By Elizabeth Heller, Berea College
Abstract – This paper uses findings from five journals to demonstrate the significance of quality metrics in healthcare. It also highlights the challenges faced in the process of reviewing, analyzing, and compiling the quality metrics of an accountable care organization. In particular, it showcases challenges experienced during an eight-week internship at the Stephanie Tubbs Jones Health Center, facility of the Cleveland Clinic located in East Cleveland. I use evidence-based findings from inter-professional strategies to help solve the challenges to improving the quality metrics of an accountable care organization. Lastly, I describe the importance of quality metrics and how they may be used in a future nursing career.
The Quality Metrics of an Accountable Care Organization
The Significance of Quality Metrics in Healthcare
“As I continue my education to become a nurse practitioner my goal is that patients who lack education and social support will not become lost in the system,” write Elizabeth Heller, Berea College.
Quality metrics function to evaluate the care given by healthcare providers. The organization where I interned, the Cleveland Clinic, pays particular attention to its quality data so that it can constantly improve its healthcare. A 2010 article in the New England Journal of Medicine notes healthcare’s recent emphasis on quality scores and how they have evolved during the past twenty years. In 1998 the Joint Commission to the Centers for Medicare and Medicaid Services (CMS) began the first national program for the measurement of hospital quality. The Joint Commission, an independent, not-for-profit organization, certifies and accredits over 20,000 health care organizations in the United States (The Joint Commission, 2016). The CMS’ quality program evolved in 2004 when the Commission began penalizing hospitals financially for failing to report identical data (Chassin, 2010). Today, healthcare facilities such as the Cleveland Clinic use quality scores to frame daily decisions. They evaluate events ranging from the efficiency of services to the care provided by staff and providers. These evaluations help facilities determine where to focus efforts in order to improve overall care and work productivity.
The Quality Metrics of A1C Tests As an intern at the Stephanie Tubbs Jones Health Center, I was assigned to perform evaluations to improve the facility’s quality. I first began working on the quality scores of diabetic patients who were overdue for an A1C test. According to the American Diabetes Association (2006), the A1C test is the most widely accepted test for assessing glycemic control in patients with diabetes. It is more accurate than a single blood glucose reading because it measures the amount of glucose that sticks to red blood cells over two to three months rather than looking at a single reading (Delamater, 2006). I was asked to contact patients at Stephanie Tubbs who had an A1C considered in the diabetic range and who had not seen their primary care provider since 2015 or before. I asked the patients if they were still seeing their provider; if not, I removed them from the facility’s records. This deletion automatically improved the provider and facility’s quality scores. On the other hand, if the patients said they were still seeing their primary care provider, I scheduled an appointment for them to check their A1C levels. Both the removal and the confirmation from patients enable us to improve the patients’ quality of care. If they were removed, they would stop receiving calls from our facility. However, if they still wished to be seen at Stephanie Tubbs, we made the next available appointment. This appointment had the potential to improve their health by assessing how well they were controlling their diabetes.
The Quality Metrics of Colorectal Cancer Screenings I also worked on the quality metrics of patients who needed a colorectal cancer screening. According to the American Journal of Gastroenterology (2016), colorectal cancer is the third most common cancer in the world. The Center offered two options to most individuals due for a colorectal cancer screening. First, the most reliable screening is a colonoscopy. A colonoscopy is most recommended by physicians unless there is an underlying health issue. However, because this screening is a surgery, requiring a general anesthesia, many patients refuse it. The second, and less reliable screening is called a fecal occult blood test (FOBT). This test may detect only polyps that have begun bleeding. Once a polyp reaches the size that it bleeds, the chances of colorectal cancer already being present within the body are much higher (Mandel et al., 2000).
Beginning at the age of 50, everyone should receive a colonoscopy every ten years, or complete a FOBT annually, assuming no complications are seen (Rex et al., 2009). I began my colorectal cancer screening project with patients over 50 years of age in need of either a colonoscopy or an FOBT. Like the A1C project, I first called the patients who had not seen their providers since 2015 and then proceeded to contact the entire group of patients.
Challenges in Quality Metrics There were two main challenges in contacting patients who needed a colorectal cancer screening. First, many of these patients had no idea what a colonoscopy was. When I knew about this lack of knowledge, I could explain the procedure and the reason it was recommended. A simple explanation often relieved worries about the procedure, and the patient then agreed to schedule a colonoscopy. After these explanations, I wondered why healthcare providers had failed to explain this imperative screening. The patient outreach phone calls revealed that most of the patient population of Stephanie Tubbs lacked general medical education.
The second challenge was the lack of social support for lower socioeconomic status patients at the Center. Often times, patients agree to a colonoscopy, but when told that they need someone to take them home after the procedure, they had no one. This lack of social support was a major problem for the population with which I worked. Most of the patients that came to Stephanie Tubbs Jones relied on public transportation. The Center even offered a shuttle to pick up and drop off patients that lived within a five mile radius. Nevertheless, with procedures such as a colonoscopy, patients need additional support for health maintenance that the Center cannot provide.
Solving the Challenges in Quality Metrics After contacting over a thousand patients who often faced these challenges, I thought critically about what could be done to solve the problems. Although the problems seem simple, they are the root of poor quality scores and poor health for impoverished communities such as East Cleveland. I found answers from Dr. Bonnie Raingruber (2004) who tells us two ways to meet these challenges. She explains that health education and health promotion are two distinct activities needed for quality healthcare.
The inter-professional experiences I experienced throughout my internship gave me hope that health education and promotion were being implemented at Stephanie Tubbs Jones. However, even though these evidence-based strategies were executed, I found that new methods of communication and documentation were needed to address the lack of education and social support. First, I began making notes within the system of patient records so that when patients came in to see their provider a note, “Health Maintenance- Colorectal Cancer Screening or A1C test” popped up. This small reminder helps providers who have only a few minutes to review a patient’s chart.
Second, I composed a binder for each provider filled with their A1C and colorectal cancer screening reports. The chart below is an example.
These charts allow providers to be more aware of patients and their needs. The most significant action I took to conquer the challenges was mailing out FOBT kits and having colonoscopies scheduled after the doctors had approved the orders.
Why Quality Metrics Matter I am eager to see how the new implementations will affect quality review, analysis, and compilation at Stephanie Tubbs Jones. The changes will not be automatic, and may even take years. After completing this internship, I recognize the importance of health maintenance to both patients and providers. Although I was able to overcome some of the challenges associated with health maintenance, I was not able to resolve two stagnant problems: lack of social support and patient education. These two problems cannot be fixed by just one person. As I continue my education to become a nurse practitioner my goal is that patients who lack education and social support will not become lost in the system. My hope is that education and social support will receive new emphasis to in order to improve healthcare facilities’ quality scores and, most important, the quality of patients’ lives.
Delamater, A. (2006). Clinical Use of Hemoglobin A1c to Improve Diabetes Management. American Diabetes Association, 6-8.
Heller, E. (2016). Compiled Colonoscopy Report. Cleveland Clinic.
The Joint Commission. (2016). About The Joint Commission.
Mandel, J., Church, T., Bond, J., Ederer, F., Geisser, M., Mongin, S., … Snover, D. (2000). The Effect of Fecal Occult-Blood Screening on the Incidence of Colorectal Cancer. The New England Journal of Medicine, 343, 1603-1607.
Raingruber, B. (2014). Contemporary health promotion in nursing practice. Burlington, MA: Jones & Bartlett Learning.
Rex, D., Johnson, D., Anderson, J., Schoenfeld, P., Burke, C., & Inadomi, J. (2009). Colorectal Cancer Screening. American College of Gastroenterology.