Development of The Commonwealth Fund’s WhyNotTheBest.org—a free tool with which to benchmark hospital performance on measures of quality and safety, outcomes, and costs—began with a question. We asked: if the U.S. health care system is not the “best in the world,” as has been amply demonstrated, what will it take to get us there?
Late in 2008, the foundation launched WhyNotTheBest.org to test the theory that making hospital performance data readily available and easy to use could both facilitate and spur efforts to improve. While performance benchmarking sites such as Hospital Compare (run by the Centers for Medicare and Medicaid Services) and U.S. News and World Report’s rankings target consumers, WhyNotTheBest.org explicitly targets professionals—clinicians as well as researchers, consultants, and others engaged in efforts to promote health care quality. This benchmarking tool enables robust comparisons: users can find and compare hospitals by region, size, ownership, or type of institution (such as safety-net hospitals, academic health centers, or teaching hospitals); track trends; and identify top performers. And there are no hidden or trade secrets about how measures are defined and calculated: only nationally vetted, standardized measures are reported, and the methodology and data sources are public.
Over time, WhyNotTheBest.org has grown to include more than 100 measures, drawn from Hospital Compare, states’ all-payer discharge data (meaning data from both public and private payers), the Institute of Medicine, and other sources. (See list of measure categories.) An interactive map enables users to explore performance variation by region and track the spread of new care delivery models, such as accountable care organizations and medical homes. And an improvement resources section includes nearly sixty case studies showcasing hospitals’ best practices and strategies for reducing readmissions, improving safety, and other efforts.
The audience for the tool has also expanded to include some 4,500 monthly visitors and nearly 11,200 registrants. To spread the word about the tool, The Commonwealth Fund hosts a webinar series featuring WhyNotTheBest.org users’ “stories from the field.” In the most recent webinar (in September) three people with different perspectives—a provider, consultant, and researcher—described how they use WhyNotTheBest.org in their work.
A Surgeon’s Use
The first presenter, William Scharf, talked about his use of WhyNotTheBest.org in his role as a physician change agent in the OSF HealthCare System. During meetings with groups of surgeons and nurses, Scharf presents WhyNotTheBest.org reports showing how well they have succeeded in providing all aspects of recommended surgical care. Historically, many OSF hospitals—like many hospitals nationally—have performed well on many individual measures, but fell short of providing “highly reliable” care—typically one-fourth of patients failed to receive perfect care.
Scharf asked: “Would you mail a letter if it failed to reach its recipient one out of every four times? Or use an ATM [automatic teller machine] if it failed to give you cash 25 percent of the time? Why should one of every four of our surgical patients fail to receive basic care intended to improve their outcomes and help avoid infection?”
After getting the attention of surgical teams, Scharf works with them to remove roadblocks and design more reliable care systems—an approach that has led to rapid improvement. One OSF hospital that was on the lower end of performance on WhyNotTheBest.org’s composite measure of recommended surgical care in 2007—it delivered all recommended care only 91.75 percent of the time—had improved to 99.67 percent by 2012. For the composite measure, it recently ranked in the top sixth percentile of all hospitals.
A management consultant’s use
The next presenter, James Donohue of ECG Management Consultants, described how he runs WhyNotTheBest.org reports on measures of recommended care, readmission rates, and patient experiences to help hospital clients understand how they compare with their peers, as well as with regional and national benchmarks. Providers are increasingly interested in differentiating themselves from competitors on the basis of quality and care management as they engage in negotiations with health plans and consider making the transition to a reimbursement system that is based on quality, not just volume.
Donohue also consults with health care providers as they develop their population health management capabilities. For this work, he draws on WhyNotTheBest.org’s measures of population health, utilization, and costs to help providers understand the relative health status and costs in their region, at baseline, and to project what resources will be required to improve population health and manage care.
A researcher’s use
The final presenter, David Schulke of the Health Research and Educational Trust (HRET), an affiliate of the American Hospital Association, described how he uses WhyNotTheBest.org to compile large-scale reports comparing the performance of all hospitals in a particular state. As part of his work leading Patient Safety Learning Networks in thirty-two states, he focused on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures of patient experiences—using the statewide reports to identify areas where many hospitals struggle, such as keeping patients’ rooms quiet at night. He also uses the reports to recruit leading hospitals to share their improvement strategies with other hospitals during collaborative learning sessions.
Schulke uses WhyNotTheBest.org’s map to demonstrate the wide variation in readmission rates across the nation and to encourage hospitals with higher-than-average rates to implement Boston University’s Project RED toolkit, designed to reengineer discharge processes. The tool was developed with support by the Agency for Healthcare Research and Quality; National Heart, Lung and Blood Institute; Blue Cross Blue Shield of Massachusetts Foundation; and the Patient-Centered Outcomes Research Institute.
The future of public reporting
It’s heartening to hear these stories—they validate our belief that trusted measures of performance can be a force for positive change. But there remain many challenges to public reporting generally, including the time lag in reporting, confusion and discordance among the many hospital rating systems, and the uncertainty around which kinds of measures are meaningful and offer practical tools to inform improvement efforts.
Most important, there needs to be a conversation about the value of public reporting in health care. The business case for tools such as WhyNotTheBest.org is far from established. In the past twenty-five years, a consensus has emerged that transparency is a fundamental attribute of our health care system. If that is the case, then the question is whether information about the quality of care should be viewed as a public good; and if so, how might community, regional, state, or national public reporting systems be sustained? We at The Commonwealth Fund aim to further the discussion around these issues.
To playback the archived webinar or download the slides, visit The Commonwealth Fund website at http://www.commonwealthfund.org/Events/2013/Webinar-Using-WhyNotTheBest-to-Measure-and-Improve-Stories-from-the-Field.aspx.