iProtean—Introduction to Quality

Improving quality and reducing cost, while always a staple of board and executive discussions and retreats, has catapulted to the top of the list of priorities because of components of the Accountable Care Act (ACA) and the Medicare Shared Savings Program:  accountable care organizations, medical homes, bundled payments.


Designing the structures and operational details within each organization consumes an unprecedented amount of leadership, management, physician and staff time, and uncertainty about the challenges to the ACA, now being decided by the Supreme Court, suggests dual strategies—with and without the structural components of health reform.


“The linking of reimbursement to quality is here to stay but the mechanics of how to do so are still in their infancy.  One thing however is certain:  the delivery of high-quality care and the accurate measurement of the ability to do so is the foundation of ACOs as a new model of health delivery . . . Although seemingly complex in their form and implementation, these measures do not represent the end of the quality journey.  They are only the beginning of a long and interesting shift away from volume-based payment toward payment measured by the value of the care delivered.”  (Mark W. Brown, M.D., The ACO Handbook. American Health Lawyers Association, 2012.)


To successfully deal with these issues at the board level, board members should have a firm grounding in quality and their responsibilities to ensure high quality care for patients and financial stability for the organization.  In the iProtean course, Introduction to Quality, Barry Bader, Todd Sagin, M.D. and Brian Wong, M.D. discuss the impact of health reform as well as the history of quality, quality as a core responsibility, physician credentialing, six aims that define quality and the quality committee.


Barry Bader, Bader & Associates

The healthcare system is in the midst of not merely change, but many people believe transformation in the way we pay for medical care and, as a result, in the way we deliver medical care.  We have predominantly had in this country a fee for service-based system.  Generally, insurers as third parties and government as the provider for the elderly and the poor paid individual fees to doctors, and paid fees to hospitals for visits and procedures.  While there certainly are benefits to a fee-based system, one of its financial incentives is to reward volume:  the more you do, the more you are paid.  Perversely, if a patient goes into the hospital and suffers an adverse occurrence, or develops a hospital-acquired infection, traditionally hospitals and doctors would provide more services to help the patient get better—and they would get paid more.


This system is one that we as a country cannot afford any longer.   No matter what happens in Congress, in state capitals  and at the Supreme Court with some specific pieces of healthcare reform legislation, there is a general consensus that we are going to be changing from a payment system that has been volume driven through fee-for-service payments to a system that will be value driven.  In a value-driven system, hospitals, physicians and other providers along the continuum of care are going to be paid based on value; that is, how efficiently they are able to provide high quality outcomes, excellent patient service and excellent patient experience.  So, we are more likely to see insurance carriers and government take populations of patients with certain kinds of medical conditions and provide a global budget to a network of hospitals, physicians and other providers to be able to provide care.  We are going to change from paying for volume to paying for value.  Over time this will fundamentally affect the work of the hospital and health system governing board and its quality committee.


How might that change?  Well, value-based care is going to be heavily driven by best practices for treating these particular kinds of patients.  The board and the quality committee will be looking very much at whether the organization is embracing best practices and how well it is following best practices.  They will also want to raise the culture questions, “Are we flexible as we apply best practices so we never lose sight of the needs of individual patients?  Do we provide sufficient discretion for physicians to, when justified, deviate from a protocol?”  The last thing we want is cookbook medicine.  What we want is patient-focused care.  Boards and quality committees are going to be looking at this more frequently and comprehensively.


Brian Wong, M.D., The Bedside Trust

There is an old conventional wisdom:  low cost equals low quality.  But the paradigm shift that must occur is that we have to reduce cost and improve quality.  There is an incredible amount of duplication and waste that exists in our healthcare.  Today’s overall cost equation involves not doing less care, but providing less redundant care, less harmful care, less unnecessary care.  That is how you decrease cost.  Those things are fundamental key drivers to improving quality, because how can you say something is quality if it’s redundant or wasteful or inefficient?


Todd Sagin, M.D., J.D., Sagin Healthcare Consulting

Historically we have relied on the medical staff to make sure there was high quality care delivered in our hospitals, and if the board was able to assure there was a high quality, competent, medical staff, that was considered adequate.  The board didn’t really need to look beyond the credentials of the physicians when it thought about quality of care.  However, over the last 10 to 15 years we have become concerned that that alone has not raised the bar for quality in our institutions, and that more is necessary to change the culture of our institutions and the systematic processes in our institutions to assure that safer care, higher quality care is actually achieved.  It is the board’s responsibility to make sure these things happen.  This is critical to the mission of the institution, and the board has to take a leadership role.  In fact, many people believe that it is because boards have not been out front providing such a leadership role that we haven’t made more progress.  Physicians, for example, typically focus on care for their individual patients.  They tend not to be focused on the broader institution and how it functions to assure safe care.  Without the board prodding them and leading the way and setting benchmarks and expectations, it is hard for the rest of the institution to rally around the significant changes that are necessary to instill a culture of quality in our hospitals.


Barry Bader, Bader & Associates

We are used to seeing boards have finance committees.  Traditionally, hospital and health system boards did not have quality committees, but if quality is as important a responsibility as finance, and if there is a need for the board to really understand how quality is being assessed and assured and how physicians are being recommended for appointment or disciplinary action, there is a need for a committee that can develop a fuller understanding to do the hard work and to bring well-documented recommendations to the board.  That’s the work of a quality committee.


Brian Wong, M.D., The Bedside Trust

The quality committee in my opinion is the most important committee of all because it goes to the heart of the matter.  It goes to why we are in this business which is to take care of patients, improve quality and reduce harm to the patients.


The reason there is value in a board quality committee is you have dedicated expertise, dedicated focus on that one subject, just as you have dedicated experts on an audit committee or a strategic planning committee or a finance committee.  This requires some dedicated effort, and all board members need to take a turn on the quality committee to understand how it works, and what is being asked and how it conducts itself.


For a complete list of iProtean courses, click here.


iProtean Symposium & Workshop

Mark the Date!! October 10 – 12, 2012 at The Lodge at Torrey Pines, La Jolla, CA. Faculty: Barry Bader, Dan Grauman, Marian Jennings and Brian Wong, M.D. For more information, click here.


For more information about iProtean, click here.