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Published 7/1/2008
Robert H. Haralson III, MD, MBA

The advantages of the quality initiative

Don’t let controversy overshadow the value of quality initiatives

Controversy surrounds the multiple quality initiatives that exist today. Among these initiatives are the Physicians Quality Reporting Initiative, the multiple versions of pay for performance, care coordination, medical home demonstration products, and efficiency programs. Although these programs may appear burdensome or sound like previously failed efforts (gatekeepers and capitation), the quality initiative may be the best thing that has happened in medicine in the last 50 years.

We need to evaluate what we are doing to our patients. Treatments and processes that are measured will improve; once they are no longer measured, they will revert. Consider, for example, turn-over time in the operating room. Announce that turn-over time is being measured, and it improves. Stop measuring it and the turn-over time reverts to its original length. To improve quality of medical care, we need to measure quality on a continuous basis.

Orthopaedics can do better
Ample data exist that the medical care we are providing can improve. The Institute of Medicine’s To Err Is Human report in 2003 suggested that many patients were dying due to preventable medical errors. A 2004 study by Elizabeth McGlynn, PhD, demonstrated that only about half of the medical care provided to patients is appropriate. Among the conditions she assessed were treatments for fractured hips, low back pain, and impingement syndrome.

The fractured hip study provides a good example of how orthopaedists are doing.

Dr. McGlynn measured the number of times patients with fractured hips received the following preoperative treatments: complete blood panel, coagulation study, chemistry panel, urinalysis, electrocardiogram, antibiotics the day of surgery, antibiotics on admission, thrombophlebitis prophylaxis, documentation of presence or absence of fracture risk factors within 2 months of the hip fracture, and an assessment of fall risk factors (for patients who reported falling). Arguably, all of these measures should be performed for every patient (although the orthopaedist may not be the one doing all of them). But Dr. McGlynn found that only 22 percent of patients had all of these tests/treatments. Even orthopaedics can do better.

One reason McGlynn’s study stands out is that all of the measures had to be met for credit to be given. Many studies that include several measures will give credit if any of the measures are met; hers did not. This “composite measure set” is considered by many experts as more reflective of good care than simply measuring one parameter at a time.

Composite measures encourage providers to run through a checklist of valuable services, not unlike an airline pilot who must perform the same checklist before every flight. Composite measures assess systems, rather than individual physicians. Ample evidence exists that systems need improving, more than individual physicians. Medical errors occur because the system broke down, which usually requires a series of errors.

But do they work?
Whether quality programs improve care is still uncertain, but recent data is supportive. The Premiere study, funded by the Centers for Medicare and Medicaid Services (CMS) is an example. In this study, which involved 260 hospitals in 38 states and measured two high-volume diagnosis areas, the best-performing hospitals were those that implemented the most process and outcome measures. Hospitals that implemented 75 percent to 100 percent of the measures had fewer complications, fewer readmissions, shorter lengths of stay, and lower costs.

Another aspect of quality programs that stirs debate is the focus on process measures rather than outcome measures. Although the patient may be most concerned about the outcome of a treatment, process remains important. Outcomes may show that a problem exists, but process measures can identify the source of the problem. Process can also serve as a surrogate for outcomes. For example, length of stay is a common process measure; shorter hospital stays for procedures such as total joint replacement could indicate that patients are not having complications after surgery.

“Efficiency” is also a controversial measure. Defining efficiency as lower costs does not contribute to quality. Data demonstrates that cost and quality have an inverse relationship; as quality goes down, costs go up. The medical community insists that any measure of efficiency include both quality and cost; we would prefer that quality be addressed first, so that improvements in quality drive down costs. As Susan Nedza, MD, former medical officer at CMS and now the president of the American Medical Association, has rightly pointed out, “If we (physicians) don’t make this (the quality initiative) work, it (measures of efficiency) will all be on costs.” For no other reason, physicians should be heavily involved in the quality initiative.

AAOS involvement
The AAOS is heavily involved in the entire quality initiative. Although the quality initiative is much needed, we must be sure that the measures actually result in improving the quality of care and that the data collection is not so burdensome that providers cannot afford to participate.

Robert H. Haralson III, MD, MBA, is medical director of the AAOS. He can be reached at haralson@aaos.org


  1. Kohn LT, Corrigan JM, Donaldson MS, (ed): To err is human: Building a safer health system. Committee on Quality of Health Care in America. Institute of Medicine, National Academy Press, Washington, D.C. Access online at http://www.nap.edu/openbook.php?isbn=0309068371
  2. Kerr EA, McGlynn EA, Adams J, Keesey J, Asch SM: Profiling the quality of care in twelve communities: Results from the CQI study. Ann Arbor Veterans Affairs Center for Practice Management and Outcomes Research, USA.