What exactly do we mean by quality in health care, particularly in the ED? Louis Graff, MD, likes to talk about the triad of quality: clinical quality, financial quality, and service quality.
Service quality might be how quickly a patient is seen by a physician and how often information was given about care. Clinical quality might be reflected by how quickly the patient was taken to the cardiac catheterization lab or how reliable the ED was in giving antibiotics in less than four hours to a pneumonia patient. Financial quality would be shorter inpatient length of stay and costs for certain tracked and defined diagnoses. While the broad brushstrokes of what quality means have been accepted, details of what and how to measure quality are still a work in progress.
Currently the Centers for Medicare and Medicaid Services (CMS) are developing quality measures to be used in pay for performance. Thankfully, the Joint Commission and most other regulatory and quality organizations have agreed to mirror what CMS considers quality measures to limit the amount of data tracking required of hospitals. The process has been long and complex with numerous quality organizations and initiatives including the Physician Quality Reporting Initiative (PQRI) coming together with recommendations to CMS regarding ED performance measures. But an important point has been reached: The National Quality Forum has vetted all the recommendations made from various organizations, and has endorsed a set of 10 ED measures of performance and quality.
The need for such measures should be understood. Currently there are significant lapses and deficiencies in care rendered in the ED. Sentinel events (defined by the Joint Commission as an unexpected occurrence involving death or serious physical or psychological injury or the risk of it) and medical errors are overrepresented in the ED. There are astounding regional variations in utilization and a wholesale disconnect between performance and payment. Hospitals can actually receive higher payments for substandard care and complications. Then there is the issue of cost. At this rate and with current trending, the CMS budget in 2030 will consume an estimated 50 percent of the entire U.S. budget. The move to hold EDs accountable for the care given by crafting performance measures is reasonable in its inception.
Using data on morbidity, mortality, and disease impact, choosing clinical guidelines well supported in the literature, and selecting areas where a lack of adherence to accepted clinical guidelines was demonstrated, the Joint Commission developed measures for acute myocardial infarction, pneumonia, and congestive heart failure. Performance on these core measures (though voluntary) is becoming nearly uniform, and is reported for public access on the Hospital Compare web site. (http://www.hospitalcompare.hhs.gov) The table lists the current core measures tracked and reported by the ED.
Work already done by PQRI on clinical quality measures, along with input from the Leapfrog Group, the Hospital Quality Alliance, the American Medical Association, the Ambulatory Care Quality Alliance, and the National Committee for Quality Assurance was sent to the National Quality Forum, which acted as a clearinghouse for the recommendations, and a final version was created. Three measures on time from ED arrival to discharge or admission were submitted by CMS for endorsement, and it was expected that all would be endorsed by the National Quality Forum.
Next month: A bold list of performance measures from the National Quality Forum expected to be incorporated into the CMS pay-for-performance scheme. You may be surprised at what made it onto this greatest hit list.
AMI and Pneumonia (PN) NQF-Endorsed Measures for ED Patients
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