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All Hands Meeting September 25, 2008. Theme: “Quality Improvement” The Big Picture: Brian Goldstein (15 min) Quality Programs: Darren DeWalt (10 min) Application to our practice: Annie Whitney (10 min) Clinic staff and provider roles: Kelly Andress and Cristin Colford (10 min)

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All hands meeting september 25 2008
All Hands MeetingSeptember 25, 2008

  • Theme: “Quality Improvement”

  • The Big Picture: Brian Goldstein (15 min)

  • Quality Programs: Darren DeWalt (10 min)

  • Application to our practice: Annie Whitney (10 min)

  • Clinic staff and provider roles: Kelly Andress and Cristin Colford (10 min)

  • Miscellaneous: (10 min)

    • Home health/equipment/etc.: Judy Martin

    • Flu vaccines: Judy Martin

    • Rabies vaccine limitations: Judy Martin



Collaborators
Collaborators

  • William Furman, MD

  • David Weber, MD

  • Larry Mandelkehr, MBA

  • Celeste Mayer, PhD, RN

  • Many Department Chairs

  • Many of you

  • PIPS Staff

  • House Staff

  • Medical Staff Committees

  • Hospital Epidemiology

  • Nursing

  • UNC P&A

  • Many others . . . .


UNC Health Care

Strategic Framework


Performance improvement and patient safety division values
Performance Improvement and Patient Safety Division-- Values

  • Our focus is to promote and support System-level improvements in patient care

  • If you want to say you improved it, you have to measure it

  • A great culture is a key to outstanding care


Performance improvement
Performance Improvement

  • Acute care

  • Prevention

  • Care of chronic conditions/populations

  • Deliver appropriate care more often

  • Steer more care to experienced practitioners

  • Deliver Less “inappropriate” care, less care of unproved benefit

  • Improve “efficiency”; i.e. eliminate non-value-added “waste” in care delivery

  • Help make “improving performance” the objective of every person in the organization








Fisher, ES, et.al. Health Affairs, Web Exclusives, 7 Oct. 2004, pp19-32


Patient safety
Patient Safety

  • Definition: Eliminating and mitigating potential harms in the course of doing good

  • “Be more careful” goals

  • Standardized processes

  • Ensure competencies

  • More timely interventions

  • Involve patients and families

  • Design tools with human nature in mind

  • Promote a culture of safety

    • Teamwork

    • “Reporting” culture

    • “Just” culture

    • Learning culture

    • Executive involvement



Pay for performance
Pay for Performance

  • UNC (and Rex) seeing first significant programs

  • Medicare – “Value based purchasing” using Core Measures

  • Private insurers -- generally planning to use existing public programs

  • BCBSNC “customized” partnership with UNC and Rex


Pay for performance current reality in our market
Pay for Performance – current reality in our market

  • Performance-related reimbursement for the entire System will be driven by the performance of a relatively small subset of people – at UNC: faculty, residents, and some Hospitals staff

  • The measured “performance” represents only a sliver of what we do

  • The measures are flawed


Pay for performance medicare
Pay for Performance - Medicare

  • Plans October 2008 shift to tie 2-5% of DRG payments to performance

  • Separately – several “complications” will no longer be paid for if they are deemed to occur during hospitalization


Pay for performance bcbs
Pay for Performance -- BCBS

  • Core Measures

  • Additional measures proposed by UNC and Rex

  • For UNC P&A – certification in meeting care goals for Diabetes and Cardiovascular diseases, and in using data effectively to improve care

  • Likely >$10 Million annually (including Rex) potential marginal reimbursement




Centers for medicare and medicaid services surgical care improvement measures
Centers for Medicare and Medicaid ServicesSurgical Care Improvement Measures

  • Administer prophylactic antibiotics (when indicated) within one hour of surgical incision (two hours for Vancomycin; for cases involving tourniquet, administer abx before tourniquet applied)

  • Choose a prophylactic antibiotic consistent with current recommendations (these will be reflected on the paper version of the Pre-Procedure Orders Form; we are still working on a CPOE order set)


Surgical care improvement measures
Surgical Care Improvement Measures

  • Administer prophylactic antibiotics for no more than 24 hours after surgery end time (48 hours for CABG and other cardiac surgery)

  • When hair removal is indicated, CLIP hair and do not SHAVE hair (no razors), AND DOCUMENT THIS CORRECTLY (don’t dictate “shaved”)


Surgical care improvement measures1
Surgical Care Improvement Measures

  • Prevent Venous Thromboembolism: Order and ensure prophylaxis before, and/or immediately after, surgery (e.g. enoxaparin, SCD or TEDs)

  • For patients on a beta-blocker prior to admission, make sure patient continues to receive beta-blocker perioperatively (from 24 hours pre-op, to discharge from PACU; or within six hours post-op if patient skips PACU); IF BETA-BLOCKER CONTRAINDICATED, DOCUMENT WHY


Surgical care improvement measures2
Surgical Care Improvement Measures

  • For cardiac surgery patients ONLY -- Ensure that the 6am post-op serum glucose (on POD #1 and POD #2) is less than or equal to 200 mg/dl

  • For colorectal surgery patients ONLY– Maintain “immediate” postoperative normothermia within 15 min after leaving OR (defined as > 96.8 °F)


CollaborativeMeasures

33


Patient Satisfaction

  • Results of two (2) questions from UNC’s Press- Ganey survey results will be used to determine UNC’s score:

    • Overall rating of care received during your visit?

    • Likelihood of your recommending this hospital to others?

  • Survey results for the twelve-month period ending May 31 will be provided to BCBSNC no later than July 1 of the year in which the increase is to be implemented

  • 34


    Ventilator Associated Pneumonias and Catheter Associated Bloodstream Infections

    • Data will be a weighted, pooled rate per 1,000 ventilator days (or central line days, respectively) for these intensive care units: Coronary Care, Cardiothoracic, Medicine, Pediatric, Neurosurgery, and Surgery.

    • Evaluation period:

      • July 2008 – June 2009 for the 2009 increase

      • July 2009 – June 2010 for the 2010 increase

    35


    Prophylactic antibiotics within Bloodstream Infectionsone hour of surgery

    • Data will be evaluated according to the individual measure score of the Surgical Infection Prevention Core Measure, calculated as described in Section A above

    • Evaluation period will be as follows:

      • October 2008 – March 2009 for the 2009 increase

      • October 2009 – March 2010 for the 2010 increase

    36


    NCQA Physician Recognition Bloodstream Infections

    37


    NCQA Physician Recognition Bloodstream Infections

    38


    NCQA Physician Recognition Bloodstream Infections

    39


    Questions

    Questions? Bloodstream Infections


    Health care quality and recognition programs

    Health Care Quality and Recognition Programs Bloodstream Infections

    Dr. Darren DeWalt


    Why worry about quality
    Why Worry about Quality? Bloodstream Infections

    • Americans receive about half of recommended care.

    Care that meets quality standards

    McGlynn et al. NEJM 2003


    Current payment for medical care
    Current Payment for Medical Care Bloodstream Infections

    • Fee-for-Service

    • If we document talking about a problem with a patient, we can get paid.

    • Assume that the meeting with the doctor accomplished all the recommended care….doctors are highly trained and will do the right thing

    • This was designed when medical care was mostly acute care (patient comes in with infection, we diagnose, treat with antibiotics, episode over)

    • Current care is more complex, mostly chronic illnesses like diabetes, asthma, heart disease, high blood pressure


    Emphasis on quality
    Emphasis on Quality Bloodstream Infections

    • Patients/payers/policy makers want more emphasis on the quality of their medical care and less on “quantity”

    • How do we demonstrate that we provide quality medical care?

    • Measure what we do and improve upon it

    • Our patients deserve this!!!


    Role of recognition programs
    Role of Recognition Programs Bloodstream Infections

    • National Committee on Quality Assurance (NCQA) provides recognition to doctors and practices

    • They create standards to judge whether care is good

    • Public reporting of recognition status is coming

    • Payers are now providing enhanced payment for practices that are NCQA recognized (so-called Pay for Performance)


    Certification programs
    Certification Programs Bloodstream Infections

    • Specialty Boards (American Board of Internal Medicine) are requiring that all physicians demonstrate measurable quality in order to maintain certification

    • State Medical Boards are moving in this direction


    Future of performance assessment
    Future of Performance Assessment Bloodstream Infections

    • We will be expected to produce evidence that our care quality is excellent

    • No more reliance upon reputation

    • Requires ongoing assessment and improvement

    • This will drive us to provide better care for our patients


    New ways of doing things
    New Ways of Doing Things Bloodstream Infections

    • Performance measures help us identify what we can do better

    • We design better ways to do our jobs

    • Our patients receive better care

    • We like our jobs better and patients have better health


    How do we accomplish this
    How do we accomplish this? Bloodstream Infections

    Everyone is needed!


    Ppc pcmh content and scoring
    PPC-PCMH Content and Scoring Bloodstream Infections

    **Must Pass Elements


    Ncqa diabetes application changes to yellow sheet

    NCQA Diabetes Application & Changes to “Yellow Sheet” Bloodstream Infections

    Annie Whitney and

    Dr. Robb Malone


    Ncqa diabetes physician recognition program dprp
    NCQA Diabetes Physician Recognition Program (DPRP) Bloodstream Infections

    • Patient Eligibility

      • Diagnosis of diabetes at least one year

      • Under care of physician at least one year

        • Only attending physicians can apply

      • Between 18 and 75 years old

    • Abstract data from 200 consecutive patient visits


    Ncqa diabetes physician recognition program dprp1
    NCQA Diabetes Physician Bloodstream InfectionsRecognition Program (DPRP)


    Where we were june 2008
    Where we were – June 2008 Bloodstream Infections

    x

    x*

    x

    x

    Goal <

    x = goal not met IM Total Points: 55 Points Needed: 75

    ^ Attending Physicians Only; * UNC Eye only


    Application june 18 july 31
    Application: June 18 – July 31 Bloodstream Infections

    x = goal not met IM Total Points: 90 Points Needed: 75


    Ncqa diabetes physician recognition program dprp2
    NCQA Diabetes Physician Bloodstream InfectionsRecognition Program (DPRP)

    Total Points = 90


    Thanks
    Thanks! Bloodstream Infections

    • We were ready to apply because of all the improvement work we have done over the past 3 to 5 years

    • Thanks to Shaun McDonald

    • Thanks to the front desk staff for ordering labs and processing yellow sheets

    • Thanks to the nurses who are critical to success in monofilaments, smoking and UNC eye

    • Thanks to diabetes care assistants for help with outside eye records and all that they do for our patients with diabetes


    Where are we going
    Where are we going? Bloodstream Infections

    • First, get diabetes recognition

      • Our diabetes program is first rate, but we can do better

      • Further improvement will require efforts by everyone (phone room, front desk, nursing, providers)

    • Next, we will pursue NCQA Patient-Centered Medical Home recognition

    • We plan to continue to be a model of excellence at UNC and across the country


    New diabetes yellow sheets

    New Diabetes “Yellow” Sheets Bloodstream Infections


    Major changes
    Major Changes Bloodstream Infections

    • Front-desk space for POC ordering

      • Space for initials to confirm ordering

    • Provider prompting to order urine microalbumin

      • Recommendation to order yearly if not taking ACE-i or ARB

    • Contraceptive status for females

    • New Foot Care Plan in Place


    Contraceptive status

    Important to assess contraceptive status in females of child-bearing age due to high use of ACE-i/ARBs and statins

    Important to educate patients to potential risks if not using reliable contraception

    Dr. Liz Dehmer and Dr. Amy Weil are working on improving attention to contraceptive issues

    Contraceptive Status


    Diabetic foot care

    Nurses are doing great with monofilament exams but we can give better care to those at high risk for foot complications

    Developed risk stratification and new prompts based on risk

    Thanks to Dr. Aleman, Dr. James Hawk and Dr. Elaine Sunderlin for developing the new foot care plan

    Diabetic Foot Care


    Examples of new yellow sheet prompts
    Examples of New Yellow Sheet Prompts give better care to those at high risk for foot complications

    Monofilament testing indicated- All nurse driven

    → Low Risk - yearly

    Visual inspection indicated- All nurse driven

    → Intermediate Risk – every 6 months

    → High Risk – every 3 months


    Examples of new yellow sheet prompts1
    Examples of New Yellow Sheet Prompts give better care to those at high risk for foot complications

    Comprehensive exam indicated- Nurse and provider driven

    → High Risk – once a year


    Back of yellow sheet
    Back of Yellow Sheet give better care to those at high risk for foot complications


    Clinic staff and provider roles

    Clinic staff and provider roles give better care to those at high risk for foot complications

    Kelly Andress and

    Dr. Cristin Colford


    Miscellaneous

    Miscellaneous give better care to those at high risk for foot complications

    Judy Martin


    Miscellaneous1
    Miscellaneous give better care to those at high risk for foot complications

    • Home health/equipment/etc

    • Flu vaccines

    • Rabies vaccine limitations


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