There are several issues that would be valuable to consider in identifying candidate measurement areas and developing performance measures for the hospital outpatient setting, including:
- The type of care and services delivered in the hospital outpatient setting is not homogenous across hospitals or populations served. Services/procedures delivered in the hospital outpatient setting vary hospital-to-hospital as a function of size, location, service mix, and populations served. Because hospitals will vary in their ability to report on various performance measures, it will be important to include some measures that all hospitals can report on to enable cross comparisons of performance and to enhance the ability of all hospitals to participate.
- The problem of small numbers. A key consideration in selecting any performance measure is whether a provider has a sufficient number of events to score in a stable and reliable way. It is important to consider the number of events that occur at the hospital- level for any given condition, service/procedure, or use of drugs/biologicals, to determine whether it is even feasible to measure performance and how many hospitals could be expected to produce scores. The fact that the small numbers problem is compounded when attempting to stratify performance scores by subgroups of patients, such as by race/ethnicity, socio-economic status, and/or gender, also merits consideration.
- Existing measures specifications may need to be modified prior to applying in hospital outpatient setting. Existing measures are being applied in other settings, where the data to populate the measure differ (i.e., the codes used to pull administrative data) and the process of delivering the care may differ. These differences will need to be carefully reviewed to determine whether and how adjustments to the measures specifications are required if they are to be applied to the hospital outpatient setting.
- Physician engagement will be critical. Much of the care delivered by facilities in the hospital outpatient setting is dependant on the actions of physicians, both those practicing in the hospital outpatient setting and those in the community who are ordering services delivered in the HOPS. Therefore, it is important to engage these physicians in measurement and accountability requirements and to coordinate measurement efforts so that the measures for which physicians are individually held accountable are aligned with hospital measures.
- Alignment with other measurement efforts will minimize reporting burden and strengthen their performance improvement signals to providers. Continuing to coordinate measurement efforts with key organizations such as the Hospital Quality Alliance (HQA), Ambulatory Quality Alliance (AQA), and the Joint Commission, as well as internally within CMS, to align measurement across settings of the health care system will be important to ensure that a consistent message is sent to all providers regardless of the setting(s) in which they provide care. This is a particularly critical undertaking given that the care delivered for a specific condition should not vary simply because of where a patient happens to present with that condition. To the extent possible, CMS could consider using the same measures to evaluate care in the hospital outpatient setting as are employed in other settings in which CMS tracks performance.