The Need to Perform Continuous Quality Improvement on CQI

I am concerned that we have made healthcare quality improvement such a complex undertaking that it is losing its utility. Originally, quality improvement in automotive factories consisted of an industrial engineer and a team comprised of front-line workers. The performance data was plotted on process control charts by the production line worker (with the charts created by the industrial engineer), and incremental improvement was undertaken by frontline teams.

This provided frontline staff with a sense of process ownership and cultivated pride in its reform. The expense associated with CQI was minimal (beyond CQI training for a portion of the frontline leadership and the wage expense of those assigned to the teams).

This is significantly different than the concept of CQI today. Now we have:

• moderators and facilitators,
• an entire hierarchy of Six Sigma professionals,
• a CQI department that collaborates with
• quasi-CQI departments (i.e., some portion of the functionality of nursing informatics, risk management, credentialing, etc.),
• an externally imposed infrastructure of accreditation, core measures, pay-for-performance (which requires measurement of performance),
• data reporting staff, and
• a hierarchy of executive leadership providing oversight to the quality infrastructure.

Chekhov couldn’t have imagined a more complex system, but he would have found it ironic that this complex system was designed to simplify complex systems. Am I wrong to wonder if we have, in short, created a jobs program for a newly created quality improvement industry?

CQI and Core Measures

Robert Crawford, MBA, Adjunct Instructor

In “Continuous Quality Improvement in Health Care: Theory, Implications, and Applications” (Second Edition), UNC’s Curtis McLaughlin and Arnold Kaluzny describe how Core Measures and the subsequent prescriptivist approaches to reporting healthcare quality came about. Core Measures represents a sequence of binomial (yes/no) reporting items, such as, was aspirin prescribed and delivered to that heart attack patient within one hour of arrival? The text notes that this approach to reporting quality metrics was arrived at only after the physician practice community strongly opposed a number of other initiatives. In each case, the practitioner community and its representatives objected, arguing that the data was not risk-adjusted, accurately collected, precisely calculated, et cetera.

It was out of frustration that Core Measures came to pass. Desperate to provide patients with some means of identifying quality and seeking to compel providers of care to compete on price and quality in a strong healthcare inflation environment, the logic supporting Core Measures became attractive. Core Measures takes the view that, if we know a particular practice represents optimal care, then it should be a simple matter of reporting whether that treatment was delivered. It either happened or did not. No risk adjustment is necessary, because the measures cover practices that are so straightforward and nearly universal that the justifiable exceptions are rare and unlikely to skew the data results. The industry hated the idea, but it was adopted over those objections. The Centers for Medicare and Medicaid Services (CMS) and other payers simply came to the conclusion that no proposal would avoid objection and that the industry would not propose an alternative of its own.

Core Measures, as a practice, is often referenced as being consistent with Continuous Quality Improvement (CQI). The logic and support seems to assert that any endeavor seeking to advance the quality of care must, by definition, be consistent with the Total Quality Management (TQM) work of Walter Shewhart, Joseph Juran, and Philip Crosby, and the efforts to convert it to healthcare settings by Avedis Donabedian and Edwards Deming. Using the aspirin and heart attack question as a surrogate, let’s consider two different scenarios.

Scenario 1: A hospital reports low numbers on the aspirin measure. In this circumstance, what is senior management inclined to do? Does this measure tell leadership anything about the quality of their cardiac care, beyond whether aspirin was prescribed and delivered? Does it provide any indication of the surgical approaches and outcomes for Coronary Artery Bypass Graft (CABG) cases? Does it even inform them about the efficiency and quality of their emergency operations for heart attack patients? With each of these, I can only conclude that it does not, because the question and results lacks sufficient granularity to provide actionable information. In this case, the hospital’s senior leadership can only become focused on the central issue asked by the question. Desperate to improve their results and given the efficacy and minimal side effects of aspirin, senior leadership may justifiably conclude that aspirin should be offered to everyone visiting the facility. This will surely include all of the patients who come through the door, and they may then honestly report 100% compliance with the Core Measures requirement.

Scenario 2: A hospital posts higher numbers on the aspirin measure. In this case, senior leadership has fully satisfied the requirement, and there is nothing about this measure that compels them to consider the quality of cardiac care. Confronting other, more-dire challenges, they are inclined to move on to the next crisis, rather than focus on this significant contributor to the single largest cause of death in the United States.

Under neither scenario is this approach consistent with quality improvement, as a data-driven, incremental improvement of process quality, to the benefit of the patient. It results from no actionable collection of data. It does not seek to incrementally improve on an internal benchmark of prior performance. It does not address a targeted process. And, for the hospital, it is not designed or motivated to benefit the patient, but, rather, to satisfy a reporting requirement.

While Core Measures may represent a step in the right direction, it is not a substitute for Continuous Quality Improvement, and executive leaders within healthcare should not see it as such and, more importantly, neither should those in health policy positions.