Since the Institute of Medicine (now known as the National Academy of Medicine) released To Err Is Human: Building a Safer Health System at the dawn of the century, health insurers have attempted to create payment programs linked to quality metrics.1 The impact has resulted in widespread engagement in “quality” reporting for payment, but have these efforts truly generated a “quality program” that helps patients better assess surgical value? Are delivery systems more focused on quality and improvement in the delivery of health care services, or is it more likely that the focus largely targets the insurer metrics and payment? Have insurers’ “quality” efforts really resulted in better surgical care and outcomes?
For more than half a century, the American College of Surgeons (ACS) has viewed quality in the context of programs that are evidence-based and demonstrate improvement in care, while measurements are key components of such programs. Therefore, for many years, the ACS has raised concerns that the quality metrics health insurers use have failed to drive improvement in surgical care because they are disconnected from the health care delivery process and sporadic in nature.
Insurers measure erratic components of care discretely, measuring the individual surgeon separately from the hospital, separately from the anesthesiologist, separately from the pathologist, and so on. The result is an overly burdensome measurement system and a fragmented picture of “quality.” Furthermore, measuring quality of care based only on seemingly pieced-together and unsystematic measures has unintended consequences.
Instead, the College has advocated for an approach that replaces pieced-together measures with a quality program that focuses overarchingly on the care of the patient, including the goals and outcomes important to the patient, while also valuing the infrastructure, resources, and processes needed to deliver optimal care and improvement.
A collaborative approach
As a result of a collaborative effort, a systematically organized set of measures that represents the spectrum of an effective quality program will be implemented as part of a national value-based payment program. This opportunity was accomplished through a partnership between the ACS and the Center for Medicare & Medicaid Innovation (CMMI), also known as the Innovation Center, which was established under the Affordable Care Act to test innovative payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care.2 The measure set will be part of the Bundled Payments for Care Improvement Advanced (BPCI-A) program. The BPCI-A was designed with the intent of incentivizing hospitals and clinicians to work collaboratively to achieve high-value care.
As a start, this endeavor is being performed in metabolic and bariatric surgery. This is the first time this type of a representative set of measures will be implemented and specifically include a component (a verification measure) that addresses the fundamental infrastructure of a quality program. The verification measure is an opportunity to demonstrate the value of a comprehensive program and represents an important shift in how insurers can incentivize better quality care.
Details about the verification measure
In the full set of measures, the new verification measure for BPCI-A is a voluntary measure for participants in the Bariatric Surgery Clinical Episode. The measure, Bariatric Surgery Standards for Successful Programs, follows the Optimal Resources for Metabolic and Bariatric Surgery (MBS) 2019 Standards, which promote the critical elements necessary to provide safe, effective, and high-quality care to MBS patients. The measure will incentivize a framework for building a quality program, including the right structure, processes, and key outcomes to foster a high-fidelity quality improvement (QI) cycle.
The Bariatric Surgery Standards for Successful Programs measure also focuses on the collective multidisciplinary nature of the bariatric care model, including defining team member roles; requiring a cultural commitment to patient safety from leadership; and promotes the proper resources needed to support optimal care for MBS patients. The Innovation Center selected this measure based on multiple studies that demonstrate that specific structural processes improve patient safety in metabolic and bariatric surgery, resulting in reduced postoperative complications, lower inhospital mortality, reduced length of stay, and lower costs.3,4
To report the verification measure, the facility or physician group practice must be an accredited bariatric center, which means it has met all the 2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) or similar program standards; at present more than 90 percent of bariatric surgery operations occur in MBSAQIP hospitals or practices. The goal of the measure is to incentivize accredited bariatric centers to go beyond basic compliance of standards and to consider how to further enhance efforts to become exemplary models of care. In other words, as part of BPCI-A, the Centers for Medicare & Medicaid Services (CMS) will reward hospitals and surgical care centers that show an exemplary commitment to continuous QI.
The verification measure includes six structural domains to score the bariatric surgery clinical episode, which were chosen from the 41 program standards. The score is determined based on whether a verified center “meets” the criteria enumerated in the standards, “exceeds” the criteria, or is considered “exemplary” based on the criteria. The score from this measure, along with other quality measures in the bariatric surgery quality measure set, is then used to adjust the reconciliation amount for the bundled payment relative to a target set based on historical data specific to that participant.5 The six MBSAQIP standards chosen for the measure domains are firmly linked to an infrastructure that promotes safer and higher quality of care as follows:6
- An MBS committee—to promote multidisciplinary discussion, communication, and decision making
- An MBS director—to promote leadership
- Patient education pathways—to promote standardized education and patient inclusion
- Patient care pathways—to promote reliability and effectiveness
- Adverse event monitoring—to promote continuous quality evaluation
- QI initiatives—to promote continuous quality improvement and outcomes
One example of how a participating group or hospital would achieve a score that “exceeds” the Quality Improvement Initiatives Standard is to demonstrate an increasing number of QI initiatives beyond the documentation of one QI—the minimum standard—as illustrated in Table 1. To be designated as “exemplary” a facility could engage in multiple QI activities and document improvements in patient outcomes, which will allow for increasing opportunities to surpass the current evidence-based standard to motivate the multidisciplinary team to work together to raise the ceiling on care on a systemwide or department-wide level.
It is worth noting that although the score itself only considers six standards, compliance with all of the MBSAQIP clinical program standards must be met to report this measure for the bundled bariatric episode. The reason for this approach is that the bariatric verification measure incentivizes adherence with the full clinical program, which is organized on the basis of the patient’s condition, similar to the integrated practice unit (IPU) framework, as described by Porter and colleagues.7 The organization of these programs is first and foremost multidisciplinary, yet also integrated for optimal care of a patient’s condition. Thus, the scored standards included in the verification measure were chosen because they highlight the multidisciplinary and integrated nature of the MBSAQIP program, including the multidisciplinary MBS committee; the MBS director, who integrates the different program components; QI, which requires contributions from multiple disciplines and integration for improvements, and so on.
It will be critical to obtain the comprehensive nature of this measure for future iterations or similar measures in other conditions. If standards are separated and processes or outcomes looked at in silos, the totality of a quality program is not considered and, unfortunately, can fall apart. The entire program must be valued altogether, where the sum is greater than the parts. As we initiate this endeavor, the reason we’re looking at a limited number of standards to be scored in the first iteration of the measure is for scaling purposes.*
The goal of future implementations, however, is to score additional standards, beyond the initial six, to help program participants move compliance even further toward providing increasingly higher-quality care—without increasing burden—to best serve their local patient population.
*Although only a subset of facilities will participate in BPCI-A and be scored, those participants will be benchmarked with all verified bariatric centers.
Implementation of a quality program framework
The verification measure focuses on a bariatric clinical accreditation quality program because it gauges the quality of the BPCI-A Bariatric Surgery Clinical Episode. However, in the future, a quality program framework that specifically targets surgical quality improvement could, and should, be implemented so that the hospital will support, evaluate, and improve surgical quality care across all surgical departments and include all surgical procedures (regardless of the presence of a formal clinical program, procedure volume, and so forth). The QI program includes such attributes as demonstrable commitment to surgical quality from the C-suite; appointment of a surgical quality officer and surgical quality committee; establishment of a hospital safety culture; a formal case review process; standard surgeon onboarding, credentialing, and privileging policies; data systems organized to find problems (such as complications and inefficiencies) and fix them; and so on.
The ACS Quality Verification Program is the ACS quality program for achieving QI for use across the House of Surgery.8 This standards program draws from Donabedian’s structure, processes, and outcomes quality model, which has proven to be an effective way to conceptualize quality of care.9 As mentioned earlier, the ACS’ assertion that surgical quality should be delivered and measured as a full program fundamentally operationalizes the entire Donabedian quality model. Figure 1 conceptually demonstrates the layers for achieving surgical quality with the ACS Quality Verification Program at the base. This program sets the standards for structure and process components by defining the resources, infrastructure, and processes needed to achieve optimal QI.
The ACS Clinical Programs set the standards for clinical care and these programs are where condition- or specialty-specific (such as Bariatric, Trauma, Geriatrics) standards are added. Layering on top of clinical accreditation are appropriate and adequate processes that further help to implement the care model. Moving up in the hierarchy of the key components are monitoring of clinical outcomes with accurate, clinical, risk-adjusted data—the model used in the National Surgical Quality Improvement Program (ACS NSQIP®)—followed by outcomes reporting by the patient, or patient-reported outcomes (PROs). Each component of the quality model builds on and is interrelated to the others, pulling the information to assess the essential components for a patient, allowing for patients, clinicians, and payors to assess more completely the quality of care. The ideal for the systematically organized set of measures is to represent the spectrum of an effective quality program by focusing on each layer of this pyramid.
Challenges and opportunities
It is important to recognize that although the quality as a program framework has proven to drive higher quality in surgery and is more meaningful than the status quo to surgical teams, there always are challenges to any new change. We anticipate challenges and opportunities regarding communicating and implementing a new way of thinking about quality evaluation and improvement. Yet there also is great opportunity to identify how best to scale a quality program in an equitable way given the broad spectrum of settings, types of hospitals, resources, and surgical specialties.
A major challenge and opportunity will be changing the quality framework for clinicians. Although surgeons may agree we need to move toward better and more aligned incentives and care quality (and value), the lack of a clearly uniform and articulated path toward value may result in fits and starts as increasingly more and better value-based care opportunities arise. Surgeons seek clarity for what a value-based model will look like, how it will transform care delivery and workflow, how attribution will be determined, and how the business model for employers (that is, hospitals, group practices, and so on) and clinicians will change. Surgeons want to be sure they can continue to serve their patients and keep their doors open. However, for surgical teams who participate in quality programs at their institution, this move to a quality program framework might offer an easier transition because many hospitals would rely on the overarching operationalization of the Donabedian structure process outcomes model to drive improvement in surgical care and outcomes. Within the ACS Quality Programs, verification of standards, infrastructure, and data provide surgeons and the surgical teams with the resources and environment needed to deliver optimal care and assist in reaching quality goals. This is why it is so important that health insurers value quality programs that hospitals and clinicians rely on, develop, and maintain.
Perhaps the most significant challenge is the change that will be needed by insurers to align their payment programs with specific quality programs, such as MBS. Surgeons, surgical teams, and hospitals will continue to provide the best care possible and will do their best to respond to payment incentives. Aligning the best team-based care with the right payment should become the goal. This means a quality program and a payment program must measure and reward the combination of the right structure, process, and outcomes delivered by the entire surgical team with shared accountability. Without any changes to align quality and payment across the care team, continuing the current measurement system serves as a distraction and strains or burdens efforts to build a quality program. The quality teams working within misaligned systems end up chasing metrics for payment reporting rather than building metrics for quality improvement.
The health care system needs a framework for quality that follows the surgical patient’s care journey and allows for surgeons and patients to assess the value of that care by reporting and sharing meaningful information. The BPCI-A program is the first to implement a “quality as a program” strategy instead of the usual “quality as a measure.” The ACS is optimistic that the implementation of this tactical strategy will help optimize the need to reward excellence in care by turning insurers’ attention to the major elements for creating and sustaining a functioning and effective quality program, and simultaneously move beyond the use of just a few non-systematically organized performance measures, which often are of comparatively limited value to patients. The ACS believes that incentivizing the program in its entirety is the way to implement a quality program. With the right framework, surgical care teams will define surgical care fit for quality measurement and improvement while patients and insurers will be able to better assess surgical value.
- Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press, 2000. Available at: https://doi.org/10.17226/9728. Accessed August 26, 2020.
- The Centers for Medicare & Medicaid Services. About the CMS Innovation Center. Available at: https://innovation.cms.gov/about. Accessed August 26, 2020.
- Azagury D, Morton JM. Bariatric surgery outcomes in U.S. Accredited vs. non-accredited centers: A systematic review. J Am Coll Surg. 2016;223(3):469-477. Available at: www.journalacs.org/article/S1072-7515(16)30267-8/fulltext. Accessed August 26, 2020.
- Nguyen NT, Nguyen BS, Nguyen, VQ, et al. Outcomes of bariatric surgery performed at accredited vs. nonaccredited centers. J Am Coll Surg. 2012;215(4):467-474. Available at: www.ncbi.nlm.nih.gov/pubmed/22727608. Accessed August 26, 2020.
- Center for Medicare & Medicaid Innovation. BPCI Advanced Model Overview Fact Sheet—Model Year 4. Available at: https://innovation.cms.gov/media/document/bpci-advanced-my4-all-fact-sheets. Accessed August 26, 2020.
- American College of Surgeons. Quality Programs. Optimal Resources for Metabolic and Bariatric Surgery 2019 Standards. Available at: www.facs.org/-/media/files/quality-programs/bariatric/2019_mbsaqip_standards_manual.ashx. Accessed August 26, 2020.
- Porter ME, Lee TH. The strategy that will fix health care. Harvard Business Review. 2013;91(10):50–70. Available at: https://hbr.org/2013/10/the-strategy-that-will-fix-health-care. Accessed August 26, 2020.
- American College of Surgeons. Optimal Resources for Surgical Quality and Safety. Available at: www.facs.org/quality-programs/about/optimal-resources-manual. Accessed August 26, 2020.
- Donabedian A. Evaluating the quality of medical care. Milbank Q. 2005;83(4):691-729.