Transcript VALUE BASED PURCHASING

Value Based-Purchasing (VBP)
3/17/15
Lynda Caine, RN, BSN, MPH, CIC
Infection Prevention Officer
Overview
• Value-Based Purchasing (VBP) for HealthcareAssociated Infections (HAI)
– Central Line-Associated Bloodstream Infections
(CLABSI)
– Catheter-Associated Urinary Tract Infections
(CAUTI)
– Surgical Site Infections (SSI) for COLO procedures
• NH HAI 2013 Report Card
• “Care Bundles” for Infection Prevention
• Health and Human Services (HHS) National
Action Plan HAI 2020 Targets
What is Value-Based Purchasing?
• The concept of value-based purchasing is that buyers
should hold health care providers accountable for both
cost and quality of care
• Value-based purchasing brings together information on
the quality of health care, including patient outcomes
and health status, with data on the dollar outlays going
towards health
• It focuses on managing the use of the health care
system to reduce inappropriate care and to identify
and reward the best-performing providers based on
– How well they perform on each measure, or
– How much they improve their performance on each
measure compared to their performance during a baseline
period
Effective VBP Elements
• Standardized Performance Measurement
– Is care safe, timely, efficient, effective, equitable
and patient-centered? Each element is critical
• Transparency and Public Reporting
• Payment Innovation – rethink reimbursement
based on performance
• Informed Consumer Choice – to steer
consumers to high value providers
CMS Value-Based Purchasing
Domain Weighting
State of New Hampshire
HEALTHCARE-ASSOCIATED INFECTIONS
2013 HOSPITAL REPORT
“Care Bundles” for Infection Prevention
• The Institute for Healthcare Improvement (IHI) is
a main driver behind bundle-based care.
• Bundles are frameworks for addressing clinical
healthcare conditions using evidence-based best
practices.
• A bundle is a set of interventions, when grouped
and implemented together, promote best
outcomes with a greater impact than if
performed individually.
• Care bundles aim to ensure that patients receive
recommended treatments on a consistent basis.
Do Bundles Work?
(Yes. Sometimes. But Not Always.)
INFECTION
BUNDLE
DOES THE BUNDLE WORK?
CLABSI Central Line-Associated
Bloodstream Infection
Central Line Insertion Bundle
Yes
CLABSI Central Line-Associated
Bloodstream Infection
Central Line Maintenance
Bundle
Yes
VAP Vent-Associated
Pneumonia
VAP Bundle
Yes
CAUTI Catheter-Associated
Urinary Tract Infection
CAUTI Bundle
Sometimes
CDI C difficile Infection
C. diff Bundle
Sometimes, But Not Always
CH Performance Standards for Hospital VBP Program
CH Performance Standards for Hospital VBP Program
NHSN Standardized Infection Ratio (SIR)
“The Observed-to-Expected Ratio”
• To calculate the SIR, divide the number of our
observed events by the number NHSN “expected”
or “predicted” events
• For example:
6 observed CAUTI
1.878 expected CAUTI
= SIR of 3.195 or greater than expected
RATE OF INFECTION/CATHETER DAYS FOR NH HOSPITALS
HOSPITAL
DHMC
CONCORD
ELLIOT
CMC
SNHMC
PORTSMOUTH
ST JOES
WENTWORTH
CHESHIRE
LAKES
EXETER
# BEDS # ICU BEDS CAUTIS
405
80*
23
238
18
9
281
40*
6
235
20
6
148
20
2
254
14
3
208
11
0
142
11
0
116
10
0
110
10
0
100
10
2
FOLEY
DAYS
10504
3158
1942
3706
1659
2646
774
1329
523
1303
1480
RATE PER
1000
CATH
DAYS
2.2
2.8
3.1
1.6
1.2
1.1
0
0
0
0
1.4
SIR
1.07
2.38
2.53
1.35
0.93
0.74
0
0
0
0
1.04
PT DAYS
119653
62431
62251
49708
43568
36841
31451
31042
20097
20036
18126
* INCLUDES PEDI ICU
Source: State of NH Healthcare-Associated Infections 2013 Hospital Report
CAUTI Bundle
• Raise Staff awareness that CAUTIS are serious, cause patient harm and
increase the risk for multidrug resistant organisms and C. difficile
• Renew focus on decreasing total catheter days in the ICU & housewide
• ASK! Does the patient need a foley? (WTF)
• Use straight caths and condom caths when possible
• Insert catheter using aseptic technique
• Secure catheter to the leg
• Maintain closed, sterile system
• Hand hygiene before and after touching catheters
• Disinfect bedrails every shift
• Do pericare twice a shift, once with ScrubStat
• Use Fecal Containment Device to contain feces
• Document reason for use of catheters
• Discuss why catheters are in place during rounds
• Audit use of the nurse-driven protocol for catheter removal
• Remove the foley as soon as possible!
• Discuss and de-brief all CAUTI events at the unit level with Staff, leadership
and infection prevention
HHS proposes new HAI Action Plan targets for 2020
On February 25, the U.S. Department of Health and Human Services (HHS) proposed 2020 targets for the National Action Plan to Prevent
HAIs: Roadmap to Elimination (NAPHAI). The proposed targets were established by a steering committee of HAI prevention experts from
federal agencies, with input from national stakeholders, including APIC. If finalized, the proposed targets would replace previous targets
that expired in December 2013 and would establish January 2015 as the new baseline for all measures.
CH Performance Standards for Hospital VBP Program
NHSN CH Surgical Site Infections 2010 through 2014
ALOS for CH COLO SSIs Patients 2013 =
23.4 days
Average Length Of Stay (ALOS) FOR ALL COLO PATIENTS 2013 = 14.12 DAYS
Joint Commission Project:
“7S Bundle” to Reduce Colorectal SSIs
Joint Commission Participants
Joint Commission Project
“7S Bundle” to Reduce Colorectal SSIs
• Surgical site infections (SSIs) are the second most common healthcareassociated infection (HAI)
• SSI rates are disproportionately higher among patients following
colorectal surgeries
• Resulting SSIs are known to have significant patient complications with
adverse clinical and economic impact
• Preventing colorectal SSIs is a complex problem with multiple variables
specific to patients and patient populations, institutional factors, surgical
practice and process
• Participating hospitals used Lean, Six Sigma, and change management
methods to understand why infections were occurring at their facilities and
how to prevent them
• Participants focused on improving the care received by colorectal surgical
patients, from preadmission to 30-days after surgery
Source: http://www.centerfortransforminghealthcare.org/assets/4/6/SSI_storyboard.pdf
Joint Commission Project Results
• After two-and-a-half years, there was an overall
reduction in superficial incisional SSIs by 45
percent and in colorectal SSIs by 32 percent
• Participants attained cost savings of more than
$3.7 million for the 135 estimated colorectal SSIs
avoided during the project period
• Applying the reduction in SSIs to the annual case
load of colorectal surgeries at participating
hospitals suggests that they will experience 384
fewer SSI cases and save $10.6 million per year as
the result of this work
Source: http://www.centerfortransforminghealthcare.org/assets/4/6/SSI_storyboard.pdf
Mayo Clinic – No “Silver Bullet”
“7S Bundle” to Reduce Colorectal SSIs
1. SAFETY – is the Operating Room safe?
2. SCREEN – do we screen for patient risk factors and
presence of MRSA and MSSA?
3. SHOWERS – do we have patients cleanse their body
the night before and the morning of surgery with
CHG?
4. SKIN PREP – are we prepping the skin with CHG?
5. SOLUTION – do we irrigate with normal saline?
6. SUTURES & WOUND PROTECTORS – do we use wound
protectors?
7. SKIN CLOSURE – do we seal the incision or cover it
with an antimicrobial dressing to prevent
contamination?
SHEA: Strategies to Prevent Surgical Site
Infections in Acute Care Hospitals 2014 Update
1.
2.
3.
4.
5.
6.
7.
Administer antimicrobial prophylaxis according to evidence-based standards
and guidelines
Do not remove hair at the operative site unless the presence of hair will
interfere with the operation
Control blood glucose during the immediate postoperative period for
surgery patients
Maintain normothermia (temperature of 35.5°C or more) during the
perioperative period
Optimize tissue oxygenation by administering supplemental oxygen during
and immediately following surgical procedures involving mechanical
ventilation
Use alcohol-containing preoperative skin preparatory agents if no
contraindication exists
Use impervious plastic wound protectors for gastrointestinal and biliary tract
surgery
Source: AJIC Vol. 42 No.8 pages 823
Conclusion
• Value-based purchasing is a necessary catalyst
for transforming the health care delivery
system and getting to the goal of a high
quality and affordable system
Resources
• http://nursingpathways.kp.org/national/quality/i
nfectioncontrol/toolkit
• http://www.centerfortransforminghealthcare.org
/assets/4/6/SSI_storyboard.pdf
• http://www.apicmn.org/2011%20Presentations/
004b%20Colorectal%20SSI%20Reduction%20%20Dr%20Robert%20Cima.pdf
• http://www.qualityreportingcenter.com/wpcontent/uploads/2015/02/IQR-FY2017_VBPDomain-Weighting-Infographic.pdf