By Thomas Graham, CFO, AMC Registry, Inc.
The Medicare Modernization Act of 2003 (MMA)
provided financial incentive for hospitals to
report what they termed “quality of care
data” in their treatment of heart attack
(acute myocardial infarction), heart failure,
and pneumonia. Although compliance was voluntary,
non-compliant inpatient acute care hospitals
faced losing a financial incentive in their
annual Medicare fee schedule update. Further
incentives, including potential increased
reimbursement for facilities performing
in the upper 10 percent, were suggested. The
paper chase was on. Yet, we can demonstrate
that compliance data collection alone (i.e.
payment for reporting rather than performance)
does not ensure that emergency department processes
will become more economically efficient –
or guarantee that more lives will be saved.
Improving The Process of Care Giving
Without attention to those ED processes, however,
the purpose of data collection becomes uselessly
inverted: information on care driven
by the culture and fear of noncompliance, rather
than quality of care. The fact is, the
process of care giving should drive the
data. When this happens, the result is not just
“good” health care, but great
health care reflected by a change resulting
in a culture of improvement and a healthier
bottom line.
AMC Registry, Inc. of Columbus, Ohio is in
the business of providing hospitals with unique
data tracking and analysis software and reporting
technology. AMC’s Process Improvement &
Management Dashboards (piMD) allow hospitals
to access, track, analyze, as well as compare
and contrast clinical, operational, and quality
indicators. Users can access and display real
time information tracked by AMC databases. Users
can view individual patient or summary information
and safely share information throughout the
hospital or an entire healthcare network. Most
importantly, the user can derive knowledge to
support timely, data driven decisions all at
the “push” of an on-screen button.
Outcomes, success measurement, patient statistics,
and other data are displayed in an easy-to-interpret
graphic format. Extensive drill-down capabilities
identify procedural, clinical, and diagnostic
liabilities, improve performance (medically
and fiscally), and then effect permanent change.
Since 1991, AMC has specialized in improving
the care process for patients with symptoms
of Acute Coronary Syndrome (chest pain). Founded
by Anthony Joseph, MD, a 30-year veteran of
emergency medicine, AMC has studied the day-to-day
practices of hundreds of hospitals and patients
who arrive in emergency departments complaining
of chest pain. What we have discovered is that
real quality improvement in emergency cardiac
care only takes place when processes and handoffs
are analyzed and mated with clear clinical guidelines
and proven treatment methods.
While MMA has established reporting criteria,
it does not tally the ultimate outcome of an
emergency department’s performance in chest
pain cases – correct diagnosis and early
reperfusion - or death. Even beyond the primary
purpose of saving lives comes the tandem concern
of any hospital, namely, staying ahead of the
cost curve.
It is this duel “cost of quality”
that concerns AMC. Compliance data collection
alone does not result in actionable information
that can change processes that drive the quality
of care.
Crisis In The Emergency Department
Let’s take a look at the basic problem.
Emergency department visits have increased more
than 26 percent since 1993, while the number
of emergency departments decreased by over 12
percent. Each year, some eight million patients
come to those hospital emergency rooms complaining
of chest pain. Some will be correctly diagnosed
with heart attack and lives will be saved. Others
will be sent home, diagnosed with something
as simple as acid reflux. But a precious few
of those sent home may have been misdiagnosed
and will later suffer a catastrophic heart attack
as evidenced by the front page article in the
October 25, 2006 issue of USA Today, “A
preventable tragedy? When a heart attack goes
undiagnosed” Why? Because emergency room
processes are more designed to recognize a heart
attack in process than symptoms indicating one
may be imminent. Add to this the limited resources
of the average emergency room which are stretched
to the limit, and weighed down by an operating
culture that is heavily focused on administrative
processes and (there’s that word again)
compliance. A crowded emergency department may
divert ambulances to other hospitals, diverting
needed revenue at the same time. Patients tired
of waiting may simply walk out, creating a medical—
and legal—risk. Combined, the problem is
a bubbling mix of medicine, litigation, and
economics.
At AMC, we believe that hospital leadership
must recognize that the operating culture must
change from one of compliance to a culture of
improvement. Even the cost savings approach
using Six Sigma methodology is not going to
solve flaws in the clinical process, even though
some improvement may occur. As Dr. W. Edwards
Deming said, “Best efforts and hard work,
not founded by new knowledge, only dig deeper
the pit you are in.” In short, a best efforts
approach is simply not good enough. The aviation
model of “zero defects’ and “never
events” must be adopted.
Process Improvement Brings Clinical and
Financial Improvement
That new knowledge is the variation that exists
within the existing process. Those clinical
processes must be improved to provide precision,
accuracy, and timely outputs that meet healthcare
guidelines. Virtually all physicians and nurses
agree that reducing time to treatment is all-important
– the first 30 to 60 minutes are critical.
In spite of this, hospitals continue to struggle
to develop the necessary procedural guidelines
to ensure desired outcomes. And, despite widely
known diagnostic methods in the case of chest
pain, emergency rooms have cumbersome systems
– from check-in to gowning, to administering
a few hundred milligrams of aspirin – that
delay that diagnosis. Existing systems are only
made worse as increasing demand places emergency
department resources at the breaking point.
AMC’s prescription for emergency departments
is to establish a strategic plan to admit, quickly
(and correctly) diagnose, and treat patients
on preferred treatment methods using our risk
stratification approach. Our methods reflect
day-to-day clinical practice, tracks trends,
and provide a basis for local and regional comparisons.
This improvement process is based on guidelines
recently published by the American College of
Cardiology/American Heart Association on the
management of patients with STEMI and NSTEMI
Myocardial Infarction.
Clinical process improvement must also be linked
to financial strategic planning. The financial
outcomes that result from clinical process decisions
must be clearly understood. Cardiovascular programs
are one of the most profitable service lines
in hospitals. In fact, chest pain is the second
leading reason why patients visit the ED. As
a result, the CV business plan and the financial
strategies embedded therein will ultimately
impact the bottom line of the entire organization.
Linking the clinical and business decision-making
process is essential.
Clinicians often have more than one treatment
option available for heart patients. Yet, the
financial outcomes may be substantially different
between those options. As a result, non-standardized
clinical decisions can sacrifice profit margins
– and the profitability of the hospital.
A plan must be developed that identifies a clinical
pathway that appropriately risk-stratifies the
patient while using an emergency triage process
that is symptoms-based. This clinical approach
should yield an evidence-based care while yielding
the greatest financial outcome for that care
(evidence-based financial outcomes). AMC links
these clinical and financial outcomes so that
both appropriate clinical decisions can be made
and financial performance is optimized.
The Cost of Quality
As in any industry, customer satisfaction is
the key to business success and viability. In
the healthcare industry, standard write-offs
approach a whopping 60 percent of gross charges.
Hospitals cannot afford to have patients leave
their emergency departments without rendering
care because of excessive emergency department
length of stay. If this condition exists, tools
of improvement science must be used to understand
and improve the processes that result in lost
patients and the resulting lost revenue. Furthermore,
hospitals cannot afford to have patient charges
denied or further reduced by any payor as a
result of poor quality.
A hospital’s lost revenue resulting from
patients leaving the emergency department without
receiving treatment is enormous. Patients tired
of waiting may simply walk out, creating a medical
– and legal – risk. The average admission
rate for patients visiting the emergency department
is 13%, so the financial impact is enormous.
Emergency department overcrowding caused by
inefficiencies may also cause ambulance diversion.
When this happens, EMS must divert to another
emergency department, resulting in lost revenue
from high acuity patients as well as poor perception
in the EMS and general community.
The foregoing clearly illustrates why the tools
of improvement science and the examination of
processes (not compliance) must be used to identify
the barriers to the processes that are causing
extended time in the emergency department. We
can demonstrate that correcting this problem
alone can increase revenue without increasing
market share.
Of course, improved market share is the goal
of most hospital administrators. The best way
to increase market share in any hospital service
line is to provide the highest quality of patient
care, and have it recognized by both medical
professionals and the community at large. AMC
identifies the pathways to the highest quality
of care in a way that is clearly visible to
all care givers and, with the proper marketing
and outreach, to paying constituents as well.
Improved Outcomes
Finally, no implemented strategy is fully valuable
without measurable results. For the hospital,
AMC’s patented methodology was developed
to maximize a hospital’s compliance with
ACC/AHA guidelines for dealing with patients
with chest pain during those first critical
minutes after arrival.
This improved performance is achieved with
the partnering of AMC representatives who attend
regular meetings of a hospital Chest Pain Committee,
organized under AMC guidelines. In addition,
quarterly Chest Pain Reports produced by AMC
track the facility’s performance-to-goal,
reports variances, and provides appropriate
control charts.
As for the all-important patient, his or her
satisfaction with their emergency department
visit is most often affected by the length of
time before a clear diagnosis is given, and
then the length of time for treatment. The overall
objective of AMC’s process initiative is
to rapidly get to a diagnosis and move the patient
into the correct treatment pathway. This is
a proven means to improve patient outcomes as
well as satisfaction scores.
For the physician, the sole objective of AMC’s
Chest Pain initiatives is the improvement of
the care process for ACS patients. It is a physician-led
initiative reflecting the guidelines established
by the physician’s own professional organizations.
Additionally, the hospital’s physicians
play an important role in the improvement process.
Through AMC’s partnering effort, the initiative
tracks and measures facility compliance to those
guidelines, assuring these health care professionals
that nationally accepted standards are being
met.
The Bottom Line
Senior leadership needs to manage compliance
and performance because neither is optional
– both are required to ensure sustainable,
long-term success. Yet, hospitals have a choice.
They need to decide if compliance or improvement
should drive the nature of quality care. Are
your data collection efforts for compliance
reporting working for or against
your hospital?
To find out more about AMC Registry, Inc.,
or request a live remote demonstration of our
software and reporting system for evaluating,
monitoring, measuring, and comparing your performance
in emergency department diagnosis and treatment
of chest pain patients, call me, Tom Graham,
at 614.457.9190, ext. 134. Also, log on to our
e-newsletter website @ amcedge.com for a free
subscription.
