Measuring and Reporting Individual Physician Performance

1. Measuring and Reporting Individual Physician Performance SEPTEMBER 2011 Penny Andrew

2. Overview • What is physician performance measurement? • Why? • What is happening internationally? • What performance measures are being used? • How are performance measures being used? • What are the pitfalls? • Unintended consequences • Confidentiality • Public reporting

3. What is physician performance measurement?

4. End Results Idea Ernest Amory Codman (1869 – 1940)

5. Why measure physician performance?

6. A multitude of potential uses... • Stimulate improvements in quality / maintain standards • Reduce/eliminate unacceptable variation • Reduce cost – the "business case for quality" • Promote the use of providers that deliver the best quality for price – "value-based purchasing" • Promote accountability • MOPS/certification • Pay for Performance P4P • Public reporting • Engage and empower consumers

7. What is most important? Reflection on clinical practice/quality improvement “Measures are the only way we can really know if care is safe, efficient, effective, and patient-centered. Performance measures also help us improve faster” TIM FERRIS MD MPH 

8. What is happening internationally?

9. USA

11. Background: Physician Performance Measurement Initiatives Measures Development AHRQ – CAHPS standardised patient experience surveys NCQA – HEDIS clinical quality measures NQF - > 500 endorsed performance measures AMA – Physician Consortium for Performance Improvement (PCPI) 266 clinical performance measures (structure, process, outcome) Measurement and Reporting Federal CMS – Physician Quality Reporting System State Cardiac Surgery Reporting Systems Employers & Health Plans Leapfrog Group & Bridges to Excellence State & Regional Collaboratives Massachusetts MHQP California Pay for Performance (P4P) initiative Medical/Speciality Societies See RAND working paper: Providing Performance Feedback to Individual Physicians: Current Practice and Emerging Lessons July 2006 Roski , Kim M. Current efforts of regional and national performance measurement initiatives around the United States. Am J Med Qual. 2010;25(4):249-54

12. US public reporting Pay for performance (P4P) initiatives CMS Physician Quality Reporting System (PQRS) State reporting cardiothoracic surgeons Consumer reporting

13. US public reporting – CMS PQRI CMS – Physician Quality Reporting System P4P +2% + 0.5%maintenance of certification incentive Names of eligible practices and individual physicians but not results...yet

14. US – state reporting on cardiothoracic surgery

15. US – state reporting on cardiothoracic surgery

16. US Variation Reporting - Dartmouth Atlas http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

17. UK

18. UK physician performance measurement and reporting Slower to start...but catching up fast NHS surveys (patient experience reporting) Picker Europe 2004 > Quality Outcome Framework (QOF)

19. UK 2005 > Quality Outcomes Framework (P4P primary care) GP practice-level performance reporting

20. UK 2005 > Quality Outcomes Framework (P4P primary care) GP practice-level performance reporting

21. UK NHS Choices 2010 > NHS Choices Consumer Comments GP practice performance Quality Accounts

22. UK NHS Choices 2010 > NHS Choices Consumer Comments GP practice performance

23. UK Quality Accounts Quality Accounts All providers of NHS services (Primary Care QAs from June 2012) Mandatory indicator reporting + local priorities

24. UK Quality Accounts All providers of NHS services (Primary Care QAs from June 2012) Mandatory indicator reporting + local priorities

25. UK Primary Care Variation Measurement and Reporting Dr Foster Primary care variation measurement and reporting

26. AUSTRALIA

27. Australian Commission on Safety and Quality in Health Care ACSQHC 55 National Safety and Quality Indicators 13 Primary Care Indicators 2 main purposes: priorities and system-level strategies for safety and quality improvement inform quality improvement activities of service providers http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/217E5A28E94590E0CA2577C900111538/$File/TNI-Sep2009.PDF

28. Australia RACGP http://www.racgp.org.au/

29. Australia RACGP Clinical Audit Tool http://www.clinicalaudit.com.au/

30. NZ

31. NZ Lots of data, lacking in intelligence! Ministry of Health NMDS Health Independence Reports (14 quality & effectiveness indicators Health Targets

32. NZ PHO Performance Management Programme DHBNZ P4P PHO performance – individual PHOs

33. NZ PHO Performance Management Programme

34. NZ Private Organisations Healthstat Best Practice Advocacy Center (BPAC)

35. NZ Public Reporting Health Quality and Safety Commission Serious and Sentinel Event Reporting In the future... Variation reporting (NZ Atlas) Quality Accounts

36. NZ Maintenance of Professional Standards Medical Council of NZ Recertification and CPD Continuing professional development is involvement in clinical audit, peer review and CME, aimed at ensuring that a doctor is competent to practise medicine Clinical audit is a process used to assess, evaluate and improve the care of patients in a systematic...by objectively measuring your performance against standards... It involves a cycle of continuous improvement of care, based on explicit and measurable indicators of quality. It has a statistical basis Regular practice review is informed by a portfolio of information provided by the doctor, which may include audit outcomes and logbooks

37. NZ RNZCGP Aiming for Excellence Aiming for Excellence 2011 —The Standard for New Zealand General Practice APPENDIX: Develop practice-based activities to improve clinical outcomes for patients https://rnzcgp.org.nz/assets/documents/CORNERSTONE/Aiming-for-Excellence-2011.pdf

38. NZ Quality Measures Library http://202.89.42.8/dev/library/index.php

39. What are the pitfalls?

40. Unintended consequences of measuring and reporting • Possible dysfunctional consequences – organisations or individuals may: • concentrate on the clinical areas being measured to the detriment of other important areas ('tunnel vision') • pursue narrow organisational objectives at the expense of strategic coordination (‘sub-optimisation’) • concentrate on short-term issues and neglect long-term criteria (‘myopia’) • place greater emphasis on not being exposed as an outlier rather than on a desire to be outstanding (‘convergence’) • be disinclined to experiment with new and innovative approaches for fear of appearing to perform poorly (‘ossification’) • alter their behaviour to gain strategic advantage (‘gaming’) • indulge in selective and creative data gathering, classification and coding, perhaps extending to outright misreporting and fraud (‘misrepresentation’) Huw Davies Measuring and reporting the quality of health care: issues and evidence from the international research literature. NHS Quality Improvement Scotland, 2006

41. Pitfalls • Methodological robustness of measures • Sample size • Incomplete patient list • Risk adjustment • Attribution • Bias • Limitations of type of measure (structure/process/outcome)

42. Focus on the Vital Few! There are many things in life that are interestingto know. It is far more important, however, to work on those things that are essentialto quality rather than spend time working on what is merely interesting! The challenge is to be disciplined enough to focus on the essential (or vital few) things • 2009 Institute for Healthcare Improvement, R. Lloyd 42

43. Measurement Guidelines • Report and study a few key measures monthly • Don’t overdo process indicators • Use available data bases to develop measures • Integrate data collection into daily routines • Plot data on key measures each month 43

44. Pitfalls • Confidentiality of performance information?

45. When must information be disclosed? • Entities with powers to require disclosure of information • HDC • s62 Health and Disability Commissioner Act • Coroners • Commissions of Inquiry • Courts • Tribunals • Mortality Review Committees

46. When must information be disclosed? • Rights to information • NZ Bill of Rights • Section 14 Freedom of expression Everyone has the right to freedom of expression, including the freedom to seek, receive, and impart information and opinions of any kind in any form • Consumers' Code of Rights • Right 6 Right to be Fully Informed including: • information that a reasonable consumer, in that consumers' circumstances, would expect to receive • the identity and qualifications of the provider

47. When must information be disclosed? • Official Information Act 1982 • Applies to government officials/bodies e.g. MOH/Crown Entities/DHBs • Starting point of the Act is the "principle of availability" • Good reason for withholding includes protecting personal privacy • Public interest balancing test – reason for withholding must outweigh public interest in disclosure

48. How can information be protected? Official Information Act and Privacy Act Personal privacy Mortality Review Committees Schedule 5 NZ Public Health and Disability Act Protected Quality Assurance Activities (PQAAs) Sections 54-63 Health Practitioners Competence Assurance Act

49. Protected Quality Assurance Activities • Section 53 of the HPCAA defines a QAA as: an activity that is undertaken to improve the practices or competence of one or more health practitioners by assessing the health services performed by those health practitioners… • Gazetted PQAA Notice required

50. Effect of the Protected Status of a QAA • Subject to certain exceptions, a protected QAA means that: • any information that becomes known solely as a result of the activity is confidential; and • any documents brought into existence solely for the purposes of the activity are confidential; and • no civil or disciplinary proceedings lie against any person in respect of conduct engaged in good faith in connection with a protected QAA