“What gets measured gets done” is an all-too-familiar doctrine in Washington among health policy experts in their quest to leverage payment to evidence of value. This linkage was strengthened on November 27, 2013, when the Centers for Medicare & Medicaid Services (CMS) released its 2014 Physician Fee Schedule (PFS). Its focus on quality reporting has far-reaching implications for all medical specialties.
The quality movement was first introduced in manu-facturing nearly 50 years ago with the teachings of W. Edwards Deming, Philip B. Crosby, Joseph M. Juran and others. It has gone through several iterations, including Total Quality Management, Continuous Quality Improvement and its more recent relatives in ISO 9000, Lean Manufacturing and Six Sigma. The quality movement has migrated to most industries and has spawned the development of associations, professions and recognition, such as the Malcolm Baldrige National Quality Award. While there are some differences among quality systems, four attributes are common:
• The critical role of customers/users in defining quality
• The importance of data and measurement
• Breakdowns, and thus improvements, in quality can be attributed to systems, not to individuals
• Quality is a long-term and continuous process of improvement.
Despite this history, health care, as an industry, has been relatively late to the movement. Now, however, most parties agree that the only solution to our current health care challenge is to focus on value and the triple aim of better care, healthy people and reduced per-capita cost.
Until recently, one could summarize the key roles of medical societies as twofold: professional education and advocacy. This is changing, and quality is rapidly becoming the third leg of the specialty society “stool.” I recently attended a meeting of medical specialty executives focused on the impact of the quality movement on our respective societies. Overwhelmingly there was a consensus that the drive for value in medicine is creating in our organizations the concept of “quality” as a core competence. I found that most of our counterpart organizations, like us, were engaged in multiple activities, including the development of specialty-wide and/or procedural registries, development and maintenance of measures, increased emphasis on standards and guidelines, and development of integrated models of care (such as the Perioperative Surgical Home). Large-scale clinical data registries are viewed as essential. They provide the real-world experience to help drive and evaluate other quality measurement activities. Interestingly, as specialty societies mature in the quality realm, there is increasing collaboration, in particular around joint measures.
The specialty of anesthesiology and ASA have been focused on quality for many years through the leadership of several committees, including Standards and Practice Parameters and Quality Management and Departmental Administration, and the formation of the Anesthesia Quality Institute (AQI) in 2010. From a staff perspective, we recently brought these related activities together into a single division, under the direction of Richard Dutton, M.D., M.B.A., Chief Quality Officer.
At its core is the AQI, which has been amassing data at an accelerating rate. In just five years and with the participation of nearly 25 percent of our active members, it has compiled more than 14 million cases, turning this valuable information into data that are being sought by regulators, policymakers, our peers and other governmental agencies.
“We’re already at the front, and we need to get to the next level first,” Dr. Dutton advised me. “We’re the natural leaders of this system because we see all patients. We’re one of the only specialties who do. Surgeons know just their patients – but we know them all.”
As government continues to drive the change from fee-for-service to bundled care, it’s imperative that a data-driven measurement process be in place to incentivize quality care. This is where the AQI’s role becomes paramount. Dr. Dutton noted:
“It’s going great for AQI, and thus for ASA and anesthesiology. When we started collecting data five years ago, we were behind almost everyone else – upwards of 20 years behind. Today, we’re no worse than even. By this time next year, we will be the clear leader over all specialties, largely through our emphasis on the passive collection of electronic records. This puts us in a position of leadership in the Perioperative Surgical Home and beyond.”
Similarly, ASA formed in 2012 a new Quality and Regulatory Affairs (QRA) department that has taken the lead to advance quality measurement, develop regulatory materials for members, and actively participate in external quality and regulatory opportunities such as those with The Joint Commission and CMS. Recently, ASA secured written support from CMS in pursuing shared accountability measures. CMS has signed a letter endorsing such measures and encouraged measure stewards to actively engage ASA in developing joint accountability measures and revising existing ones. Recently, ASA successfully submitted four measures to CMS for 2015 PQRS consideration. These measures address post-anesthetic transfer of care, use of aspirin for patients with coronary artery stents, and prevention of postoperative nausea and vomiting in adult and pediatric patients.
Despite our progress, this is a relatively new activity for us – as it is for most of medicine – yet our specialty and our society have the knowledge, skills and, most of all, the will to lead. Our staff looks forward to working with you on this important journey.