In the popular sense, quality is a somewhat subjective concept, which can be described and valued but not so easily measured. In medicine, however, quality has become a quantity, measured in processes and outcomes and geared not only to targets and mandates but also, increasingly, to physician payments.

In a setting of limited resources, the counterweight and measuring stick for quality is value, which can be defined simply as “patient health outcomes per dollar expended.” As a result, physicians must be able to “measure outcomes and understand costs,” Dr. Zuckerman said.

Indeed, outcomes are at the center of what the Centers for Medicare and Medicaid Services (CMS) insist that hospitals and physicians not only measure but also achieve to get paid. This mandate takes on universal importance “because in all likelihood, whatever CMS institutes with respect to hospital and physician reimbursement, the commercial payers will quickly follow,” Dr. Zuckerman said.

Current initiatives
In the public sector, much of the quality drive operates under the CMS Physician Quality Reporting System (PQRS), by which providers must report from a set of measures. Providers who don’t report PQRS measures in 2013 will face a 0.5 percent penalty in 2015. Conversely, reporting on at least three measures qualifies a provider for a 1.5 percent bonus.

The last year to begin participation in the Medicare Electronic Health Records (EHRs) incentive program is 2014. CMS has defined stages of meaningful use of EHRs. Regardless of which stage (I or II) physicians are in, beginning in 2014, they will have to report on both core objective and Clinical Quality Measures (CQM), such as screening patients for fall risk and performing a foot examination for diabetic patients. Dr. Sachdev noted that the CQMs for total knee and hip arthroscopy contain provisions for outcome reporting.

Some quality initiatives are essentially punitive. For example, CMS will deny payment for certain hospital-acquired conditions, such as retained foreign objects, pressure ulcers, blood incompatibility, falls, catheter-associated urinary tract infections, surgical site infections, and venous thromboembolism (VTE)/pulmonary embolism. The Joint Commission’s Surgical Care Improvement Project (SCIP) includes several related preventive measures.

The AAOS has taken an active role in forwarding quality initiatives for orthopaedics by hosting three Quality Institutes since 2011, issuing Clinical Practice Guidelines and Appropriate Use Criteria, and helping establish the American Joint Replacement Registry.

Institutional change
Providing a perspective on the measurement of quality in a hospital setting was Joseph A. Bosco III, MD, the chief quality officer at the NYU Hospital for Joint Diseases.

“We measure what we value,” Dr. Bosco said, “and we need to have a firm definition of what we are measuring. When we talk about retained foreign bodies or length of stay or length of a procedure, we need clear definitions so we can measure and compare across the board.

“Certain things are easy to measure, such as admissions,” he continued. “Others, such as VTEs, are harder to measure. There has to be a balance. You really need strong data management to make important decisions.”

According to Dr. Bosco, a “culture of accountability” is also needed. Transparency is a prerequisite when building a fully integrated healthcare system, and gathering data is essential. Dashboards and scorecards—“basically euphemistic terms for ‘things we can all understand,’” said Dr. Bosco—are effective means of reporting data.

Data are key when discussing the need for improvement because it eliminates the personal factor and focuses on results. Reliability of data is important so that staff and stakeholders can’t dismiss it arbitrarily.

“Sometimes the first thing people do when you show them data is to start poking holes in it. Involving physicians and stakeholders in determining what data are important and how the data will be gathered is an incremental process, but it is key for effecting change,” said Dr. Bosco.

“Never events” and “near misses”
So-called “never events” are serious, reportable events identified by the National Quality Forum as largely preventable. They include wrong site, wrong patient, and wrong procedure surgeries; unintentional retained foreign body in the patient after surgery; and perioperative death in an ASA Class 1 patient.

Dr. Bosco said that although “never events” seem easy to define, they sometimes lack clear delineations. For example, a very small (No. 7) needle left in a patient after the site is sewn is not considered a foreign body. Similarly, removing a drill bit that breaks off in the bone may cause more harm to the patient than leaving it in and letting the patient know what happened. Because the standard for reportable retained bodies is an object discovered after the skin is closed, one option is to leave the skin open, while closing the underlying layers, until object counts have been verified.

Dr. Bosco also discussed the importance of recording near misses. Simply doing a raw count of never events is not a sound method of measurement. “A wrong-side surgery may occur only once every 10 years. We need to look at instances where something could have led to a never event, such as the surgeon’s booking the wrong side or failing to do a proper timeout.”

He pointed out that although near misses are often caught, “one time in a million, those holes in the Swiss cheese are going to line up and it’s not going to be caught.” Tracking near misses helps identify trends. “If you see your near misses are decreasing, you know you are on the right track.”

Disclosures: Dr. Zuckerman—Exactech; Neostem; Joint Innovation Technology; SLACK Inc.; Thieme; Wolters Kluwer Health–Lippincott Williams & Wilkins. Dr. Sachdev—Bristol Myers- Squibb; Eli Lilly; General Electric; Johnson & Johnson; Procter & Gamble; Sanofi-Aventis; Stryker; Zimmer; Exscribe. Dr. Bosco—3M; MAKO.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org