The Journal of Healthcare Contracting

The Ultimate Quest
Through benchmarking and the sharing of data, hospitals learn to provide high quality care at lower costs
By Laura Thill

It’s one thing for hospitals to benchmark to see where they stand among other institutions on patient safety, quality of care and healthcare costs. It’s quite another to know what steps to take in order to improve on these measures. Through its QUEST program (Quality, Efficiency, Safety and Transparency), Premier healthcare alliance is providing members with a systematic yet broad transformative approach to high quality care across the entire patient experience - and saving them money in the process.

QUEST is a voluntary, three-year project involving 166 nonprofit hospitals across 31 states seeking to improve quality of care and patient outcomes. The program encompasses five performance targets:

Save lives by achieving a mortality rate 17 percent less than expected.
Safely reduce the cost of care below the midpoint among participating hospitals.
Deliver the most reliable and effective care for each patient.
Improve patient safety by preventing incidents of harm in 20 categories, such as healthcare-acquired infections and birth injuries.
Increase patient satisfaction by improving the patient care experience.

The goal is for participating hospitals to save approximately 8,628 lives each year (a 17 percent reduction in mortality) and ensure an additional 22,364 patients receive all appropriate evidence-based care measures annually.

Why it will work
The healthcare industry has been trying for years to reduce mortality, improve quality of care and decrease costs. Whether or not experts agree that hospitals are making inroads here, the question begs: Why will this program work?

There is a significant difference between traditional benchmarking in hospitals and the goals QUEST is working to accomplish, according to Richard Bankowitz, MD, vice president and medical director, Premier Healthcare Informatics. "It is essential to benchmark in order to understand where we are compared to our peers," he explains. "Knowing the gap between existing performance and best practice is important. But, the next step is transparency. Allowing others to see where you are in relationship to the entire group and to best practice is such a strong motivator and a requirement among the QUEST cohort. Participants are required to share their outcomes, good and bad, among the group. This type of transparency among peers is a strong motivator and leads to performance improvement."

However, it’s not enough for hospitals to know where they stand, says Mike Alkire, president, Premier Purchasing Partners. "They need to know what to do in order to improve," he points out. "The collaborative nature of QUEST allows participants to identify the high performers and learn from them." By bringing together providers, clinical experts and manufacturers, as well as an advisory panel of 20 experts from such groups as the Institute for Healthcare Improvement, the American Hospital Association and the Agency for Healthcare Research and Quality, QUEST is making this happen, he adds.

Scalability
A lack of collaboration among hospitals is not the only reason why the nation has been slow to adopt changes that could facilitate patient safety and improve quality of care. "Studies have shown that it can take up to 17 years to move from reporting an initial research finding to a point where there is close to 100 percent physician adoption of an effective intervention," says Bankowitz. "This rate of adoption is far too slow and means we will see incremental changes at best."

In addition, it’s one thing for hospitals to focus on - and succeed at - one specific intervention, he continues. "Highly focused interventions are capable of bringing about improvement in narrowly defined aspects of care. That’s the easy part," he says. "But, this approach does not work when you try to scale this type of change across all of the processes and evidence-based care that constitute the entire patient experience. Providing high-reliability, high-quality care across the continuum requires a systematic and broad transformative approach.

"This is the whole point of QUEST," says Bankowitz. "As for how we plan to accomplish this, we believe we can rely on the 80/20 rule. We know, for example, the conditions that are responsible for the largest number of deaths in excess of [those] predicted, and we can target interventions toward these conditions. We also know the evidence-based care processes that are most problematic for hospitals to deliver reliably, and we can target these as well." Finally, the five QUEST performance targets (e.g., reduce harm, impact mortality, increase satisfaction, etc.) are interrelated, he notes. "If we impact harm, we can certainly impact mortality, [as well as] lower cost. Satisfaction is likely to increase as well," he says.

Is that to say policymakers, providers and clinicians have set the bar too low for improvements achieving healthcare outcomes? "I think the problem lies with execution rather than expectations," says Bankowitz. Consumers and providers have very high expectations regarding healthcare outcomes, he states. But, they have low expectations with regard to the execution of healthcare delivery. "The current state of healthcare delivery cannot properly be called a system," he says. "Delivery is fragmented, incentives are misaligned and communication during hand-offs is poor or nonexistent. We seem to tolerate this lack of coordination in healthcare, whereas we would not [do so] in other industries.

"In order to improve, we need a systematic approach that measures what we are doing well and not so well from the patient’s [perspective], and we need to pay particular attention to coordination of care and proper alignment of incentives across the continuum," Bankowitz continues. "Fortunately, this seems to be changing."

That’s not the only thing that’s changing, notes Alkire. "Misaligned financial incentives really get in the way of our efforts to improve quality of care," he says. "Whereas supply chain management is not typically on the CEO agenda, today’s economy and the need to reduce costs is changing that. Supply chain management is becoming a strategic imperative for the hospital, the same as safety and quality." We have to align evidence-based practices with proper economic incentives, he adds.

A growing proposition
Currently, 160 hospitals in 31 states participate in QUEST. This includes a mix of urban and rural facilities, teaching and non-teaching, and a range of sizes. A total of 2.3 million patients will be treated each year of the three-year project.

Originally, Premier convened the top performers from its Hospital Quality Incentive Demonstration project (HQID), as well as partners from IHI, Blue Cross Blue Shield, AHRQ and others, according to Bankowitz. The group provided a broad outline for the five performance targets, although these metrics may continue to evolve, he explains. "We know, for example, that we aren’t done with our exploration of measuring harm, and we are always looking for new ways to improve such," he says. ""Likewise, we continue to explore the primary and secondary drivers of both cost and mortality. QUEST charter members set the groundwork, and we need to continuously build off of their initial efforts."

That said, Premier continues to accept applications from manufacturers interested in participating in QUEST CIP (see related sidebar), adds Alkire. However, the GPO has no plans to implement "a second wave" of CIP until it finalizes research from the initial phase.

"Experts from the QUEST hospitals will test [product] solutions," he says. "Our hope is that each QUEST hospital will ultimately test at least one. At the conclusion of each wave, a body of evidence will be available to help hospitals determine if these new products actually do what they say they will, and in turn help clinicians make medically sound, evidence-based judgments about their appropriate use. Once the data is collected and properly reviewed, we will publish all appropriate data, staying in line with transparency as a main theme of the QUEST collaborative."

Saving lives is achievable, according to Bankowitz and Alkire. And, in as much as QUEST is successful in helping providers reduce medical errors, the project will help save lives. "We know from our initial QUEST data that a small number of important and common conditions account for a large proportion of deaths," says Bankowitz. "We are carefully examining these causes of death, and many of our QUEST interventions will focus on these conditions. Through the QUEST collaborative, we can identify the best practitioners in these areas and then share their best practices to the entire cohort."

Sidebar #1
What is QUEST

QUEST is a voluntary, three-year project with 166 not-for-profit hospitals across 31 states designed to springboard hospitals to new levels of performance. Using benchmarked data from the Premier healthcare alliance’s clinical database, Premier and the Institute for Healthcare Improvement (IHI) identified the main factors that lead to deaths, errors and excessive costs. Using this information, hospitals are able to share best practices and systematically initiate efforts to dramatically improve quality and patient outcomes. QUEST’s three-year performance improvement targets are to:

Save lives - Achieve a mortality rate that is 17 percent less than expected.
Safely reduce the cost of care - Reduce inpatient costs below the midpoint among participating hospitals.
Deliver the most reliable and effective care - Deliver every recommended evidence-based care measure for each patient.
Improve patient safety - Prevent incidents of harm in more than 20 categories, including healthcare-acquired infections (HAIs) and birth injuries.
Increase satisfaction - Dramatically improve the patient care experience.

Sidebar #2
QUEST Comparative Innovation Program

In December 2008, Premier selected six finalists for Wave 1 of the QUEST Comparative Innovation Program (CIP), which tests the effectiveness of healthcare products and technologies through QUEST: High Performing Hospitals.

The finalists, selected from a group of 80 applicants, were evaluated by multi-disciplinary clinical teams and selected based on their potential to help hospitals achieve the goals of QUEST. The solutions will be tested in the real world and measured by QUEST hospitals to determine their effectiveness in improving the quality, reliability, safety and cost-effectiveness of care.

The selected solutions address key issues in healthcare, including improving emergency response times, enhancing doctor/nurse communications and preventing healthcare-acquired infections such as methicillin-resistant Staphylococcus aureus (MRSA), urinary tract infections and ventilator-associated pneumonia.

"The Comparative Innovation Program will accelerate patient access to technologies, proven to be safe and effective, by placing these solutions in the hands of those who provide patient care," says Andy Brailo, Premier vice president of strategic accounts and QUEST CIP lead.

The CIP is open to all suppliers, medical device manufacturers, pharmaceutical manufacturers and service providers, regardless of whether they are on contract with the Premier healthcare alliance. Premier is accepting applications for Wave 2 of the CIP, and interested manufactures can apply at: http://www.premierinc.com/about/suppliers/quest/index.jsp?ref=quest.

The six technologies identified as Wave 1 finalists include the following:

Bard Medical Division Bardex I.C. Foley Catheter, said to reduce catheter-associated UTIs.
BD (Becton, Dickinson and Company) - BD GeneOhm^TM MRSA Assay, designed to rapidly identify MRSA-colonized patients, enabling swift interventions to prevent infection and transmission.
Covidien Mallinckrodt Hi-Lo Evac Endotracheal Tube, said to reduce VAP;
Remel (part of Thermo Fisher Scientific) Spectra^TM MRSA, designed to detect nasal colonization of MRSA to aid in its prevention and control of it.
Sage Products Inc. Toothette Q-Care Oral Cleansing and Suctioning Systems, said to reduce VAP.
Vocera Communications Solution, designed to reduce emergency response times and improve doctor-nurse communications.