After more than a year of planning, VHA hospitals have launched a strategy they hope will catapult them to the forefront of the public's dawning interest in hospital quality.
A cadre of 42 VHA hospitals is starting to collect data on strokes, specifically on the length of time it takes to diagnose patients and administer the latest therapies to minimize the damage that stroke can cause.
The pilot project is designed to set VHA hospitals apart from their competition. VHA is banking that its member hospitals' quality will be so clearly superior that patients will prefer VHA over other hospitals.
Stroke is the first of a series of initial indicators. Next will come myocardial infarction, congestive heart failure and community-acquired pneumonia. The list will expand and will be available to all of VHA's 1,800 hospital members that want to participate.
Kenneth Smithson, M.D., VHA vice president of clinical and customer service quality, says: "If we can change the field of competition from cost to include quality, everybody's going to win: purchasers, providers and above all, patients."
VHA's strategy has five key steps:
* Choose clinical indicators that will be useful to the broadest audience.
* Facilitate providers' data collection.
* Report results so they can be easily compared across organizations.
* Make all the information public.
* Release information as a nonproprietary tool available to all.
Though VHA concedes that the market is awash in quality indicators, it says nobody else is doing anything quite like this. The National Committee for Quality Assurance's system, called the Health Plan Employer Data and Information Set, considers only health plans.
On the hospital side, data collected for Oryx, the performance measurement system devised by the Joint Commission on Accreditation of Healthcare Organizations, can't be used to compare organizations, because hospitals can choose the clinical indicators they find most valuable for internal use. Further, the JCAHO has promised not to make Oryx data public.
VHA's effort is called the Purchaser-Provider Partnership on Health Service Quality, or P3 for short. The P3 task force comprises eight people from large purchasers and employee benefits consulting firms, and six physicians and executives from member hospital organizations, plus consultants and VHA staff.
At a session in Dallas last October, participants in the P3 task force talked about the problems and challenges of making quality matter to purchasers and the ultimate consumers, patients.
Stuart Barker, M.D., VHA's senior vice president, defined the challenge as "producing data that withstands the paranoia of the American public."
Jan Brown, chief operating officer of Market Strategies, Southfield, Mich., emphasized the importance of "co-opting" employee benefits consultants and brokers into subscribing to the P3 goals and process. "They greatly influence purchasers' decisions," and they "do not see an association between higher cost and higher quality," she said.
Yet, she noted, over the past five years, "qualitatively and quantitatively, consumers have changed." In 1993, only 8% of consumers surveyed were interested in quality of care, according to Market Strategies; by 1998 that figure had hit 23%. Clearly the message that quality matters is getting through.
Consumers often define quality according to their own care preferences. Denise Lynn, a human resources manager at Dallas-based American Airlines, reported at the meeting that her employees consider quality based on what their health plans will cover. People who want chiropractic maintenance care are angry when the plan will cover only restorative chiropractic care. They regard that as poor quality in the plan.
Yet when quality is recognized and broadcast to the public, the effect can be galvanizing and rewarding. John Hillenmeyer, chief executive officer of Orlando (Fla.) Regional Healthcare System, recalled that when U.S. News and World Report put stickers on local copies of its "best hospital" issue touting Orlando Regional as one of the best in Florida, the hospital was deluged with calls.
The potential for agreement on clinical indicators that can be applied equitably to hospitals across the spectrum remains questionable. How can data-gathering be made easy and cheap enough to be worth the trouble? How can it be made relevant to volume purchasers and finicky consumers without being dumbed down to the point that it has no scientific worth or statistical validity?
The stroke indicator project will be the first test. The 42 hospitals received the survey in late July and are now abstracting charts, which they will submit in late August. The preliminary report will be ready by early September. At that time, it should be possible to pick out certain benchmark organizations.
Marilyn Rymer, a neurologist who directs the stroke center at Saint Luke's Hospital in Kansas City, Mo., says the P3 instrument uses stroke diagnosis and treatment as a proxy for true outcomes.
Outcomes for stroke patients can be assessed only 90 days after the event. "That can be very difficult to come by," she says. "We can't keep piling on new expectations of calling everybody at 90 days and tracking them down. It's really a burden for staffing and costs."
Instead, P3 is collecting data on other factors that, when applied quickly, should lead to best outcomes. They include: Is a CT scan available at all times? How fast is the turnaround from the emergency room to the CT scan? Is the clot buster tissue plasminogen activator, or TPA, being administered within three hours of onset of symptoms? Do patients get aspirin within 48 hours? Is prophylaxis in place to prevent deep-vein thrombosis?
"You adopt those practices, and by inference the outcomes are better," Rymer says. "The evidence says this works. Then we're saying to the purchasers, 'We are doing this, and we can prove it.' "