is entirely understandable. The federal government invests a significant portion of its budget in health care. Policymakers—rightly in my view—want to measure the value of that investment. And the public’s interest in these measures is understandable, too. Patients—and their families—want to know they and their loved ones are receiving the best care possible. Indeed, we all want to empower ourselves by seeking reliable information.

Physicians and members of the hospital community support the principles of accountability. After all, we rely on data and quality measures each day. Every good administrator or physician knows that you cannot manage and improve what you cannot measure. Using proper measures are a core part of delivering the best health care to the communities we serve.

Quality measures and systems that evaluate the performance of health care providers should give people clear information to make informed health decisions. Unfortunately, the measures intended to be a road map for people seeking information can sometimes lead to a dead end. Consider, for example, the 30-day readmission rate. Conventional wisdom says that if a patient is discharged from a hospital, that hospital should have delivered care sufficient for that individual to stay well for at least 30 days.

While that standard may seem reasonable at first blush, it is not necessarily true. In fact, the research suggests that readmission rates often are driven by socioeconomic factors. This means hospitals that disproportionately care for our poorest and sickest patients will have worse readmission rates, even if there is no difference in the care itself. Using the readmission measure as a factor in the quality of care may not be a reliable benchmark to measure how well hospitals are providing care.

These are the types of unintended consequences that we must guard against. Improper measures can obscure the important work that health providers do in providing quality patient care. Given how easily data can be misconstrued, how best can we weigh the differing sets of performance data that could mislead even those who consider themselves to be well-informed?

With this question in mind, the AAMC recently convened an advisory panel of experts to craft The Guiding Principles for Public Reporting of Provider Performance to help sort the facts. Developed in conjunction with the University HealthSystem Consortium (UHC) and endorsed by five leading hospital associations, the principles serve as a tool for teaching hospital executives and their staff to evaluate and respond to reports that attempt to evaluate the performance of health care providers on quality metrics. According to the guiding principles (available online at www.aamc.org/publicreporting), performance data reports should be driven by three principles: purpose, transparency, and validity.

First, what is the report’s purpose? Its target audience and intended purpose should be stated clearly, and the measures and data display should fit that purpose. Second, the report’s methodology should be transparent. All the information necessary to understand the data should be available to the reader. In addition, the results should be able to be replicated, and limitations in data collection, methodology, and financial interests should be disclosed. Finally, is the report valid? The data collection, scoring, and benchmarking should produce an accurate reflection of what is being measured. Taken together, these guiding principles can help teaching hospitals and others to appropriately evaluate quality performance data.

So where do we end up? Quality rankings—although often devised with the best of intentions—may not reflect the actual hospital performance or physician quality, potentially causing more problems than they solve. But we can be aware of that fact and take great care to adhere to the principles of clearly stated purpose, transparent methodology, and demonstrable validity in each measure that matters to patients. In this way, we can ensure the use of meaningful measures for both those delivering care and those receiving care.

Darrell G. Kirch, M.D., AAMC President and CEO