BUSINESS ESSENTIALS CHERI L. CANON, MD, CYNTHIA S. SHERRY, MD
An Introduction to Basic Quality Metrics for Practicing Radiologists Jonathan B. Kruskal, MD, PhD, Ammar Sarwar, MD
INTRODUCTION The Patient Protection and Affordable Care Act of 2010 is transforming the delivery of health care in the United States from a volumebased, fee-for-service model to one that aims to reward the delivery of value-added care [1]. Currently, a majority of radiology practices use an array of process metrics to measure and manage their performance; however, soon they will need to embrace emerging, to-be-defined metrics that measure value and how radiologists contribute to health care costs and outcomes. In this brief review, we describe current and anticipated future metrics that will be used to manage radiologic services. WHAT IS QUALITY AND HOW IS IT MEASURED? A contemporary definition of quality in the emerging value paradigm is the extent to which the right study, done in the right way, at the right time, in the right location, on the right patient and the right anatomic location results in the correct interpretation and an accurate, actionable report to be communicated to the referring clinician, which is acted upon in a timely manner
330
resulting in appropriate care being delivered, or not delivered, to satisfied customers.
care outcomes or cost (ie, health care value).
Each of these steps should be measured, but without careful thought, the resulting data may become difficult to analyze, compare, and manage. If these quality metrics will be collected, the selected metrics should be SMART: specific, measurable, attainable, realistic, and timely [2].
WHAT ARE “VALUE-BASED” METRICS? To stay relevant in the new paradigm, radiologists must manage their role in health care using value-based metrics. The term value has been eagerly embraced in our specialty, yet little progress has been made to identify specific metrics that measure it [6,7]. Regulatory groups have filled this void, linking reimbursement to metrics; however, the impact of their proposed metrics in truly improving the quality of care has been questioned [8]. Therefore, radiologists need to be intimately involved in the process of creating new metrics. This requires a thoughtful approach, knowledge of our customers, and patient-centric thinking. Additionally, radiology metrics should go beyond internal process management, with a more global focus on population health. True value-based metrics are disease specific and measure how radiology affects the health status of each patient and his or her process of recovery after each episode of care and how it sustains the health of each patient after each episode of care.
WHAT ARE METRICS, AND WHICH ARE WE CURRENTLY USING? Metrics are indicators selected to manage performance in a practice [3]. Different imaging metrics are currently being used: a survey of metrics used by radiology practices identified customer satisfaction, access to imaging services, and turnaround time as major categories [4]. The ACR’s Intersociety Conference in 2006 proposed 46 metrics reflecting categories of access, appropriateness, regulatory requirements, patient safety, and physician performance [5]. However, a random selection of metrics will not drive an organization toward achieving its mission and will more likely confuse and overwhelm health care providers. The majority of metrics in current use measure the health care process, not health
ª 2015 Published by Elsevier on behalf of American College of Radiology 1546-1440/15/$36.00 n http://dx.doi.org/10.1016/j.jacr.2014.12.010
Health-status metrics indicate a patient’s survival or degree of health. From a radiologist’s perspective, survival metrics might be measured as mortality (eg, procedure-related mortality) or time spent in the imaging value chain (time from symptom onset to diagnosis of a life-threatening conditions: how did timely communication of an accurate report affect care in the trauma setting?). Degreeof-health metrics might include the extent of pain relief after an imageguided analgesic procedure or the ability to return to routine activities after a procedure. Process-of-recovery metrics are those that illustrate treatment dysfunction or time to recovery. Treatment dysfunction can be measured by readmission rates, additional management requirements (medications, blood products, nurse visits) or repeat imaging rates. Procedure complications, delays, and adverse events are all included in this category. The time-to-recovery metrics include access to our services, the many complex metrics buried within report turnaround time, and time for effective communication of critical results. One such metric, which is already closely monitored on a facility level, is length of stay (LOS). However, creating a radiologyspecific LOS measure would highlight our role in improving the time of inpatient recovery (how often did a radiologic study or procedure contribute to reducing LOS?). Other examples of value-based metrics in this category include cumulative costs of disposables, cost savings per episode of care, evidence-based blood product utilization, and the timing and appropriate use of prophylactic antibiotics. Health-sustainability metrics reflect the nature of recurrences and
any long-term consequences of care, including those resulting from errors of omission or commission. Helping identify early recurrences (oncologic imaging) and assisting in population health maintenance (screening mammography) are just two examples of how radiologists help sustain health between acute episodes of care.
biopsy, process metrics include the number of passes, room use time, needle size, and measuring compliance with the universal protocol. Outcomes metrics, on the other hand, include the complication rate, the percentage of diagnostic samples, and pain relief. From a cost perspective, metrics might include the impact on LOS and on selection of treatment or costs resulting from complications.
HOW ARE EPISODES OF CARE LINKED TO VALUE-BASED METRICS? An episode of care is the collection of all clinically related services that are provided to treat a discrete diagnostic condition in one patient from symptom onset until treatment is complete. Defining disease-specific episodes of care will help transform the process metrics of today to outcomes metrics in the future. In a patient with lower quadrant pain, process metrics such as access time and peer review data will transform to outcome metrics such as time to establish a treatable diagnosis or appropriateness of follow-up recommendations. In a patient with breast cancer, current metrics such as access time to screening, procedure outcomes, and customer satisfaction will likely transform to the percentage of patients diagnosed with resectable lesions and the percentage of patients requiring repeat biopsies because of inadequate sampling.
WHAT METRICS SHOULD WE USE? Much thought has gone into trying to define value-based metrics that we can all use to benchmark our performance, but more work remains to be done [9]. We will continue to use process metrics to measure, benchmark, and improve our technical, diagnostic, and procedural processes. Additionally, we will continue to use metrics recommended by regulatory agencies, but we need to expand these to measure and reflect the impact of our services on care delivery. No single category of metrics can be effective in isolation; using process and outcomes metrics in combination is important, and these must serve as targets for continuously improving service quality. New value-based metrics must measure and reflect how radiologists contribute to the overall care of each patient. This is our challenge and our opportunity.
WHAT ABOUT METRICS FOR PROCEDURES? Unlike traditional imaging metrics such as peer review of imaging discrepancies, emerging value metrics are easily translatable to imageguided procedures. For a liver
CONCLUSIONS Health care reform, enacted in response to the escalating costs of providing care, is now affecting how our performance as radiologists is managed and measured. We must strive to improve population health by
Journal of the American College of Radiology Kruskal, Sarwar n Business Essentials
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providing high-quality, outcomefocused, and cost-effective imaging; creating the right tools to measure our role will be critical for radiologists and our patients in the new paradigm.
REFERENCES 1. Rawson JV. Roots of health care reform. J Am Coll Radiol 2012;9:684-8. 2. Doran GT. There’s a S.M.A.R.T. way to write management’s goals and objectives. Manage Rev 1981;70:35-6.
3. Abujudeh HH, Kaewlai R, Asfaw BA, Thrall JH. Quality initiatives: key performance indicators for measuring and improving radiology department performance. Radiographics 2010;30:571-80. 4. Ondategui-Parra S, Bhagwat JG, Zou KH, et al. Use of productivity and financial indicators for monitoring performance in academic radiology departments: U.S. nationwide survey. Radiology 2005;236: 214-9. 5. Dunnick NR, Applegate KE, Arenson RL. Quality—a radiology imperative: report of the 2006 Intersociety Conference. J Am Coll Radiol 2007;4:156-61.
6. Lee CI, Enzmann DR. Measuring radiology’s value in time saved. J Am Coll Radiol 2012;9:713-7. 7. Heller RE. The total value equation: a suggested framework for understanding value creation in diagnostic radiology. J Am Coll Radiol 2014;11:24-9. 8. Federman AD, Keyhani S. Physicians’ participation in the Physicians’ Quality Reporting Initiative and their perceptions of its impact on quality of care. Health Policy 2011;102:229-34. 9. McGlynn EA, Schneider EC, Kerr EA. Reimagining quality measurement. N Engl J Med 2014;371:2150-3.
Jonathan B. Kruskal, MD, PhD, and Ammar Sarwar, MD, are from Beth Israel Deaconess Medical Center, Boston, Massachusetts. Jonathan B. Kruskal, MD, PhD: Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02115; e-mail: [email protected].
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Journal of the American College of Radiology Volume 12 n Number 4 n April 2015
An Introduction to Basic Quality Metrics for Practicing Radiologists Jonathan B. Kruskal, MD, PhD, Ammar Sarwar, MD
INTRODUCTION The Patient Protection and Affordable Care Act of 2010 is transforming the delivery of health care in the United States from a volumebased, fee-for-service model to one that aims to reward the delivery of value-added care [1]. Currently, a majority of radiology practices use an array of process metrics to measure and manage their performance; however, soon they will need to embrace emerging, to-be-defined metrics that measure value and how radiologists contribute to health care costs and outcomes. In this brief review, we describe current and anticipated future metrics that will be used to manage radiologic services. WHAT IS QUALITY AND HOW IS IT MEASURED? A contemporary definition of quality in the emerging value paradigm is the extent to which the right study, done in the right way, at the right time, in the right location, on the right patient and the right anatomic location results in the correct interpretation and an accurate, actionable report to be communicated to the referring clinician, which is acted upon in a timely manner
330
resulting in appropriate care being delivered, or not delivered, to satisfied customers.
care outcomes or cost (ie, health care value).
Each of these steps should be measured, but without careful thought, the resulting data may become difficult to analyze, compare, and manage. If these quality metrics will be collected, the selected metrics should be SMART: specific, measurable, attainable, realistic, and timely [2].
WHAT ARE “VALUE-BASED” METRICS? To stay relevant in the new paradigm, radiologists must manage their role in health care using value-based metrics. The term value has been eagerly embraced in our specialty, yet little progress has been made to identify specific metrics that measure it [6,7]. Regulatory groups have filled this void, linking reimbursement to metrics; however, the impact of their proposed metrics in truly improving the quality of care has been questioned [8]. Therefore, radiologists need to be intimately involved in the process of creating new metrics. This requires a thoughtful approach, knowledge of our customers, and patient-centric thinking. Additionally, radiology metrics should go beyond internal process management, with a more global focus on population health. True value-based metrics are disease specific and measure how radiology affects the health status of each patient and his or her process of recovery after each episode of care and how it sustains the health of each patient after each episode of care.
WHAT ARE METRICS, AND WHICH ARE WE CURRENTLY USING? Metrics are indicators selected to manage performance in a practice [3]. Different imaging metrics are currently being used: a survey of metrics used by radiology practices identified customer satisfaction, access to imaging services, and turnaround time as major categories [4]. The ACR’s Intersociety Conference in 2006 proposed 46 metrics reflecting categories of access, appropriateness, regulatory requirements, patient safety, and physician performance [5]. However, a random selection of metrics will not drive an organization toward achieving its mission and will more likely confuse and overwhelm health care providers. The majority of metrics in current use measure the health care process, not health
ª 2015 Published by Elsevier on behalf of American College of Radiology 1546-1440/15/$36.00 n http://dx.doi.org/10.1016/j.jacr.2014.12.010
Health-status metrics indicate a patient’s survival or degree of health. From a radiologist’s perspective, survival metrics might be measured as mortality (eg, procedure-related mortality) or time spent in the imaging value chain (time from symptom onset to diagnosis of a life-threatening conditions: how did timely communication of an accurate report affect care in the trauma setting?). Degreeof-health metrics might include the extent of pain relief after an imageguided analgesic procedure or the ability to return to routine activities after a procedure. Process-of-recovery metrics are those that illustrate treatment dysfunction or time to recovery. Treatment dysfunction can be measured by readmission rates, additional management requirements (medications, blood products, nurse visits) or repeat imaging rates. Procedure complications, delays, and adverse events are all included in this category. The time-to-recovery metrics include access to our services, the many complex metrics buried within report turnaround time, and time for effective communication of critical results. One such metric, which is already closely monitored on a facility level, is length of stay (LOS). However, creating a radiologyspecific LOS measure would highlight our role in improving the time of inpatient recovery (how often did a radiologic study or procedure contribute to reducing LOS?). Other examples of value-based metrics in this category include cumulative costs of disposables, cost savings per episode of care, evidence-based blood product utilization, and the timing and appropriate use of prophylactic antibiotics. Health-sustainability metrics reflect the nature of recurrences and
any long-term consequences of care, including those resulting from errors of omission or commission. Helping identify early recurrences (oncologic imaging) and assisting in population health maintenance (screening mammography) are just two examples of how radiologists help sustain health between acute episodes of care.
biopsy, process metrics include the number of passes, room use time, needle size, and measuring compliance with the universal protocol. Outcomes metrics, on the other hand, include the complication rate, the percentage of diagnostic samples, and pain relief. From a cost perspective, metrics might include the impact on LOS and on selection of treatment or costs resulting from complications.
HOW ARE EPISODES OF CARE LINKED TO VALUE-BASED METRICS? An episode of care is the collection of all clinically related services that are provided to treat a discrete diagnostic condition in one patient from symptom onset until treatment is complete. Defining disease-specific episodes of care will help transform the process metrics of today to outcomes metrics in the future. In a patient with lower quadrant pain, process metrics such as access time and peer review data will transform to outcome metrics such as time to establish a treatable diagnosis or appropriateness of follow-up recommendations. In a patient with breast cancer, current metrics such as access time to screening, procedure outcomes, and customer satisfaction will likely transform to the percentage of patients diagnosed with resectable lesions and the percentage of patients requiring repeat biopsies because of inadequate sampling.
WHAT METRICS SHOULD WE USE? Much thought has gone into trying to define value-based metrics that we can all use to benchmark our performance, but more work remains to be done [9]. We will continue to use process metrics to measure, benchmark, and improve our technical, diagnostic, and procedural processes. Additionally, we will continue to use metrics recommended by regulatory agencies, but we need to expand these to measure and reflect the impact of our services on care delivery. No single category of metrics can be effective in isolation; using process and outcomes metrics in combination is important, and these must serve as targets for continuously improving service quality. New value-based metrics must measure and reflect how radiologists contribute to the overall care of each patient. This is our challenge and our opportunity.
WHAT ABOUT METRICS FOR PROCEDURES? Unlike traditional imaging metrics such as peer review of imaging discrepancies, emerging value metrics are easily translatable to imageguided procedures. For a liver
CONCLUSIONS Health care reform, enacted in response to the escalating costs of providing care, is now affecting how our performance as radiologists is managed and measured. We must strive to improve population health by
Journal of the American College of Radiology Kruskal, Sarwar n Business Essentials
331
providing high-quality, outcomefocused, and cost-effective imaging; creating the right tools to measure our role will be critical for radiologists and our patients in the new paradigm.
REFERENCES 1. Rawson JV. Roots of health care reform. J Am Coll Radiol 2012;9:684-8. 2. Doran GT. There’s a S.M.A.R.T. way to write management’s goals and objectives. Manage Rev 1981;70:35-6.
3. Abujudeh HH, Kaewlai R, Asfaw BA, Thrall JH. Quality initiatives: key performance indicators for measuring and improving radiology department performance. Radiographics 2010;30:571-80. 4. Ondategui-Parra S, Bhagwat JG, Zou KH, et al. Use of productivity and financial indicators for monitoring performance in academic radiology departments: U.S. nationwide survey. Radiology 2005;236: 214-9. 5. Dunnick NR, Applegate KE, Arenson RL. Quality—a radiology imperative: report of the 2006 Intersociety Conference. J Am Coll Radiol 2007;4:156-61.
6. Lee CI, Enzmann DR. Measuring radiology’s value in time saved. J Am Coll Radiol 2012;9:713-7. 7. Heller RE. The total value equation: a suggested framework for understanding value creation in diagnostic radiology. J Am Coll Radiol 2014;11:24-9. 8. Federman AD, Keyhani S. Physicians’ participation in the Physicians’ Quality Reporting Initiative and their perceptions of its impact on quality of care. Health Policy 2011;102:229-34. 9. McGlynn EA, Schneider EC, Kerr EA. Reimagining quality measurement. N Engl J Med 2014;371:2150-3.
Jonathan B. Kruskal, MD, PhD, and Ammar Sarwar, MD, are from Beth Israel Deaconess Medical Center, Boston, Massachusetts. Jonathan B. Kruskal, MD, PhD: Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02115; e-mail: [email protected].
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Journal of the American College of Radiology Volume 12 n Number 4 n April 2015
