Quality Improvement Committee
WHA’s Quality Improvement Committee (QIC) includes about two dozen physician and clinical leaders from across Washington. In October 2019, these leaders joined in publishing a report showing that 51 percent of services provided in the state were low value. This work demonstrates the trust among competitors to share information with one another and the public for the higher purpose of increasing high quality care, and offers an example that could be replicated across the nation to further build trust among competing organizations in pursuit of a shared purpose of improving health care quality and safety. Why does this build trustworthiness? This collaboration enhances the competency of the organizations involved and this transparent data sharing is an act of caring – putting patient interests above self-interest.
How It Works
The QIC is responsible for the integrity of all of the Alliance’s reporting and plays a significant role. For example, in the First, Do No Harm report released in October of 2019, using the Milliman MedInsight Health Waste Calculator™ (Calculator) the Alliance analyzed waste for the 47 tests, procedures, and treatments commonly recognized as overused by the Choosing Wisely® campaign and the medical community. The Alliance found that of the 9,526,365 services examined for both the commercially and Medicaid-insured in Washington state, 51% were determined to be low-value, meaning they were either wasteful or likely wasteful. This resulted in an average of 846,973 people receiving at least one low-value service each year (that’s equivalent to approximately 11% of the total state population), at a total estimated cost of $703 million.
But the results are not the story here, it’s the backstory. When the Alliance previewed the results to the QIC, the members asked, “Can you give medical groups something to really work with, like how they are each doing on these waste categories?” The Alliance then presented the QIC with blinded statewide results, from the least to most wasteful medical groups. When asked whether the Alliance should publish the blinded results or identify medical groups in its public release, the QIC responded, “Not only should you release them, you are obliged to.” What is striking is that none of the physician members knew how their medical groups had performed, just that they, and everyone else, should know.
Skills and Competencies
Trust is the key attribute that makes the QIC work. Since its inception, the Alliance has facilitated this opportunity for opposing views to be shared and discussed in an open and respectful way over many years of conversations. These clinicians respect each other even when they disagree and are willing to engage in hard discussions that support the overall mission of the Alliance to work together to promote health and improve the quality and affordability of health care.
Now entering its 17th year, the Alliance has sought to improve health care through evidence-based practices supported through its data analysis. This mission would have been rife with mistrust and suspicion if the Alliance did not have the clinician-led QIC to act as the decision-making body of what can and cannot be counted and what should and should not be included in its reporting. They say “you can’t improve what you don’t measure.” But what you measure and how you measure it are not easy choices.
Beginning with the first Community Checkup report issued in 2008, the QIC has been front and center in answering those questions, selecting the measures, and developing the reporting methods, including provider attribution, statistical reliability, and reporting thresholds. As a result, the Alliance is recognized for producing robust and reliable results. One recent issue illustrates the nature of the QIC, when it grappled with the question of whether a surgical group, which at times delivers primary care, should be included in the Alliance’s reporting on primary care. Rather than being left to Alliance staff to decide, the QIC engaged in a thoughtful and deliberate assessment of all considerations before making its decision.
The QIC’s effectiveness is illustrated in its work and its reputation. The QIC deliberated for more than a year on a new idea from a QIC member: using 29 measures considered strong indicators of primary care to produce one weighted score and statewide ranking of medical groups. From conception to release in September 2020, the QIC made all of the decisions, from selecting the measures and statistical methodology to deciding how to report the findings.
The Alliance recognizes top performers in its reporting. But when there are high performers, there are also low performers and some medical groups may not like their results. Sometimes, this can lead to disputes by medical groups. When this occurs, the Alliance can provide the QIC’s considerations and decision-making process. Particularly in terms of the waste report, it is telling that despite low performance by some, the Alliance has lost no members.
In addition, the Alliance has seen little attrition in attendance at QIC meetings, and many members have been on the QIC for several years. When one considers all of the pressures on clinical leaders in 2020, it is significant that QIC involvement is such a high priority.
Critical to making change in health care is transparency and providing support for evidence-based practices. The QIC model enables a neutral convener to establish a mechanism for clinical leaders to contribute to the improvement of the health care system. With a QIC, there is a transparent process whereby health care purchasers, plans, and providers have access to trusted information to increase high quality care and reduce low-value services. While the Alliance is a statewide organization, the QIC model could be replicated in other states or across regions to help improve the health care system across the nation