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Are You Measuring the Wrong Key Performance Indicators?
By Steven Littlehale

In this post-Affordable Care Act environment, it is essential for those responsible for discharging patients to postacute care to ensure that they are selecting the most appropriate skilled nursing facility (SNF). To accomplish this goal, case managers, discharge coordinators, accountable care organizations, and other stakeholders need to address these key questions:

• What are the key performance indicators (KPIs) being used to identify and monitor the best SNFs?

• What is the best way to measure the effectiveness of an SNF's preferred provider network? Are the right structural, process, and outcome metrics being monitored?

• Is using the Centers for Medicare & Medicaid Services (CMS) Five-Star Quality Rating System the best KPI for these purposes?

Limitations of CMS Five-Star Rating System
According to CMS, the Five-Star Quality Rating System was created "to help consumers, their families, and caregivers compare nursing homes more easily and to help identify areas about which you may want to ask questions." A rating from 1 to 5 is assigned to an SNF after taking into account factors such as health inspection ratings, staffing, and certain quality measures.

Because the rating system is primarily derived from survey data, it has limitations as a KPI for managing such concerns as rehospitalization, patient satisfaction, and cost. Also, the Five-Star Quality Rating System is suboptimal as a process improvement tool for SNFs. The weak correlation between the CMS Five-Star rating and readmissions and length of stay limits its usefulness as a predictive tool of an SNF's success in a preferred provider network.

Alternatives to CMS Rating System
There are superior KPIs that discharge planners and care coordinators can use to predict and monitor SNF performance. These KPIs are directly correlated to the outcomes that matter most, such as rehospitalization. For example, it is important to consider metrics such as registered nurse (RN)-to-patient ratio, proportion of RNs to total licensed nurses, availability of physicians or physician extenders, proportion of patients on pain or behavioral management programs, and the use of contract staff. These KPIs all predict rehospitalization.

Ultimately the best KPIs have the following qualities:

• They are readily understood, with no questions about veracity or origin.

• They are agreed upon by all stakeholders. In other words, all parties are on the same page and agree to the value of the measure.

• They are transparent and recognized as being valid. Each KPI identified should allow all stakeholders to identify numerators and denominators. That is, KPIs should identify who or what triggered an event and when.

• They include metrics endorsed by the National Quality Forum, a third party that evaluates data used in the public domain for monitoring and reimbursement for its scientific validity.

• They use actionable KPIs. It is essential to measure what can be managed or manage what can be measured. In either case, KPIs should be incorporated into quality improvement strategies. This is where claims-based data in particular fall short.

The Pathway to Better Outcomes
To ensure better outcomes, begin by conducting an environmental scan to assess the SNF's outcome baseline. Once this is established, it is possible to develop an improvement plan. This baseline must be put into context of the SNF's case mix and specific market. In other words, an SNF that specializes in the care of people with mental illness will have different outcomes than one specializing in complex orthopedic care.

Case-mix adjustment levels the playing fields and helps stakeholders develop a complete and valid evaluation. It is important to remember that KPIs are impacted by specific market conditions, such as the availability of RNs.

Affordable Care Act provisions have driven health care providers to make process improvements by analyzing valid data. This is a benefit for the industry and patients alike, especially in a postacute care setting after discharge. So what is the bottom line? Improved quality measures and fewer readmissions lead to higher levels of patient satisfaction and enhanced reputations for health care providers.

Making Changes in Postacute Care Performance
In order to monitor and improve postacute care performance, an efficient process needs to be in place, not only to capture data but to analyze it as well. Having SNFs self-report is a recipe for failure for all parties concerned. There is enough available National Quality Forum–approved data that can be leveraged to identify the actionable steps needed to make the best decisions regarding postacute care.

Being able to convince providers that they can trust the KPIs and that no additional, labor-intensive data capture is needed to verify the original analytics delivered means peace of mind for postacute care providers.

Additionally, on the SNF side, the use of KPIs to improve patient care requires a commitment from executive leadership to make the needed changes that become apparent after analyzing the data. In this context, sourcing the most statistically valid data, where there is concurrence and trust, is key. Traditionally, health care has focused on volume instead of value. This ideological shift will take time, much like the analogy of one person pushing a large ship away from a dock. It takes a while to build momentum but, once achieved, it can enhance outcomes for providers, patients, and their families.

— Steven Littlehale is executive vice president and chief clinical officer for PointRight, Inc, which provides data analytic services nationwide to skilled nursing facilities, hospital systems, and other clients who are responsible for postacute care.