As consultants, we rely on metrics to assess the impact of our work. Thus, when our clients don’t already measure what we might improve, we face an uphill battle. And the battle becomes particularly frustrating when institutions don’t measure what we consider to be most important: value to the patient. But what do we mean by “value”? Very recently, Michael Porter defined it as health outcomes achieved per dollar spent.
We applaud his definition because it’s consistent with our position that perioperative systems should be judged by a double bottom line: quality of outcomes and financials.
Porter is very careful to stress that outcomes must be measured in terms of results achieved for the patient; process measures are not outcomes. Moreover, he points out that the principal reason for collecting the outcome measures is to enable “innovations in care.”
He may not agree, however, with our preferred outcome metric for the perioperative system – the rate of complications – because his definition of outcomes is much more comprehensive than ours. In addition, he correctly asserts that the relevant costs must be measured along the value-delivery chain. By contrast, we are content to restrict them to the perioperative system.
I won’t try to describe Porter’s outcome measures hierarchy, other than to say that it does indeed include what’s important to the patient, such as the degree of health recovery, time to recovery, whether the treatment process introduced complications and whether health recovery was sustained. Most of the metrics, while highly appropriate, are not collected now and may be difficult to define precisely.
While awaiting others to address this measurement challenge, we recommend that hospitals follow the pragmatic route and establish programs to reduce the rate of complication, e.g., the 30-day, risk-adjusted morbidity rate. The value of concentrating on that metric is that it’s important to patients; it can be measured and improved; and a collaborative (NSQIP) already exists to risk adjust the results and to link the clinicians committed to its improvement. Indeed, some – too few? – Clinicians have become champions and crusaders in the cause of reducing complications.
What’s needed now is for more hospital executives to demonstrate their leadership by championing the effort by investing in additional staff to capture the data and to systematically improve performance. By doing so, they will lay a foundation for Porter’s more meaningful and sophisticated approach.