Getting Buff Spread,Transparency and Reliability

1. Getting Buff Spread,Transparency and Reliability Kansas State Network Council Meeting Jeff Spade Vice President, NCHA August 2007 jspade@ncha.org

2. Getting Buff • Public Policy Imperatives • NC CAH Performance Improvement Project • Performance Improvement Primer • Performance Improvement Concepts That Work

5. Me.

9. Public Policy Imperatives Medicare Mandates in MMA • Voluntary submission of 10 inpatient measures. • Update is 0.4% higher for those who submit. • No payment difference based on submitted data.

10. CMS Value-Based Purchasing Plan • Beginning FY 2007, hospitals report 21 measures or lose 2% in Medicare PPS reimbursement. • Value-based payments beginning FY 2009. • No payment increase allowed for patients with hospital-acquired infections. • Two VBP listening sessions: • January 17, 2007 • April 12, 2007

11. VBP Program Details • Budget neutral. • In-line with IOM and MedPAC. • Build on existing CMS measures. • Three domains: • Clinical quality • Patient centered care • Efficiency • Performance measures and payments for outpatient care.

12. Goals of CMS Value-Based Purchasing Program • Improve clinical quality. • Reduce adverse events. • Encourage patient centered care. • Avoid unnecessary costs. • Stimulate investments in improving quality and/or efficiency. • Make performance results transparent and comprehensible, empowering consumers.

13. CMS and Premier Quality Demonstration Project • Performance rates of >76% may prevent: • 5,700 deaths and 8,100 complications • 10,000 readmissions and 750,000 hospital days • For 59,000 pneumonia cases: • Patients receiving the least number of quality measures cost the hospital $11,107. • Patients receiving the highest number of quality measures cost the hospital $8,351 -- a savings of $2,756 per case.

14. Key Lessons for Hospitals From a CMS exec: “We are moving toward value-based payments to hospitals.” “More important for hospital and system managers may be the trend toward incentives for preventingadmissions.”

15. CMSwww.hospitalcompare.hhs.gov

16. nchospitalquality.org

18. “If you’re going to be naked, you’d better be buff!”Don Tapscott and David TicollThe Naked Corporation Performance Reporting and Transparency

19. CAH & Rural Hospital Improvement Project • Based on CMS indicators for pneumonia and heart failure. • In partnership with NC Office of Rural Health, NCHA and CCME. • Commitment by 26 small, rural hospitals. • Utilizes an optimal care score to measure performance. • Workshops and collaborative learning along with performance reporting. • Considered a national model for CAHs.

20. Improvements Achieved By • Collaborative workgroups, coaching & mentoring, sharing resources. • Initial focus on pneumonia and heart failure & development of reliable care processes. • Performance measurement, benchmarks and transparency are key. • Analyses and reports feature: • Summary of inclusions and exclusions. • Composite or “optimal care” scores. • CAH mean and hospital performance vs. NC and national benchmarks (top 10% performance) and reliability targets (10-2 performance). • Spider graphs to share with med staff and board.

21. 95% Reliability National Top 10%

22. “All-or-None” Measurement • Also Optimal Care or “perfect care”. • A more stringent outcome measure that reflects ability to manage care processes. • Completion of a full set or bundle of tasks. • Emphasizes patient centered care and focuses on system-wide improvement. • Appropriateness of care measures help to focus improvement efforts. • JCAHO and CMS are moving toward optimal care measures.

23. Pneumonia Spider Graph

24. Heart Failure Spider Graph

25. Sum of numerators Sum of denominators Composite Score Calculation For each patient: Received care for all measures for which they qualify? Qualified for any measure (1=yes, 0=no) For hospital rate:

26. 95% Reliability National Top 10%

27. Top 10% NC Performance 103% Improvement

28. 95% Reliability National Top 10%

29. Top 10% NC Performance 35% Improvement

31. Performance Improvement Primer • Patient Centered Care • Design for Reliability (zero defect rates) • Evidence-based Practice • Clinical Process Improvement • Rapid Cycle Improvement • Collaborative Learning and Spreading Innovations • Measurement and Segmentation (small tests of change) • Commitment of Leadership • This is THE WORK of Healthcare Organizations and Professionals

32. Performance Improvement Primer • The Concepts of Innovation, Diffusion and Spread • Spread is the Diffusion of Innovation

33. Early Adopters 13% Early Majority 35% Late Majority 35% Traditionalists 15% 2% Innovators The Nature of People(Everett Rogers)

34. Target Early Adopters Early Adopters are the key to successful spread of changes ….. • Receptive to change. • More socially integrated than innovators, often opinion leaders. • Trusted by peers to evaluate changes. … Remember “Hey Mikey, he’ll try it”

35. Act Plan Study Do Model for Improvement • What are we trying to accomplish? • How will we know that a change is an improvement? • What changes can we make that will result in an improvement?

36. Performance Improvement Primer Transparency and Reliability

37. Transparency and Reliability When hospitals’ quality data is reported publicly… • Performance improves (for the measures being reported). • Market share doesn’t change appreciably. • Reputation improves considerably. Hibbard J, J Stockard, and M Tusler: Hospital performance reports: impact on quality, market share, and reputation. Health Affairs 2005, 24, #4: 1150-116025

40. Transparency and Reliability A process achieves exactly the results it is designed to achieve.

41. Definitions of Reliability Reliability is failure free operation over time. David Garvin, Harvard Choose the patient focus, who expects optimal care by all-or-none measures. IHI Innovation Team

42. Levels of Reliability in Health Care (Amalberti, Nolan)

43. Concentrate Your Work Here!

44. Starting Labels of Reliability • Chaotic process: Failure in greater than 20% of opportunities • 10-1: 80 or 90 percent success. 1 or 2 failures out of 10 opportunities • 10-2: 5 failures or less out of 100 opportunities • These are IHI definitions and are not meant to be the true mathematical equivalent.

45. Top 10% NC Performance 103% Improvement

46. Concepts for 10-1 Performance • Common equipment, standard order sheets, multiple choice protocols, procedures & policies • Personal checklists • Feedback on compliance • Suggestions to work harder next time • Awareness and training • Intent, vigilance and hard work

47. Concepts for 10-2 Performance • Decision aids and built-in reminders. • Desired action is the default. • Redundant processes utilized. • Scheduling used in design development. • Habits and patterns known and included in design. • Standardization of processes based on clear specification and articulation of the norm. • Uses human factors and reliability science to design sophisticated failure prevention, identification and mitigation.

48. How To Accomplish 10-2 Performance 1.Need an established, standardized improvement process, focused on rapid cycle improvement. 2. Use reliability concepts in process design. 3. 10-2 reliability requires outcomes of 95% or better. Set that as the target. 4. A commitment to measurement ..... 'rule of threes' as measurement guide. If you measure 30 cases and have three or more faults, then quit measuring and concentrate on redesign because the process is 10-1. 5. Use segmentation to develop and test the reliability of the design. Segmentation allows control of variables while the process is redesigned. Once the process is standardized to 10-2 reliability on the segmented group, then it can rollout to the broader population.

49. The Pneumovax Example • Commonly described in order sheets as “Give Pneumovax if indicated” • Poorly defines a process. • Default is too commonly not to give the Pneumovax • No testing of competency or training of new employees can occur

50. The Three Step Design for Reliability