Strategic, Quality & Operational Metrics
Practical Considerations in Oncology Medical Homes & ACOs
May 4, 2014
Jeff Patton, MD, Gina McKinney & Wes Chapman
Preface: In this article we take a look at how we are characterizing, prioritizing and utilizing metrics in a real world PCMH and ACO in oncology.
Quality metrics: Bricks and mortar of an Oncology PCMH/ACO
Building the Quality Pyramid
Metrics are difficult to design, expensive to gather and frequently difficult to interpret, but they form the bricks and mortar of design and delivery for value based care. In the last few years, various professional organizations and Agencies of the Federal Government have begun promulgating standardized metrics to foster operational excellence, standardized processes based on best practices and comparability. These operational and quality metrics are at the core of an increasing array of government sponsored payment programs including:
- Meaningful Use: a program with extensive and growing lists of metrics focused on documenting the functional utility of EMRs and related clinical IT tools,
- PQRS: a program designed to reward data gathering and resultant practice compliance with government delineated metrics,
- QOPI: a quality initiative sponsored by the American Society of Clinical Oncology (ASCO) with a broad and growing set of metrics,
- COA: a medical home program with a tight and functional group of metrics, and
- NCQA: the metrics and SOPs required to design, implement and operate a patient centered specialty practice (PCSP).
There is a large amount of duplication or functional equivalence in many of these metrics, and we have designed our medical home to operate with the maximum amount of re-use of existing metrics – in fact we are using metrics that we are otherwise gathering for all of the certification metrics associated with our efforts.
The Quality Metrics Pyramid
As we discussed in last week’s article, our medical home model is being launched based on efforts in four key areas – pathways, care plans, patient management and palliation. Our strategic metrics are targeted at measuring how we are doing, on a broad basis, in each of these four key areas. We design strategic metrics to give meaningful reporting against critical quality objectives. We are using 11 distinct key metrics at the strategic level, 3 home grown and 8 from the Community Oncology Alliance (COA), as outlined below. These measures target the interface of patient care and payment, and require close adherence to best practices. It is important to note that our strategic metrics include a very important outcome metric – survival rates for breast, colorectal and NSC lung cancer. While these are absolutely critical metrics, they are very much long-term in nature, reducing to 10 the effective number of management metrics at the strategic functional level. From our perspective, 10 is a manageable level of metric reporting for strategic considerations.
A limited number of Strategic Metrics
Quality metrics in our system are how we prove that we are doing our job, and doing it right. From a practical perspective these metrics are also what CMS and other payers use to determine our levels of quality – and how we get paid. A large medical oncology practice typically has millions of revenue/penalty dollars and equal or greater amounts of cost tied up in compliance with these metrics and SOPs.
Additionally, compliance with these quality requirements requires substantial investment in systems, and frequently involves actual changes in how care is delivered.
PCSP, PQRS, QOPI – Important Standards in Clinical Oncology
Meaningful Use Impacts almost all areas of Patient Care
“You can’t manage what you can’t measure.”
Operational metrics are the basis of cost cutting, daily dashboards and continuous process improvement. Some operational metrics – waiting time as an example – are ubiquitous and perennial. Others are situational specific, and may be in place only for a few months after a QI project is concluded, as an example. In any event, one of the primary purposes of operational data is the measurement of actual vs. budget – or actual vs. standard. Ultimately, operational metrics must confirm conformance with plans and SOPs, and serve as the basis for control and flow charting.
Very few of the payer or governmental metrics conform to operational applications, which relieve some of the reporting burden, but the result is to reduce the focus on operations.
Until very recently, most management/payment systems associated with clinical care delivery have been designed to optimize the frequency and cost associated with patient encounters – from the provider’s perspective. Issues relating to access and denial of service/best practices have been assumed to be irrelevant to most of the served population. As the world moves gradually to systems based on value, metrics associated with measuring care delivery become central to maintaining the integrity of the care delivery system.