Accurate Measurement In California's Safety-Net Health Systems Has Gaps And Barriers

Abstract

Patient safety in ambulatory care has not been routinely measured. California implemented a pay-for-performance program in safety-net hospitals that incentivized measurement and improvement in key areas of ambulatory safety: referral completion, medication safety, and test follow-up. We present two years of program data (collected during July 2015-June 2017) and show both suboptimal performance in aspects of ambulatory safety and questionable reliability in data reporting. Performance was better in areas that required limited coordination or patient engagement-for example, annual medication monitoring versus follow-up after high-risk mammograms. Health care systems that lack seamlessly integrated electronic health records and patient registries encountered barriers to reporting reliable ambulatory safety data, particularly for measures that integrated multiple data elements. These data challenges precluded accurate performance measurement in many areas. Policy makers and safety advocates need to support the development of information systems and measures that facilitate the accurate ascertainment of the health systems, patients, and clinical tasks at greatest risk for ambulatory safety failures.

Keywords: Ambulatory Care; Patient Safety; Performance Measurement; Quality Of Care; Safety-Net Systems.

EXHIBIT 2. Seventeen safety-net public health care systems’ performance on closing the referral loop in years 1 and 2 of their participation in the California Public Hospital Redesign and Incentives in Medi-Cal (PRIME) Program

SOURCE Authors’ analysis of data provided by the California Department of Health Care Services. NOTES Year 1 was July 1, 2015–June 30, 2016, and year 2 was July 1, 2016–June 30, 2017. All seventeen systems were Designated Public Hospitals. Systems G and P reported suppressed data in year 1. Systems A–I used comprehensive electronic health record systems. Systems G and H used locally developed registries. Percentages were determined using the number of eligible patients as the denominator and the number of patients who had the desired outcome as the numerator. Systems D, K, L, M, and Q reported divergent changes from year 1 to year 2; see the text for details.

EXHIBIT 3. Five safety-net public health care systems’ performance on warfarin monitoring and timely follow-up of abnormal international normalized ratio (INR) in years 1 and 2 of their participation in the California Public Hospital Redesign and Incentives in Medi-Cal (PRIME) Program

SOURCE Authors’ analysis of data provided by the California Department of Health Care Services. NOTES Year 1 was July 1, 2015–June 30, 2016, and year 2 was July 1, 2016–June 30, 2017. These optional measures were reported by only these five systems. Systems A, B, and I used comprehensive electronic health record systems. Percentages were determined as described in the notes to exhibit 2. System P reported a divergent change from year 1 to year 2 for follow-up of abnormal INR; see the text for details.

EXHIBIT 4. Five safety-net public health care systems’ performance on timely follow-up after an abnormal fecal immunochemical test (FIT) and timely biopsy after a high-risk abnormal mammogram in years 1 and 2 of their participation in the California Public Hospital Redesign and Incentives in Medi-Cal (PRIME) Program

SOURCE Authors’ analysis of data provided by the California Department of Health Care Services. NOTES Year 1 was July 1, 2015–June 30, 2016, and year 2 was July 1, 2016–June 30, 2017. These optional measures were reported by only these five systems. System Q reported supressed data in year 1. Systems C and E used comprehensive electronic health record systems. Percentages were determined as described in the notes to exhibit 2. System O reported changes from year 1 to year 2 that were divergent for both measures; see the text for details.