Transcript ipro.org
A More Perfect Union: Better Health; Better Care; Lower Costs through Improvement
Jean D. Moody-Williams, RN, MPP Director, Quality Improvement Group
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2012 Quote
Collaboration is Hard Work!
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Characteristics of a Learning Organization
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It should review data and respond to it - with tests of new solutions and ideas - every week.
It should bring all participating sites together by phone, in person or webinar frequently It should set one or two quantifiable, project-level goals, with a deadline, preferably defined in terms of outcomes, related to the project’s area of work. It should invest more in learning than in teaching.
Characteristics of a Learning Organization
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It should employ regional “innovator agents It should celebrate success It should use metrics to measure its success such as:
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Rate of testing
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Rate of spread Time from idea to full implementation Commitment rate (rate at which 50% of organizations take action for any specific request)
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Number of questions asked per day Network affinity/reported affection for the network
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Operating Values for Change
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Rapid Cycle Improvement in Quality Improvement Activities and Outputs Customer Focus and Value of the Quality Improvement Activities Ability to Prepare the Field to Sustain the Improvements Valuing Innovation Commitment to “Boundarilessness” Unconditional Teamwork Commitments Secured/Participants Engaged/Results toward Achieving Targets
Measuring Progress Towards Goals
1. Track national progress towards the program goals; 2. Support local quality improvement measurement; 3. Obtain feedback on progress, in close to real time, so the project can be effectively managed; and 4. Evaluate the program’s impact on achieving stated goals.
J Patient Saf - Volume 8, 2012:
Paul McGann1, MD Hackbarth etAndrew D. Hackbarth1, MPhil, William B. Munier2, MD, MBA, Noel Eldridge2, MS, Jack Jordan1, MS, Chesley Richards3, MD, MPH, Niall J. Brennan1, PhD , Dennis Wagner1, MPA,
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National and CMS Quality Strategy Aims
Better Health Better Care Lower Cost
Foundational Principles:
• • • • Enable innovation Foster learning organizations Eliminate disparities Strengthen infrastructure and data systems
Goals Make care safer Strengthen person and family engagement Promote effective communication and coordination of care Promote effective prevention and treatment Promote best practices for healthy living Make care affordable
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Implementation Levers at CMS
Fraud & Abuse Enforcement Target surveys Quality Assessment Performance Improvement Coverage of services Physician Feedback report Quality Resource Utilization Report Physician Value Modifier Readmissions
Payment Policy Survey & Cert.
Program Integrity CMMI Demos & Research
ACOs Community Based Transitions Care Program Dual Eligibles Demonstration Projects Pilots Quality ESRD QIP Hospital VBP Plans for Skilled Nursing Facility and Home Health Agencies, Ambulatory Surgical Centers
VBP
QIOs QIO Innovation Projects ESRD Networks Learning Communities
Q.I. HHS Programs
Partnership for Patients Million Hearts National Quality Strategy Data.gov
COP Other CMS programs
HITECH Hospital Inpatient Quality Reporting Programs Hospitals, Home Health Agencies, Hospices, ESRD facilities
Improving Individual Patient Care
January 31, 2013
C.7.1
Hospital Acquired Infections (HAIs)
Early Outreach: •CAUTI: –ICU/Non-ICUs: •CLABSI: –ICU/Non-ICUs: 672 hospitals 1,269 units 151 hospitals 245 units
CLABSI Progress Rates
2.50
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1.50
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Baseline MP1 55.00
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35.00
25.00
MP2 CLABSI RATE MP3 RIR MP4 MP5 15.00
CAUTI Progress – Incidence Rate Rates
2.10
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1.90
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Baseline MP1 MP2 CAUTI RATE MP3 RIR MP4 MP5 -5.00
Reason for Increased CAUTI rates • The reason behind the increase in national CAUTI SIR figures appears to be multifactorial: •
New Reporters into NHSN:
• The CMS IPPS rule in January 2012, which coincided with the first two quarters of this goal, added ~2,000 new CAUTI reporters into NHSN. • Many of these hospitals had higher CAUTI SIRs increasing the aggregate SIR figure.
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Better Reporters:
• Widespread outreach and education efforts of CDC throughout 2012 to improve accuracy in reporting would reduce underreporting errors and contribute to increase in CAUTI figures.
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Reducing Catheter Use:
• Reducing urinary catheter use decreases the denominator in the SIR calculation making it more difficult to show reductions in the SIR.
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The need for more aggressive implementation of infection prevention strategies:
• Increased implementation of infection control and prevention methods consistently applied within a system that is dedicated to a culture of safety is needed to further impact CAUTI reductions on a wide scale.
CAUTI Progress – Utilization Rate Early National Rates
41,0 40,0 39,0 38,0 37,0 Baseline MP1 MP2 CAUTI Util Rate CAUTI Util RIR MP3 MP4 7,00 6,00 5,00 4,00 3,00 2,00 1,00 0,00
CLABSI and CAUTI SIR
Collaboration Example
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COLLABORATION
provides the opportunity to share both evidence based infection prevention strategy and data-driven results on a broader scale.
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CMS
continues to lead regular interagency meetings to ensure continued knowledge and coordination between the 10th SOW QIO and PfP’s HEN contractor efforts at the state, local and facility-level. – In working to promote CUSP principles nationwide,
AHRQ
’s contractor for the CUSP for CAUTI project, and QIOs are contractually obligated to work together to educate recruited facilities on principles of CUSP.
CDC
continues to work closely with state HAI coordinators to accelerate prevention efforts at the state level.
CDC’s most recent funding opportunity announcement sets forth that one of the primary responsibilities of an HAI coordinator is to ensure coordination of state-based prevention initiatives (e.g. CUSP, QIO, Partnership for Patients) and facilitate connections with leads of the various federally-supported prevention efforts.
Pressure Ulcer Progress Early National Rates
CLABSI Rate in CUSP National Project
Quarters of participation by hospital cohorts, 2009– 2012
C.7.2 - Healthcare Acquired Conditions (HACs): Phase I
QIO outreach as of 01/31/2013: Pressure Ulcers: 788 Nursing Homes and Physical Restraints: 981 Nursing Homes Early and Preliminary Physical Restraints Results Total Baseline: Q4Y10+Q1Y11 # Num.
Denom.
Rate Recruited 1,006 15,334 164,857 9.30
# Recruited 1,004 Current Period: Q2Y12+Q3Y12 Num.
Denom.
Rate 8,024 169,106 4.74
RIR 48.99
National Nursing Home Quality of Care Collaborative (NNHQCC); Phase II
High Performing Nursing Home site visits (10) completed by November 2012 Recruitment by January 31, 2013: Over 4,208 nursing homes NNHQCC LAN Event activities start February 26, 2013 Change Package finalized and shared with QIOs and homes
Best Practice Nursing Homes Using prescribed criteria as of 1/1/13 QIO Nursing Homes Recruited that desire to Become Best Practice Facilities since the 1/31/13 Launch = 4500+
Reducing Adverse Drug Events
QIO/PSPC Teams on 01/31/2013:over 215 teams Anti-coagulant focus only: 36 teams Diabetic focus only: 43 teams Anti-psychotic focus: 42 teams Multi-focus: 62 teams
ADE Rates per Month
Quality Reporting and Incentives Highlights
• 97% of hospitals successfully report data to the Hospital Inpatient Quality Reporting (IQR) Program • Intensive support to providers experiencing difficulty reporting new measures such as NHSN measures • Successful first year for the Hospital Value Based Purchasing (VBP) Program, with over $900 million redistributed based on quality based on IQR data
National Medicare 30 Day Readmissions
Innovation Center Initiatives
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Innovation Center Initiatives Support Care Transformation
ACO Initiatives: Shared Savings Program, Pioneer, Advance Payment, Learning Sessions Bundled Payments for Care Improvement Innovation Advisors Program Multi-Payer Advanced Primary Care Practice Demonstration Comprehensive Primary Care Initiative Partnership for Patients Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration Medicaid Health Home State Plan Option State Demonstrations to Integrate Care for Dual Eligible Individuals Demonstration to Improve Quality of Care for Nursing Facility Residents Financial Models to Support State Efforts to Coordinate Care for Medicare-Medicaid Enrollees 34
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CMS work in Progress for PAC settings, over Next Year:
Developing 30-day Readmission Quality Measures for NHs, LTCHs, IRFs.
Key Considerations from Technical Expert Panels: Risk Adjustment may need to vary by provider setting, population. Various models to consider.
Planned Readmissions exclusions? Reasons/diagnoses may vary by provider setting.
30-day Readmission Measurement Period: Could cover the 30 days after hospital discharge. Could have separate measure to cover the 30 days after PAC discharge.
PAC Readmission: Other CMS Targeting Strategies
• CMS is currently updating the surveyor interpretive guidance for transfer and discharge planning regulations • New regulations are being developed to establish Quality Assurance and Performance Improvement (QAPI) programs in all CMS-certified nursing homes. 36
It Worked!!
http://jama.jama
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Rehospitalization Trends, Intervention and Comparison Communities
-5.7% (p<.001) -2.1% (p=.08) P=.03 (difference)
Hospitalization Trends, Intervention and Comparison Communities
-5.7% (p<.001) -3.1% (p<.001) P=.01 (difference)
QIO Accomplishments as of March 31, 2013
# of Engaged Communities
# of Beneficiaries Living there # Formally Recruited Communities # Communities with Signed Coalition Charter # Applications Submitted # Communities Receiving Formal Funding # Recruited Hospitals # Recruited Nursing Homes # Recruited Home Health Agencies # Recruited Hospice Facilities # Recruited Dialysis Facilities # Recruited Outpatient Physicians
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12,455,368 227 221 125 81 859 1533 901 342 91 > 1300
National Coalition of QIO-engaged Communities Early Progress 4.4
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National Coalition of QIO-engaged Communities Early Progress 6.0
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State by State Admissions/1000
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State by State Readmissions/1000
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State by State ED Visits/1000
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State by State Observation Stays/1000
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ESRD Networks Continue to Make Progress
Fistula First Catheter Last Graphs when necessary
National AV Fistula Rate Reaches 60.6% in April 2012
ESRD
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• Working to develop better anemia management, bone and mineral metabolism, HAI measures and patient experience of care measures • Active involvement in care coordination to reduce hospital admissions • Exploring issues of volume, nutrition and quality of life • Beginning the second year of the ESRD QIP
Moving in the Right Direction
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