Whether it’s a payer-specific program, a voluntary initiative or recognition, or a government incentive program, the push to move from pay-for-volume to pay-for-performance is everywhere in healthcare.

Most would agree that incentivizing quality is vital to improving our healthcare system, but there is little agreement on the best way to measure and reward quality (and even less standardization…), resulting in a patchwork of overlapping and conflicting programs. Some providers choose to do the bare minimum under quality programs just to avoid payment cuts, but for many specialties and organizations, that approach may leave significant money on the table.

To make the most of your available value-based reimbursement opportunities while avoiding burnout among providers and staff, it’s important to take a wholistic and targeted approach to quality improvement and reporting activities. The following steps will help you achieve success whether you are involved in one or many programs:

Step 1: Inventory

In order to succeed, you must first know what is being measured and how it is measured.

  • Take inventory of all programs in which you participate and their measures. You may have to gather guides and measure details from payers or government websites.
  • Pay attention to differences in measure specifics between programs. For example, one diabetic A1c measure might look for the A1c to be completed, another might look for an A1c less than 9, and a third might look for A1cs less than 8.
  • Pay attention to how each measure is reported to the measuring program or organization (e.g., claims-based, EHR interface/registry, attestation, manual chart abstraction, etc.).
  • Create a single list of all measures and relevant differences or requirements. Keep it up-to-date as programs change.
  • Look at your practice or organization to see what processes you already have in place to meet the measures. Determine if the measure activity is being done, and if so, if it is measurable and reportable.
  • Try to get baseline data on your measure performance from any available source.

Step 2: Make a Plan for Change

Now that you know what is being measured, how it is measured, and (hopefully) how you are doing, create a targeted plan to address any measures where you are performing below the target.

  • Use your baseline data (or gather baseline data) to identify the measures where improvement is needed.
  • Involve staff from all levels in planning how to positively impact these measures. Change in one part of a practice or organization rarely leaves other parts unaffected; ensure staff from multiple departments, areas, or disciplines are involved in the plan for change to avoid unintended downstream effects and to ensure a variety of viewpoints are heard.
  • Think about three main questions for each measure: 1) How will you know/remember when an action is needed or due? 2) How will you document that the action has been completed (or why it was not)? 3) How will you get that information to the program that is measuring it?
  • Be creative. Your EHR vendor or an outside organization may offer you one way to meet and report a measure, but don’t be afraid to look for other ways that better suit your workflows. Think strategically about who can or should perform quality actions and the least cumbersome way to get the data to the measurement program. Many tasks can be completed by support staff rather than providers, including non-clinical staff such as receptionists, billers, etc.
  • It’s OK to ignore some measures. If you disagree with a measure clinically or it is truly unattainable for your patient population, you may need to disregard it. It is important to prioritize efforts where you can make a difference.
  • Start small. Don’t try to address everything at once. Start with one or two high-priority measures or changes. If possible, aim for “low hanging fruit” as a start.

Step 3: Implement Changes

The best plans can still fail without good implementation. Make sure to lay the groundwork so your plans can succeed.

  • Educate broadly. Ensure everyone involved in the new process understands what is changing, what will remain the same, and why these changes are taking place. Hopefully, some of their peers were involved in making the plan and can help with education.
  • Allow for feedback and answer all questions. Education is not a one-way flow of information. An email or memo of what to do will likely not be enough. It is important to communicate in person with involved staff and allow for questions and feedback.
  • Document the process. Whether it’s step-by-step instructions, a checklist, or something else, it’s important to have a reference of the expected way to complete the new process. This is helpful in cases where staff cannot remember or do not agree on what they heard in training, or when new staff or leadership join a team.

Step 4: Measure and Report Progress

Regular measurement of progress is critical to understanding if your plan worked as intended, as well as maintaining engagement from all involved.

  • Set a regular schedule for reviewing results on the targeted measure(s). This could be weekly or monthly, but in most cases should not be longer than monthly at the start of a new process.
  • Share results broadly. Sharing results with all involved parties helps keep staff and providers engaged in the process. If results and feedback aren’t shared, it can be easy for people to think the new process doesn’t matter anymore or isn’t being measured. Ways to share can include posting on a bulletin board or white board in a break area, sending results out by email, sharing at a staff meeting, or any other way of getting the information out regularly to everyone involved.
  • Assign the task of checking, documenting, and disseminating the results. With everything else going on in a healthcare organization, quality improvement activities can get pushed to the back burner. Ensure that the task of reviewing and sharing the results is completed by specifically assigning it to someone in the organization; even someone outside of the quality improvement process can be quickly trained to gather and share this data.

Step 5: Continuous Improvement

For meaningful quality improvement to take place, ongoing review and adjustments are necessary.

  • If your new process worked exactly as intended and your measure performance improved – great! Keep watching the numbers until you reach your goal for the measure, then go back to Step 2 for the next measure(s) you want to target. Continue to track performance on all measures over time, however, to ensure progress on early measures is not lost as new processes are added.
  • In many cases, the new process may not have had the desired results, or the implementation may have brought new issues to light – that’s OK too! You will have learned valuable information and engaged staff. Revisit the plan to determine what should be changed to achieve your desired results.

Approaching quality improvement activities by considering both the measurement programs and the organization as a whole lays the foundation for ongoing improvement and success, even as programs and the very definition of “quality” as measured by outside entities continue to change.