OPPE and Hospital Performance Evaluation

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1 OPPE and Hospital Performance Evaluation 2012 Midas+ User Symposium Gary O. Goldsmith, MD Mount Auburn Hospital Cambridge, Massachusetts

2 Handout Note This handout only includes selected slides It is anticipated that ideas, insights and additional material will develop in the course of the workshop

3 Introduction Goals Format Outline Questions

4 Q&S Graphic Novel Software: Snagit (

5 Where are you with OPPE? 1. Newbies 2. Early 3. Middle 4. Good shape 5. Experts

6 Mount Auburn Hospital Harvard Teaching Hospital Community-oriented ~200 beds ~1000 medical staff Q&S CPOE Meditech AQC Blue Cross Medicare Pioneer ACO

7 Variation Common theme Practice styles Hospital involvement

8 Software Meditech MIDAS+ Statit rl Solutions

9 Quality & Safety Susan Abookire, Director Andrew Gardner, Data Manager 3 data analysts

10 Boston Medicine

11 Gorillas Tertiary Partners (Mass General/Brigham & Women s) Beth Israel Deaconess Tufts Medical Center Boston Medical Center For profit Steward Health Care System

12 Mt. Auburn Hospital Catchment Area

13 Fewer beds

14 Higher occupancy

15 Community vs. Teaching

16 Health Care Costs 16

17 Uninsured Patients 1.8%

18 Health Reform Higher Costs

19 Challenges Financial Competitive Morale Reporting Quality Yours

20 The Ecology of OPPE Musings about OPPE and its environment Things you know about healthcare costs The sudden healthcare crisis Outliers/means, improvement/risk Where data people (us) fit in Accountable Care Organizations

21 Increasing costs

22 but

23 slowing? In Hopeful Sign, Health Spending Is Flattening Out NYTimes 4/28/12 Much of the slowdown is because of the recession but some of it to changing behavior by consumers and providers of health care. In 2009 and 2010, total nationwide health care spending grew less than 4 percent per year, the slowest annual pace in more than five decades. CMS Experts were surprised at a drop in spending on some hospitalized seniors people enrolled in Medicare, whose coverage the recession should not affect. If the growth in Medicare were to come down to a rate of only 1 percentage point a year faster than the economy s growth, the projected long-term deficit would fall by more than one-third.

24 Compared to

25 Where does $ go?

26 Maxims Beware the man with a simple solution to a complex problem. He s not always wrong, but rarely entirely right. Good quality is a side effect of good care and good care is a side effect of good quality. Identify the outliers, move the mean.

27 Risk/Improvement Improvement How much? How many? Other Risk Likelihood Severity Detection Other

28 ACO (Accountable Care Organization)

29 Limits other options

30 Here s Mount Auburn

31 CMS Innovation Center Accountable Care Organization (ACO) Medicare Shared Savings Program Advanced Payment Initiative Comprehensive Primary Care Initiative Bundled Payments for Care Improvement Initiative to Reduce Avoidable Hospitalizations Community Based Care Transition Independence at Home Demonstration

32 Coming soon to a hospital near you Independence at Home Demonstration 1) Delaware 2) Florida 3) Georgia 4) Kentucky 5) Massachusetts 6) Michigan 7) New York 8) North Carolina 9) Ohio 10) Oregon 11) Texas 12) Wisconsin

33 ACO 18 States 1) Arizona 2) California 3) Colorado 4) Florida 5) Illinois 6) Indiana 7) Iowa 8) Maine 9) Massachusetts 10) Michigan 11) Minnesota 12) Nevada 13) New Mexico 14) New York 15) Pennsylvania 16) Texas 17) Vermont 18) Wisconsin

34 What is an ACO? Group of doctors, hospitals, providers Group practice IPA Partnerships Hospitals Health centers

35 Five in Boston Pioneer Medicare ACO Atrius Health Beth Israel (BIDPO) MACIPA Partners Healthcare Steward Health Care Medical group practice Network of IPAs IPA Integrated delivery system Integrated delivery system

36 ACO: CMS Goals High quality Coordinated care Reduced costs Risk-sharing/Savings-sharing Medical Home model

37 A Glimpse of the Future Population-based payment Paradox: population management only succeeds by intense focus on the individual Significant outpatient focus Fee for service Medicare HIT focus: >50% PCPs MU certified EHR Robust quality measures 33 Measures Medicare Shared Savings Program

38 33 measures in 4 Quality Domains Care coordination/patient safety (6) Preventive health (8) At-risk populations: Diabetes (6) Hypertension (1) Ischemic Vascular Disease (2) Heart Failure (1) Coronary Artery Disease (2) Patient/caregiver experience (7)

39 Care coordination/patient safety 1. Risk-Standardized, All Condition Readmission 2. COPD or Asthma in Older Adults (AHRQ PQI #5) 3. Congestive Heart Failure (AHRQ PQI #8 ) 4. % PCP Qualify for EHR Incentive Payment 5. Medication Reconciliation After Inpatient D/C 6. Falls: Screening for Fall Risk

40 Preventive health 1. Influenza Immunization 2. Pneumococcal Vaccination 3. Adult Weight Screening and Follow-up 4. Tobacco Use Assessment/Cessation Intervention 5. Depression Screening 6. Colorectal Cancer Screening 7. Mammography Screening 8. Screening for High Blood Pressure

41 At-risk Populations 1. Hemoglobin A1c Control (<8 percent) 2. Low Density Lipoprotein (<100) 3. Blood Pressure <140/90 4. Tobacco Non Use 5. Aspirin Use 6. Hemoglobin A1c Poor Control (>9 percent) 7. Controlling High Blood Pressure 8. Complete Lipid Panel and LDL Control (<100 mg/dl) 9. Use of Aspirin or Another Antithrombotic 10. Beta-Blocker Therapy for (LVSD) 11. Drug Therapy for Lowering LDL-Cholesterol 12. ACE Inhibitor or ARB Therapy

42 Patient/caregiver experience 1. Timely Care, Appointments, and Information 2. How Well Your Doctors Communicate 3. Patients Rating of Doctor 4. Access to Specialists 5. Health Promotion and Education 6. Shared Decision Making 7. Health Status/Functional Status CAHPS -

43 Perception Reality OPPE depends on how you look at it The view from other perspectives Think like an anthropologist Others perceptions of OPPE Not mission-critical Make-work Only important to administration

44 Stakeholders in OPPE? Informaticists Hospitals Physicians Regulators???

45 Strategies Strong support Physician champion Powerful committee Q&S department CEO OPPE Aikido Defend yourself Redirect force Protect your attacker

46 OPPE Aikido Become an ally Bearer of bad news Help to make it better Help solve problems Educate Work together Put some control in their hands TJC did Indicators and timing: organized medical staff

47 Strategies: getting started Identify respected believers Mine what you re already doing Payers: CMS, Leapfrog Quality entities: NSQIP, STS (CT surgery) Regulators: State, Federal Public reporting: CMS, BCBS Get their input What do they do? The Rolling Stones

48 Strategies: Easy Hard Easy Procedure-based (events) Hard Surgery GI Pulmonary Medicine ( cognitive ) (processes) Consults Time-based Revisits, follow up

49 Strategies Take an active role Build an indicator Revise Repeat

50 Meetings: Chairman s day 5: :30 7:00 Wake up Desk work Med Exec Committee Patients Dept planning meeting Patients Charts, dictation Meet with problem physician Prepare presentation PTA meeting

51 Meetings Anthropologist You: commonalities, DB one-to-many Them: unique, intrusive, questionable value One on one Repetitive Be patient, but persistent

administrative boondoggle 15 min lack of time inadequate resources

52 Usual first meeting 5 min late 10 min explain OPPE 15 min busy work bureaucratic intrusion useless waste of time duplication of effort administrative boondoggle 15 min lack of time inadequate resources no support staff administrative demands other responsibilities 15 min work

53 Anthropologist: doctors Competitive Strive for excellence Do the best for their patients Data- and detail-oriented; skeptical Defined/restricted by their work Chronically stressed Fearful of litigation Usual range of personalities

54 Kubler-Ross Denial Anger Bargaining Depression Acceptance

55 Loss of control Medicine: struggle for control over biology, behavior, environment Incomplete knowledge, limited technology Do an inherently imperfect job perfectly Personalities Past: practice medicine, solve problems Now: quality, efficiency, regulation, being watched intertwined with clinical activity Patients

56 Being heard People have to feel they have been heard Each person was given two ears and one tongue, so that we may listen more than speak. Rabbi Kerry M. Olitzky and Lori Forman, Sacred Intentions Native Americans Talking Stick - give the person holding it the honor of speaking while all the others have the duty to listen. One of the most common complaints they don t feel heard. Douglas Stone, Bruce Patton, and Sheila Heen, Difficult Conversations: How to Discuss What Matters Most Understanding what someone is saying doesn t mean that you agree with him. Whether you agree is not the issue in the listening process. Center for Conflict Resolution

57 Meetings: Strategies Big goal: not to win, but to complete task Immediate goal: indicators, leave You can t succeed by fighting with people Be flexible Don t debate every detail Acknowledge when they re right Hmm. There s some truth in that. We should work on it.

58 Meetings: Strategies Explain Handouts, references Teach Practical Reframe the task We have to do this Useful to chiefs/chairs, departments, doctors Do you want to be their IS department?

59 Meetings: Strategies Have a practical starting place Choices, suggestions Henry s list Datavision Internet Friends, associates

60 Meetings: Strategies Create ownership/control Involved in the process If we don t do this, someone else will Relevant measures, not arbitrary requirements What makes sense to them? If reject, redirect Examples: Other departments did X,Y,Z Suggest resources Colleagues Other institutions Professional organizations

61 Meetings: Strategies Anticipate problems Variation Practice styles and affiliations Solo/Group Coverage Defined populations/open to all Prepaid/FFS Clinical practice Own patients/hospitalists Hospital relationships Admit/refer Low volume

62 Meetings: Strategies Seduce them with data Have something to present Volumes, a few measures Teachable moments Aha! Moments Follow up Summarize Next steps Set timetables Write up your notes,

63 Specifics:TJC What does TJC do? Creates standards OPPE goals Identify problems Timely resolution

64 Specifics: What do you need? A defined process Who reviews performance data How often will it be reviewed How will it be used (re: privileges) How are data incorporated into credentials file Approved Criteria Organized Medical Staff Documentation A plan Referenced by bylaws/governing documents

65 Specifics: FPPE My opinion: TJC unclear re: purpose, focus Granting privileges New staff Additional privileges Problems Previously Focused Review

66 Specifics: OPPE Maintaining privileges TJC Six competencies (suggested, not required) Identify and resolve problems Ongoing Every 6 months? 8 months? Is more often better? Diminishing returns Much of data is quarterly or semi-annual Perhaps identify a few for dashboard

67 What is your role? Gather data Convert data to information

68 Commercial Product Rollout Identify customers/clients/users Customer feedback during development Adequate resources Clear objectives Right process Position your product Give them what they need Find motivated people/early adopters Leverage past success From various sources

69 Who? decides what data to use? Organized medical staff Departments gathers, organizes and presents data? You sees and reviews data? Chair/chief, CMO, QA, MEC, Cred Comm Whole department? Individual physicians? If not, should they? When?

70 When? 6 vs 8 months Enough time to evaluate How much time to prepare, distribute? Maintenance, repetition

71 Where? Actions re: privileges must be documented Where stored? No requirement that it be stored continuously in credentials file. <source?> Simple: who, what, when reviewed and results Credential files Separate peer-review-protected folder

72 How? Simple/Complex Manual Hardware/software Process Iterative, agile

73 What? -1 Clinical Medical record Chart review Direct observation Discussion with others Consultants, surg assistants, nurses, admin M&M conferences Infection rates Guideline compliance CME participation

74 What? - 2 Quality Outcomes Incidents Complaints Peer reviews Rule violations Patients Complaints, complements Surveys

75 What? - 3 Volume Procedure performed in past two years? Regular procedures Emergency procedures Simulations? Layered approach General: Everyone (may vary between depts.) Specialty-specific: everyone Specialty-specific: subsets Specific departments

76 What? - 4 Review options OFI CME/training/proctoring/mentoring/suspension Meets expectations No issues, doing well, meetings, teaching, call Exceeds expectations OR times/los/outcomes/patient satisfaction Positive as well as negative Share gains/wins

77 Challenges -1 Technical issues clean data Maintenance time/resource commitment Midlevels CNM/CRNA/PA/NP TJC: equivalent to medical staff process Intensity: Inpatient higher; Outpatient lower

78 Challenges - 2 Zero data is, in fact, data Low/No-volume providers Increasing trend Retired/part-time Surgeons mostly in surgicenters Options Hospitals may use peer recommendations when there is insufficient peer review data to assess a practitioner s competence. Refer and Follow MS , EP2

79 Challenges 3 What kind of institution are you? No EMR non-discrete data What if everyone passes a measure? Risk adjustment Benchmarks Attribution Skeptics Cookbook medicine Your list

80 Thank you

81 CMS Innovation Center Some references Accountable Care Organizations Summary and Analysis of the Final Rule: Summary.pdf ACO 2012 Program Analysis Service-Payment/sharedsavingsprogram/ downloads//aco_qualitymeasures.pdf

82 Some references TJC Standards BoosterPak for FPPE/OPPE /downloads/boosterpak_fppe_oppe_final. pdf Navigating TJC OPPE Requirements asqqps7_info.shtml

83 Some references Top Ten Barriers to Dispute Resolution TopTenBarriers.html Listening A Tool for Resolving Conflict

84 OPPE and Hospital Performance Evaluation 2012 Midas+ User Symposium Gary O. Goldsmith, MD Mount Auburn Hospital Cambridge, Massachusetts

Improving Quality of Care for Medicare Patients: Accountable Care Organizations

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Improving Quality of Care for Medicare Patients: FACT SHEET Overview http://www.cms.gov/sharedsavingsprogram On October