Matt Bolch talks with two hospital executives about the clinical and cultural changes resulting from their P4P programs.

Any improvement in clinical quality scores can save patient lives, but only the highest scores bring financial rewards to hospitals in a pay-for-performance model.

That’s what East Alabama Medical Center and more than 260 other hospitals that are participating in a pilot pay-for-performance project have discovered. Providing a standardized level of care is a lofty goal, but delivering and documenting that care can be difficult during the frenzied dance of caregivers that occurs when a critically ill patient is wheeled through the doors of the ED. Physicians often have their own agendas and treatment protocols that may conflict with standards, and any change in individual behavior can be a challenge.

Still, the 352-bed hospital in Opelika, Ala. scored in the top 50% of participants after the second year in five clinical areas as outlined in the CMS/Premier Hospital Quality Incentive Demonstration project. Congress has mandated that Medicare develop a plan by fiscal year 2009 to implement value-based purchasing, which links reimbursement to quality of care and other outcomes. The Centers for Medicare & Medicaid Services developed the three-year pilot project with Premier, an alliance of nonprofit hospitals dedicated to improving patient outcomes while safely reducing the cost of care.

“We strive to deliver perfect care, but that may not be enough in the pay-for-performance arena,” said Laura Bell, director of clinical effectiveness at East Alabama Medical Center. “Hospitals are really going to be stressed to get this done to be paid.”

But the main goal is to improve patient care, and the Alabama hospital fully embraced the project, examining current practices and developing standardized care methodologies that were rolled out to staff and physicians. “The project gave us the opportunity to look closely at our delivery processes and continue to improve them,” said Janice Baker, vice president and chief quality officer. “Being able to network with other providers in the project was also beneficial.”

Tying quality to bonuses
Participating hospitals report process and outcome measures in five clinical areas: acute myocardial infarction, congestive heart failure, coronary artery bypass graft, pneumonia, and hip and knee replacement. Hospitals that finish in the top 10% on any measure received payouts in the project, and East Alabama Medical Center was in the top 10% in coronary artery bypass graft and the top 20% in treating heart failure at the end of year two.

“Hospitals were competing to perfect, which makes everyone better,” Bell said. “It challenged all hospitals to work on their processes and design ways to deliver perfect care.” Bell noted that the hospital scored in the 95th percentile in all initiatives but one.

The quality scores of hospitals in the pay-for-performance pro-ject on 18 publicly reported indicators is six percentage points higher (85% versus 79%) than hospitals not participating in the pilot, according to Premier. At the Alabama hospital, administrators used a multidisciplinary approach for each process, tying the quality initiatives to the strategic plan and incorporating any potential payments to the hospital’s bonus program for those involved, including physicians, nurses, case managers, and pharmacists.

But Bell stressed that the pilot wasn’t about the money. “We’re continuing more as an improvement project,” Bell said. “The benefit is knowing the patient is receiving high-quality care. If it was just about checking boxes, I’d be in a different job.”

Changing workflow
Some of the processes involved changing workflow to include a new standard for care. In the case of pneumonia, the quality indicator states the patient should receive pneumoccoccal screening and/or vaccination prior to discharge. But a physician must order the test and/or vaccine before it can be done. Working with the medical executive committee, the hospital changed its default standard of care to include the necessary test or vaccine after checking for contraindications and talking to the patient. “Unless the patient refuses, the order is put on the chart, and a nurse handles it,” Bell said.

Other processes required changing long-held habits for many physicians. The standard of care for coronary artery bypass and hip and knee replacement calls for prophylactic antibiotics one hour prior to surgery, continuing no longer than 24 hours following surgery. Many physicians order antibiotics for longer periods of time, despite evidence that it doesn’t curb infection rates.

The first step was to meet with physicians, show them the evidence, and encourage them to change their behavior. In individual meetings, physicians were shown their antibiotic use against norms, again making the case to discontinue use within 24 hours of surgery. “Physicians are used to seeing their individual data and want to do well,” Bell said. “We’ve been doing this long enough now that it’s become part of the culture.”

If pay-for-performance measures become the reimbursement standard for hospitals, Bell said she believes that the use of EMRs will be vital for facilities to consistently meet those standards. A hospital could fail in the quality indicator of giving an aspirin upon arrival to those suffering from a heart attack simply because that step wasn’t documented. “Hospitals have to figure out how to make an EMR capture that data every time,” Bell said. “A patient could have gotten an aspirin at home, and if 95% compliance puts a hospital in the 50th percentile, they won’t get paid.”

East Alabama Medical Center continues to hone its processes to create a standardized, reportable care platform, which Bell believes puts the facility on the leading edge for expected changes in how hospitals get reimbursed. “Healthcare has been changing so much for hospitals, and now it’s going to affect physicians in their office practices.”

Baker agrees that the demonstration project improved the standard of care at the facility. “I like to think that EAMC physicians, nurses, and other caregivers always try to give every patient the right treatment, at the right time, every time,” Baker said. “The money was a nice reward, but we do it because it is the right thing to do.”

Matt Bolch, This e-mail address is being protected from spam bots, you need JavaScript enabled to view it , is a freelance writer based in Atlanta.