Data sharing has become an important part of healthcare delivery.  Whether it is laboratory or procedure results, patient health information is increasingly being shared.  The use of data to evaluate the quality of patient care is now getting the attention it deserves.  Data has always existed but no one knew what it meant.  It was “hidden” in paper which was “hidden” in medical records. It was time consuming and expensive to count records one at a time to determine the quality of care.  The data could not be aggregated, analyzed or turned into information which could affect the direction or the quality of healthcare.

Those days are gone.  They went first with information which was looked at months after the healthcare was delivered.  Healthcare companies laboriously review patient chars and count how many times patients had immunizations, or screening tests.  Eventually, healthcare providers were given this information but in that it was 12 to 18 months after the event, they didn’t care much.

With the advent of electronic health records (EHR), data sharing has entered a new era.  With EHR data can be aggregated quickly.  Information that once took days and weeks to collect can now be collected in seconds.  Data can be analyzed quickly and treatment strategies can be developed as quickly. 

The public reporting of quality data is increasingly becoming the standard for healthcare organizations and for healthcare providers.  However, few organizations are publishing quality performance by provider name; SETMA began that in 2009.  Ultimately, transparency at the provider level will become the national standard.

A brief history of healthcare accreditation organizations in healthcare

There are now dozens of organizations which offer one form of healthcare accreditation or another.  The following are the oldest and perhaps principle ones:

1. The Joint Commission on Hospital Accreditation was founded in 1951 and had a significant change in focus in 1965 when it because the official organization for hospital accreditation. 
2. The Accreditation Association for Ambulatory Care (1979)
3. Accreditation Commission for Health Care (1985)
4. Utilization Review Accreditation Commission  (1990)
5. National Committee for Quality Assurance (1990)

These organizations publish standards for quality performance and provide surveys and often site visits for organizational accreditation.  The fact that most of these accreditation organizations have only existed for the past thirty years or so, lets you know how young healthcare quality assessment is. 

Healthcare Organizations which have voluntarily submitted to review by these accreditation bodies subject themselves to new standards of excellence.  Hospitals do not voluntarily receive surveys; it is required.  Eventually, the same will be required for all healthcare provider organizations (physicians, dentist, nurse practitioners and physician assistants) as well.  SETMA has both AAAHC accreditation for ambulatory care and medical home, and NCQA recognition for medical home and diabetes care.  There are about 250,000 groups of physicians in the United States and many more physicians who are in solo practice. Currently fewer than 3,000 groups have any form of accreditation or recognition for quality performance.  Less than 1% of those publicly report quality performance by provider name.

Public Reporting

In that SETMA began pubic reporting on over 200 quality metrics by provider name in 2009, it was logical that when we were given our results on Hospital Cord Measures that we would publicly report those also.  The following is an explanation of Core Measures and SETMA’s results at Baptist Hospital of Southeast Texas for 2011. We hope soon to receive our results and to publicly report them from Christus St. Elizabeth and from the Medical Center of Southeast Texas.  The Baptist Core Measures can be reviewed at Public Reporting Core Measures. 

What are Core Measures?

Hospitals across the country adhere to a set of care processes called Core Measures, which were developed by The Joint Commission, the nation's predominant standards-setting and accrediting body for inpatient health care, to improve the quality of health care by implementing a national, standardized performance measurement system. The Core Measures were derived largely from a set of quality indicators defined by the Centers for Medicare and Medicaid Services (CMS). They have been shown to reduce the risk of complications, prevent recurrences and otherwise treat the majority of patients who come to a hospital for treatment of a condition or illness. Core Measures help hospitals improve the quality of patient care by focusing on the actual results of care.

Comparing Performance

Hospitals across the country are measured and compared by The Joint Commission against all other accredited institutions on their performance in these Core Measures. You will note there is a time lag of several months between when data is reported from hospitals and when it is posted for the public to review. Hospitals have to wait for state and national statistics to be compiled before it can post its quality data for a given period. Hospitals report their results internally and more and more hospitals are beginning to share this data with the public.

What does each of the Core Measures stand for?

There are 33 Core Measures altogether, in 4 categories (acute myocardial infarction, community-acquired pneumonia, congestive heart failure, and surgical care improvement project). Under each category, key actions are listed that represent the most widely accepted, research-based care process for appropriate care in that category.

It is important to note that these care recommendations are subject to the professional medical advice of each patient's physician and the particular health conditions of each patient. If a physician determines that a patient is not an appropriate candidate for a particular care process, the patient will not be included in the data. A good example is aspirin. Some patients are allergic to aspirin; for others, taking aspirin will make another medical problem worse. In these cases, the patient's physician may determine that aspirin should not be administered or prescribed for the patient. Therefore, the patients will not be included in the data.

The following are technical descriptions of all of the core measures.
Core Measures (Process of Care Measures)
Accurate as of March 1, 2012

The following are SETMA’s results for admission during 2011 at Baptist Hospital of Southeast Texas.   The color coding lets you know whether or not SETMA meets the national benchmarks or not. Those in “green” meet or exceed the benchmarks.  Those in “yellow” are a the low end of the benchmarks.  And those in “pink or red” need improvement.

The following Core Measures are for groups of metrics and represent the area in which SETMA will focus our attention the most in the coming year.  The categories are Perfect Care for Acute Myocardial Infarction, Heart Failure, Pneumonia and Perfect Care for Surgical Care. 

SETMA performance for the following group of Core Measures is excellent.