Benchmarking: How do you measure clinical quality?

Deb Beaulieu

Deb Beaulieu

Many practices track their financial performance, but following the money alone is too narrow of a way to assess your practice's true success, according to a recent article from Medscape Today about benchmarking your practice. As the author, Deborah Walker Keegan, president of Medical Practice Dimensions, Inc., in Arden, N.C., writes: Quality is as important as quantity. But as we've noted previously, "quality" is one of those words that can have a chameleon-like definition at times.

For today's purposes, simply ask yourself: How well are you improving your patients' health? There are several ways to measure this, one of which is to measure your ratio of well visits to sick visits, which is thought to have dual implications. As Brandon Betancourt, administrator of Salud Pediatrics in Chicago, once posted on his own blog, Pediatric Inc, "measuring wellness-to-sick ratio estimates the focus a practice has on preventive care." He added, "Data shows that practices that have fewer sick visits to well visits tend to be practices with better financial outcomes."

As Betancourt wrote in November 2011, "Better performing pediatric practices rate between 1.9 and 1.6 sick visits for every 1 well visit. But experts say that if your practice is within the 3:1 or 4:1 range, your practice is heavily focused on acute visits, which can lead to difficulty in making ends meet."

A more recent experiment at Betancourt's practice, however, revealed more of a conundrum in the finances of providing more preventive care. To summarize, an outside researcher tested the theory, using data from two Salud physicians, that the more preventative care a patient receives, the fewer non-preventive services he or she will receive in the primary care setting. As it turned out, the calculations confirmed that for every preventative service provided, on average there were 0.8 fewer non-preventative services at the practice. In other words, all else being equal, a patient who received five preventive services would likely end up getting four more subsequent non-preventive services than a patient who got 10 preventive services.

But here's the conflict: "From a mere financial standpoint, the patient with five well visits and four sick visits is far less expensive than the patient with 10 well visits," he wrote. These results are illustrative of some of the inherent conflicts between doctors and insurers, at least on paper, and the complexity practices face in navigating them.

Keep in mind, however, that this particular experiment did not take into account any additional care the patients received outside Betancourt's practice, such as with specialists or at the hospital. Perhaps, tracking yet another benchmark--avoidable emergency department visits and hospital admissions--would further point to the value of preventive care, along with other principles of sound practice management.

In fact, Walker Keegan recommended practices do just that, by creating a systematic method for obtaining information about your patients' use of the ED and hospital. For example, take a sample one-month period and calculate the number of ED visits and admissions that were avoidable or potentially avoidable, she suggested.

"If your practice has a high level of preventable visits and admissions," she wrote, "create a quality plan to expand patient access, care outreach, continuity of care and transition management. Track this benchmark over time by sampling your data on a quarterly basis, with the goal of reducing your practice's rate to zero."

At the end of the day, there is never going to be a single benchmark that answers everything there is to know about your practice's performance, nor is there going to be one action you can take to improve it. We know that your goals are to keep your patients healthy and keep your practice running in order to do it, two missions that can sometimes be at odds. But so many experts I've talked to have said that practices all too often don't measure and analyze enough data, if they conduct any benchmarking at all.

As healthcare continues to evolve (think accountable care organizations, global payments, etc.), others are going to be tracking how you measure up to their definition of quality. In the meantime, it's up to you to examine the big picture--to collect and crunch the numbers that show what it takes (and costs) to manage patients' health. You can't control how third parties choose to reconcile that data, but you can make sure you know your metrics so you're not operating in the dark.

We've covered just two measures of clinical quality here, but there are countless others. What clinical quality benchmarks do you track that allow you to keep from being overwhelmed while ensuring your practice is making the right improvements? – Deb (@PracticeMgt)