The New African Perspective: Growth and Transformation
The New AU building in Addis Ethiopia
Thursday, July 15, 2010
Exotic or Criminal Financial Instruments? Abacus and Goldman Sacks settling with 350 Million after getting 3.5 Billion earnings?
Dear Patriotic Global Citizens and Friends of African Union and Greater Ethiopia Without Borders
I could not help but comment on how the Goldman and his Sacks manage criminal wrong doing. They pay settlement without penalty and due process. What type of legal system is this protecting criminals.
What about
Goldman Sachs earned 3.4 Billion and gets 550 Million for its exotic criminal financial activities? 250 Million to Abacus Investors injured by the criminal activities and 300 million to US treasury.
Should we be fooled again? This is peanuts to the level of financial crime they committed and collect it Exotic Financing. Imagine Alakeda calling its 911 fiasco and criminal genocidal terror "Exotic adventure" and getting away with it.
We need some like President Bush that will say to the Goldmen that We have heard you Abacus Investors, you will hear from us soon! Can President Obama do some thing like this to these financial criminals who sank over 4 Trillion Dollars? Time will tell.
Why Do We Call Financial Instruments "Exotic"?
Because some of them are from Japan.
By Brian Palmer
Posted Wednesday, July 14, 2010, at 6:53 PM ET
Why do we call financial instruments "exotic"?
Three Republican senators have agreed to support the financial regulatory reform bill, making passage extremely likely. The legislation will more tightly regulate so-called exotic financial instruments like credit default swaps. When did people start referring to certain investments as exotic?
They've been doing it here and there for decades, but the term didn't become really popular until 1990. Many financial types have used the word "exotic" to describe newfangled or risky investments.
For example, in 1980, then-chairman of the Federal Reserve Paul Volcker, who worried that speculating with borrowed money might destroy the already fragile economy, issued the following warning to bankers: "This is hardly the time to search out for new exotic lending areas or to finance speculative or purely financial activities that have little to do with the performance of the American economy."
(Volcker continues to make the same argument. In a December 2009 conference, he singled out ATMs as perhaps the only useful financial innovation in the last 25 years.) Despite Volcker's prominence, his phrasing didn't go viral. It was Berkeley professor Mark Rubinstein's 1990 working paper, Exotic Options, that made the word a term of art in high finance.
RELATED IN SLATE
Daniel Hemel assailed a plan to let banks regulate credit default swaps. Daniel Gross warned of the dangers of empty creditors. Erica S. Peril offered a list of kid-friendly finance books. Juliet Lapidos explained what makes a loan exotic.
Rubinstein told the Explainer that he doesn't recall exactly why he chose the word exotic and acknowledges several possible sources for the coinage. First, some categories of options are named for their geographic origins. An American option allows its holder to buy or sell something at a particular price, regardless of its market value, anytime before the option expires.
The European option, in contrast, can only be exercised on the expiration date itself. In both styles, which have been around for centuries, the value of the option is based on the difference between the fixed option price and the market price of the underlying asset at the time you exercise the option. (For example, if the option lets you buy a stock for $10, and you exercise it on a day the stock is selling for $100 on the market, the option is worth $90.) In 1987, executives at the Tokyo office of an American bank sold the first Asian option.
Unlike the American and European versions, the value of the Asian option depends on the average price of the underlying asset over the period the option was held, not just the price at the moment the option is exercised. The allure of the hot new option from the Far East may have struck Rubinstein as exotic.
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On the other hand, Rubinstein might have picked the term up at the track. Novice gamblers usually make straight bets, predicting which horse will win, place, or show. But there are other possibilities, known as exotic wagers. You can win the trifecta by picking the first-, second-, and third-place horses in order. Predict the fourth-placed pony as well, and it's a superfecta. In the 1970s and early 1980s, Rubinstein was researching a racetrack-betting tactic that guaranteed profits. (He published his system in the journal Management Science in 1981.) It's possible, he says, that the word exotic was in his mind from that earlier work.
Journalists were also familiar with exotic wagers, which underwent public scrutiny long before exotic financial instruments. Many track-watchers blamed a series of race-fixing scandals in the 1970s and 1980s on high-payout exotic bets, which made cheating worthwhile. (To put it in perspective, a successful $1 bet on the superfecta in the 2010 Kentucky Derby paid a whopping $101,284.60.) For years, newspapers published calls for an end to the exotic wagers, but the system survived the controversy.
Got a question about today's news? Ask the Explainer.
Explainer thanks Mark Rubinstein of the University of California-Berkeley.
Like Slate and the Explainer on Facebook. Follow us on Twitter.
5 CommentsAdd Yours Or join the discussion
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Monday, July 12, 2010
World Bank Assessment of Ethiopia's 2009 Achievements
The World Bank’s country policy and institutional assessment (CPIA) rating is conducted annually and one of the factors that determine how much money each country is granted. Ethiopia performed best in its economic management, writes TAMRAT G. GIORGIS, FORTUNE STAFF WRITER.
WB Rating Slams Ethiopia’s Gender Inequality
Country fares above average but stands lower than its peers in region
The World Bank has made public its annual assessments of the policies and institutional qualities of member countries eligible for grants from the International Development Association (IDA), an organisation in the World Bank Group.
Known as Country Policy and Institutional Assessment (CPIA), the rating is conducted under the watchful eye of the chief economists of the regions. CPIA ratings constitute one third of the factors determining how much of the IDA’s annual seven billion dollars will go to each member country.
Apart from the CPIA ratings, the World Bank also considers factors such as a country’s population size and record of utilising grants, in deciding how much money to contribute to that country.
“We have only so much to give to all the countries under the IDA,” said Shantayanan Devarajan, chief economist of the World Bank for Africa region. “That is where selection comes [in]. But if we are to base our selection only on population size, India would take all the grants earmarked under the programme [and the] Maldives would get nothing.”
Seeing as countries with higher population sizes are constrained by their CPIA ratings, the Bank has a policy of not granting an amount of less than seven million dollars to any small country, according to the chief economist. However, many countries are in the middle of this matrix.
The CPI assessments are first compiled by a team of experts at a country level, before being sent to World Bank headquarters for review by chief economists from the six regions the bank is working in. Members of country teams always favour higher ratings for the countries they work on, according to the chief economist.
“[However], we want to look at policies not intended for implementation, but [which] are actually being implemented and bear results,” Devarajan told participants of the meeting.
The assessments are then sent to regional experts at the central departments who compare countries’ scores with each other. The final ratings, however, are decided at a meeting of experts from different regions, networks and central departments of the World Bank.
In 2004, the Bank reviewed the set of criteria used to judge countries; subsequently the criterion was downsized by four, to only 16. Moreover, the Bank’s management decided to begin disclosing these ratings on August 9, 2004.
For over four decades the World Bank has been very reluctant to disclose the content of these assessments. There were very few officials with access to these documents in the countries’ offices of the Bank, according to a staff member from the Bank’s office in Addis Abeba.
“It [was] a profound shift,” Devarajan said.
However, there appears to be a good reason for the Bank officials to have kept the assessments confidential seeing that many political leaders, whose countries are subjects of the review, do not like them.
Prime Minister Meles Zenawi, views the CPIA ratings as an ideological instrument of western neoliberals, interested only to impose the Washington Consensus, a list of policy manuals prescribed by the World Bank, including fiscal discipline, liberalisation of the financial sector, and privatisation.
Devarajan and his colleague had a three-hour debate with Meles in Addis Abeba in June 2009; they parted after agreeing to disagree, according to reliable sources. Their attempt to persuade Meles that aid works better in recipient countries where there are good policies in place and the institutions to implement these policies are strong did not fly high with him.
“He wants to be judged by the results his policies produce, not by the means that allow him to reach the end,” Devarajan told Fortune. This appears to be the message the Ethiopian government wished to send through its representative attending the meeting.
“We want the assessment to be more result orientated,” Hashim Ahmed, macroeconomic advisor to the government, told the meeting. “The results are what matter at the end. Look at how well we performed in meeting the Millennium Development Goals (MDGs).”
Meeting the MDGs does not stop the World Bank from passing judgment on the quality of a country’s policies and the strengths of its institutions. The latest judgment, for 2009, was revealed last week.
Ethiopia’s overall rating in the assessment, which comprises four categories and 16 sub-categories, stands at 3.4 points out of six. It is one decimal point above the average for countries borrowing from the IDA, but three decimal points lower than Kenya, and four decimal points below Rwanda and Tanzania.
Ethiopia performed best in its economic management, where it scored 3.7 points for its macroeconomic management and the quality of its fiscal and debt policies.
The lowest point, like most IDA borrowers, is registered in structural policies such as trade, the financial sector, and its business regulatory environment. Ethiopia’s rating of 3.2 points is lower than the average borrower by two decimal points.
The Bank’s assessment sees resource mobilisation by the Ethiopian financial sector as “modest and below potential,” and emphasises that long-term finance is unavailable from private banks.
“The coverage of [the] national land registration system is still not able to furnish the market with details of available land,” according to the assessment. “The use of land as collateral by investors is still not practical with banks as the market value of land is difficult to determine.”
However, none of the ratings were as controversial as the Bank’s conclusion on gender issues. Ethiopia’s social inclusion policies for gender equality scored three points, lower by four points from the average borrower and five points below Rwanda and Tanzania, although equal with Kenya.
“We are not happy with the rating on gender,” Hashim told Fortune. “Women’s empowerment and girls’ education take time, even generations.”
Hashim raises issues of women suffrage in the United States, which was enacted in 1960s.
“Even today, for every one dollar an American male makes, a woman gets only 72 cents,” he said. “Rating on gender ought to be taken within context of culture, history and laws.”
While the government is not happy about its ratings on gender equality, neither are delegates from non-governmental organisations.
The World Bank lacks acknowledging improvements made on the gender front and in areas of environmental protection, said Meshesha Shewarega (PhD), executive director for Christian Relief and Development Association (CRDA), the largest consortium representing 304 NGOs in Ethiopia.
The existence of laws that empower women and the enrolment of girls in elementary schools have increased, said Meshesha. By the bank’s own admission female participation in schools from first to eighth grades improved from 84pc in 2006, to 85pc the following year, and 91pc in 2009.
“So much has been achieved in bridging the gap over the past five years, and in meeting MDGs in areas of gender and health provisions,” Meshesha told Fortune. “All these have not been properly credited.”
These were the sort of acknowledgments that enabled Ethiopia to get the points it did. In their absence, its ratings, particularly compared to other countries, would have deteriorated further, Devarajan argues.
Despite these ideological objections, the assessment for 2009 is complete and has already contributed to the decision of the IDA to grant Ethiopia one billion dollars in loans in the current fiscal year.
The revealing and influential documents are available on the Bank’s website, www.worldbank.org
WB Rating Slams Ethiopia’s Gender Inequality
Country fares above average but stands lower than its peers in region
The World Bank has made public its annual assessments of the policies and institutional qualities of member countries eligible for grants from the International Development Association (IDA), an organisation in the World Bank Group.
Known as Country Policy and Institutional Assessment (CPIA), the rating is conducted under the watchful eye of the chief economists of the regions. CPIA ratings constitute one third of the factors determining how much of the IDA’s annual seven billion dollars will go to each member country.
Apart from the CPIA ratings, the World Bank also considers factors such as a country’s population size and record of utilising grants, in deciding how much money to contribute to that country.
“We have only so much to give to all the countries under the IDA,” said Shantayanan Devarajan, chief economist of the World Bank for Africa region. “That is where selection comes [in]. But if we are to base our selection only on population size, India would take all the grants earmarked under the programme [and the] Maldives would get nothing.”
Seeing as countries with higher population sizes are constrained by their CPIA ratings, the Bank has a policy of not granting an amount of less than seven million dollars to any small country, according to the chief economist. However, many countries are in the middle of this matrix.
The CPI assessments are first compiled by a team of experts at a country level, before being sent to World Bank headquarters for review by chief economists from the six regions the bank is working in. Members of country teams always favour higher ratings for the countries they work on, according to the chief economist.
“[However], we want to look at policies not intended for implementation, but [which] are actually being implemented and bear results,” Devarajan told participants of the meeting.
The assessments are then sent to regional experts at the central departments who compare countries’ scores with each other. The final ratings, however, are decided at a meeting of experts from different regions, networks and central departments of the World Bank.
In 2004, the Bank reviewed the set of criteria used to judge countries; subsequently the criterion was downsized by four, to only 16. Moreover, the Bank’s management decided to begin disclosing these ratings on August 9, 2004.
For over four decades the World Bank has been very reluctant to disclose the content of these assessments. There were very few officials with access to these documents in the countries’ offices of the Bank, according to a staff member from the Bank’s office in Addis Abeba.
“It [was] a profound shift,” Devarajan said.
However, there appears to be a good reason for the Bank officials to have kept the assessments confidential seeing that many political leaders, whose countries are subjects of the review, do not like them.
Prime Minister Meles Zenawi, views the CPIA ratings as an ideological instrument of western neoliberals, interested only to impose the Washington Consensus, a list of policy manuals prescribed by the World Bank, including fiscal discipline, liberalisation of the financial sector, and privatisation.
Devarajan and his colleague had a three-hour debate with Meles in Addis Abeba in June 2009; they parted after agreeing to disagree, according to reliable sources. Their attempt to persuade Meles that aid works better in recipient countries where there are good policies in place and the institutions to implement these policies are strong did not fly high with him.
“He wants to be judged by the results his policies produce, not by the means that allow him to reach the end,” Devarajan told Fortune. This appears to be the message the Ethiopian government wished to send through its representative attending the meeting.
“We want the assessment to be more result orientated,” Hashim Ahmed, macroeconomic advisor to the government, told the meeting. “The results are what matter at the end. Look at how well we performed in meeting the Millennium Development Goals (MDGs).”
Meeting the MDGs does not stop the World Bank from passing judgment on the quality of a country’s policies and the strengths of its institutions. The latest judgment, for 2009, was revealed last week.
Ethiopia’s overall rating in the assessment, which comprises four categories and 16 sub-categories, stands at 3.4 points out of six. It is one decimal point above the average for countries borrowing from the IDA, but three decimal points lower than Kenya, and four decimal points below Rwanda and Tanzania.
Ethiopia performed best in its economic management, where it scored 3.7 points for its macroeconomic management and the quality of its fiscal and debt policies.
The lowest point, like most IDA borrowers, is registered in structural policies such as trade, the financial sector, and its business regulatory environment. Ethiopia’s rating of 3.2 points is lower than the average borrower by two decimal points.
The Bank’s assessment sees resource mobilisation by the Ethiopian financial sector as “modest and below potential,” and emphasises that long-term finance is unavailable from private banks.
“The coverage of [the] national land registration system is still not able to furnish the market with details of available land,” according to the assessment. “The use of land as collateral by investors is still not practical with banks as the market value of land is difficult to determine.”
However, none of the ratings were as controversial as the Bank’s conclusion on gender issues. Ethiopia’s social inclusion policies for gender equality scored three points, lower by four points from the average borrower and five points below Rwanda and Tanzania, although equal with Kenya.
“We are not happy with the rating on gender,” Hashim told Fortune. “Women’s empowerment and girls’ education take time, even generations.”
Hashim raises issues of women suffrage in the United States, which was enacted in 1960s.
“Even today, for every one dollar an American male makes, a woman gets only 72 cents,” he said. “Rating on gender ought to be taken within context of culture, history and laws.”
While the government is not happy about its ratings on gender equality, neither are delegates from non-governmental organisations.
The World Bank lacks acknowledging improvements made on the gender front and in areas of environmental protection, said Meshesha Shewarega (PhD), executive director for Christian Relief and Development Association (CRDA), the largest consortium representing 304 NGOs in Ethiopia.
The existence of laws that empower women and the enrolment of girls in elementary schools have increased, said Meshesha. By the bank’s own admission female participation in schools from first to eighth grades improved from 84pc in 2006, to 85pc the following year, and 91pc in 2009.
“So much has been achieved in bridging the gap over the past five years, and in meeting MDGs in areas of gender and health provisions,” Meshesha told Fortune. “All these have not been properly credited.”
These were the sort of acknowledgments that enabled Ethiopia to get the points it did. In their absence, its ratings, particularly compared to other countries, would have deteriorated further, Devarajan argues.
Despite these ideological objections, the assessment for 2009 is complete and has already contributed to the decision of the IDA to grant Ethiopia one billion dollars in loans in the current fiscal year.
The revealing and influential documents are available on the Bank’s website, www.worldbank.org
Tuesday, July 6, 2010
Ethiopia and Africa Splitting into two in 10 million years?
Africa to split in two within ten million years
EMMA WOOLLACOTT | Mon 28th Jun 2010, 06:19 am#africa #afur #horn-of-africa
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Within 10 million years the Horn of Africa will fall away and a new ocean will form, says a team at the University of Leeds.
The scientists, who say their conclusion show that geology can be fast and furious, have created a 3D interactive movie based on their model of the Afar rift in Ethiopia. It shows how the African continent is cracking open both above and below ground.
In this remote desert a 40-mile segment of plate boundary cracked open by as much as eight metres over ten days in 2005. The gap filled with 2.5 cubic kilometres of molten rock.
Since then, the crack has been growing wider and longer with the latest eruptions taking place as recently as last month. The
scientists studying the region believe that a new ocean is slowly forming and will eventually split the African continent in two.
"The process of ocean formation is normally hidden deep beneath the seas, but in Afar we have are able to walk across the region as the Earth's surface splits apart - it really is amazing.
"We now have the opportunity to conduct all sorts of experiments in this unique natural laboratory, to further understand the processes involved in shaping the surface of the Earth. It is helping us to understand and mitigate natural hazards like earthquakes and volcanic eruptions," said Dr Tim Wright of the University of Leeds School of Earth and Environment.
"The activity in the last five years in Afar has been truly incredible - we have been witnessing the plates split apart in real time in front of our eyes. Our research has shown the importance of molten magma in the whole process - we have been able to track the magma from below the Earth's crust until it is intruded into cracks and solidifies into new crust, or is erupted at the surface."
The 3D movie can be seen this week in London at the Royal Society Summer Science Exhibition.
EMMA WOOLLACOTT | Mon 28th Jun 2010, 06:19 am#africa #afur #horn-of-africa
Share on Twitter
Share on Facebook
Share on Stumbleupon
Share on Digg
Share this article Add / View comments
Within 10 million years the Horn of Africa will fall away and a new ocean will form, says a team at the University of Leeds.
The scientists, who say their conclusion show that geology can be fast and furious, have created a 3D interactive movie based on their model of the Afar rift in Ethiopia. It shows how the African continent is cracking open both above and below ground.
In this remote desert a 40-mile segment of plate boundary cracked open by as much as eight metres over ten days in 2005. The gap filled with 2.5 cubic kilometres of molten rock.
Since then, the crack has been growing wider and longer with the latest eruptions taking place as recently as last month. The
scientists studying the region believe that a new ocean is slowly forming and will eventually split the African continent in two.
"The process of ocean formation is normally hidden deep beneath the seas, but in Afar we have are able to walk across the region as the Earth's surface splits apart - it really is amazing.
"We now have the opportunity to conduct all sorts of experiments in this unique natural laboratory, to further understand the processes involved in shaping the surface of the Earth. It is helping us to understand and mitigate natural hazards like earthquakes and volcanic eruptions," said Dr Tim Wright of the University of Leeds School of Earth and Environment.
"The activity in the last five years in Afar has been truly incredible - we have been witnessing the plates split apart in real time in front of our eyes. Our research has shown the importance of molten magma in the whole process - we have been able to track the magma from below the Earth's crust until it is intruded into cracks and solidifies into new crust, or is erupted at the surface."
The 3D movie can be seen this week in London at the Royal Society Summer Science Exhibition.
Thursday, July 1, 2010
Learning from Experience the Quality Improvement tool
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Today’s Big ACGME and Joint Commission Announcements: The Courage To – and Not To – Change
One of the mantras of performance improvement is that caregivers and provider organizations should learn from their experiences. That’s all well and good, but how about policy-setting organizations?
A few moments ago in the on-line version of the New England Journal of Medicine, two of the Biggest Kahunas in the safety and quality worlds – the Joint Commission (TJC) and the Accreditation Council for Graduate Medical Education (ACGME) – announced bold new policies. To their credit, both organizations have learned from their experiences… and their mistakes.
Let's start with the Joint Commission. In a gutsy move, three TJC leaders (led by CEO Mark Chassin) call for raising the bar on measures whose purpose is public accountability (i.e., measures used for pay for performance or public reporting programs). Mark was nice enough to invite me to co-author the manuscript, and I was proud to do so. I think it’s an important statement.
We begin today’s article by tracing the surprisingly brief history of national quality measurement. “Over the past decade we have learned that standardized data can be collected by thousands of hospitals to identify and implement substantial improvements in care,” we write. “We believe that the ‘proof of concept’ phase of national quality measurement and public reporting has now been completed.”
But, while quality measurement has led to real progress, there have been several speed bumps along the way – particularly when flawed measures have become national standards. To move the field forward, we propose that any measure being used for accountability purposes must:
1.…be based on a strong research foundation (at least two studies using robust methods, often randomized trials);
2.…capture whether the evidence-based care has actually been delivered; (“Organizations that wish to improve their performance record [on things like smoking cessation or discharge counseling] may be tempted to create clever… forms with just the right check-boxes… to satisfy the chart reviewers rules, instead of doing the hard work of improving their clinical care,” we observe);
3.…address a process relatively proximate to the desired outcome; and
4.…have minimal or no adverse consequences.
We then point to six existing TJC/Medicare measures that do not stack up, including measures of smoking cessation counseling and discharge instructions (which fail to capture the care process of interest and are subject to gaming); the measure of LV systolic function in hospitalized patients with heart failure (not proximate enough to an outcome of interest); and the measure of door-to-antibiotics time for patients with pneumonia (unanticipated consequence of unnecessary antibiotics for patients who don’t actually have pneumonia).
On the glass-is-half-full side of the ledger, of the 28 core measures publicly reported in 2010 by TJC and Medicare, 22 of them do meet all four criteria. Reassuringly, since the advent of public reporting, we’ve seen striking improvement in performance on these measures: whereas only 20% of US hospitals nailed more than 90% of all 22 measures in 2002, nearly 71% did so in 2008.
While the NEJM article describes a new philosophy around quality measurement, this is not just an academic exercise. In today’s issue of the Joint Commission’s online newsletter, TJC announced that it would embrace this approach for all its present and future quality and safety measures, and it challenged other stakeholders to do the same. Bravo.
We concluded our article this way:
Eliminating measures that do not pass these accountability tests and replacing them with ones that do will reduce unproductive work on the part of hospitals, enhance the credibility of the program with physicians and other key stakeholders, and increase the positive effect that all these programs will have on health outcomes for patients.
Let’s turn now to the ACGME, which today released its long-awaited revised residency duty hour regulations (they are subject to public comment for about 6 weeks before they become the Law of the Land). You know the background: in 2003, the organization famously made the “80-hour work week” a medical term of art. (I recently met Bertrand Bell, whose “Bell Commission” originally crafted New York state's 80-hour limits following the death of Libby Zion. “How did you choose 80?” I asked the curmudgeonly Dr. Bell, now in his 80s. “Sixty seemed too little, and 100 seemed too much,” he told me. “So we split the difference.”)
In their article in today's NEJM, ACGME leaders, led by CEO Tom Nasca, chronicle the positive changes that the 2003 regs were supposed to usher in, and why so many of them failed to materialize. For example, concerns have been raised that the regulations created a shift-work mentality among residents, have overemphasized duty hours over the equally important issue of housestaff supervision, and failed to account for the maturation stages of residents as they move through their years of training. Most damning, while there is evidence that residents’ quality of life improved after the 2003 duty hours limits, there is no evidence that the regulations resulted in better quality or safety.
In light of continued national anxiety about patient safety, some fairly aggressive recommendations in a 2008 IOM report, the fact that most other industrialized countries have duty hour limits of 50-60 hours/week, and substantial push from sleep researchers and other experts, the betting was that the ACGME would slash the duty hours limits again. For the last several months, the buzz among residency directors and teaching hospital leaders has crescendoed – like a World Cup crowd armed with noisy Vuvuzelas. Might the number of duty hours indeed be cut, perhaps down to as few as 60?
Cue the drum roll…..
And the answer is: the duty hour limits will remain 80 per week.
Yet the new regulations do call for substantial changes. For example, they:
•Insist on direct, in-house attending-level supervision of interns (either at the bedside or “on site and available to provide direct supervision”)
•Allow housestaff workload and autonomy to escalate as residents become more senior.
•Promote the primacy of education over service in curricular decision-making.
•Forbid 30-hour shifts for interns; the maximum intern shift will now be 16 hours (more senior residents can still do overnight shifts of up to 28 hours, with “strategic napping” encouraged).
I’m pleased that the ACGME resisted the pressure to cut the weekly duty hours further. In addition to the massive costs of replacing resident labor (with hospitalists or allied health professionals), I believe that lower hours would be detrimental to training: residents would be forced to pack more work into less time, shorter hours would further promote a run-for-the-doors mentality, we’d be stuck with even more risky handoffs, and – I know I sound like an old fogey – I worry that even good residency programs are graduating residents who aren’t ready to be practicing doctors because they haven’t cared for enough patients, exercised enough autonomy, or developed their professional compass around when it is in their patient’s interest for their physician to work while tired.
By retaining the 80-hour work week, I'm guessing that the ACGME hopes to give programs and hospitals some breathing room to focus on some of the more challenging, but ultimately more important, issues, including how to promote a culture of safety among residents and their programs, how to enhance supervision of trainees early in their training cycle while allowing graduated autonomy as residents move up the food chain, and how to emphasize education over service in resident rotations.
At UCSF Medical Center, anticipating the need for around-the-clock supervision and a ban on 24-hour shifts (we predicted that they would be forbidden for all trainees, not just interns), we will launch overnight hospitalist attending coverage starting next week. Although it will take a few organizational back flips to comply with the new intern 16-hour limits, today’s ACGME announcement means that the amount of transformation and associated costs will be significantly less than we anticipated. I’m hoping that we – and teaching hospitals everywhere – take advantage of this break by focusing some of our energy and resources on relieving housestaff of many of their clerical tasks that soak up their limited hours, rebalancing rotations to emphasize education over service, and improving handoffs. I think these moves would honor the spirit of what the ACGME intended to do.
Kudos to Tom Nasca and the ACGME for not taking the easy path: cutting duty hours to give the appearance of acting decisively in the name of safety. While one might arguably improve safety in the short term by slashing resident hours and replacing trainees with senior faculty (assuming we could find, and afford, enough of the latter), we would ultimately pay the price in safety and quality as a generation of undertrained individuals grew up to become our future physician workforce. The ACGME’s choices reflect an appropriate balancing of safety today and safety tomorrow, which is as it should be.
Taken together, both of today’s announcements are the products of courageous executives helping their organizations to make hard choices – choices that will be controversial but strike me as well considered and generally wise. As important as the individual decisions, both Chassin and Nasca have demonstrated that – even as they require that their accredited hospitals and training programs engage in continuous improvement and learn from their mistakes – they are guiding their own organizations to do the same.
Published Wed, Jun 23 2010 7:18 PM by Bob Wachter
Filed under: Quality Improvement, Hospital Care, Pay-for-performance, Transparency and Reporting, Quality Measurement, Medical Education/Academia, Hospitalists/Hospital Medicine, Patient Safety/Medical Errors, Health Policy
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9 Comments
Josh Adler MD said:
This is a very encouraging direction for The Joint Commission and I second your characterization as courageous. On the ACGME work hours announcement, this is encouraging in some respects. Not lowering the 80 hours does provide breathing room and recognizes the potential training value inherent in the long hours. But, the ACGME is noticibly silent on the profound effects that modifcations to duty hours have on the ability of hospitals and clinics to provide care. This is not to say that reducing hours was wrong, in fact it was certainly the correct direction to move. But, there has been little attention paid to the unintended (or perhaps intended) consequences for care delivery, including the vast number of hand offs created, the marked increases in allied health professionals employed (and their associated costs), and the impact on supervising physicians.
Thu, Jun 24 2010 1:26 AM
Bob Wachter said:
I can't resist this – my sports-nut of a son just sent me this link in honor of the World Cup (plus I think he was proud of the fact that I worked "vuvuzela" into my blog). His subject line was "Your New Homepage." It's pretty funny.
http://www.vuvuzela-time.co.uk/www.wachtersworld.com
You'll need your sound on, but not too loud.
-- Bob
Thu, Jun 24 2010 2:48 AM
Brian Clay, MD said:
@ Dr. Adler --
On the contrary, the new proposed regulations also include a Common Program Requirement that rotations "should be structured to minimize the number of handoffs required." I'm still attempting to determine how one does that with a reduction in maximum shift length (one would almost certainly cede that there will be more handoffs now than previously).
There are also new program requirements about training our housestaff in the skills of communication around handoffs and transitions of care. As an academic hospitalist and an associate program director for an internal medicine residency, I welcome these changes, as it gives our own division of hospital medicine standing to advance this curriculum and skill set to the residency at large, rather than just as individual attending physicians on our ward teams.
There is an additional upside to the new rules: if programs take the new rules as effectively closing the door on overnight call (and go to night team structures as a result), it affords an opportunity for many programs to move toward a unit-based, geographically cohorted model of care, where phenomena like multidisciplinary rounding with nursing and case management can occur much more easily.
We in hospital medicine should continue to take as a task for ourselves the research and advancement of effective and efficient handoffs -- our residents are going to need those skills.
Thu, Jun 24 2010 2:11 PM
Sumant said:
Actually, it's not clear if the proposed regulations require in-house attending-level supervision for interns. The regulations do say that interns require in-house supervision at all time, but also state that "for many aspects of patient care, the supervising physician may be a more advanced resident".
Fri, Jun 25 2010 4:39 AM
Guido Candiotti, MD said:
Based on the 4 measures to evaluate a quality measure, EHRs and CPOEs would fail on several to be useful, yet, the JC is serving out CPOE as though it is safe. Readers take note that two Harvard studies already report no improvement in costs or outcomes at highly wired hospitals. I am surprised you joined Dr. Chassin in this report.
Fri, Jun 25 2010 5:12 PM
Bob Wachter said:
Re: Sumant's comment: "not clear" is correct. I read the NEJM article, as well as the ACGME website, several times and still couldn't be sure I understood what kind of in-house supervision is needed for interns. I spoke to a friend who consulted with ACGME on the new regulations and is a senior educational leader at a major academic program; she too was not certain. This will obviously need to be clarified...
-- Bob
Sat, Jun 26 2010 6:05 AM
jqyoung said:
Brian: can you say more about how these changes might move us "toward a unit-based, geographically cohorted model of care." And what do you mean by this? I found this comment intriguing. Thanks.
Sat, Jun 26 2010 6:09 AM
Brian Clay, MD said:
jqyoung --
When residents admit new patients under the construct of a 30-hour shift, more often than not those patients are distributed among several patient care units in the hospital. This creates inefficiency on rounds (multiple floors to round on each day); it also hampers the ability of the housestaff (and their attending physicians) to work in conjunction with all of the ancillary services caring for the patient (nursing, therapies, case management) that, for the most part, are centered on a given patient care unit.
It is often the case that, on any hospital floor, the nurses, therapists, social workers, and case managers all know each other and work closely together, but the patients on that floor might have eight or nine separate physician service teams with primary responsibility for that set of 25 or so patients.
When overnight call goes away, the natural next construct for covering the hospital is to have several day shift teams, and one (or more if needed) night shift teams, with handoff moments in the early morning and early evening. All patients admitted at night will be passed off to their primary team in the morning.
If you set up a system where multiple day teams can admit concurrently, it is possible to actually match a resident team to an actual geographic set of beds (say, a hospital floor). In this way, that team would care for the patients on that floor, and that floor only. When admissions come to that floor (whether during the day, or passed off from the night team), a single resident team takes care of them.
Now you have a resident team structured the same way as the nurses, therapists, etc. -- based on a hospital unit. This gives the greatest opportunity to have physicians, nurses, and other team members rounding together on the patients and putting everyone on the same page in terms of the plan for the patient.
Mon, Jun 28 2010 9:30 AM
wrs said:
There has never been a randomized controlled study to show that parachutes work. Would the proposed framework support a hypothetical quality improvement project to measure the use of parachutes?
With The Joint Commission supporting an evidence-based practice framework, does this mean that there will be an elimination of current standards for which good evidence is lacking?
Mon, Jun 28 2010 10:34 PM
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Today’s Big ACGME and Joint Commission Announcements: The Courage To – and Not To – Change
One of the mantras of performance improvement is that caregivers and provider organizations should learn from their experiences. That’s all well and good, but how about policy-setting organizations?
A few moments ago in the on-line version of the New England Journal of Medicine, two of the Biggest Kahunas in the safety and quality worlds – the Joint Commission (TJC) and the Accreditation Council for Graduate Medical Education (ACGME) – announced bold new policies. To their credit, both organizations have learned from their experiences… and their mistakes.
Let's start with the Joint Commission. In a gutsy move, three TJC leaders (led by CEO Mark Chassin) call for raising the bar on measures whose purpose is public accountability (i.e., measures used for pay for performance or public reporting programs). Mark was nice enough to invite me to co-author the manuscript, and I was proud to do so. I think it’s an important statement.
We begin today’s article by tracing the surprisingly brief history of national quality measurement. “Over the past decade we have learned that standardized data can be collected by thousands of hospitals to identify and implement substantial improvements in care,” we write. “We believe that the ‘proof of concept’ phase of national quality measurement and public reporting has now been completed.”
But, while quality measurement has led to real progress, there have been several speed bumps along the way – particularly when flawed measures have become national standards. To move the field forward, we propose that any measure being used for accountability purposes must:
1.…be based on a strong research foundation (at least two studies using robust methods, often randomized trials);
2.…capture whether the evidence-based care has actually been delivered; (“Organizations that wish to improve their performance record [on things like smoking cessation or discharge counseling] may be tempted to create clever… forms with just the right check-boxes… to satisfy the chart reviewers rules, instead of doing the hard work of improving their clinical care,” we observe);
3.…address a process relatively proximate to the desired outcome; and
4.…have minimal or no adverse consequences.
We then point to six existing TJC/Medicare measures that do not stack up, including measures of smoking cessation counseling and discharge instructions (which fail to capture the care process of interest and are subject to gaming); the measure of LV systolic function in hospitalized patients with heart failure (not proximate enough to an outcome of interest); and the measure of door-to-antibiotics time for patients with pneumonia (unanticipated consequence of unnecessary antibiotics for patients who don’t actually have pneumonia).
On the glass-is-half-full side of the ledger, of the 28 core measures publicly reported in 2010 by TJC and Medicare, 22 of them do meet all four criteria. Reassuringly, since the advent of public reporting, we’ve seen striking improvement in performance on these measures: whereas only 20% of US hospitals nailed more than 90% of all 22 measures in 2002, nearly 71% did so in 2008.
While the NEJM article describes a new philosophy around quality measurement, this is not just an academic exercise. In today’s issue of the Joint Commission’s online newsletter, TJC announced that it would embrace this approach for all its present and future quality and safety measures, and it challenged other stakeholders to do the same. Bravo.
We concluded our article this way:
Eliminating measures that do not pass these accountability tests and replacing them with ones that do will reduce unproductive work on the part of hospitals, enhance the credibility of the program with physicians and other key stakeholders, and increase the positive effect that all these programs will have on health outcomes for patients.
Let’s turn now to the ACGME, which today released its long-awaited revised residency duty hour regulations (they are subject to public comment for about 6 weeks before they become the Law of the Land). You know the background: in 2003, the organization famously made the “80-hour work week” a medical term of art. (I recently met Bertrand Bell, whose “Bell Commission” originally crafted New York state's 80-hour limits following the death of Libby Zion. “How did you choose 80?” I asked the curmudgeonly Dr. Bell, now in his 80s. “Sixty seemed too little, and 100 seemed too much,” he told me. “So we split the difference.”)
In their article in today's NEJM, ACGME leaders, led by CEO Tom Nasca, chronicle the positive changes that the 2003 regs were supposed to usher in, and why so many of them failed to materialize. For example, concerns have been raised that the regulations created a shift-work mentality among residents, have overemphasized duty hours over the equally important issue of housestaff supervision, and failed to account for the maturation stages of residents as they move through their years of training. Most damning, while there is evidence that residents’ quality of life improved after the 2003 duty hours limits, there is no evidence that the regulations resulted in better quality or safety.
In light of continued national anxiety about patient safety, some fairly aggressive recommendations in a 2008 IOM report, the fact that most other industrialized countries have duty hour limits of 50-60 hours/week, and substantial push from sleep researchers and other experts, the betting was that the ACGME would slash the duty hours limits again. For the last several months, the buzz among residency directors and teaching hospital leaders has crescendoed – like a World Cup crowd armed with noisy Vuvuzelas. Might the number of duty hours indeed be cut, perhaps down to as few as 60?
Cue the drum roll…..
And the answer is: the duty hour limits will remain 80 per week.
Yet the new regulations do call for substantial changes. For example, they:
•Insist on direct, in-house attending-level supervision of interns (either at the bedside or “on site and available to provide direct supervision”)
•Allow housestaff workload and autonomy to escalate as residents become more senior.
•Promote the primacy of education over service in curricular decision-making.
•Forbid 30-hour shifts for interns; the maximum intern shift will now be 16 hours (more senior residents can still do overnight shifts of up to 28 hours, with “strategic napping” encouraged).
I’m pleased that the ACGME resisted the pressure to cut the weekly duty hours further. In addition to the massive costs of replacing resident labor (with hospitalists or allied health professionals), I believe that lower hours would be detrimental to training: residents would be forced to pack more work into less time, shorter hours would further promote a run-for-the-doors mentality, we’d be stuck with even more risky handoffs, and – I know I sound like an old fogey – I worry that even good residency programs are graduating residents who aren’t ready to be practicing doctors because they haven’t cared for enough patients, exercised enough autonomy, or developed their professional compass around when it is in their patient’s interest for their physician to work while tired.
By retaining the 80-hour work week, I'm guessing that the ACGME hopes to give programs and hospitals some breathing room to focus on some of the more challenging, but ultimately more important, issues, including how to promote a culture of safety among residents and their programs, how to enhance supervision of trainees early in their training cycle while allowing graduated autonomy as residents move up the food chain, and how to emphasize education over service in resident rotations.
At UCSF Medical Center, anticipating the need for around-the-clock supervision and a ban on 24-hour shifts (we predicted that they would be forbidden for all trainees, not just interns), we will launch overnight hospitalist attending coverage starting next week. Although it will take a few organizational back flips to comply with the new intern 16-hour limits, today’s ACGME announcement means that the amount of transformation and associated costs will be significantly less than we anticipated. I’m hoping that we – and teaching hospitals everywhere – take advantage of this break by focusing some of our energy and resources on relieving housestaff of many of their clerical tasks that soak up their limited hours, rebalancing rotations to emphasize education over service, and improving handoffs. I think these moves would honor the spirit of what the ACGME intended to do.
Kudos to Tom Nasca and the ACGME for not taking the easy path: cutting duty hours to give the appearance of acting decisively in the name of safety. While one might arguably improve safety in the short term by slashing resident hours and replacing trainees with senior faculty (assuming we could find, and afford, enough of the latter), we would ultimately pay the price in safety and quality as a generation of undertrained individuals grew up to become our future physician workforce. The ACGME’s choices reflect an appropriate balancing of safety today and safety tomorrow, which is as it should be.
Taken together, both of today’s announcements are the products of courageous executives helping their organizations to make hard choices – choices that will be controversial but strike me as well considered and generally wise. As important as the individual decisions, both Chassin and Nasca have demonstrated that – even as they require that their accredited hospitals and training programs engage in continuous improvement and learn from their mistakes – they are guiding their own organizations to do the same.
Published Wed, Jun 23 2010 7:18 PM by Bob Wachter
Filed under: Quality Improvement, Hospital Care, Pay-for-performance, Transparency and Reporting, Quality Measurement, Medical Education/Academia, Hospitalists/Hospital Medicine, Patient Safety/Medical Errors, Health Policy
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9 Comments
Josh Adler MD said:
This is a very encouraging direction for The Joint Commission and I second your characterization as courageous. On the ACGME work hours announcement, this is encouraging in some respects. Not lowering the 80 hours does provide breathing room and recognizes the potential training value inherent in the long hours. But, the ACGME is noticibly silent on the profound effects that modifcations to duty hours have on the ability of hospitals and clinics to provide care. This is not to say that reducing hours was wrong, in fact it was certainly the correct direction to move. But, there has been little attention paid to the unintended (or perhaps intended) consequences for care delivery, including the vast number of hand offs created, the marked increases in allied health professionals employed (and their associated costs), and the impact on supervising physicians.
Thu, Jun 24 2010 1:26 AM
Bob Wachter said:
I can't resist this – my sports-nut of a son just sent me this link in honor of the World Cup (plus I think he was proud of the fact that I worked "vuvuzela" into my blog). His subject line was "Your New Homepage." It's pretty funny.
http://www.vuvuzela-time.co.uk/www.wachtersworld.com
You'll need your sound on, but not too loud.
-- Bob
Thu, Jun 24 2010 2:48 AM
Brian Clay, MD said:
@ Dr. Adler --
On the contrary, the new proposed regulations also include a Common Program Requirement that rotations "should be structured to minimize the number of handoffs required." I'm still attempting to determine how one does that with a reduction in maximum shift length (one would almost certainly cede that there will be more handoffs now than previously).
There are also new program requirements about training our housestaff in the skills of communication around handoffs and transitions of care. As an academic hospitalist and an associate program director for an internal medicine residency, I welcome these changes, as it gives our own division of hospital medicine standing to advance this curriculum and skill set to the residency at large, rather than just as individual attending physicians on our ward teams.
There is an additional upside to the new rules: if programs take the new rules as effectively closing the door on overnight call (and go to night team structures as a result), it affords an opportunity for many programs to move toward a unit-based, geographically cohorted model of care, where phenomena like multidisciplinary rounding with nursing and case management can occur much more easily.
We in hospital medicine should continue to take as a task for ourselves the research and advancement of effective and efficient handoffs -- our residents are going to need those skills.
Thu, Jun 24 2010 2:11 PM
Sumant said:
Actually, it's not clear if the proposed regulations require in-house attending-level supervision for interns. The regulations do say that interns require in-house supervision at all time, but also state that "for many aspects of patient care, the supervising physician may be a more advanced resident".
Fri, Jun 25 2010 4:39 AM
Guido Candiotti, MD said:
Based on the 4 measures to evaluate a quality measure, EHRs and CPOEs would fail on several to be useful, yet, the JC is serving out CPOE as though it is safe. Readers take note that two Harvard studies already report no improvement in costs or outcomes at highly wired hospitals. I am surprised you joined Dr. Chassin in this report.
Fri, Jun 25 2010 5:12 PM
Bob Wachter said:
Re: Sumant's comment: "not clear" is correct. I read the NEJM article, as well as the ACGME website, several times and still couldn't be sure I understood what kind of in-house supervision is needed for interns. I spoke to a friend who consulted with ACGME on the new regulations and is a senior educational leader at a major academic program; she too was not certain. This will obviously need to be clarified...
-- Bob
Sat, Jun 26 2010 6:05 AM
jqyoung said:
Brian: can you say more about how these changes might move us "toward a unit-based, geographically cohorted model of care." And what do you mean by this? I found this comment intriguing. Thanks.
Sat, Jun 26 2010 6:09 AM
Brian Clay, MD said:
jqyoung --
When residents admit new patients under the construct of a 30-hour shift, more often than not those patients are distributed among several patient care units in the hospital. This creates inefficiency on rounds (multiple floors to round on each day); it also hampers the ability of the housestaff (and their attending physicians) to work in conjunction with all of the ancillary services caring for the patient (nursing, therapies, case management) that, for the most part, are centered on a given patient care unit.
It is often the case that, on any hospital floor, the nurses, therapists, social workers, and case managers all know each other and work closely together, but the patients on that floor might have eight or nine separate physician service teams with primary responsibility for that set of 25 or so patients.
When overnight call goes away, the natural next construct for covering the hospital is to have several day shift teams, and one (or more if needed) night shift teams, with handoff moments in the early morning and early evening. All patients admitted at night will be passed off to their primary team in the morning.
If you set up a system where multiple day teams can admit concurrently, it is possible to actually match a resident team to an actual geographic set of beds (say, a hospital floor). In this way, that team would care for the patients on that floor, and that floor only. When admissions come to that floor (whether during the day, or passed off from the night team), a single resident team takes care of them.
Now you have a resident team structured the same way as the nurses, therapists, etc. -- based on a hospital unit. This gives the greatest opportunity to have physicians, nurses, and other team members rounding together on the patients and putting everyone on the same page in terms of the plan for the patient.
Mon, Jun 28 2010 9:30 AM
wrs said:
There has never been a randomized controlled study to show that parachutes work. Would the proposed framework support a hypothetical quality improvement project to measure the use of parachutes?
With The Joint Commission supporting an evidence-based practice framework, does this mean that there will be an elimination of current standards for which good evidence is lacking?
Mon, Jun 28 2010 10:34 PM
Leave a Comment
Comments to Wachter's World are welcome provided that they are:
•On topic, i.e. you have read the post and are commenting on its topic.
•Adding something to the post, i.e. "you stink" and "you rock" are equally useless.
•Polite, or at least professional.
•Not overly promotional or outright spam.
I may remove any comment that does not meet these criteria.
Accountability Measures to Promote Quality Improvement
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Published at www.nejm.org June 23, 2010 (10.1056/NEJMsb1002320)
Accountability Measures — Using Measurement to Promote Quality Improvement
Mark R. Chassin, M.D., M.P.P., M.P.H., Jerod M. Loeb, Ph.D., Stephen P. Schmaltz, Ph.D., and Robert M. Wachter, M.D.
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Measuring the quality of health care and using those measurements to promote improvements in the delivery of care, to influence payment for services, and to increase transparency are now commonplace.
These activities, which now involve virtually all U.S. hospitals, are migrating to ambulatory and other care settings and are increasingly evident in health care systems worldwide. Many constituencies are pressing for continued expansion of programs that rely on quality measurement and reporting.
In this article, we review the origins of contemporary standardized quality measurement, with a focus on hospitals, where such programs have reached their most highly developed state.
We discuss some lessons learned from recent experience and propose a conceptual framework to guide future developments in this fast-moving field. Although many of the points we make are relevant to all kinds of quality measurement, including outcome measures, we focus our comments on process measures, both because these account for most of the measures in current use and because outcome measures have additional scientific challenges surrounding the need for case-mix adjustment.
We write not as representatives of the Joint Commission articulating a specific new position of that group, but rather as individuals who have worked in the fields of quality measurement and improvement in a variety of roles and settings over many years.
A Brief History of Hospital Quality Measurement and Reporting in the United States
Although the ubiquity of quality measurement and reporting makes it difficult to remember a health care landscape without them, these trends are remarkably recent. In 1998, the Joint Commission launched its ORYX initiative, the first national program for the measurement of hospital quality, which initially required the reporting only of nonstandardized data on performance measures.1
In 2002, accredited hospitals were required to collect and report data on performance for at least two of four core measure sets (acute myocardial infarction, heart failure, pneumonia, and pregnancy)2; these data were made publicly available by the Joint Commission in 2004.
When the program started, no consensus existed regarding the kinds of measures on which data should be gathered by hospitals, no data on quality of care were collected systematically by hospitals, and little information on nationally standardized measures of hospital quality was available to the public. Few hospitals used national data on quality measures to improve clinical care processes; in fact, hospitals strongly resisted collecting data on quality measures and reporting them publicly.
The changes over the past decade have been breathtaking. The National Quality Forum has endorsed more than 600 quality measures.3 In 2004, the Centers for Medicare and Medicaid Services (CMS) began financially penalizing hospitals that did not report to the CMS the same performance data they collected for the Joint Commission, and in 2005, the CMS began its own public reporting.4,5 Today, hospitals provide data to the Joint Commission from a selection of 57 inpatient measures; currently, 31 of these are publicly reported, and there are plans to add the remaining, newly implemented measures over time.6,7 The CMS also includes additional data on patient satisfaction and outcomes (death and readmissions) for common medical conditions such as pneumonia and heart failure.
The Effect of Quality Measurement
As we consider the effect of this new quality-measurement and reporting effort, there is much to celebrate. Many measures are quite robust, with tight, evidence-based links between process performance and patient outcomes. With the use of these measures, we have seen gratifying improvements in the performance of hospitals. For example, in 2009, a total of 98.3% of eligible patients with acute myocardial infarction received a beta-blocker at hospital discharge, as compared with 87.3% of such patients in 20028 (the Joint Commission's hospital performance-measure data warehouse; 2009 data will be available to the public in September 2010).
Equally important, the consistency of hospital performance on key quality measures — such as prescribing beta-blockers and angiotensin-converting–enzyme inhibitors (or angiotensin-receptor blockers) to patients with an acute myocardial infarction and, in selected patients undergoing surgery, administering and discontinuing prophylactic antibiotics at the appropriate times to reduce surgical site infections — has increased dramatically in recent years (Figure 1). For example, in 2009 (data available to the public in September 2010), 96.8% of hospitals showed performance levels greater than 90% in administering beta-blockers at discharge to patients who had had an acute myocardial infarction, as compared with 49.1% in 2002.
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Figure 1. Performance of U.S. Hospitals on Four Publicly Reported Quality Measures.
The performance of U.S. hospitals from 2002 through 2009 on four publicly reported quality measures regarding patients with acute myocardial infarction (Panels A and B) and the appropriate administration of prophylactic antibiotics in patients undergoing surgery (Panels C and D) are shown. Two measures were chosen from the measure set for acute myocardial infarction and two from the measure set of surgical care, which began data collection in 2004. There were similar increasing trends for other measures of performance. ACE denotes angiotensin-converting enzyme, ARB angiotensin-receptor blocker, and LVSD left ventricular systolic dysfunction.
Because these quality-measurement and reporting programs were not implemented with the use of an experimental design, and virtually all U.S. hospitals participate in them, it is not possible to know how many of these improvements would have occurred in the absence of standardized measurement, Joint Commission accreditation requirements, public reporting, or the threat of Medicare payment penalties. On the other hand, no other national data on quality of which we are aware show such high levels of performance, nor are there other national examples of the greatly narrowed variation around high levels of performance that these data currently exhibit.
This quality-measurement and improvement effort is not without cost. Although some information can be collected relatively inexpensively from administrative data sets, many data elements — particularly those that capture the granular clinical detail that make the data credible — require painstaking and expensive review of medical records, most of which are paper records. The requirements are such that a small industry of performance-measurement–system vendors, extensively vetted and operating under stringent quality standards, supports the ORYX initiative.9 The Joint Commission and the CMS have worked hard to ensure that in the case of the measures that are common to both programs, definitions and requirements for data collection are identical, allowing most data elements to be collected only once. ORYX vendors then submit the same data to both the Joint Commission and the CMS, satisfying both accreditation and payment requirements.10
In other words, over the past decade we have learned that standardized data can be collected by thousands of hospitals to identify and implement substantial improvements in care. Although measure specifications must keep up with emerging and evolving science, these challenges have not proved to be insurmountable. We believe that the "proof of concept" phase of national quality measurement and public reporting has now been completed.
Room for Improvement
Despite the progress that has been made, even proponents of the national quality programs of the Joint Commission and the CMS identify room for improvement. To address legitimate concerns about the program, we propose that such programs now focus explicitly on maximizing health benefits to patients.
Achieving this goal requires examining closely the roster of measures currently included in these programs, establishing criteria to separate measures that advance this goal from those that do not, and replacing poorly performing measures with better ones. To make these goals operational, we suggest that all quality measures used in national transparency and payment programs — both existing ones and proposed new ones — be vetted against four criteria.
First, a measure must be based on a strong foundation of research showing that the process addressed by the measure, when performed correctly, leads to improved clinical outcomes. We note here that a strong foundation means more than one study, however persuasive any single investigation might be. We do not expect that this evidence base will consist solely of data from randomized trials, though much of it will. We believe that a high bar, one that exceeds the typical standard used for the development of practice guidelines, is appropriate for measures that are used in national programs of quality measurement and improvement, since these programs affect thousands of hospitals and millions of patients. Fortunately, the state of the science has advanced to the point that we now have many measures from which to choose that meet this criterion.
Second, the measurement strategy must accurately capture whether the evidence-based care has been delivered. For example, the Joint Commission and the CMS currently measure aspirin administration after an acute myocardial infarction by reviewing a medication-administration record (or its equivalent) — a measure that genuinely captures the process of interest.11 On the other hand, we measure the presence of comprehensive discharge planning and of smoking-cessation counseling by whether a clinician has checked off a box or otherwise documented that such activities occurred.
We know that for patients with heart failure, comprehensive education at discharge and coordination of care after discharge lead to improvements in functional outcomes, reductions in emergency department visits, and fewer hospitalizations,12 but our current measure is incapable of judging the quality of the process (i.e., whether the process is delivered with sufficient effectiveness to make improved outcomes likely). Organizations that wish to improve their performance record may be tempted to create clever discharge-instruction forms with just the right check-boxes and printed information summaries to satisfy the chart reviewers' rules concerning compliance with the measure, instead of doing the hard work of improving their clinical care.
We were, therefore, not surprised when researchers recently found no relationship between hospital performance on the discharge-instruction measure for heart failure and readmission rates.13 We need a better measure for this important process; until we find one, measuring a check-box serves only to give us a false sense of accomplishment and reward "gaming."
Third, the measure should address a process quite proximate to the desired outcome, with relatively few intervening processes. Measures of appropriately administered medications meet this test, whereas the measure calling for an assessment of left ventricular function in patients with heart failure does not. With respect to the latter measure, although all patients with heart failure should have their ventricular function measured at some point, many other correctly performed clinical processes must occur after the test has been performed for the patient to have an improved outcome. The beneficial effect of processes as far upstream from outcomes as this one will be nullified if important processes closer to the outcome are not performed effectively. In such cases, we believe that the measurement of these processes is of little value, especially in the hospital inpatient setting.
This criterion should be applied somewhat differently in ambulatory care settings, where it will be appropriate for some accountability measures to address processes that are quite upstream from outcomes, such as measures of the evidence-based use of mammography or Pap smears.
Even in these cases, though, we believe that such upstream measures will be inadequate by themselves to serve as accountability measures. To provide a more complete assessment of quality, they should be coupled with measures of more downstream processes, such as the timeliness of follow-up and communication of results and the occurrence and appropriateness of definitive treatment when abnormal test results are found.
Fourth, the measure should have minimal or no unintended adverse consequences. Some evidence suggests that administering the first dose of an antibiotic to a patient with community-acquired pneumonia within the first several hours after the patient's arrival at the hospital improves outcomes.14 However, the initial Joint Commission and CMS measure of that process (first dose of antibiotic within 4 hours [later relaxed to 6 hours] after arrival at the hospital) undoubtedly led to the inappropriate administration of antibiotics to patients who did not truly have pneumonia.15,16 Although "diagnostic uncertainty" was added to the measure criteria as a data element, permitting hospitals to exclude some such patients, the fundamental flaw in the measure remains.16
In summary, measures currently used in national quality programs that do not meet the criteria for accountability measures include: three measures concerning smoking-cessation counseling — those for adults with acute myocardial infarction, adults with heart failure, and adults with pneumonia — and the measure concerning discharge instructions for patients with heart failure, because these measures fail to accurately capture the care process; a measure concerning the evaluation of left ventricular systolic function in patients with heart failure, because it is not sufficiently proximate to the outcome; and a measure calling for the initial administration of antibiotics in patients with pneumonia within 6 hours after the patient's arrival at the hospital, because it has the potential to cause adverse consequences (see Table A in the Supplementary Appendix, available with the full text of this article at NEJM.org).
A Way Forward — A Focus on Accountability Measures
We believe that measures that meet all four criteria (Table 1) will have the greatest likelihood of improving patient outcomes. Therefore, although other measures may be useful for internal quality-improvement purposes, we propose that only those measures that meet all four criteria be used for purposes of accountability (e.g., for accreditation, public reporting, or pay-for-performance). Of the 28 Joint Commission 2010 core measures that are aligned with Medicare, we believe that 22 meet all four criteria and could be deemed "accountability measures" (see Table B in the Supplementary Appendix).
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Table 1. Four Criteria for Accountability Measures That Address Processes of Care.
Achieving the goal of improving health outcomes requires, of course, that hospitals make improvements in the clinical processes of care assessed by these accountability measures. Experience to date shows that such improvement is taking place at an accelerating pace. Table 2 shows the progress that hospitals have made in improving their performance on these measures — from a performance rate of 81.8% in 2002 to a rate of 95.4% in 2009. Moreover, by 2009, among all 3123 reporting hospitals, the 22 accountability measures that were in use at that time assessed about 12.5 million opportunities to provide specific elements of evidence-based care. The percentage of hospitals whose performance across all their accountability measures exceeded 90% increased substantially — from 20.4% in 2002 to 85.9% in 2009.
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Table 2. Improvement in Performance on Accountability Core Measures from 2002 through 2009.
Challenges in Implementing a Program of Accountability Measures
Implementing these criteria presents several challenges to all the key stakeholders, but we believe that these challenges are manageable. We recognize that many current measures will not meet the stringent accountability criteria. We need to be certain that measures that do not qualify still remain available for other important purposes, when they are appropriate. For example, individual health care organizations could consider using them for their own quality initiatives. After local experimentation and modification, some may ultimately be added to the set of accountability measures.
There are other challenges as well. A narrow focus on quality measures in hospitals may miss the importance of postdischarge care for a patient — for example, a patient with heart failure. The proposed development of bundled payments and accountable care organizations may facilitate the development of inpatient and outpatient measures that are more integrated, which will be particularly useful when high-quality care requires the coordination of care across the continuum. As indicated earlier, the four criteria for accountability measures may require some adaptation for the assessment of ambulatory care. We believe, however, that these criteria can serve as a useful framework for identifying accountability measures in nonhospital settings.
Finally, the process of improving our system of high-stakes quality measurement requires perpetual vigilance. Although some unintended adverse consequences can be anticipated and avoided during the initial evaluation of a measure, others may not become evident until many hospitals use the measures. A vital part of this program, largely absent today, will be a formal process of assessing experience with the measures and using that information to improve the development of measures and decisions regarding deployment.16
The Goal — Measurement for Improvement
We call on all stakeholders that promulgate, support, or advocate for programs that use incentives of various sorts designed to promote quality in hospitals and health systems and among physicians to consider adopting this framework for accountability measures. For its part, the Joint Commission is incorporating this framework into its programs. We believe that the time is right for such a consensus to emerge. Far from the past attitude of resistance to all measurement, hospitals and physicians have embraced the measurement, and even the reporting, of robust and authentic quality metrics as an important mechanism to drive the improvement of clinical processes. In doing so, they have achieved substantial gains that have undoubtedly saved thousands of lives.
Fortunately, as the science has advanced, we now have a surfeit of measures that meet all four accountability criteria with which to populate accreditation, public reporting, and pay-for-performance programs. Eliminating measures that do not pass these accountability tests and replacing them with ones that do will reduce unproductive work on the part of hospitals, enhance the credibility of the program with physicians and other key stakeholders, and increase the positive effect that all these programs will have on health outcomes for patients.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
Source Information
From the Joint Commission, Oakbrook Terrace, IL (M.R.C., J.M.L., S.P.S.); and the Department of Medicine, University of California, San Francisco, San Francisco (R.M.W.).
This article (10.1056/NEJMsb1002320) was published on June 23, 2010, at NEJM.org.
References
Lee KY, Loeb JM, Nadzam DM, Hanold LS. An overview of the Joint Commission's ORYX initiative and proposed statistical methods. Health Serv Outcomes Res Methodol 2000;1:63-73. [CrossRef]
Williams SC, Schmaltz SP, Morton DJ, Koss RG, Loeb JM. Quality of care in U.S. hospitals as reflected by standardized measures, 2002-2004. N Engl J Med 2005;353:255-264. [Free Full Text]
NQF-endorsed standards. Washington, DC: National Quality Forum. (Accessed May 27, 2010, at http://www.qualityforum.org/Measures_List.aspx.)
Centers for Medicare and Medicaid Services. Medicare modernization update. (Accessed May 27, 2010, at http://www.cms.hhs.gov/MMAUpdate/.)
Idem. Hospital quality initiatives: Hospital Quality Alliance. (Accessed May 27, 2010, at http://www.cms.hhs.gov/HospitalQualityInits/33_HospitalQualityAlliance.asp.)
The Joint Commission. 2009 ORYX performance measure reporting requirements for hospitals and guidelines for measure selections. (Accessed May 27, 2010, at http://www.jointcommission.org/NR/rdonlyres/64C5EDF0-253A-42CE-9DE5-C8AFE6755267/0/09_Oryx_hap.pdf.)
Idem. Performance measurement initiatives. (Accessed May 27, 2010, at http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/default.htm.)
Idem. Improving America's hospitals: the Joint Commission's annual report on quality and safety. 2009. (Accessed May 27, 2010, at http://www.jointcommission.org/NR/rdonlyres/22D58F1F-14FF-4B72-A870-378DAF26189E/0/2009_Annual_Report.pdf.)
Idem. Listed systems supporting core measures. (Accessed May 27, 2010, at http://www.jointcommission.org/NR/rdonlyres/3E3D16BE-3D28-47B9-86C3-DBC4D736407D/0/CoreDirectory3_24.pdf.)
Hospital quality data: CMS needs more rigorous methods to ensure reliability of publicly released data. Washington, DC: Government Accountability Office, January 2006. (Accessed May 27, 2010, at http://www.gao.gov/new.items/d0654.pdf.)
The Joint Commission and Centers for Medicare and Medicaid Services. Specifications manual for national hospital quality measures. 2009. (Accessed May 27, 2010, at http://www.jointcommission.org/performancemeasurement/performancemeasurement/historical+nhqm+manuals.htm.)
Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. JAMA 2004;291:1358-1367. [Free Full Text]
Jha AK, Orav EJ, Epstein AM. Public reporting of discharge planning and rates of readmissions. N Engl J Med 2009;361:2637-2645. [Free Full Text]
Houck PM, Bratzler DW, Nsa W, Ma A, Bartlett JG. Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia. Arch Intern Med 2004;164:637-644. [Free Full Text]
Kanwar M, Brar N, Khatib R, Fakih MG. Misdiagnosis of community-acquired pneumonia and inappropriate utilization of antibiotics: side effects of the 4-h antibiotic administration rule. Chest 2007;131:1865-1869. [Free Full Text]
Wachter RM, Flanders SA, Fee C, Pronovost PJ. Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure. Ann Intern Med 2008;149:29-32. [Free Full Text]
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Published at www.nejm.org June 23, 2010 (10.1056/NEJMsb1002320)
Accountability Measures — Using Measurement to Promote Quality Improvement
Mark R. Chassin, M.D., M.P.P., M.P.H., Jerod M. Loeb, Ph.D., Stephen P. Schmaltz, Ph.D., and Robert M. Wachter, M.D.
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Measuring the quality of health care and using those measurements to promote improvements in the delivery of care, to influence payment for services, and to increase transparency are now commonplace.
These activities, which now involve virtually all U.S. hospitals, are migrating to ambulatory and other care settings and are increasingly evident in health care systems worldwide. Many constituencies are pressing for continued expansion of programs that rely on quality measurement and reporting.
In this article, we review the origins of contemporary standardized quality measurement, with a focus on hospitals, where such programs have reached their most highly developed state.
We discuss some lessons learned from recent experience and propose a conceptual framework to guide future developments in this fast-moving field. Although many of the points we make are relevant to all kinds of quality measurement, including outcome measures, we focus our comments on process measures, both because these account for most of the measures in current use and because outcome measures have additional scientific challenges surrounding the need for case-mix adjustment.
We write not as representatives of the Joint Commission articulating a specific new position of that group, but rather as individuals who have worked in the fields of quality measurement and improvement in a variety of roles and settings over many years.
A Brief History of Hospital Quality Measurement and Reporting in the United States
Although the ubiquity of quality measurement and reporting makes it difficult to remember a health care landscape without them, these trends are remarkably recent. In 1998, the Joint Commission launched its ORYX initiative, the first national program for the measurement of hospital quality, which initially required the reporting only of nonstandardized data on performance measures.1
In 2002, accredited hospitals were required to collect and report data on performance for at least two of four core measure sets (acute myocardial infarction, heart failure, pneumonia, and pregnancy)2; these data were made publicly available by the Joint Commission in 2004.
When the program started, no consensus existed regarding the kinds of measures on which data should be gathered by hospitals, no data on quality of care were collected systematically by hospitals, and little information on nationally standardized measures of hospital quality was available to the public. Few hospitals used national data on quality measures to improve clinical care processes; in fact, hospitals strongly resisted collecting data on quality measures and reporting them publicly.
The changes over the past decade have been breathtaking. The National Quality Forum has endorsed more than 600 quality measures.3 In 2004, the Centers for Medicare and Medicaid Services (CMS) began financially penalizing hospitals that did not report to the CMS the same performance data they collected for the Joint Commission, and in 2005, the CMS began its own public reporting.4,5 Today, hospitals provide data to the Joint Commission from a selection of 57 inpatient measures; currently, 31 of these are publicly reported, and there are plans to add the remaining, newly implemented measures over time.6,7 The CMS also includes additional data on patient satisfaction and outcomes (death and readmissions) for common medical conditions such as pneumonia and heart failure.
The Effect of Quality Measurement
As we consider the effect of this new quality-measurement and reporting effort, there is much to celebrate. Many measures are quite robust, with tight, evidence-based links between process performance and patient outcomes. With the use of these measures, we have seen gratifying improvements in the performance of hospitals. For example, in 2009, a total of 98.3% of eligible patients with acute myocardial infarction received a beta-blocker at hospital discharge, as compared with 87.3% of such patients in 20028 (the Joint Commission's hospital performance-measure data warehouse; 2009 data will be available to the public in September 2010).
Equally important, the consistency of hospital performance on key quality measures — such as prescribing beta-blockers and angiotensin-converting–enzyme inhibitors (or angiotensin-receptor blockers) to patients with an acute myocardial infarction and, in selected patients undergoing surgery, administering and discontinuing prophylactic antibiotics at the appropriate times to reduce surgical site infections — has increased dramatically in recent years (Figure 1). For example, in 2009 (data available to the public in September 2010), 96.8% of hospitals showed performance levels greater than 90% in administering beta-blockers at discharge to patients who had had an acute myocardial infarction, as compared with 49.1% in 2002.
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Figure 1. Performance of U.S. Hospitals on Four Publicly Reported Quality Measures.
The performance of U.S. hospitals from 2002 through 2009 on four publicly reported quality measures regarding patients with acute myocardial infarction (Panels A and B) and the appropriate administration of prophylactic antibiotics in patients undergoing surgery (Panels C and D) are shown. Two measures were chosen from the measure set for acute myocardial infarction and two from the measure set of surgical care, which began data collection in 2004. There were similar increasing trends for other measures of performance. ACE denotes angiotensin-converting enzyme, ARB angiotensin-receptor blocker, and LVSD left ventricular systolic dysfunction.
Because these quality-measurement and reporting programs were not implemented with the use of an experimental design, and virtually all U.S. hospitals participate in them, it is not possible to know how many of these improvements would have occurred in the absence of standardized measurement, Joint Commission accreditation requirements, public reporting, or the threat of Medicare payment penalties. On the other hand, no other national data on quality of which we are aware show such high levels of performance, nor are there other national examples of the greatly narrowed variation around high levels of performance that these data currently exhibit.
This quality-measurement and improvement effort is not without cost. Although some information can be collected relatively inexpensively from administrative data sets, many data elements — particularly those that capture the granular clinical detail that make the data credible — require painstaking and expensive review of medical records, most of which are paper records. The requirements are such that a small industry of performance-measurement–system vendors, extensively vetted and operating under stringent quality standards, supports the ORYX initiative.9 The Joint Commission and the CMS have worked hard to ensure that in the case of the measures that are common to both programs, definitions and requirements for data collection are identical, allowing most data elements to be collected only once. ORYX vendors then submit the same data to both the Joint Commission and the CMS, satisfying both accreditation and payment requirements.10
In other words, over the past decade we have learned that standardized data can be collected by thousands of hospitals to identify and implement substantial improvements in care. Although measure specifications must keep up with emerging and evolving science, these challenges have not proved to be insurmountable. We believe that the "proof of concept" phase of national quality measurement and public reporting has now been completed.
Room for Improvement
Despite the progress that has been made, even proponents of the national quality programs of the Joint Commission and the CMS identify room for improvement. To address legitimate concerns about the program, we propose that such programs now focus explicitly on maximizing health benefits to patients.
Achieving this goal requires examining closely the roster of measures currently included in these programs, establishing criteria to separate measures that advance this goal from those that do not, and replacing poorly performing measures with better ones. To make these goals operational, we suggest that all quality measures used in national transparency and payment programs — both existing ones and proposed new ones — be vetted against four criteria.
First, a measure must be based on a strong foundation of research showing that the process addressed by the measure, when performed correctly, leads to improved clinical outcomes. We note here that a strong foundation means more than one study, however persuasive any single investigation might be. We do not expect that this evidence base will consist solely of data from randomized trials, though much of it will. We believe that a high bar, one that exceeds the typical standard used for the development of practice guidelines, is appropriate for measures that are used in national programs of quality measurement and improvement, since these programs affect thousands of hospitals and millions of patients. Fortunately, the state of the science has advanced to the point that we now have many measures from which to choose that meet this criterion.
Second, the measurement strategy must accurately capture whether the evidence-based care has been delivered. For example, the Joint Commission and the CMS currently measure aspirin administration after an acute myocardial infarction by reviewing a medication-administration record (or its equivalent) — a measure that genuinely captures the process of interest.11 On the other hand, we measure the presence of comprehensive discharge planning and of smoking-cessation counseling by whether a clinician has checked off a box or otherwise documented that such activities occurred.
We know that for patients with heart failure, comprehensive education at discharge and coordination of care after discharge lead to improvements in functional outcomes, reductions in emergency department visits, and fewer hospitalizations,12 but our current measure is incapable of judging the quality of the process (i.e., whether the process is delivered with sufficient effectiveness to make improved outcomes likely). Organizations that wish to improve their performance record may be tempted to create clever discharge-instruction forms with just the right check-boxes and printed information summaries to satisfy the chart reviewers' rules concerning compliance with the measure, instead of doing the hard work of improving their clinical care.
We were, therefore, not surprised when researchers recently found no relationship between hospital performance on the discharge-instruction measure for heart failure and readmission rates.13 We need a better measure for this important process; until we find one, measuring a check-box serves only to give us a false sense of accomplishment and reward "gaming."
Third, the measure should address a process quite proximate to the desired outcome, with relatively few intervening processes. Measures of appropriately administered medications meet this test, whereas the measure calling for an assessment of left ventricular function in patients with heart failure does not. With respect to the latter measure, although all patients with heart failure should have their ventricular function measured at some point, many other correctly performed clinical processes must occur after the test has been performed for the patient to have an improved outcome. The beneficial effect of processes as far upstream from outcomes as this one will be nullified if important processes closer to the outcome are not performed effectively. In such cases, we believe that the measurement of these processes is of little value, especially in the hospital inpatient setting.
This criterion should be applied somewhat differently in ambulatory care settings, where it will be appropriate for some accountability measures to address processes that are quite upstream from outcomes, such as measures of the evidence-based use of mammography or Pap smears.
Even in these cases, though, we believe that such upstream measures will be inadequate by themselves to serve as accountability measures. To provide a more complete assessment of quality, they should be coupled with measures of more downstream processes, such as the timeliness of follow-up and communication of results and the occurrence and appropriateness of definitive treatment when abnormal test results are found.
Fourth, the measure should have minimal or no unintended adverse consequences. Some evidence suggests that administering the first dose of an antibiotic to a patient with community-acquired pneumonia within the first several hours after the patient's arrival at the hospital improves outcomes.14 However, the initial Joint Commission and CMS measure of that process (first dose of antibiotic within 4 hours [later relaxed to 6 hours] after arrival at the hospital) undoubtedly led to the inappropriate administration of antibiotics to patients who did not truly have pneumonia.15,16 Although "diagnostic uncertainty" was added to the measure criteria as a data element, permitting hospitals to exclude some such patients, the fundamental flaw in the measure remains.16
In summary, measures currently used in national quality programs that do not meet the criteria for accountability measures include: three measures concerning smoking-cessation counseling — those for adults with acute myocardial infarction, adults with heart failure, and adults with pneumonia — and the measure concerning discharge instructions for patients with heart failure, because these measures fail to accurately capture the care process; a measure concerning the evaluation of left ventricular systolic function in patients with heart failure, because it is not sufficiently proximate to the outcome; and a measure calling for the initial administration of antibiotics in patients with pneumonia within 6 hours after the patient's arrival at the hospital, because it has the potential to cause adverse consequences (see Table A in the Supplementary Appendix, available with the full text of this article at NEJM.org).
A Way Forward — A Focus on Accountability Measures
We believe that measures that meet all four criteria (Table 1) will have the greatest likelihood of improving patient outcomes. Therefore, although other measures may be useful for internal quality-improvement purposes, we propose that only those measures that meet all four criteria be used for purposes of accountability (e.g., for accreditation, public reporting, or pay-for-performance). Of the 28 Joint Commission 2010 core measures that are aligned with Medicare, we believe that 22 meet all four criteria and could be deemed "accountability measures" (see Table B in the Supplementary Appendix).
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Table 1. Four Criteria for Accountability Measures That Address Processes of Care.
Achieving the goal of improving health outcomes requires, of course, that hospitals make improvements in the clinical processes of care assessed by these accountability measures. Experience to date shows that such improvement is taking place at an accelerating pace. Table 2 shows the progress that hospitals have made in improving their performance on these measures — from a performance rate of 81.8% in 2002 to a rate of 95.4% in 2009. Moreover, by 2009, among all 3123 reporting hospitals, the 22 accountability measures that were in use at that time assessed about 12.5 million opportunities to provide specific elements of evidence-based care. The percentage of hospitals whose performance across all their accountability measures exceeded 90% increased substantially — from 20.4% in 2002 to 85.9% in 2009.
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Table 2. Improvement in Performance on Accountability Core Measures from 2002 through 2009.
Challenges in Implementing a Program of Accountability Measures
Implementing these criteria presents several challenges to all the key stakeholders, but we believe that these challenges are manageable. We recognize that many current measures will not meet the stringent accountability criteria. We need to be certain that measures that do not qualify still remain available for other important purposes, when they are appropriate. For example, individual health care organizations could consider using them for their own quality initiatives. After local experimentation and modification, some may ultimately be added to the set of accountability measures.
There are other challenges as well. A narrow focus on quality measures in hospitals may miss the importance of postdischarge care for a patient — for example, a patient with heart failure. The proposed development of bundled payments and accountable care organizations may facilitate the development of inpatient and outpatient measures that are more integrated, which will be particularly useful when high-quality care requires the coordination of care across the continuum. As indicated earlier, the four criteria for accountability measures may require some adaptation for the assessment of ambulatory care. We believe, however, that these criteria can serve as a useful framework for identifying accountability measures in nonhospital settings.
Finally, the process of improving our system of high-stakes quality measurement requires perpetual vigilance. Although some unintended adverse consequences can be anticipated and avoided during the initial evaluation of a measure, others may not become evident until many hospitals use the measures. A vital part of this program, largely absent today, will be a formal process of assessing experience with the measures and using that information to improve the development of measures and decisions regarding deployment.16
The Goal — Measurement for Improvement
We call on all stakeholders that promulgate, support, or advocate for programs that use incentives of various sorts designed to promote quality in hospitals and health systems and among physicians to consider adopting this framework for accountability measures. For its part, the Joint Commission is incorporating this framework into its programs. We believe that the time is right for such a consensus to emerge. Far from the past attitude of resistance to all measurement, hospitals and physicians have embraced the measurement, and even the reporting, of robust and authentic quality metrics as an important mechanism to drive the improvement of clinical processes. In doing so, they have achieved substantial gains that have undoubtedly saved thousands of lives.
Fortunately, as the science has advanced, we now have a surfeit of measures that meet all four accountability criteria with which to populate accreditation, public reporting, and pay-for-performance programs. Eliminating measures that do not pass these accountability tests and replacing them with ones that do will reduce unproductive work on the part of hospitals, enhance the credibility of the program with physicians and other key stakeholders, and increase the positive effect that all these programs will have on health outcomes for patients.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
Source Information
From the Joint Commission, Oakbrook Terrace, IL (M.R.C., J.M.L., S.P.S.); and the Department of Medicine, University of California, San Francisco, San Francisco (R.M.W.).
This article (10.1056/NEJMsb1002320) was published on June 23, 2010, at NEJM.org.
References
Lee KY, Loeb JM, Nadzam DM, Hanold LS. An overview of the Joint Commission's ORYX initiative and proposed statistical methods. Health Serv Outcomes Res Methodol 2000;1:63-73. [CrossRef]
Williams SC, Schmaltz SP, Morton DJ, Koss RG, Loeb JM. Quality of care in U.S. hospitals as reflected by standardized measures, 2002-2004. N Engl J Med 2005;353:255-264. [Free Full Text]
NQF-endorsed standards. Washington, DC: National Quality Forum. (Accessed May 27, 2010, at http://www.qualityforum.org/Measures_List.aspx.)
Centers for Medicare and Medicaid Services. Medicare modernization update. (Accessed May 27, 2010, at http://www.cms.hhs.gov/MMAUpdate/.)
Idem. Hospital quality initiatives: Hospital Quality Alliance. (Accessed May 27, 2010, at http://www.cms.hhs.gov/HospitalQualityInits/33_HospitalQualityAlliance.asp.)
The Joint Commission. 2009 ORYX performance measure reporting requirements for hospitals and guidelines for measure selections. (Accessed May 27, 2010, at http://www.jointcommission.org/NR/rdonlyres/64C5EDF0-253A-42CE-9DE5-C8AFE6755267/0/09_Oryx_hap.pdf.)
Idem. Performance measurement initiatives. (Accessed May 27, 2010, at http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/default.htm.)
Idem. Improving America's hospitals: the Joint Commission's annual report on quality and safety. 2009. (Accessed May 27, 2010, at http://www.jointcommission.org/NR/rdonlyres/22D58F1F-14FF-4B72-A870-378DAF26189E/0/2009_Annual_Report.pdf.)
Idem. Listed systems supporting core measures. (Accessed May 27, 2010, at http://www.jointcommission.org/NR/rdonlyres/3E3D16BE-3D28-47B9-86C3-DBC4D736407D/0/CoreDirectory3_24.pdf.)
Hospital quality data: CMS needs more rigorous methods to ensure reliability of publicly released data. Washington, DC: Government Accountability Office, January 2006. (Accessed May 27, 2010, at http://www.gao.gov/new.items/d0654.pdf.)
The Joint Commission and Centers for Medicare and Medicaid Services. Specifications manual for national hospital quality measures. 2009. (Accessed May 27, 2010, at http://www.jointcommission.org/performancemeasurement/performancemeasurement/historical+nhqm+manuals.htm.)
Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. JAMA 2004;291:1358-1367. [Free Full Text]
Jha AK, Orav EJ, Epstein AM. Public reporting of discharge planning and rates of readmissions. N Engl J Med 2009;361:2637-2645. [Free Full Text]
Houck PM, Bratzler DW, Nsa W, Ma A, Bartlett JG. Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia. Arch Intern Med 2004;164:637-644. [Free Full Text]
Kanwar M, Brar N, Khatib R, Fakih MG. Misdiagnosis of community-acquired pneumonia and inappropriate utilization of antibiotics: side effects of the 4-h antibiotic administration rule. Chest 2007;131:1865-1869. [Free Full Text]
Wachter RM, Flanders SA, Fee C, Pronovost PJ. Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure. Ann Intern Med 2008;149:29-32. [Free Full Text]
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