At Pediatrix®, our mission is Take great care of the patient, every day and in every way™. But how do we know whether our care is great or just good enough or worse, whether it is poor or negligent? To answer this, we need some way to measure the quality of the care we provide. One approach to such measurement is the use of Clinical Quality Metrics (CQMs). CQMs are standardized statistics that summarize the processes we use and the outcomes we achieve.
There are more CQMs than any one person or organization can measure. More than 2,200 CQMs have been inventoried by the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers the two largest public health insurance programs, Medicare and Medicaid. Other organizations have their own lists of CQMs, including the National Quality Forum, Healthy People 2030, The Joint Commission (TJC, formerly known as JCAHCO) and the Society for Maternal-Fetal Medicine (SMFM). There are several dozen CQMs that can be used to measure the quality of maternity care and also several dozen that can be used to measure neonatal care. New metrics are being added every year and others get retired. It is challenging to keep up with the roster of metrics applicable to a given specialty.
Types of Clinical Quality Metrics
This figure (credit: SMFM) shows a sick patient about to enter the health care system, where they are treated with various interventions and ultimately exit the system with some outcome. Every step along the way can be measured, from the patient’s ability to get seen in a timely manner to their satisfaction with the result. There are CQMs designed to measure each component.
No single measurement can summarize the entire patient journey. By analogy, think of a rating system to summarize whether a restaurant is great, fair or poor. You wouldn’t judge a restaurant as great if the food was amazing, but the prices were outrageous, the service was slow, the space was dingy, the neighborhood felt unsafe or there was no available parking. Each of these factors can be judged separately and all contribute to the overall quality of the restaurant. Similarly for health care, several components must be considered to evaluate the quality of an encounter, a practice, a facility or an organization.
Outcome metrics address the question, “Do we get good results?” The goals of health care are to optimize both health outcomes and patient satisfaction. Patient satisfaction is a critical outcome, but too often neglected. We may pat ourselves on the back when we get good health outcomes, but if we have poor interactions with our patients and families, we will develop a bad reputation, we will lose referrals and ultimately our practice will fail. Conversely, if we have great bedside manner and our patients love us, but our outcomes are poor, that’s what we call being a “quack.” Great care must achieve both great outcomes and high satisfaction.
Process metrics address the question, “Do we do the right things?” Process metrics are sometimes preferred over outcome metrics because processes are under our direct control whereas outcomes may depend on factors outside our control. Bad outcomes may occur even if we do everything right. Conversely, even if we make errors, the outcome may still be satisfactory. By measuring processes rather than outcomes we are measuring the quality of what we do, no matter the results. Note that our motto, Take great care of the patient, refers to the process of care, not the outcome. Of course, it is assumed that consistently great care will most often result in the best outcomes.
Structure metrics address the question, “Do we have the right personnel, equipment, facilities?” Some examples include: What percentage of our sonographers have Registered Diagnostic Medical Sonographer certification for the types of exams they perform? What percentage of our blood pressure machines have had periodic maintenance and calibration in the past 12 months? Is our hospital or practice accredited by a recognized organization?
Access metrics address the question, “Do we have barriers that prevent patients from receiving our care?” Some examples include: What percentage of new patients can get an appointment within one week? What percentage of encounters with non-English speaking patients use a certified translation service? What percentage of no-show encounters are attributed to the parking fees at our facility?
Patient experience metrics are derived from patient surveys addressing their perceptions about how they were treated, regardless of the outcome. Some examples include: When you phoned the provider’s office, did you get an answer to your medical question the same day? Did you see the provider within 15 minutes of your appointment time? Did the provider explain things in a way that was easy to understand? Did the provider spend enough time with you?
How Quality Metrics are Used
CMS, the federal agency that oversees Medicaid and Medicare, wants to know whether there is value in the care it is paying for. CMS has several quality programs that require mandatory tracking and reporting of various CQMs by facilities, practices and providers. The metrics are used in various “incentive payment programs” or “alternative payment models” in which financial bonuses or penalties are based on meeting specific benchmarks for performance. A summary of CMS programs relevant to obstetrical care was presented in a recent review from SMFM.
Private health plans and hospitals. Pediatrix has several “value-based” contracts with payers or facilities that hold us accountable to specified quality metrics in order to receive financial bonuses. In MFM care, we have contracts based on process metrics that track the percentage of patients who receive low-dose aspirin if they have high-risk factors for preeclampsia, who are screened for prenatal and postpartum depression or who have fetal echocardiogram when indicated for diabetes or in-vitro fertilization pregnancy. In OB hospitalist care, we have hospital contracts that track the percent of patients who have high-degree perineal lacerations, who have prolonged postpartum hospital stay or who have cesarean delivery despite “low risk” status (nulliparous term singleton vertex presentation [NTSV]). In neonatal care, we have value-based incentive contracts based on rates of late-onset neonatal sepsis (LONS), severe intraventricular hemorrhage (IVH), severe necrotizing enterocolitis (NEC), severe retinopathy of prematurity (ROP), breastmilk feeding at discharge and other metrics. In all these specialties, we have a curated list of preferred metrics that can be used in contract negotiations.
Accreditation organizations. TJC requires that accredited facilities with maternity services report five perinatal care (PC) measures annually:
- PC-01 is the percentage of early term births (370/7 to 386/7 weeks) that do not have an indication for early term delivery.
- PC-02 is the percentage of NTSV patients delivered by cesarean.
- PC-05 is the percentage of singleton term newborns who are fed only breastmilk during their entire hospitalization.
- PC-06 is the percentage of term newborns who have unanticipated moderate or severe complications.
- PC-07 is the percentage of deliveries with severe obstetrical complications.
Two previous TJC PC metrics have been retired: PC-02 measured the percentage of very preterm births (before 32 weeks) in which antenatal corticosteroids were initiated and PC-03 measured the rate of newborn bloodstream infections.
Public reporting. CMS maintains a website at medicare.gov/care-compare where consumers can look up various quality indicators for doctors and hospitals. Other publicly-reported quality information is posted by the Leapfrog Group and US News & World Report. Yelp posts crowd-sourced reviews on both hospitals and doctors that are reflections of patient experience and satisfaction. Because patients may go to all these places to get information about us, it is a good idea for providers to periodically look up the listings for themselves and for the facilities where they practice so they can learn what their patients might find there.
Quality improvement. CQMs can be used to track how facilities and providers are performing, to identify areas to target for improvement and to track progress in quality improvement. Pediatrix maintains a suite of Power-BI dashboards for neonatology that show how each neonatal intensive care unit is doing on various CQMs, including rates of neonatal mortality, LONS, severe IVH NEC, severe ROP, chronic lung disease, length of stay, hepatitis B vaccine and breastmilk feeding in first week and at discharge. Similar dashboards are in development for MFM, OB hospitalist and pediatric cardiology.
Limitations of Quality Metrics
Although tracking CQMs can provide a useful gauge to help us understand whether we are taking great care of our patients, there are some important caveats to their use.
Costs: It is burdensome and expensive to track down the data needed to report CQMs such as those required by CMS or TJC. One organization estimated that is took an average of 2.5 physician hours and 12.5 staff hours per week to extract and enter data for quality reporting, at an annual cost of $40,000 per physician. Time spent on quality reporting detracts from time available for patient care and may contribute to physician burnout, which in turn may decrease quality of care. A prominent hospital system estimated that it spent over $5,600,000 annually in personnel time and vendor fees to track 162 unique metrics and report them to various entities.
Unintended harm: Efforts to improve performance on a CQM may have adverse effects in other areas. This potential exists whenever an intervention that benefits the mother has the potential for harm to the newborn or vice versa. For example, if OBs avoid performing cesarean deliveries to keep their NTSV cesarean rate low (TJC metric PC-02) even in the face of abnormal fetal heart rate tracings they may inadvertently increase the rate of newborn hypoxic-ischemic encephalopathy. To counter this tendency, TJC introduced a balancing metric (PC-06) measuring the rate of newborn complications.
Disparities and inequities: Quality improvement projects need to keep track of progress for people of all racial groups and people who have barriers that may reduce access to care, including various social drivers of health such as food or housing insecurity, transportation issues, language barriers or low income. For example, if a hospital wants to improve the rate of exclusive breastmilk feeding (TJC PC-05), they will need to have lactation consultants with cultural sensitivity and language skills to address cultural beliefs that discourage breastfeeding in some racial or ethnic groups, and they will need to have printed materials at the appropriate educational level and in the appropriated languages for the patients in the local community.
Simplification
Many experts have decried the current state of the “quality-industrial complex” – the vast array of organizations and companies whose sole purpose is to help navigate the complexities of measuring and reporting clinical quality. Steps to overhaul the system are needed, both to provide a more focused view of quality and also to reduce the burdens that quality measurement places on physicians and their staff.
One approach to simplification is the development of core measure sets, carefully curated lists of CQMs that are evidence-based, clinically relevant and of high value to payers. The Core Quality Measures Collaborative (CQMC) is a consortium of private payers, CMS and several professional societies that publishes core measure sets for 10 specialties, including cardiology, neurology, OBGYN and pediatrics. Some of the metrics in these sets are relevant for our subspecialties (pediatric cardiology and neurology, MFM and neonatology) but most of them are more appropriate for generalists.
CMS has recognized that the proliferation of CQMs has caused confusion, burden and misalignment of approaches for measuring common clinical scenarios. In early 2023, they introduced the “Universal Foundation”, a set of 10 CQMs for general adult care and 13 CQMs for pediatric care. Unfortunately, the pediatric measures are largely focused on ambulatory general pediatric care and are mostly not relevant to the subspecialty care provided by Pediatrix. An add-on set of five CQMs for maternity care was appended in early 2024, again mostly focused on generalist OBGYN and OB hospital care, though some of them may have possible relevance to some of our MFM practices. CMS intends to develop additional add-on sets for specific populations; perhaps these will be more relevant to MFM, neonatology and other pediatric subspecialties.
Conclusions
Despite their limitations, quality metrics provide a standardized way to assess whether we are truly fulfilling our mission to Take great care of the patient, every day and in every way™. Great care involves great processes performed by great people in great facilities, removing barriers to access and providing a great patient experience to achieve the best health outcomes and highest patient satisfaction. That’s a tall order. No one claims perfection on all these points, but we can strive to continually improve in those areas where we know we are not great. Our mission is aspirational, a target to aim for. Quality metrics can help us move ever closer to our goal of providing great care.
About Andrew Combs, M.D., Ph.D.:
Dr. Combs is a seasoned MFM specialist serving as the company’s senior advisor for MFM Clinical Quality for its Center for Research, Education, Quality and Safety and chair of the Research Advisory Committee.
Dr. Combs has practiced as an MFM specialist for more than 30 years. Since 2014, he has led Pediatrix’s continuous quality and safety improvement workgroup for MFM, which develops quality metrics and best practices statements for the company’s national network of MFM practices.