Since the publication of the Institute of Medicine's 1999 report To Err is Human, health care has been moving toward total performance transparency as a way to improve patient safety and quality.

Today, our ability to collect, analyze and report data across the health care continuum puts that goal in sight. However, the ability to measure quality—to quantify the previously unmeasurable—has empowered the Centers for Medicare & Medicaid Services to alter its reimbursement schema significantly. This change has practical implications for health care executives; it means not only looking at a broader array of data, but embracing a new way of thinking about metrics and developing new policies to support their use.

Beyond Core Measures

CMS always has been a main driver behind the patient safety and health care quality agenda. The fact that its payment criteria increasingly are outcomes-based puts additional pressures on caregivers and leaders alike to take a longer and wider view of patient care. Proving adherence to protocols endorsed by traditional bodies like the Joint Commission is no longer enough to guarantee reimbursement—CMS now can pay for performance as measured by outcomes.

Existing policies designed to encourage compliance with treatment protocols for such core measures conditions as acute myocardial infarction and children's asthma care will prove insufficient for guaranteeing positive outcomes across all conditions. In fact, of the 20 conditions identified by Medicare as responsible for 95 percent of the agency's costs—known as high-impact conditions—only AMI, congestive heart failure and stroke are core measures. We need a more holistic approach that encompasses more conditions.

CMS itself endorses this approach by increasingly looking to organizations like the Healthcare Information and Management Systems Society and the National Quality Forum as endorsing bodies. For example, among NQF's assigned tasks in its contract with Health & Human Services is the use of its consensus development process to endorse performance measures. By giving a voice to organizations that develop quality metrics, CMS has signaled its intent to continue on the pay-for-performance path and to extend its reach beyond the scope defined by the Joint Commission.

Outcomes, Not Just Protocols

Putting policies in place to ensure good outcomes for all conditions, particularly Medicare's high-impact ones, requires an infrastructure designed to support a longer and wider focus. Hospital executives, physician leaders and the board must be vocal proponents of this holistic approach and enforce accountability by expanding the list of metrics required by core measures to include the high-impact conditions. (Of course, specialty hospitals may require a different set of metrics.)

Not only must these metrics grow, but the type of metric must change. Rather than relying on forward-looking measures—for example, if you comply with an AMI protocol you should have a positive outcome—leaders will need to start with the outcome and work backward to determine why it was undesirable. This will require an entirely new set of policies and procedures designed to focus direct caregivers' attention beyond the scope of core measures protocols for a limited number of conditions to outcomes for a far wider range of conditions.

For example, rather than rewarding organizations for spending a large percentage of available resources on ensuring that caregivers comply with pneumonia protocols, reimbursement will be tied to a reduction in pneumonia readmissions. Not only would this encourage health care organizations to adopt protocols that have proven effective, it will drive them to adopt protocols appropriate to their specific patient populations, such as the elderly or children.

In addition, there must be accountability around high-impact, chronic conditions like diabetes and obstructive pulmonary disease that require management, especially across the continuum of care. Currently, none exists.

To maintain the highest level of reimbursement from CMS, an infrastructure must be established to support increased accountability, including more frequent and detailed board reviews and performance-based rather than protocol-based incentives.

Clinician Collaboration

Traditionally, the board's quality management role was somewhat independent of its fiduciary responsibility. New CMS policies, however, have brought managing quality of care solidly under the fiduciary umbrella and represent a seismic shift in the relationship between practitioners and health care leaders.

The board's demand for increased accountability from the medical staff likely will cause some tension. Leaders need to be prepared for this and rely more heavily on their management and communication skills to ensure a smooth transition. Physicians must be engaged from the outset and fully involved in decisions around what that accountability encompasses.

The amount of information that needs to be collected to maximize CMS reimbursement puts an additional administrative burden on the medical staff, which will further strain the relationship. Health care leaders, including the board, must collaborate with staff to find ways to reduce this burden and be prepared to fund technology and other initiatives that support data collection and analysis efforts.

Quality's Dollar Value

CMS has given organizations the opportunity to improve care quality significantly. Although its reimbursement plan places additional burdens on hospitals already stretched thin, the agency has directed attention to outcomes by assigning a dollar value to quality of care.

With widespread acceptance of evidence-based protocols, health care has matured to the point where it can look at outcomes rather than focusing narrowly on processes. In this changing environment, boards must ensure that health care organizations measure performance in ways that are comprehensive and meaningful.

Sanjaya Kumar, M.D., MPH (, is founding president and CEO of Quantros Inc., Milpitas, Calif.