Hospital Performance and  Quality Reporting

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2. Disclaimer. Kevin Warren, Becky Heinsohn and TMF Health Quality Institute do not have relevant financial relationships to disclose.. 3. Objectives. Describe the national hospital quality improvement efforts and initiativesDescribe the central role quality plays in the efforts to improve healt

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Hospital Performance and Quality Reporting

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1. 1 Hospital Performance and Quality Reporting Critical Access Hospital Conference Austin, Texas June 25, 2009 Kevin Warren, SVP, Operations Becky Heinsohn, RN, CPHQ, Director, Patient Safety TMF Health Quality Institute

2. 2 Disclaimer Kevin Warren, Becky Heinsohn and TMF Health Quality Institute do not have relevant financial relationships to disclose.

3. 3 Objectives Describe the national hospital quality improvement efforts and initiatives Describe the central role quality plays in the efforts to improve healthcare Recognize benefits of voluntary quality data reporting Identify and discuss other factors for consideration

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5. 5 “Knowledge is of two kinds. We know a subject ourselves, or we know where we can find information upon it.” Samuel Johnson, 1775

6. The Means to an End Collecting Information on Quality Selective Contracting with High-Quality Providers Partnering with Providers on Plans for Improvement Educating Employees on Quality Issues Rewarding High Quality and Penalizing Poor Quality Value-Based Purchasing: A Review of the Literature, Vittorio Maio, Neil I. Goldfarb, Chureen Carter et al., The Commonwealth Fund, May 2003 6

7. 7 Setting the Stage Medicare Modernization Act (MMA) 2003 0.4% holdback for non-voluntarily reporting 10 Initial Measures Deficit Reduction Act (DRA) 2005 2.0% holdback for not reporting Expansion of Publicly Reported Measure Set Report to Congress for VBP program (FY 2009) Present on Admission (Hospital Acquired Conditions) Tax Relief and Health Care Act of 2006 Incorporate hospital outpatient measures Physician Quality Reporting Initiative (PQRI) Gainsharing Demonstrations American Recovery and Reinvestment Act of 2009 Reimbursement incentives for successful “meaningful use” Regional Extension Centers to provide assistance and education with HIT adoption

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10. Between 2004 and 2013, it is anticipated that, in aggregate, approximately $7.4 Trillion dollars in health expenditures will be due to unnecessary costs at an average of 30% unnecessary cost per year National Healthcare Expenditures are expected to reach over 3 trillion dollars by 2012. That’s spending 100 million per day for the next 86 years. Between 2004 and 2013, it is anticipated that, in aggregate, approximately $7.4 Trillion dollars in health expenditures will be due to unnecessary costs at an average of 30% unnecessary cost per year National Healthcare Expenditures are expected to reach over 3 trillion dollars by 2012. That’s spending 100 million per day for the next 86 years.

11. Improve Quality Quality improvement opportunity Wennberg’s Dartmouth Atlas on variation in care McGlynn’s NEJM findings on lack of evidence-based care IOM’s Crossing the Quality Chasm findings Avoid Unnecessary Costs Medicare fee schedules and prospective payment systems are based on resource consumption and quantity of care, NOT quality or unnecessary costs avoided Tom Valluck, MD, CMS Presentation CMS’ Progress Toward Implementing Value-Based Purchasing September 13, 2007 11

12. 12 Why Does the System fall short in Providing High Quality Care? Current improvement methods are highly dependent on vigilance and hard work Focus on clinical outcomes gives clinicians a false sense of security Permissive clinical autonomy allows wide performance margins Deliberate design for reliability rarely occurs

13. What’s wrong with being right 99.9% of the time??? 12 Babies a day given to the wrong family!

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15. 15 Intent, Vigilance, and Hard Work, or Redesign? Standardization Pre-printed orders, checklists, feedback on compliance, training, education Human factors and reliability science Decision aids and reminders built into the system, redundancy in the system, forcing functions, or desired actions are the default (requires opt out to fail) Redesign of the reliable system – constantly learning from failures and redesigning the system to account for human factors and failures

16. Voluntary Reporting Why? Why not? Who reports? Why do you report? Why not report? Who reports? Why do you report? Why not report?

17. 17 Quality Data Reporting Initiatives Improved performance on clinical measures Acute myocardial infarction Heart failure Pneumonia Surgical care

18. Who Reports? Over the past 2 years, 33-35 Critical Access Hospitals in Texas have been reporting data consistently So What?? 18 Many are reporting, ARE YOU? An added benefit of reporting 2007 --23 award recipients were rural and/or Critical Access Hospitals. Hospitals were presented with their awards in a formal ceremony in Austin on June 28, 2007, with 220 hospital professionals attending. In addition to postings on the TMF Web site, award recipients were recognized in the media almost 50 times, with stories being picked up by metropolitan business journals in key Texas cities such as Dallas, Houston and San Antonio. Award's stories were featured in the Houston Chronicle, Fort Worth Star Telegram, San Antonio Express-News and other online and print publications such as Yahoo Finance, Forbes.com, MarketWatch, Managed Care online and Texas Hospitals. 2008 ---25 Critical Access hospitals entered the Texas Healthcare Quality Award with winners to be announced soon and formal ceremony planned for August 27, 2009. Types of Awards: Pass validation for the most current 3 quarters of data available at the end of the program (most likely quarters 1-3, 2008) Award of Excellence: ACM score of 90-100% and pass validation.    Quality Improvement Achievement Award: ACM score of 80-89% and pass validation. ACM score based on 11 indicators for the clinical topics of HF and PNE. Many are reporting, ARE YOU? An added benefit of reporting 2007 --23 award recipients were rural and/or Critical Access Hospitals. Hospitals were presented with their awards in a formal ceremony in Austin on June 28, 2007, with 220 hospital professionals attending. In addition to postings on the TMF Web site, award recipients were recognized in the media almost 50 times, with stories being picked up by metropolitan business journals in key Texas cities such as Dallas, Houston and San Antonio. Award's stories were featured in the Houston Chronicle, Fort Worth Star Telegram, San Antonio Express-News and other online and print publications such as Yahoo Finance, Forbes.com, MarketWatch, Managed Care online and Texas Hospitals. 2008 ---25 Critical Access hospitals entered the Texas Healthcare Quality Award with winners to be announced soon and formal ceremony planned for August 27, 2009. Types of Awards: Pass validation for the most current 3 quarters of data available at the end of the program (most likely quarters 1-3, 2008) Award of Excellence: ACM score of 90-100% and pass validation.    Quality Improvement Achievement Award: ACM score of 80-89% and pass validation. ACM score based on 11 indicators for the clinical topics of HF and PNE.

19. Success is Achievable *Achievable benchmark of care (ABC rate): Aggregate rate of top hospitals serving 10% of patient population discharges in Texas from 2008 Q1 - 2008 Q4. State and ABC rates are based on data from critical access hospitals only. ** (PPS): Items in “()” are PPS hospital data ACM – Appropriate Care Measures The ACM is a composite score that captures whether or not a patient received all the care he or she was eligible to receive. The ACM score is a measure of how often the hospital gets it right. In other words the patient is the unit of analysis. What percentage of your patients received all indicated care (all-or-none)? If the patient did not receive any care that was indicated, the case is not in the numerator. Achievable Benchmarks of Care (ABC)- superior performance that is received by the top 10% of patients or the performance of providers giving the “best” care for at least the top 10% of patients. Some providers included in the pared mean calculation will be above the benchmark and some will be below the benchmark. ACM – Appropriate Care Measures The ACM is a composite score that captures whether or not a patient received all the care he or she was eligible to receive. The ACM score is a measure of how often the hospital gets it right. In other words the patient is the unit of analysis. What percentage of your patients received all indicated care (all-or-none)? If the patient did not receive any care that was indicated, the case is not in the numerator. Achievable Benchmarks of Care (ABC)- superior performance that is received by the top 10% of patients or the performance of providers giving the “best” care for at least the top 10% of patients. Some providers included in the pared mean calculation will be above the benchmark and some will be below the benchmark.

20. 20 TMF’s Role in the Data Reporting Support Support data submission to the clinical data warehouse Validation of data submitted by providers Analysis of data and education Access to comparative performance Training on technical manual changes – regional workgroups Hospitals requirements: Sign and submit the Pledge of Participation form to TMF by the specified timeframe indicating they would submit data to the clinical data warehouse Register for QNet Exchange by the established deadline Identify a QNet administrator and complete registration process Successfully submit data by the established data transmission deadline for each quarter Meet validation requirements with 80% reliability Submit complete data in accordance with the joint CMS/JCAHO sampling requirements located on the QNet website Hospitals requirements: Sign and submit the Pledge of Participation form to TMF by the specified timeframe indicating they would submit data to the clinical data warehouse Register for QNet Exchange by the established deadline Identify a QNet administrator and complete registration process Successfully submit data by the established data transmission deadline for each quarter Meet validation requirements with 80% reliability Submit complete data in accordance with the joint CMS/JCAHO sampling requirements located on the QNet website

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22. Approach Supportive Management Structure Structures to “fool proof” change Transparency and Feedback Patient focused culture Formal Development programs Know your sources for resources 22 Leadership and governance play a key role in improvement of care. Link your QI with your mission and strategic plan. Change- standardized processes and orders plus engagement of physicians is critical. Research has consistently demonstrated the value of physician champions in quality initiatives. Taking ownership helps overcome barriers, incorporation of evidence-based practices into care and assistance in redesign or processes Transparency and feedback- participate in public reporting initiatives, share your measurements with your employees and medical staff. Patient focused culture- Healthcare workers will focus their energy on those areas of their work which they are held accountable. If all measures for a performance evaluation focus on productivity, volume, or amount of work done, quality will not be a priority for the front line Formal development programs-develop QI teams in your hospital that address quality and patient safety issues. All teach and all learn- Become a Learning Organization. You cannot be promoted unless you are a Star Quality Improver Know your sources for resources- CMS, QIO, IHI, American Heart Association- G-W-T-Guidelines, AHRQ, ARRA/HITECH $, Texas Flex Program, Grant Writing USE YOUR SIZE TO YOUR ADVANTAGE ! There is a benefit to having low patient volumes and multitasking of care providers. The nurse that works in the ED, performs infection control duties as well as med surg care knows the importance of getting correct antibiotic to each patient timely and the importance of making sure before discharge the vaccination status of each PNE patient has been addressed to prevent reoccurrence of PNE. Just as the nurse who works in OR and provides care for the post op patient knows how important the pre op timing of antibiotics, continuation of beta blockers to prevent intra operative MI plus with no evidence of post op infection the DC of antibiotics post op. Larger hospitals unlike smaller CAH and rural hospitals spend too much time trying to break down barriers and silos of care. Leadership and governance play a key role in improvement of care. Link your QI with your mission and strategic plan. Change- standardized processes and orders plus engagement of physicians is critical. Research has consistently demonstrated the value of physician champions in quality initiatives. Taking ownership helps overcome barriers, incorporation of evidence-based practices into care and assistance in redesign or processes Transparency and feedback- participate in public reporting initiatives, share your measurements with your employees and medical staff. Patient focused culture- Healthcare workers will focus their energy on those areas of their work which they are held accountable. If all measures for a performance evaluation focus on productivity, volume, or amount of work done, quality will not be a priority for the front line Formal development programs-develop QI teams in your hospital that address quality and patient safety issues. All teach and all learn- Become a Learning Organization. You cannot be promoted unless you are a Star Quality Improver Know your sources for resources- CMS, QIO, IHI, American Heart Association- G-W-T-Guidelines, AHRQ, ARRA/HITECH $, Texas Flex Program, Grant Writing USE YOUR SIZE TO YOUR ADVANTAGE ! There is a benefit to having low patient volumes and multitasking of care providers. The nurse that works in the ED, performs infection control duties as well as med surg care knows the importance of getting correct antibiotic to each patient timely and the importance of making sure before discharge the vaccination status of each PNE patient has been addressed to prevent reoccurrence of PNE. Just as the nurse who works in OR and provides care for the post op patient knows how important the pre op timing of antibiotics, continuation of beta blockers to prevent intra operative MI plus with no evidence of post op infection the DC of antibiotics post op. Larger hospitals unlike smaller CAH and rural hospitals spend too much time trying to break down barriers and silos of care.

23. 23 Board Engagement Research suggests that the more engagement of hospital leadership (C-suite, boards, and physicians), in cooperation with other healthcare professionals in QI, is associated with higher performance in clinical care. The active involvement and collaborative participation of top level leaders is essential Hospital leaders must be given the knowledge and tools to address the issue Boards and C-Suites often perceive a very active, visible level of engagement in a culture of quality and patient safety while middle management and frontline healthcare workers often have a very different perception of organizational commitment to quality and safety. Surveying hospital boards, executives and clinical staff via AHRQ Hospital Leadership & Quality Assessment Tool plus surveying your staff via the AHRQ Hospital Survey on Patient Safety Culture will provide a gauge for your readiness for change and ot chart the progress over time. DO YOU INCLUDE QUALITY REPORTS AT YOUR BOARD MEETING? DO YOU PROVIDE ANNUAL EDUCATION TO YOUR BOARD ON QUALITY IMPROVEMENT? QUALTIY OF CARE IS JUST AS IMPORTANT AS FINANCIAL HEALTHResearch suggests that the more engagement of hospital leadership (C-suite, boards, and physicians), in cooperation with other healthcare professionals in QI, is associated with higher performance in clinical care. The active involvement and collaborative participation of top level leaders is essential Hospital leaders must be given the knowledge and tools to address the issue Boards and C-Suites often perceive a very active, visible level of engagement in a culture of quality and patient safety while middle management and frontline healthcare workers often have a very different perception of organizational commitment to quality and safety. Surveying hospital boards, executives and clinical staff via AHRQ Hospital Leadership & Quality Assessment Tool plus surveying your staff via the AHRQ Hospital Survey on Patient Safety Culture will provide a gauge for your readiness for change and ot chart the progress over time. DO YOU INCLUDE QUALITY REPORTS AT YOUR BOARD MEETING? DO YOU PROVIDE ANNUAL EDUCATION TO YOUR BOARD ON QUALITY IMPROVEMENT? QUALTIY OF CARE IS JUST AS IMPORTANT AS FINANCIAL HEALTH

24. 24 Sources for Resources Your Peers Texas Organization for Rural and Community Hospitals (TORCH) TMF Health Quality Institute Office of Rural and Community Affairs (ORCA) Institute for Healthcare Improvement (IHI) National Quality Forum (NQF) Centers for Medicare & Medicaid Services (CMS) And so on…. Right care – evidence-based care Every patient – equal care Every time – consistent careRight care – evidence-based care Every patient – equal care Every time – consistent care

25. “To do things differently, we must see things differently. When we see things we haven’t noticed before, we can ask questions we didn’t know to ask before” John Kelsch, Xerox 25

26. What can you do when you get back to work? Get goals Get bold Get together Get the facts Get to the floor Get a clock Get your numbers Get the stories 26

27. “Call the Question” How do your clinical scores compare to your competitors? Are you proud of “your” performance? Does your organization relate financial performance to quality of care performance? Does improving quality really matter in your organization? Are you prepared for “quality driven” reimbursement? How are quality initiatives prioritized within your organization? Developed from AHA Get w/ the Guidelines program (Houston, 2005) 27 In every presentation, I’m always looking for one takeaway that I can apply back home. If there is at least one takeaway from this presentation, it is this slide: I would encourage you to review these questions from both a self reflection perspective as a leader as well as with your leadership team at home. You have an opportunity to be as prepared as possible for the future changes, whatever they may be, that will affect your hospital. In every presentation, I’m always looking for one takeaway that I can apply back home. If there is at least one takeaway from this presentation, it is this slide: I would encourage you to review these questions from both a self reflection perspective as a leader as well as with your leadership team at home. You have an opportunity to be as prepared as possible for the future changes, whatever they may be, that will affect your hospital.

28. 28 “What endures is your effect on other people and the kind of world, organization and culture that you've helped to create.” Jeffrey Pfeffer Stanford University [Jeffrey Pfeffer is a Professor of Organizational Behavior at Stanford.] I would challenge you, that the true measure of an embedded culture is not how it functions in your presence, but how it succeeds in your absence. “If I walk away tomorrow, what would happen?” [Jeffrey Pfeffer is a Professor of Organizational Behavior at Stanford.] I would challenge you, that the true measure of an embedded culture is not how it functions in your presence, but how it succeeds in your absence. “If I walk away tomorrow, what would happen?”

29. Contact Information Sherri Gagner Hospital Data Reporting Consultant 512-334-1717 [email protected] Christine Pencak Hospital Data Reporting Consultant 512-334-1803 [email protected] 29

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