Doctoring to the test: The unintended consequences of performance measures

As standardized exam scores increasingly define success for students, teachers and schools, parents worry about the dangers of “teaching to the test” — and of their children being judged by tests with low or unknown validity. We want our children to perform well on tests, of course, yet only if they measure something that students, patients, and teachers believe really matter. We also want the education system to inspire students develop into well-rounded people, not just skilled exam-takers.

In health care there is a similar danger of focusing on improving our “test scores” at the expense of real improvement in patient safety — and in this case, the exams have serious flaws. The federal government uses a composite measure of patient safety to help determine whether hospitals are penalized under two programs. One of those programs, the Hospital-Acquired Conditions Program, reduced Medicare reimbursements by 1 percent for 721 hospitals for their rates of preventable harms, such as serious blood clots, pressure ulcers, and accidental punctures and lacerations.

Serves them right, you might think. These hospitals are unnecessarily harming patients. That might be true if the test of their patient safety performance was scientifically sound. However, these programs have a serious methodological flaw: Many of their component measures are not based on reviews of the clinical record, but are rather derived from billing information, which produces a high rate of false positives. Indeed, for some of these measures, more than half of the incidents identified as preventable harm turn out to be false, once we review the clinical documentation. There can be many reasons for this. For instance, a patient may have had a pressure ulcer before admission that was not documented. Or a clot in a small vein might be mistakenly coded as a more serious clot known as a deep vein thrombosis.

Another reason for some hospitals to appear worse than others is that they actually look harder for preventable harm. For example, researchers found that publicly reported rates of blood clots were mainly a function of how aggressively hospitals screened patients for them. In other words, a hospital might look better if it did not screen patients, and yet that hospital might be sending patients home with undiagnosed and potentially fatal blood clots.

Despite these flaws, hospitals have no choice but to pay attention to their performance on these measures, or they risk losing a lot of revenue. In Maryland, hospitals have up to 9 percent of revenue at risk in pay for quality, when the average hospital margin is under 3 percent. This is big money to be at stake for suspect measures.

Hospitals with deep enough resources will devote them to improving their scores. For example, our hospital committed multiple full-time employees, plus the time of physicians, nurses and administrators, to raise our performance on these measures. This is highly technical work that frequently involves getting physicians to more thoroughly document their cases, so that medical billing staff can code more accurately. And we succeeded, reducing the frequency of these preventable harms by 40 percent, at least according to these measures. Yet what we improved was mostly coding, not caring. Well over 80 percent of the improvement was in how we document and code. In fewer than 20 percent of the cases did we identify a clinical improvement opportunity.

Hospitals and health care professionals want and need to do better, and yet focusing our efforts on measures whose validity is unknown or poor is not how we should spend our efforts. The public deserves real strides in preventing patient harm. Without valid measures, we will have difficulty engaging clinicians and hospitals in improvement work, providing financial incentives for truly high-quality care, or helping patients to use performance data to make choices about where to receive care.

Peter Pronovost is an anesthesiologist and director, Armstrong Institute for Patient Safety and Quality.  He blogs at Voices for Safer Care, where this article originally appeared.  He can be reached on Twitter @peterpronovost.

Image credit: Shutterstock.com

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