FAQ

Patient Safety and Reliability staff often get asked questions about the quality indicators known as Core Measures; what are they, where did they come from, why are they required, etc.

The attached FAQs were recently posted to a popular list-serve by Dr. Dale Bratzler, Medical Director of the Oklahoma Foundation for Medical Quality. Dr. Bratzler provides clinical and technical support for the SCIP Core Measures and is on the National Advisory Council of AHRQ. The information contained within Dr. Bratzler’s Q & A is applicable to all Core Measures and provides background for why these indicators carry so much importance.

1. Where did the measures come from?
   A: The measures are all based on published guidelines with input from practicing physicians and specialty societies. Each measure set has a technical expert panel which usually includes authors from the specialty society guidelines that meet quarterly to update the measure specifications. All measures are submitted to the National Quality Forum for endorsement. The endorsement process includes the opportunity for public comment from anyone.

2. Where are the studies and are they within the last five years? (Anything past this time frame is not worthy.)
   A: Actually, there are many studies that are decades old that were not routinely incorporated into practice. Use of aspirin and beta-blockers for heart attack, ACE inhibitors for heart failure, etc. have been studied for more than 30 years and yet have not been universally adopted in practice (remember that the first papers on antibiotic timing to prevent infection were published in the 1950s). There is nothing magic about studies published in the past five years as it often takes 10 - 17 years to incorporate evidence into practice. As noted before, technical expert panels made up of current guideline authors review the measures quarterly. The measure stewards often know about changes in evidence before guidelines are formally changed.

3. These measures appear to be only for the hospital’s benefit, why do physicians have to follow them?
   A: The "core measures" are profiled at the hospital level and do impact hospital payment. In October 2012 hospitals who perform poorly on the measures will see reduced reimbursement (based on care for patients starting July 1, 2011!). How long will your hospital's Board allow physicians to not follow evidence-based measures if the hospital starts having funding losses because of it?

   As I have noted many times before, physician reporting of quality metrics is currently voluntary but won't be for long. They too will be held accountable for the same type of metrics (including many that overlap with the hospital measures).

4. Which professional organization developed these measures if any?
   A: Depending on measure set, the measures are developed by contractors to the Centers for Medicare & Medicaid Services, by the Joint Commission, and by others. But as mentioned before, the actually details of the measures are developed by medical and surgical specialty societies based on published guidelines. CMS and Joint Commission, among others, put the infrastructure in place to collect and report measures. The actual measures come from evidence-rated published guidelines.

5. Who is mandating this stuff?
   A: Congress for one. In 2003, the Medicare Modernization Act (signed by President Bush) required hospitals to report 10 quality measures or lose 0.4% of the Medicare market basket update. The Deficit Reduction Act of 2005 (signed by President Bush) increased the percentage of the Medicare market basket update loss to 2% and authorized the Secretary of HHS to increase the number of required measures for public reporting. The Affordable Care Act (health reform bill) signed by President Obama required the implementation of value-based purchasing (pay-for-performance) for hospitals beginning in FY 2013 (October 1, 2012.)

   Also remember that consumer groups are demanding transparency of the health care system.

   Finally, this stuff works. It is amazing how quickly physicians and hospitals start complying with published guidelines when you start measuring performance, reporting it publicly, and attaching payment penalties to it!

6. Who wrote the guidelines?
   A: Specialty societies. CMS and Joint Commission do not write guidelines. They work with expert panels of physicians to build performance measures that are based on published evidence-rated guidelines, and then vet them through the National Quality Forum.

7. Some physicians are not buying that core measures are about patient care.
   A: Well, might as well get used to it. It is not going away, and there will soon enough be required reporting at the physician level (review the HITECH act sometime around meaningful use and payment penalties for physicians failing to report quality metrics). Talk to Consumers Union sometime and look at their website. They want transparency around issues of patient safety, infections, and quality performance.

8. I need hard evidence that show these guidelines are the right thing for all patients in our hospital.
   A: Ask the physicians to provide "hard" evidence that these are not the right things to do for patients.
   Dale W. Bratzler, DO, MPH, University of Oklahoma Health Sciences Center College of Public Health