Quality / Performance Improvement

Mike Holland Vice President, Lean Healthcare

NEXT LEVEL

Partners, LLC 1

Highlights



Quality / Performance Improvement

• •

20 questions for 10% of exam 8 knowledge areas

2

American Reinvestment & Recovery Act (ARRA)

Provide incentive payments for

Meaningful Use

of Certified EHR technology   Stage 1 Components:  Electronically capture health information in a coded format Use that information to track key clinical conditions Communicate that information for care coordination purposes  Initiate the reporting of clinical quality measures and public health information 3

American Reinvestment & Recovery Act (ARRA)

    Meaningful Use Priorities  Improve quality, safety, efficiency, and reducing health disparities Engage patients and families in their health care Improve care coordination Improve population and public health outcomes Ensure adequate privacy and security protections for personal health information  Engage decision support for national high-priority conditions 4

Stage I - Functional Measures (Final Rule) Hospital Eligible Professional Stage I - Clinical Quality Measures (Final Rule) Hospital Eligible Professional 23 Meaningful Use Functional Measures Measures with a denominator of unique patients regardless of whether the patients records are maintained using certified EHR technology 5 measures

Example: Maintain active medication list

24 Meaningful Use Functional Measures Measures with a denominator of unique patients regardless of whether the patients records are maintained using certified EHR technology 6 measures

Example: Maintain active medication list

15 Meaningful Use Clinical Quality Measures Stage I Hospital Meaningful Use Clinical Quality Measures Core Measures: Stroke 7 measures Core Measures: VTE 6 measures Measures with a denominator based on counting actions for patients whose records are maintained using certified EHR technology 9 measures

Example: Record and chart changes in vital signs

Measures with a denominator based on counting actions for patients whose records are maintained using certified EHR technology 10 measures

Example: Record and chart changes in vital signs

Core Measures: ED Throughput 2 measures – Reports Only Functional Capability Yes/No Attestation Only 9 measures

Example: Implement drug drug and drug-allergy interaction checks

Functional Capability Yes/No Attestation Only 8 measures

Example: Implement drug drug and drug-allergy interaction checks Functional reports will be developed by Cerner as part of each solution as part of that solution.

’

s departmental reports. Clients who have implemented the corresponding solution will receive the reports Cerner Millennium

® Core Measure solutions requires a subscription and services for implementation.

Please note – this does not cover the 2012 future e-submission capabilities based on pending definition and requirements.

6 Meaningful Use Clinical Quality Measures per EP Stage I Eligible Professional Meaningful Use Clinical Quality Measures or Chronic Condition Management Core Measures 3 Alternate Core Measures 3 Additional Measures for Selection by Specialty 17

Cerner Millennium

and ® Stage I Eligible Professional Meaningful Use solution

Cerner Millennium

® Chronic Condition Management solution require a subscription and services for implementation.

Quality and PI Knowledge Areas

    Benchmarking techniques Medical staff peer review and discipline process Risk management principles and programs Performance and process improvement (e.g. CQI, TQM, QA/QI, PI)     Customer satisfaction principles and tools Clinical methodologies, evidence-based medicine, population health, pay for performance Utilization review and management regulations National quality initiatives (e.g. patient safety) 6

Quality & PI

Why the focus on Quality & Performance Improvement?

      Accreditation guidelines Growing consumerism Efficiencies and cost savings Improved patient outcomes Transparency National reporting, e.g. HHS Hospital Compare http://www.hospitalcompare.hhs.gov

7

Quality & PI

  Organizations that support quality initiatives:       The Joint Commission (TJC) CMS Core Measures (NHQM, HOP) Institute of Medicine (IOM) Leapfrog Group NQF ( National Quality Forum) AHRQ (Agency for Healthcare Research and Quality) IHI (Institute for Healthcare Improvement) Baldrige National Quality Program 8

Quality & PI

The Joint Commission (TJC):  Requires organizations to systematically monitor, analyze, and improve patient outcomes  TJC National Patient Safety Goals • • • • Improve the accuracy of patient ID Improve the effectiveness of communication among caregivers Improve the safety of using high-alert medications Eliminate wrong-site, wrong patient and wrong procedures surgery • • • Improve the safety of using infusion pumps Improve the effectiveness of clinical alarm systems Reduce the risk of healthcare acquired infections 9

Quality & PI

The Joint Commission & Medical Records  The record must contain sufficient information to identify the patient and to support the diagnosis and treatment, and it must furnish adequate documentation of results.

 Requires that the medical history, diagnostic and therapeutic orders, all reports, consultations, tests, progress notes, and clinical resume are entered and signed by the attending physician.

10

Core Measures

   The Joint Commission Measures • • • • CMS/Premier Core Measures • • • • AMI CHF Pneumonia SCIP (hip and knee replacement, vascular surgery, CABG, other cardiac surgery, hysterectomy, colon surgery) Stroke VTE Readmission and Mortality (HF, AMI, Pneumonia) Children’s Asthma Care HHS Website – Hospital Compare 11

HCAHPS

Hospital Consumer Assessment Health Plans Survey  Looks at satisfaction with: • • • • Communication Pain management Environment Education of patient 12

IOM Reports Emphasis on Patient Safety

1999 – To Err Is Human 2001 – Crossing the Quality Chasm

 Between 44K and 98K people die as the result of medical errors that could have been prevented  Medical errors • • Failure of planned action as intended Use of wrong plan to achieve outcome  Common problems • • Drug and blood reactions Restraint deaths • • Falls, burns and pressure ulcers Mistaken identity  Most high risk areas • ICUs, ORs and EDs 13

Institute for Healthcare Improvement (IHI)

    100,000 Lives Campaign inspired by IOM reports • Saved 124,000 lives in 18 months Dec ‘06 – Dec ’08 5 Million Lives Campaign IHI Improvement Map IHI.org

14

Leapfrog

         Leapfrog Group’s inception 2000 – built on fact that provider performance transparency is critical to optimal functioning in marketplace Save lives by reducing preventable medical mistakes NQF endorsed practices CPOE Evidence-based Hospital Referrals (EHR) ICU Physician Staffing Never Events (Pressure Ulcers, wrong surgical site, etc.) Mortality by Surgeon Surgeon Volumes 15

HEDIS

  Healthcare Effectiveness Data and Information Set  Report card primarily from the consumers’ perspective on health plan performance Assists employers with health plan selections, etc. Measures were developed by the National Committee for Quality Assurance (NCQA  Rate health plans on quality of care, access to care, and member satisfaction with the plan  Used by more than 90 percent of America’s health plans 16

Pay for Performance P4P

 Model built on defined measures, data collection, and public reporting  Payment incentives aimed at quality, efficiency, and patient satisfaction  Focus on value while taken into account the relationship between quality and cost 17

Baldrige Criteria

 Enhance the competitiveness, quality and productivity of US organizations for benefit to all residents  Categories (7) • Leadership, Strategic Planning, Focus on Patients, Measurement & Analysis, Staff Focus, Process Management and Performance Results  Measurement of processes that have • • • • Approach Deployment Learning Integration (horizontal vs. vertical alignment) 18

Quality & PI Themes

        Processes and Progress are measurable Quality tools improve the reliability of collecting data Better decisions can be made with proper analysis Individual success improves when allowed to participate in decision making Empowerment and fear are mutually exclusive Serving the customer is paramount to survival Customers provide feedback (expectations) Acting on feedback improves customer satisfaction 19

Risk Management

      Aids in identifying, evaluating, and reducing risks that could be encountered by staff, patients, and visitors Reduces the legal and financial exposure of the organization, while TQM/CQI improves processes that may have been poorly designed, and as a result increase risk to the patient Common risk management concepts: near miss, root cause analysis, sentinel events, safety, etc.

In some organizations, the risk management function overlaps or is included with the corporate compliance function QI/PI perspective – is there a trend or disequality?

RM perspective – is an accident waiting to happen?

20

Risk Management and Medical Records

   Ownership of the medical record rests with the hospital or with the physician who keeps patient records  The owner of the record thus has the right of physical possession and control  Neither the patient nor an authorized representative has the right to physical possession of original medical records The physician or hospital can transfer a copy The hospital or physician has a legal obligation to make available to the receiving physician or hospital all information that is necessary for the care of the patient 21

Quality & PI Leadership Role

          Establish a mission and culture that are committed to excellence Nurture commitment to quality principles and

lead by example

Ensure the safety systems are in place Hold people accountable to be technically competent to meet the needs of patients Identify gaps between actual and desired performance Provide a framework to identify, debate, and resolve issues limiting clinical capability Provide training in in use of tools and statistical concepts for accurate data collection Select problems to address Understand fluctuation with a goal to reduce variation As variation is reduced, the quality becomes more consistent and patient outcomes and satisfaction improve 22

Quality and PI Medical Staff Roles

 Create and maintain the bylaws that help govern the health care organization’s setting  Provide the medical oversight for quality care, services offered, types of treatment  Establish medical privileging and credentialing of staff  Provide ongoing evaluation of the competencies related to the medical community 23

Quality & PI

   Common Process Improvement Methods  Total Quality Management (TQM) and Continuous Quality Improvement (CQI) – often used interchangeably Six Sigma – reduce variations LEAN thinking – remove waste Plan-Do-Check-Act Cycle – study the process, put plans into action, observe key learnings, and repeat the cycle with needed modifications  Rapid Cycle Improvement (Kaizen) – improve performance by incremental process changes  Review the teachings of Deming, Phillip Crosby, Juran, Ishikawa 24

Quality & PI

 TQM/CQI focus is on the system and processes, rather than the individual  PDCA cycles encourage analysis of data to assess interrelated parts of the system and how they function  As one part of a system is improved, the relationship or functioning between parts of the system can be improved  Focus on interdependencies and hand-offs 25

Quality & PI Tools

      Pareto charts – arrange data by relative importance Scatter diagrams – relationship between two qualitative variables Check sheets – collection of data that help summarize information Control charts – determine upper and lower limits of expected common cause variation Cause and Effect diagrams – AKA Fishbone diagrams Histograms – graphical display of a set of numbers and their variation 26

Quality and PI

   Examples of quality data use:  Reporting on data related to adverse effects, outcomes, incidents, complaints and malpractice Patient and family satisfaction survey Total costs per patient or per episode Compliance/Variation with clinical practice guidelines  Number of rules/alerts acted upon or ignored 27

Quality and PI

  Examples of quality in clinical performance  Using patient management protocols to guide clinical care  Using functional protocols to ensure safe, reliable, patient centered care elements Continuously improving clinical care Strengthening illness prevention and health promotion  Supporting a culture of clinical improvement 28

“…total score-able offsets put forward by the [U.S. Presidential] Administration to nearly

$950 billion over 10 years

…”

- June 13, 2009 White House release in response to how the government plans to cover the cost of health care reform

Additional CMS Savings (billions of dollars) $110 billion in Productivity Improvements over 10 years

29

The impact of $110B in Productivity Improvements on every hospital assuming…

  50% of the productivity improvements are imposed upon all acute care hospitals in the US (

will likely be more

) The improvement expectations will be imposed proportionate with hospital size (

# registered beds

)

Currently ~575,000 registered beds in US

Rough estimate of this impact on your hospital(s) over 10 years: 100 Bed Hospital =

$1M / year

250 Bed Hospital =

$2.5M / year

500 Bed Hospital =

$5M / year

1,000 Bed Hospital =

$10M / year

Prepared for this?

From NATIONAL AND LOCAL IMPACT OF LONG-TERM DEMOGRAPHIC CHANGE ON INPATIENT ACUTE CARE, Solucient, 2005 30

This will require

disruptive change

to the way we lead our healthcare organizations!



Quality

and



Costs

31

Quality & PI

Need more in-depth resources?

Applying Quality Management in Healthcare: A Process for Improvement

, Diane L. Kelly, Dr.P.H.

Continuous Quality Improvement in Health Care

, Curtis P. McLaughlin and Arnold D. Kaluzny

Crossing the Quality Chasm: A New Health System for the 21 st Century

, Committee on Quality of Health Care in America, Institute of Medicine

Error Reduction in Health Care

, Patrice L. Spath

To Err is Human: Building a Safer Health System

, Linda T. Kohn, Janet M. Corrigan, Molla S. Donaldson, Committee on Quality of Health Care In America, Institute of Medicine.

32

Quality & PI

Test Questions

The primary purpose of the quality assurance/risk management program is to: A.

Comply with licensure and accreditation standards as required by state and federal legislation B.

C.

D.

Monitor medical staff practices in order to control the increases in malpractice rates Identify potential problems that will keep the hospital from becoming a party to litigation Monitor, control, and direct the institution’s efforts towards achieving delivery of the optimal level of care 33

Quality & PI

Test Questions

In consultation with the board, the administrator has decided that an effort must be made to increase the level of involvement among management personnel in quality assessment and assurance. Which one of the following options is most likely to achieve the desired results?

A.

B.

C.

D.

Send all key management personnel to quality assessment workshops over the next year Delegate quality assessment function in question to the medical records committee Delegate quality assessment education functions to the utilization review coordinator Develop an in-house program using trained key personnel for presenting and discussing quality assurance and its implication for the organization.

34

Quality & PI

Test Questions

The governing body of a healthcare institution meets its responsibility for the quality of patient care by: A.

Delegating accountability for patient care to the committee appointed by the governing body, which provides a formal administrative liaison between the governing body, the administration, and the medical/professional staff.

B.

C.

Delegating to the chief executive officer the responsibility for developing criteria for making certain that an effective medical/professional audit is carried out.

Establishing, maintaining, and supporting through medical/professional staff and management staff an ongoing program of review and evaluation of patient/client care and action on findings D.

Establishing an effective system for utilization review, medical/professional audit activities, and credentialing of the medical/professional staff.

35

Quality and PI

Test Questions

Which of the following statements most accurately describe how the Baldrige Quality Program criteria relates to the health care sector?

A.

Addresses key areas of running a successful health care organization and is compatible with other performance improvement initiatives, i.e. Magnet status, Joint Commission and Institute For Healthcare Improvement initiatives B.

C.

D.

Valuable framework for measuring performance and planning in an uncertain environment Criteria helps health care organizations achieve and sustain the highest national levels of patient safety and patient loyalty, health outcomes, physician/staff satisfaction, revenue and market share, and community services All of the above 36

Quality and PI

Test Questions

All of the following are commonly recognized to be a right of each patient except: A.

Right to considerate and respectful care B.

Right to receive a reasonable response to his/her requests C.

Right to communicate with a caregiver in the language of the patient’s choosing D.

For dying patients, the right to receive effective pain management 37

Quality and PI

Test Questions

The governing authority assures itself about the quality of care by: A.

Holding the CEO of the health facility accountable.

B.

Making the president of the medical/professional staff an ex officio member of the governing authority C.

Approving the process and then following up regularly and continuously to see that it is being used D.

Reviewing tabulated results of incidence reports 38

Quality & PI

Test Questions

Which PI tool would best show process problems, in ranking order of the most frequent, down to the least frequent, in descending order from left to right?

A.

B.

C.

D.

Histogram Pareto Chart Scatter diagrams None of the above 39

Quality & PI

Test Questions

Which of the following statements most accurately describes the HEDIS, Health Plan Employer Data and Information Set?

A.

HEDIS indicators can easily be adopted for use by acute care hospitals B.

C.

D.

HEDIS quality indicators evaluate preventive services, prenatal care, acute and chronic illness, and mental health and substance abuse programs HEDIS was developed primarily to meet the needs of patients and their families Financial performance has no bearing on HEDIS indicators 40

More Question Areas

        Benchmarking techniques and their use Performance improvement tools and their use Board role for Quality of Care – Medical Staff Ultimate responsibility for Credentialing Functions of a Quality Council or Performance Improvement Council Understanding Patient Rights and Responsibilities Utilization review concepts Overview of the Joint Commission Standards on Medical Documentation 41