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Quality Initiative. Ensuring Success in Washington State. For audio, dial: 1-800-936-4606. Host is Washington State Hospital Association. Welcome! We will begin the presentation at 12:05 to allow all participants time to log in. Quality Initiative. Ensuring Success in Washington State.

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quality initiative

Quality Initiative

Ensuring Success in Washington State

for audio dial 1 800 936 4606

For audio, dial:1-800-936-4606

Host is Washington State Hospital Association

quality initiative1

Quality Initiative

Ensuring Success in Washington State


Diana Migchelbrink, RN, MPH

Nurse Consultant, Region X

Centers for

Medicare and

Medicaid Services

Brenda Suiter,MHA


Rural and

Public Health

Washington State

Hospital Association

Les Barnette, MD

Medical Director,

Healthcare Improvement

Qualis Health

webcast outline
Webcast Outline
  • AHA Quality Initiative
  • Medicare Modernization Act (MMA)
  • Data Collection
  • Next Steps
  • Resources

Has your hospital already signed up to participate in the Quality Initiative?



Not sure

what is the quality initiative
What Is the Quality Initiative?
  • Voluntary program for measuring hospital quality
  • Supported by:
    • AHA, AMA, Federation of American Hospitals, Association of Medical Colleges
    • The Centers for Medicare & Medicaid Services (CMS)
    • JCAHO
    • Consumer, union, and business groups
  • Measures quality in three standardized areas: heart attack, heart failure, pneumonia
  • Displays data on the web
goals of the quality initiative
Goals of the Quality Initiative
  • Create a common data set of quality information
  • Demonstrate commitment to the best patient care
  • Share information about recognized quality indicators
  • Empower consumers to make informed decisions
  • Stimulate quality improvement
benefits of the quality initiative
Benefits of the Quality Initiative
  • Eliminate duplication and confusion among different quality programs
  • Create quality reports not designed to make money
  • Engage hospitals in choosing basic measures that reflect hospital quality
  • Receive higher Medicare payments
wsha board resolution may 2003
WSHA Board Resolution May 2003
  • Encourages hospitals to participate
  • Affirms intention not to use any information generated for competitive marketing purposes
  • Supports advancing best practices in health care and improving health care
special member meeting annual meeting october 2003
Special Member MeetingAnnual Meeting, October 2003

WSHA should do more to increase the number of Washington hospitals participating in the AHA initiative.

medicare modernization act mma
Medicare Modernization Act (MMA)
  • “Prescription Drug Law”
  • Seeks to expand participation with financial incentives
  • Based on 1st quarter, 2004 data
  • Qualify by:
    • Signing up with QNet Exchange by June 1
    • Beginning data submission no later than July 1
    • Completing data submission by August 2
    • Submitting data on all 10 measures
mma payment issues
MMA Payment Issues
  • Fiscal years 2005 - 2007
  • Participation allows hospitals to get full market basket update
  • Non-participation: market basket minus 0.4%
market basket versus market basket minus 0 4
Market Basket versus Market Basket Minus 0.4%
  • Total value for Washington: $5 million annually
  • Examples of individual hospital benefit (annual figures):
    • Mason General: $21,000
    • Yakima Valley Memorial: $86,000
    • Sacred Heart: $386,000
    • Swedish: $492,000
critical access hospitals
Critical Access Hospitals
  • Washington has many (30)
  • No payment benefit
  • Challenges collecting data
  • Over 400 signed up nationwide
  • CMS trying to address their special concerns
  • Encouraged to sign up, even if not ready to submit data
the specific measures
The Specific Measures
  • Acute Myocardial Infarction (AMI)
      • Aspirin at arrival
      • Aspirin at discharge
      • Beta-blocker at arrival
      • Beta-blocker at discharge
      • ACE inhibitor for LVSD
  • Heart Failure
      • Left ventricular function assessment
      • ACE inhibitor for LVSD
  • Pneumonia
      • Initial antibiotic timing
      • Pneumococcal vaccination
      • Oxygenation assessment
the specific measures1
The Specific Measures
  • The measures are fully supported in the evidence-based medical literature
  • Endorsed by the National Quality Forum www.nqf.org
  • Reviewed by expert panels
  • Are same as JCAHO measures
  • Well accepted and included in the major published guidelines
steps to participation part 1
Steps to Participation – Part 1
  • Complete Pledge of Participation form at www.aha.org
  • Complete QualityNet Exchange registration at www.qnetexchange.org
  • Complete the Vendor Authorization form (available at www.qnetexchange.org)
steps to participation part 2
Steps to Participation – Part 2
  • Submit data to Quality Improvement Organization (QIO) Clinical Warehouse (vendor or self)
  • Submit validation medical records to Clinical Data Abstraction Center (CDAC)
  • Preview data to be publicly released
  • Data released late 2004 or early 2005 on www.cms.hhs.govwebsite
how do we get the data
How Do We Get the Data?
  • It is your data, you collect and report to JCAHO
  • Submitted by ORYX vendor or directly to “data warehouse”
  • Sent via www.qnetexchange.org (encrypted)
  • Verified quarterly by a sample of 5 charts requested by CDAC and supplied by you

If you signed up for the Quality Initiative, have you completed all of these steps?



Not sure

barriers to participation
Barriers to Participation
  • Data set
  • Gaming the data
  • Special problems for rural hospitals
  • Data transmission and display glitches
  • Complexity of submission process

Have you appointed one person to be the point person on the Quality Initiative to be sure all the steps are completed?



Not sure

patient surveys hcahps
Patient Surveys: HCAHPS
  • Hospital Consumer Assessment of Health Plans Survey (HCAHPS)www.cms.hhs.gov/hcahps
  • Research conducted by CMS and Agency for Healthcare Research and Quality (AHRQ)
  • National standard for measuring and comparing patients’ perceptions of their care
  • Pilot tested in 2003
  • Final version available on website
  • First public reporting late 2004
hcahps hospital position
HCAHPS: Hospital Position
  • Should be embedded in existing patient surveys
  • Should be a reasonable length: begin with 10 questions
  • Improve the questions over time
  • Must not impede the quality improvement work already underway
  • Must not be too costly, duplicative or cumbersome to implement
possible new measures
Possible New Measures
  • More measures in 3 conditions already included
  • Additional clinical info
    • Surgical complications
    • End of life care
    • Pain management
    • Scheduled procedures: normal delivery, knee replacement
  • Expert panel advising
pay for performance
Pay for Performance?
  • Quality Initiative: pay for participation
  • Pay for performance:
    • Reward high performers
    • Penalize low performers
  • Pilot program underway
  • Our concern: could make poor performers struggle even more
special member meeting wsha annual meeting october 2003
Special Member MeetingWSHA Annual Meeting, October 2003

Should government payment be based on quality measurements?

qualis health contacts
Qualis Health Contacts
  • Qualis Health
    • Rosa Johnson, ARNP, MN, CPHQ Manager, Medicare Operations 206-364-9700 ext. 2412 800-949-7536 ext. 2412 rosaj@qualishealth.org
    • Earl Kurashige, RNProject Manager206-364-9700 ext. 2342
    • 800-949-7536 ext. 2342 earlk@qualishealth.org
web resources
Web Resources
  • www.qnetexchange.org
    • Quality Net Exchange
    • Sign up for data transmittal
  • www.qualishealth.org
    • Qualis Health
    • Assistance with quality improvement measures and processes
cms contact
CMS Contact
  • Diana Migchelbrink, RN, MPHNurse Consultant206-615-2089dmigchelbrink@cms.hhs.gov
web resources government
Web Resources: Government
  • www.cms.hhs.gov
    • Centers for Medicare and Medicaid Services
    • Hospital data
    • User’s manuals
    • Frequently asked questions
  • www.medicare.gov
    • Medicare quality projects
    • Nursing home, home health, Medicare+Choice, dialysis quality
open door forums
Open Door Forums
  • Conference calls with two-way connections for live, open discussions
  • Personally attended by key decision makers in HHS
  • Visit www.cms.hhs.gov/opendoor/ for schedules and to sign up to participate
  • Last 30 minutes of each forum devoted to hospital quality initiative
wsha contact
WSHA Contact
  • Brenda Suiter, MHADirector of Rural and Public Health206-216-2531brendas@wsha.org
web resources hospitals
Web Resources: Hospitals
  • www.aha.org
    • American Hospital Association
    • Hospital position
    • Hospitals signed up
    • Tips and technical guidance
  • www.wsha.org
    • Washington State Hospital Association
    • Board resolution
    • Staff contacts
thank you for participating

Thank you for participating!

Please fill out the evaluation.