I’m a surgeon and hospital administrator. From my view, an important problem facing medicine is embarrassing because it is so basic: We don’t know how to measure quality. By quality I mean the medical care that is delivered to you, at the bedside, in your local hospital. And if we can’t measure it, we can’t improve it. This is a solvable problem, but the solution requires a different way of thinking about medicine, and about how patients, doctors, hospitals and payers interact.
What’s so hard about measuring quality? A major problem is that the caregivers who deliver care, and the patients who receive the care, have been disengaged from the discussion about what it really is. That discussion has been ceded to governmental agencies, which have generally gotten it wrong. Doctors become frustrated because the bureaucratic version of quality doesn’t ring true, and the process of improvement gets stuck at this earliest step.
Why shouldn’t the caregivers themselves, meaning doctors and nurses, with input from patients, say what quality really is? If the doctors and patients don’t know, we are all in trouble. This sensible approach hasn’t come from any governmental authority, but rather from a regional third-party payer, Blue Cross/Blue Shield of Michigan. What has resulted is a standardized and more informed definition of quality, and also a statewide framework for quality improvement that caregivers see as reliable and useful.
There is another important element in a new way of thinking about quality. It involves changing how hospitals interact with one another. Hospitals are often engaged in local battles for market share. It gets worse when incentive payments for quality come into play — a strategy embraced by the federal government and other payers. If hospitals come across an innovative way to improve care in this environment, they aren’t likely to share it with others, for fear of losing a financial advantage.
In what represents a remarkable change in thinking, BCBSM embraced the idea that groups of Michigan hospitals interested in certain specialty areas — they are called Collaborative Quality Initiatives — could work together using a “pay for participation” approach. That means that all hospitals, regardless of performance, would receive reimbursement for meaningful engagement in the identified improvement activities. This has produced a more collegial environment, one in which the sharing of good ideas between doctors and hospitals is facilitated rather than discouraged. So far 22 specialty-oriented CQIs have been established involving many different disciplines such as general surgery, urology, radiation therapy and trauma care. I direct the CQI involving general surgery, the Michigan Surgical Quality Collaborative. At our quarterly meetings 300 or so surgeons, nurses and anesthesiologists from 72 hospitals talk about surgical quality, what it means, and how to improve it. Most Michigan hospitals participate in the CQI program in one form or another. The enthusiasm for the new approach is unmistakable.
Patients have benefited from improved quality, and the improved quality has translated into savings for BCBSM. In a recent estimate, $230 million had been saved because post-operative complications had been avoided.
The success of Michigan’s new way of thinking about quality has shown what can happen when involved caregivers work with a committed and local private payer, without federal or state help. This model deserves consideration as other states. And BCBSM should be recognized for its willingness to take a risk, and to think differently about solving an embarrassing problem.
Darrell A. Campbell, Jr. is professor of surgery at the University of Michigan and a member of UM’s Institute for Healthcare Policy and Innovation.