Why Quality & Patient Safety Matter to Your OB/GYN Practice: Now and in the Future

1. Why Quality & Patient Safety Matter to Your OB/GYN Practice: Now and in the Future Albert L. Strunk, JD, MD, FACOG Deputy Executive Vice-President & Vice-President, Fellowship Activities American Congress of Obstetricians and Gynecologists MGMA, April 22, 2012

2. Learning Objectives • Describe how quality measure and outcomes will be important for physician compensation in the future. • Determine whether the Office Patient Safety Assessment (OPSA), a voluntary self-assessment, is right for your practice. • Examine ACOG’s Safety Certification for Outpatient Practice Excellence (SCOPE) program for defining quality and safety indicators for women’s health care in the office setting.

3. A Business Case for Quality? • High quality care costs less “It is possible to improve care and dramatically lower costs.” Don Berwick: Annals of Internal Medicine, Feb 1998 • Costs are reduced through: • Standardization of the processes of care • Elimination of “waste”

4. OB/GYN Offices and Quality • Quality = improvement in measurable outcomes • Value = desired outcomes at reduced cost • Reduced cost = elimination of “waste” • Improved outcomes = evidence based medicine

5. OB/GYN Offices and Quality OB/GYN Offices must demonstrate to purchasers and health plans that they can deliver improved outcomes at reduced cost by the application of process improvement tools and evidence-based medicine to everyday practice at the point of care to reduce unexplained clinical variation.

6. Evolving Applications of Measurement • Passive Monitoring • Incentives for High Performance • Tiering Preferred Providers • “Never” Events/No Payment • Required Ongoing Practice Evaluation • Reduced Reimbursement • Active Quality Improvement and Accountability • Public Reporting

7. What is the greatest “enemy” of quality? Unexplained Clinical Variation

8. Unexplained Clinical Variation • Necessary Clinical Variation • Necessary variation in medical practice is that which is required to adjust to the differing needs of individual patients • Unexplained Clinical Variation • Differences in medical care and patient management that are not accounted for by differences in patient symptoms or objective findings

9. Sources of Unexplained Variation • Lack of valid clinical knowledge • Poor evidence • Reliance on subjective judgment • Enthusiasm for unproven methods • If it might work, do it… • Quality = Spare no expense • Human error • Complexity • “The complexity of modern American medicine exceeds the capacity of the unaided human mind”

10. Probability of success, each step: 95% 99% 99.9% 99.99% # of steps 1 95% 99% 99.9% 99.99% 25 28% 78% 97.5% 99.7% 40 12% 66% 96% 99.5% 100 0.6% 37% 90% 99% Probability of a Complex System Performing Perfectly: Just do the math…*

11. Driving Value • Reducing quality waste and efficiency waste • Analyze the process of care • Develop change ideas • Implement change ideas and measure results in successive PDSA cycles

12. Who does ‘quality and safety’ well? • Highly complex and technologically hazardous systems which operate essentially without mishaps over long periods of time • The potential for catastrophic accidents is great and consequences severe • Repetitive tasks are performed thousands of times with a very low-error rate

14. Characteristics of High Reliability Organizations • Safety-oriented culture • Operations are a team effort • Communications are highly valued and rewarded • Emergencies are rehearsed & the unexpected practiced • “Top brass” devotes appropriate resources to safety training

15. Adapting HRO Characteristics to Health Care Organizations: • Effective communication • Time-outs • Awareness of technology • Flattening hierarchy • Stop the line • Teamwork • Drills and simulations

17. WHO Surgical Checklist

18. ACOG’sOffice Surgery Checklist

19. Office Patient Safety Assessment(OPSA) • An opportunity for members to evaluate the quality and safety of the care they are providing for their patients. • Voluntary self-assessment for ACOG members regarding safety in their own outpatient practices.

20. OPSA Results • Approximately 80 responses received for 2010 • Still available to members to complete • Analyzing 2011 responses now. • Participants receive: • Customized report of practice responses, with comparisons to national results • Recommendations for improving care with reference to ACOG and non-ACOG resources

21. OPSA National Results • Areas for possible improvement • Granting of surgical privileges and monitoring competency (41% compliance) • Quarterly drills for emergency response to untoward events (39% compliance) • Logging of dispensed medication samples (43% compliance) • Tracking whether patients referred to other physicians were actually seen and a report received (43% compliance)

22. ACOG SCOPE: ACOG ahead of the group! • 1/9/2012 AMA “widespread patient safety problems in ambulatory care such as incorrect prescribing, misdiagnosis, and poor communication” • NQF action to expand its serious-reportable events list to cover office-based settings

23. Safety Certification for Outpatient Practice Excellence • Key goals of the SCOPE Program: • Promote the highest quality of women’s health care • Provide a trusted solution to meet the external demand for quality and safety activities • Reduce redundant review programs for physicians and offices

24. Safety Certification for Outpatient Practice Excellence • Developed to evaluate and certify high-quality, safe women's health care processes in the outpatient setting. • NOT JUST FOR outpatient surgery! ANY women’s health office setting. • Two‐step process: Application with data submitted and Site Review to document Quality and safety measures in practice

25. Safety Certification for Outpatient Practice Excellence • Application: Demographics • Office management and administration • Documentation and reporting • Medication Safety • Office surgical procedures/ procedures • Equipment • Quality Improvement • Modules • Simulations and DRILLS

26. Office Management & Administration • Does the practice have a designated medical director for patient safety issues? • Is formal education, training, licensure, and board certification of staff verified? • Is there a system in place to allow staff to report if they observe potentially unsafe practices? • Upon arrival to the office, do office staff verify two patient identifiers (i.e. patient name and date of birth) for each patient?

27. Documentation & Reporting • Is there is an electronic health record system? • Are referrals to health care providers tracked? • Is there a system for documenting all incoming patient phone calls (and emails, if applicable) and responses? • Is there documentation of depression screening?

28. Office Surgical Procedures and Emergencies • Are written preoperative and post-operative instructions provided and discussed? • When a procedure is performed, is a checklist used that includes a time out • Do staff and providers conduct quarterly drills on emergency response to untoward events that may happen during a procedure and log these drills?

29. On-Site Validation • SCOPE reviewer will validate the procedures and programs described in the application • Provide on site education in patient safety as needed by the individual practice • SCOPE reviewer will make a recommendation regarding certification • ACOG SCOPE staff will decide to award certification using: information from application and visit

30. Lessons Learned • We have variable policies and procedures • We don’t have standard credentialing/proctoring practices • We don’t have standard “emergency” kits or plans (with or without surgeries in office) • We need drills and simulations for the office

31. What’s in store? • Certification will be: approved, pending, or deferred after completion for 3 years (5 years when completed two 3 year cycles) • Ongoing yearly data collection, limited but benchmarked • Reported in Obstetrics & Gynecology • Sharing of BEST PRACTICES (skills lab, drills, etc.) • Letter for negotiations with malpractice and health insurers • Interface with MOC IV for patient satisfaction surveys or other reporting • Seal for use in materials/ marketing

32. Pilot Site Comments • “Process made a difference” (universal) • “Identified KEY areas of safety the office was not attending to” • “IT WAS FUN!”

33. For more information on ACOG’s Women’s Health SCOPE Program, please visit www.scopeforwomenshealth.org SCOPE listserv: monthly updates about the progress of the SCOPE program http://suse.acog.org/mailman/listinfo/scope 202-863-2482 ajones@acog.org