How Healthcare Reform, Value-Based Care Define High-Performance

August 31, 2017 - Whether through the Triple Aim or Institute of Medicine’s six aims, healthcare reform efforts and value-based care models intend to transform health systems and hospitals into high-performing entities. But what exactly does it mean to be a high-performing healthcare organization, RAND Corporation researchers recently asked.

Despite the focus on achieving high-performance, researchers found in a literature review of articles from 2005 to the end of 2015 that the industry does not operate with a standard definition.

“Despite the growing emphasis on identifying high-performing healthcare delivery systems, it is unclear whether a consistently applied definition of high performance exists,” they wrote in a Joint Commission Journal on Quality and Patient Safety study.

Instead, they found that research about and information on high-performing healthcare organizations typically applied to a narrow clinical area, such as a high-performing hospital in terms of a specific procedure or a high-performing health system furnishing preventative services.

“However, we sought to determine if the literature supported a common definition of the overarching concept of high performance, as used in phrases such as ‘a high-performing healthcare system,’ or if there was a definition implicit in how the term high performance has been used,” they stated.

The review revealed that when researchers and stakeholders discussed high-performing healthcare organizations, they were primarily talking about superior clinical quality. Of the 57 articles analyzed, 53 used clinical quality as one of the dimensions used to measure performance.

Healthcare costs were also primarily used to determine performance, with 38 articles using it. Other performance categories used in the 57 articles studied included:

• Access with 20 articles

• Equity with 15 articles

• Patient experience with 12 articles

• Patient safety with 10 articles

• Organizational responsiveness with 4 articles

• Care coordination with 2 articles

• Physician satisfaction with 1 article

• Governance with 1 article

• Innovation with 1 article

About three-quarters of the articles used more than one of the categories to determine health system and hospital performance. Of the articles using over one category, most (14 articles) used three, but 13 employed four and 11 used two.

Clinical quality and healthcare costs were the most frequently paired performance categories, with 63 percent of the articles incorporating at least those dimensions in their definitions.

Quality and access were also commonly used together. About one-third of the articles studied used the clinical quality and access combination to define performance.

While researchers and stakeholders used general performance categories to pinpoint high-performing healthcare organizations, researchers noted that 30 percent did not include specific metrics in their performance definitions.

For example, eight articles pointed to some part of the high-performance definition used by the Commonwealth Fund Commission, which identifies high-performance as “high-quality, safe care; access for all people; efficient, high-value care; with the capacity to improve.”

Another two articles defined high-performance as achieving the Triple Aim of “better health, higher-quality care, and lower costs.”

Of the 70 percent of articles that did specify metrics, three used a single metric. Two articles defined clinical quality using risk-adjusted mortality rates and the other measured performance using a five-year operating margin.

The other 37 articles in this category used multiple metrics to measure performance categories. Most of the researchers and stakeholders used data from existing measurement projects and performance measure sets, including:

• Commonwealth Fund’s State Scorecard on Health Systems Performance with 11 articles

• CMS Hospital Compare with 4 articles

• The National Health Service Star Rating System in the UK with 2 articles

• The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey with 3 articles

• Baldrige criteria with 2 articles

• National Committee for Quality Assurance's Healthcare Effectiveness Data and Information Set (HEDIS) with 1 article

With stakeholders using differing performance categories and measures to define high-performance, researchers called on the industry to develop a common definition.

“The growing emphasis in the healthcare marketplace on rewarding high-performing health systems underscores the need to develop an agreed-on definition of high performance,” they wrote. “Moreover, the expectation by patients, payers, and policymakers that healthcare delivery systems provide high-quality and reliable care that is safe, affordable, accessible, and patient-centered, demand that any definition of high performance be necessarily multi-dimensional.”

Based on results from the literature review, researchers proposed that the industry define high-performing healthcare organizations based on six categories.

“On the basis of on our findings and prior efforts to define high performance more comprehensively, we propose that a six-dimension definition of high performance—incorporating clinical quality, cost, patient experience, access, patient safety, and equity, as identified in our review—can advance the field by establishing a rigorous foundation for measuring performance and setting a necessary and achievable standard for healthcare delivery systems in the United States,” they stated.