The first step in the development of any quality improvement initiative is to define what quality is for the given situation. The definition of quality will vary depending on perspective and interests: providers, administrators, policy makers, and patients all have their own criteria and motivations for what determines “quality care” in their eyes. For example, policy makers believe that one definition of high-quality hospital care would be if discharged patients rarely need to be readmitted for the same condition soon after the original hospitalization (e.g., defined as within 30 days for many endorsed quality measures). Providers and hospital administrators, however, would probably argue that a readmission within 30 days is an outcome or result of care quality. They would also point out that the likelihood of a readmission can be affected by a variety of factors outside of the hospital’s control. A patient’s ability to understand and follow discharge instructions, their level of medication adherence, willingness to follow-up as needed on an outpatient basis, the level of their support at home or in their community, and lifestyle choices regarding diet, exercise, and smoking, are all factors that can significantly influence whether or not the patient’s condition, which was improving or resolved upon discharge, deteriorates to the point where they require inpatient care once again. So, who is correct?
Anyone who has studied this issue at length will tell you that both are correct in some ways, but they would also probably tell you that it is more complicated than that. Regardless of which one of the players above you side with (or even if you side with neither), you can likely see each point of view and understand the reasoning behind each. You can also probably quickly identify where the lines get blurry so that determining what is true becomes difficult. For example, perhaps one believes that ensuring that patients understand discharge instructions and have the necessary support at home or in the community should be under the hospital’s purview. Or perhaps it is reasonable to look at it more holistically and say that it should be somebody’s responsibility to ensure that patients have the needed information and support once discharge. That is, the system as a whole would be better served if there was some mechanism by which patients were fully prepared and educated about the post-discharge period and were provided with all of the necessary resources to maximize their health and minimize the likelihood that they would need a subsequent inpatient stay. From this point of view, one might consider that the fact that it is incorporated into the quality metric for hospitals will likely at least pique the interest of the hospital staff and administration, which may then be incentivized to consider how it may be addressed and improved. Whether it is “fair” to assign it to hospital quality is perhaps secondary to the notion that this course of action may result in better system practices by which patients ultimately benefit.
By the same token, it might seem too much of a leap to assign full responsibility for a patient’s readmission to the hospital that previously discharged him or her. Common sense tells us that it is difficult to draw a straight line between hospital care before discharge and the likelihood of readmission a month later, and in the event of a potentially avoidable readmission, it may be more accurate to consider the contributing forces of not only the hospital, but of the system as a whole, external forces and events, and yes, even patient behavior and choices.
What this has to do with Value
The challenges and difficulties we encounter when we begin to try to define quality are similar to those we will encounter when defining value. Additionally, the measurements of quality and value are often linked and dependent on one another, so that we need to consider how the definition of one may influence the definition of the other. Defining hospital quality through readmission rates as payers tend to do has implications for the associated value that can be assigned and evaluated for payers, providers, and patients alike. Therefore, reducing the likelihood of a rehospitalization holds different value for hospitals than it does for payers, and it will mean something else for the patient who seeks to avoid another hospitalization, both in definition and in real and relative magnitude. If instead of using readmissions as the metric, hospital quality is defined differently using some other measure, the result will be different evaluations of value for all parties, which could produce different interpretations for the success or merit of a particular intervention or project. Therefore, the definitions of quality and value ultimately have repercussions both in general, and as one gets specific about the perspective: you cannot ask what the value of something is without asking, value to whom?
Finally, arguments about what is valid, reasonable, or “fair” when it comes to defining quality and value often need to be considered from multiple perspectives or in light of potentially competing goals. In our example of hospital quality assessments, if the intent is to improve the quality and value of care of the entire health system, one can more easily argue for the existence of quality measures that reflect care that should be provided to patients (even if it is not entirely clear whose responsibility it should be). If, on the other hand, the goal is to assess and compare the quality and value of care provided by individual providers or facilities, then it may be more reasonable to limit the evaluation to the activities performed when the patient is in front of the provider or within the four walls of the facility. Unfortunately, as an industry we tend to pick a measure and use it to assess quality and value for all perspectives and stakeholders. We might be better served if we were more intentional in selecting measures based on how we intended to use them, for what purpose, and for whose information and insight.