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Best Practices in Transparency: Case Study 2
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Transparency Among Organizations


 


Wisconsin Collaborative for Healthcare Quality:
Reaping the Benefits of Data Sharing System


Founded in 2003, the Wisconsin Collaborative for Healthcare Quality (WCHQ) began as a joint endeavor of health care organizations and purchasers in the state of Wisconsin to improve the quality of health care in the state by coordinating the collection and sharing of performance data. Previous efforts to track and improve the quality of care had been hampered by a number of barriers, including payer-specific data collection and analyses that relied solely on claims-based data to assess quality, which excluded Medicare, Medicaid, and self-pay patients, and thus limited data accuracy and the reach of improvement initiatives. Efforts were also slowed by a lack of buy-in from clinicians because of concerns about the relevance and validity of existing performance measures. The lack of consistency regarding physician attribution also blocked advancement because it undermined the assurance of accurate results.

Recognizing the sensitivity inherent in the collection and sharing of performance-related data, the nine founding members, which included hospitals, health systems, and physician groups in Wisconsin, chose to focus initially on trust building within the group. In late 2002, member representatives began meeting to discuss goals, expectations, and potential areas of agreement. The group met for an entire year to establish trust and identify a shared vision and goals.


 

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Working together, physicians, data analysts, and quality specialists from WCHQ member organizations developed measures to assess the quality of both hospital-based and ambulatory care. The Collaborative also commissioned the development of a repository-based data submission (RBS) tool that many member organizations continue to use to ensure secure submission of patient-level global data files. The process allows claims, clinical, and patient-related data to be collected, regardless of payer type. WCHQ analysts, under the guidance of the physician-led Measurement Advisory Committee, validate that data and measures are consistent with evidence-based standards.

 

Beginning in 2003, member organizations started sharing unblinded performance data of group practices (not individual clinicians) within their organizations. In 2004, WCHQ began posting performance data at the group level on its website. Currently, data are displayed at the medical group and clinic site level. Site-level reporting requires a minimum of three clinicians per clinic.

Collecting and Publicly Reporting Quality Metrics

The Collaborative collects and publicly reports on a variety of metrics with the majority being either process or outcome measures of ambulatory care clinical quality. Examples of specific metrics include process measures, such as cancer screening, immunization, and tobacco cessation counseling, and outcome measures, such as blood pressure, hemoglobin A1C, and cholesterol levels for patients with diabetes. In 2005, WCHQ added some cost metrics, such as an all-payer adjusted charge for inpatient cardiac care. Data are collected from two specialty registries for public reporting: The American College of Cardiology and the Society of Thoracic Surgeons. The group also assesses the patient experience via specific measures for physician groups. CGCAHPS (Clinician and Group Consumer Assessment of Healthcare Providers and Systems) data were recently publicly reported for the first time in June of 2013. Hospitals submit and publicly report their inpatient data separately via the Wisconsin Hospital Association.

Because data from all payers are included, the Collaborative allows member organizations to assess performance across their entire patient population. Members who report using the RBS system have the ability to run custom reports at any desired frequency and use the customized data reports internally so that practitioners can monitor and launch improvement initiatives. Collaborative-wide data are used to identify and share best practices from higher-achieving organizations. WCHQ has the ability to submit data on behalf of members utilizing RBS for CMS initiatives such as the physician quality reporting system and meaningful use, and currently reports for more than 2,700 physicians in Wisconsin.

In addition to providing data repository and reporting services, WCHQ facilitates work groups to foster performance improvement and convenes Collaborative-wide bi-monthly learning events to share valuable lessons and best practices.

 

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Improving Performance

Approximately half of all patients in the state are cared for by physician groups that participate in WCHQ (Lamb et al. 2013). Collaborative members initially tended to be larger practices within integrated delivery systems or multispecialty physician practices within tertiary care hospitals; more recently smaller primary care practices have joined WCHQ.

Since organizations began submitting data and sharing unblinded results within their practices, there have been significant improvements in performance among Collaborative members. A 2013 study that reviewed data from the first five years of the Collaborative’s public reporting found that its members improved significantly on ambulatory care measures and that all physician groups improved on most of the measures (Lamb et al. 2013). For example, for 15 of 16 physician groups the rate of breast cancer screening improved; the average rate of improvement was 0.07, which was statistically significant. In comparison with non-WCHQ physician groups in the state and across the country, groups participating in the Collaborative have significantly higher rates for the majority of ambulatory care measures.

WCHQ data have provided a valuable resource for better understanding the factors that facilitate performance improvement. A survey of 409 primary care clinics within WCHQ confirmed that implementation rates of appropriate diabetes interventions had increased in the period from 2003 to 2008 (Smith et al. 2012). In addition, the study found that member groups that focused on metrics related to diabetes were significantly more likely to implement one or more diabetes interventions than groups that lacked this focus.

 

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Identifying Key Success Factors

When asked to identify key success factors of the Collaborative, its president and CEO, Chris Queram, points to the upfront time spent in trust building. “In exchange for the investment of time to develop trust, the group has been able to accomplish profound changes in a relatively short amount of time.”

Queram also points to the strength of the physician leadership from member organizations and the collaborative environment within the local culture. These components were essential to the development of trust, which was a prerequisite for achieving transparency.

In addition, Queram believes that the voluntary nature of participation in the Collaborative was essential to its success. He asserts that the free sharing of data would have been impossible if participation had been mandatory. However, he acknowledges that because participation is voluntary, not every physician group participates, which is a source of frustration at times for purchasers and customer advocates. Queram believes that barriers to participation, such as a lack of dedicated quality improvement staff or information systems capable of easily capturing data, may lessen over time. With the advent of financial incentives that tie reimbursement to outcomes, Queram believes that smaller practices and other nonmembers may choose to join.

Despite the Collaborative’s focus on quality rather than safety metrics, Queram believes that many of the lessons learned are directly applicable to the sharing of safety data among clinicians. Most important, WCHQ members learned that trust building and creating a shared vision for the way in which stakeholders work together were critical. The group also learned that patient-level data must be used for the resultant analysis to be most actionable and that timely and accurate data are indispensable for engaging physicians in conversations about improvement. Finally, Collaborative members learned that physician champions are needed within each service line to address physician resistance regarding transparency.

The Collaborative work groups are currently considering metrics to add to the database, such as total cost, total resource use, and patient safety measures. The Collaborative is also working to facilitate affinity groups of members that are focused on a similar short-term goal to share best practices and accelerate performance improvement.

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References

Lamb GC, Smith MA, Weeks WB, Queram C. 2013. Publicly reported quality-of-care measures influenced Wisconsin physician groups to improve performance. Health Aff (Millwood). 32(3):536–43.

Smith MA, Wright A, Queram C, Lamb GC.2012. Public reporting helped drive quality improvement in outpatient diabetes care among Wisconsin physician groups. Health Aff (Millwood). 31(3):570–77.


 


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