CCHS: Quality and Patient Safety. J Michael Henderson, MD Guido Bergomi

Transcription

1 CCHS: Quality and Patient Safety J Michael Henderson, MD Guido Bergomi

2 Outline Integrated Quality & Safety structure Quality Goals and Performance Improvement Quality data sources Quality Reporting The Future

3 Strategic Planning Clinical Quality The Enterprise Quality Goal is to move public reported quality metrics to the top decile nationally through: Integrated infrastructure Annual Quality Goals Continuous quality improvement Optimal use of data

4 Quality Structure Board of Trustees Executive Leadership Oversight Quality Leadership Team Content Experts Develop Plan Functional Clinical Units Frontline Caregivers Implementation

5 Central Resources (Content Experts) Local Implementation (Function) CENTRAL Resources LOCAL Implementation Quality and Patient Safety Institute (QPSI) Accreditation Quality Regulation Clinical Risk Management Patient Safety Infection Prevention Performance Improvement Hospitals and Clinical Institutes Quality Director Physician Lead Nursing Director Administrator

6 Execution of Quality Goals Set Goals Communication & Education Performance Improvement Data Review

7 CCHS 2013 Quality Goals Domain Measure 2013 Targets Patient Safety Indicators < 83 / month Safety HA Pressure Ulcers II-IV < 0.13% Never Events: Wrong Site, Retained FB, Falls with injury Hospital Acquired Infections Zero CLABSI < 1/1k ICU CaUTI: 1.9/1k SSI: NHSN SIR < 1

8 Communication and Education

9 Continuous Improvement Model Create the Culture Set Goals Measure Performance Improve Reward and Recognize Improve Quality and Performance Define Plan Implement Transition

10 Quality Data Management Dashboard Patients All In Patients Hospital At discharge

11 Data Review & Accountability Board of Trustees and Executive Management To the frontline Caregiver

12 Project Portfolio Management Portfolio Summary: Active Projects Quality Project Portfolio Review Review date: 11/1/2012 Program Name QI FTE Number Projects % Earliest Start Latest End Lowest Rating QPSI Operations % 9/12/11 12/31/14 G Core Measures % 12/13/11 12/31/12 G Hospital Acquired Infections (HAI) % 9/2/11 3/1/13 Y Never Events % 1/1/12 12/31/12 G Patient Safety Indicators (PSI) % 7/11/11 7/1/13 Y Readmissions % 3/17/11 3/31/13 G Totals % 3/17/11 12/31/14 Y FTEs include QI (7.0), and Safety (1.0). Two additional QI FTE started late-october and are onboarding; their hours are not reflected above.

13 Examples Patient Safety Indicators documentation Central Line Associated Blood Stream Infections clinical processes Readmission rates models of care

14 CCHS Patient Safety Indicators # J F M A M J J A S O N D J F M A M J J

15 CLABSI 1. Insertion Bundle 2. Line Maintenance 3. Line Removal

16 ICU CLABSI Rate 4 Per 1000 line days

17 Web Tool for Data Management Realtime: reports and patient level data Management tool Data for PI

18 30 day HF Readmissions 30% 25% 20% 15% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q

19 Quality Data Sources For reporting and Improvement: - Administrative (documentation/ coding) - Abstracted (Core Measures) - Quality Databases (STS, NSQIP, NDNQI) - Clinical (eg Event reporting)

20 Type of Hospital, Location, Use of Registries HCAHPS Process Measures 30d Deaths & Readmissions AMI, HF, PN PSIs, HACs, HAIs Mammograms, CT scans, MRIs Medicare Spend per Beneficiary 7 Medical, 29 Surgical conditions

21 Where is CMS Going? 1. $$$s tied to quality metrics: - VBP, HACs, Readmissions. - Medicare Spend per Beneficiary 2. Physician Quality Reporting: - Multiple programs - Incentives, then penalties

22 Medicare Spend Per Beneficiary Required for inclusion in VBP Phases: 1. 3 days prior to admission 2. Index admission days post discharge Exclusions / Risk adjustment On HospitalCompare website

23 Physician Quality Data Reporting

24 CMS Physician Quality Payment Reform Initiatives Physician Quality Reporting System (PQRS) Incentive 2%-0.5% PQRS Mandated eprescribing Incentive 1% eprescribing Penalty 1-1.5% erx Mandated EHR Incentive Program (Meaningful Use) MU Mandated Maintenance of Certification Incentive 0.5% Incentive Accountable Care Organization?? Penalty Reporting Physician Feedback Reports No $$ Physician Compare Website MD Value Modifier

25 Physician Quality Reporting Emphasis moving to individual physicians Initial incentives for reporting data Moving to penalties for not reporting or poor performance Data flows through different routes

26 Physician Quality Reporting Physician Quality Reporting System Physician Payment Value Modifier Ongoing Professional Performance Evaluation Meaningful Use Tools Metrics Quality Alliance ACOs and Value Based Operations Commercial Payers Communication Chronic Disease Management Maintenance of Certification

27 Physician Quality Reporting Components: Set priorities in these 3 areas Metrics Tools Communication

28 CCHS Quality Programs SUMMARY Integrated infrastructure Set goals / measure performance Optimal use of data sources Engagement at all levels New horizons

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