Government regulators monitor it. Insurers have strong opinions about it. Consumers need information about it to guide their medical decisions. But what is quality health care?
Otolaryngologist Michael Glenn posed that question to an auditorium of surgeons at a “grand rounds” event at University of Utah Health Sciences on Wednesday. Quality is hard to pin down, even for the experts, acknowledged Glenn, chief medical officer at the Seattle-based Virginia Mason Health System.
Could it be, he quipped, that like the threshold test that former U.S. Supreme Court Justice Potter Stewart famously proposed for obscenity –– you know it when you see it? Perhaps, but that “impressionistic view” isn’t very helpful as health systems look to improve and be accountable for the quality of care they deliver, he said.
More useful is the definition that former Administrator of the Centers for Medicare and Medicaid Services (CMS) Don Berwick offers: “No needless deaths, no needless pain or suffering, no helplessness in those served or serving, no unwanted waiting, no waste and no one left out.” Or the way that the Institute of Medicine frames it: Safe, timely, efficient, effective, equitable and patient-centered.
Fifteen years ago, Virginia Mason set out to figure out its own definition and become a leader in health care quality. The health system concluded: Quality equals appropriateness multiplied by outcomes plus service, divided by waste. That’s its algorithm; Its gauge for success.
There was one more key factor to their formula: Transparency. Virginia Mason has opened the books on all sorts of previously closely held information, from federal safety reports to outcomes and pricing data. “It’s a little scary,” said Glenn. “No one has perfect quality scores and it’s pretty hard to just hang the laundry out there for all to see.” The metrics are messy; scores can fluctuate due to circumstances beyond a hospital’s control. “Even when looking through something as clear as water,” said Glenn, “there’s a certain amount of distortion.”
Yet, by displaying on its website how it compares to other hospitals on state-mandated quality and safety measures, Virginia Mason was able to win over a growing share of regional cardiology patients. Last year, it added the prices for 100 of its most common outpatient procedures. It also introduced an on-call service where patients can request estimates (tailored to their insurance plan) of their out-of-pocket costs for various inpatient and outpatient services. The estimates include charges from the physician, anesthesiologist, lab and other departments.
“The pathway to lower costs is the pathway to quality,” Glenn said. Focusing on quality helps avoid costly medical errors and unnecessary procedures; and focusing on cost creates better value for health care consumers. “You can’t market quality, and say, ‘Come to the place with better care,’ if you don’t disclose the cost of that care.”
As an example, Glenn points to a deal that Virginia Mason brokered with Walmart to be a health center of choice for employees undergoing spine, heart or transplant procedures. So far, the biggest savings and improvements in care have come from avoiding inappropriate procedures. That’s because a large number of patients referred to Virginia Mason for spinal surgery don’t meet the criteria, Glenn said, citing a recent article in The New Yorker by Atul Gawande.
Soon, Virginia Mason’s patients will be able to view physicians’ calendars online and schedule appointments in much the same way that they book flight and hotels. Already they can pay their medical bills through the health system’s online portal and access their charts (clinical notes and test results). And, following University of Utah Health Care’s lead, the health system intends to put its physician reviews online with patient comments and five-star ratings.
In “a sea of sameness,” the question facing every health organization is “how do you distinguish yourself?” said Glenn. Quality, no matter how it’s defined, sells. “Has it made a difference for us? We think so. Our prices are lower, our service levels are high, and our economics have improved in the last year or two.”
Kirsten Stewart is a senior writer for University of Utah Health Sciences