ATLANTA – The Institute for Quality in Laboratory Medicine (IQLM) met for the first time as a group here last Thursday, Friday and Saturday to discuss as one of its primary topics: how to go about developing a national report card on quality specifically for laboratories.
The group had its genesis at a Quality Institute Conference that met in 2003, attended by 38 partner organizations, and those attendees thought that the framework for a report on laboratories should be modeled on the landmark Institute of Medicine (IOM: Washington) 1999 report, “To Err Is Human,” which found that about 98,000 patient deaths can be attributed to medication errors and other healthcare errors annually in the U.S.
Marc Silverstein, MD, of Baylor Health Care System (Dallas), in speaking to the approximately 300 attendees at the Omni CNN Center Hotel on that subject, said that it has been suggested that one of the reasons against developing a separate report on laboratories was that it could “compete or conflict” with the National Health Quality Report produced by the Agency for Healthcare Research and Quality (AHRQ; Washington) and therefore may not get the attention it deserves.
Other unintended consequences of a report could be that providers might avoid sick patients in favor of those they could clearly help to improve performance indicators.
In support of the a national lab quality report, Silverstein said it could improve the quality of care patients receive by allowing them to review quality reports provided to purchasers of healthcare. And, he noted, “The public wants report cards.”
An overarching “potential concern,” he said, is that in this “spirit of openness,” the ability of a report to improve bottom-line results on the country’s health is “undemonstrated.”
One way to go about producing a report is to “broaden stakeholder representation,” which, Silverstein said, the IQLM is doing.
Joe Boone, PhD, of the Centers for Disease Control and Prevention (CDC; Atlanta), which was one of the initial key supporters of the IQLM, suggested that there be a “clear effort” to come up with a national report.
“We always envisioned this to be a virtual report and not a paper report, so it could link to other sites,” Boone said, referring to other reports on healthcare quality.
The IQLM conference attendees also heard reports from working committees designed to investigate components of developing a national report, such as developing quality indicators.
Lee Hilborne, MD, of the David Geffen School of Medicine at the University of California at Los Angeles (UCLA; Los Angeles), said his group on developing quality indicators was given a specific agenda, which was to define a core indicator set for laboratory practice. In doing this, he said the group kept in mind, “If Congress wanted to quickly know about America’s labs, what information should they have?”
One of the things the group decided was that quality indicator characteristics should be “broad and defensible,” he said.
Among the points on which the group agreed was that “pay for performance” is going to be “huge” in the laboratory profession, and there are efforts to pay for quality performance. Hilborne said that laboratories will be very aware of an indicator if they’re going to be measured on it, for example, whether they’re going to be rated on the amount of blood culture contamination in lab tests. And as one attendee noted, “95% of you are already gathering” this type of information, “but laboratories are doing it in so many different ways that it cannot be compared.”
The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO; Oakbrook Terrace, Illinois) also is seeking to develop definitions for standards, Hilborne noted.
Friday afternoon sessions focused on the business case for quality best practices as it related to laboratory settings; government; private insurance; health economics; information technology; international standards; the diagnostics industry; and clinicians/patients.
“Everywhere you go, I think one of the challenges [of developing quality control systems] is what is the business case,” said Rick Panning, president of laboratory services at Fairview Health Services (Minneapolis). “Those who control the purse strings want to know.” Fairview includes eight hospitals with 40 clinics.
His laboratories have implemented the LEAN system, a quality control program that originated in manufacturing with Toyota. Panning’s organization sought to, first, understand the need for change and how to fit it in with the provision of care over the organization, he said.
“Our purpose is to support high-quality patient care,” he said.
However, before implementing LEAN, the leadership of the system noticed that the laboratory system was not cost-efficient and not providing the level of services needed by the clinicians within the system.
LEAN, which is not an acronym, means, among other things, “getting rid of waste” and focusing on “flow, flow, flow” of specimens through the process or information through the process once a specimen enters the lab, Panning said.
“[LEAN is] the relentless pursuit, identification and elimination of waste,” he said, all the while attempting this “while maintaining morale” among employees. It also involves “mistake-proofing,” Panning said.
As a result of implementing LEAN, the cost of operating the labs went down “about 31% per test,” he said, with about a 40% increase in productivity.
“Stat utilization went down and now we’re moving to [testing] that doesn’t even need to be stat,” he said, because turnaround times have improved so dramatically.
His advice: don’t try to change the model, or it will not result in the performance administrators need.
“Follow your rules, don’t waver,” he said.
Stephen Jencks, MD, director of the quality improvement group in the Office of Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS; Baltimore), said that organization’s vision is: “The right care for every patient every time.” And he acknowledged that such a vision is considered “radical.”
And offering a view into how CMS “sees the business case,” he noted that CMS, through its top administrator, Mark McClellan, believes that “solving the quality [issues] is the only way we can sustain Medicare and Medicaid.”
“Incremental change is not going to get us there,” Jencks told attendees. “[It] must be transformational.”
He said that a pay-for-performance approach is “essential” and that overall, for CMS to accomplish quality goals it will have to work through partnerships, which he noted is “not the typical way CMS does business.”
He also noted it will require publication of quality and performance measures, as well as the creation and use of evidence about effectiveness. Jencks said that there already are such standards for nursing homes, and they are being worked on for physicians.
The importance of publishing such information is so that CMS can “drive out secrecy.”
“We’re paying a huge price as professionals in the amount of secrecy we have,” he said of the healthcare industry.
Jencks said that CMS has a quality council that is chair-ed by McClellan and has a number of subgroups, which is introducing a “sort of matrix management” system, he said. And while that is a difficult process, it is the only way to go, he said.
“For us, quality is a survival strategy,” Jencks said, “We are determined to help organizations understand that there is a business case for quality."