Hospital Quality Reporting: Separating the Signal from the Noise

Originally published by the Center for Studying Health System Change (HSC). HSC was a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation.

Hospital Quality Reporting: Separating the Signal from the Noise

NIHCR Policy Analysis No. 11 — April 2013

Emily Carrier, Dori A. Cross

Concerns about gaps in hospital safety and quality had prompted both public and private payers to demand greater accountability from hospitals through clinical quality measurement and reporting initiatives. Over the previous two decades, the number and scope of these programs had expanded rapidly, with hospitals required to track and report an ever-growing array of clinical process measures, outcome indicators, and patient experience scores to multiple organizations simultaneously.

This policy analysis by Emily Carrier and Dori A. Cross examined the challenges that employers and other purchasers faced in making sense of the rapidly proliferating landscape of hospital quality measures. With U.S. health care costs high and continuing to rise, purchasers were increasingly trying to identify high-value hospitals that delivered good clinical outcomes at a reasonable price. Some payers had begun incorporating quality measures into health plan contracting decisions, provider network designs, and consumer cost-sharing structures intended to steer patients toward better-performing facilities.

The Proliferation Problem

The authors found that the sheer volume of quality measures, reporting requirements, and transparency initiatives had created an environment in which employers often found it difficult to distinguish meaningful signals of quality from background noise. Hospitals reported data to the Centers for Medicare and Medicaid Services (CMS), The Joint Commission, state agencies, private accreditation bodies, and various voluntary reporting programs, each with its own measure sets, reporting timelines, and methodological approaches. The result was a fragmented information landscape where different sources might produce conflicting assessments of the same hospital's performance.

Many of the available quality measures focused on clinical processes rather than patient outcomes. A hospital might score well on whether it administered aspirin to heart attack patients within a specified time window, for example, without that score telling purchasers much about the hospital's overall clinical effectiveness, complication rates, or patient experience. Process measures were easier to standardize and collect, but their relationship to the outcomes that patients and purchasers cared about most was sometimes tenuous.

Challenges for Employers and Purchasers

For employers trying to use quality data to inform purchasing decisions, several obstacles stood in the way. First, understanding the validity and relevance of existing quality measures required a level of technical expertise that most employer benefits departments did not possess. Second, determining whether a hospital's quality scores were relevant to an employer's specific enrolled population was difficult, since many measures focused on conditions or procedures that might not represent the bulk of an employer's hospital utilization. Third, presenting quality information to employees in a way that was useful and actionable remained a significant communication challenge.

The analysis also noted that inconsistencies across quality designations could confuse rather than inform. A hospital might receive a top rating from one organization while receiving a mediocre score from another, depending on which measures were used, how they were weighted, and how performance thresholds were set. This inconsistency undermined purchaser confidence in quality rankings and made it harder to build benefit designs around them.

Recommendations for More Effective Quality Reporting

Carrier and Cross offered several recommendations for purchasers and policymakers. To pursue value-based purchasing strategies effectively, employers needed to develop a clearer understanding of which quality measures were most relevant to their employee populations and how to interpret performance data in context. Purchasers could also push for greater consistency across quality reporting programs by supporting alignment of measure sets and performance designations. Streamlining provider reporting requirements would reduce administrative burden on hospitals and potentially improve data quality by reducing the fragmentation of reporting efforts.

The authors also encouraged exploration of new measurement approaches that captured dimensions of quality important to both patients and payers but poorly reflected in existing measure sets, including care coordination across settings, patient safety events, and the total cost of an episode of care inclusive of complications and readmissions. Getting hospital quality reporting right, they concluded, was essential if the growing emphasis on value-based purchasing was to produce genuine improvements in care rather than simply adding another layer of administrative complexity to an already burdened system.

Sources and Further Reading

AHRQ — Federal health care quality research agency.

Health Affairs — Peer-reviewed health policy research.

Robert Wood Johnson Foundation — Health policy research.

Commonwealth Fund — Research on health care quality.