Objectives. Integrating Performance Improvement with Publicly Reported Quality Metrics, Value-Based Purchasing Incentives and ISO 9001/9004

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1 Integrating Performance Improvement with Publicly Reported Quality Metrics, Value-Based Purchasing Incentives and ISO 9001/9004 Session: C ANCC National Magnet Conference Thursday, October 3, :30 p.m. 4:30 p.m. Brent Ibata, PhD JD MPH Sentara Heart Hospital Norfolk, VA Objectives Describe how to integrate existing value-based purchasing metrics into performance improvement projects. Identify the twenty-five (25) FY2015 value-based purchasing metrics reported at Brent Ibata, PhD JD MPH is the Director of Operations for the Sentara Cardiovascular Research Institute. Dr. Ibata has a doctoral degree in public health studies, a master degree in public health and a law degree with a certificate in health law from the #1 ranked healthcare law school. He is the author of the book Public Health Law and the Built Environment in American Public Schools and sits on the Board of Trustees for the Association of Clinical Research Professionals (ACRP) and is the author of ACRP s top-rated column, Research Compliance, in its award winning peer-reviewed journal The Monitor. Previously, he was the Director of a multidisciplinary outpatient research clinic; an Assistant Professor in the Division of Neurosurgery at Saint Louis University; and a six year member of the audit committee for the American College of Surgeons Oncology Group (ACOSOG). Dr. Ibata teaches research ethics for the University of Liverpool, FDA law for Northeastern University; and has adjunct faculty appointments at Eastern Virginia Medical School and Old Dominion Universities School of Nursing. Dr. Ibata is also a certified member of Mensa. 1

2 Outline 1. History of healthcare quality 2. CMS Conditions of Participation 3. Publicly reported quality metrics (hospital compare) 4. Value-Based Purchasing (VBP) Metrics 5. ISO ISO Value-Based Purchasing Domains (FY ) 8. Sentara Heart Hospital Sample Performance Improvement Projects Evolution of the Specialty Hospital Evolution of Hygiene 2

3 Evolution of Reimbursement $ DRG VBP Evolution of Quality To Err is Human Institute of Medicine (2000) At least 44,000 Americans die each year as a result of a medical error (may be as high as 98,000). Total cost between $17 and $29 billion (lost income, lost productivity, disability and healthcare costs). 3

4 Crossing the Quality Chasm Institute of Medicine (2001) Establish a New Environment for Care Focus and align the environment toward the six aims for improvement. Safe, effective, patient-centered, timely, efficient, equitable Provide, where possible, assets and encouragement for positive change. Align Payment Policies with Quality Improvement Hospital Value Based Purchasing Medicare Prescription Drug Improvement and Modernization Act of 2003 (Pub. L ) Origin of Hospital Inpatient Quality Reporting Program Reduced annual payment update by 0.4% to non-participating hospitals or hospitals that failed to meet criteria for reporting. Deficit Reduction Act of 2005 (Pub. L ) Increased reduction to 2% Patient Protection and Affordable Care Act of 2010 (Pub. L ) Authorized 1 st national Hospital Value Based Purchasing Pay-for- Performance program. Effective FY2013 for discharges on or after October 1, October 1, 2012 Value-Based Purchasing Funded by DRG percentage 1.0% FY2013 Equivalent to $850 million Increases 0.25% each year up to 2.0% in 2017 Process Measures (FY2013) 70% Clinical Process of Care Measures National Benchmark mean performance for top 10% National Threshold 50 th percentile for all» Below National Threshold = 0» Between benchmark and threshold = % Patient Satisfaction (HCAHPS) 4

5 CMS Condition of Participation [A] hospital must develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program As part of its quality assessment and performance improvement program, the hospital must conduct performance improvement projects. The number and scope of distinct improvement projects conducted annually must be proportional to the scope and complexity of the hospital s services and operations, (42 CFR ). The Joint Commission All hospitals want better patient outcome and, therefore, are concerned about improving the safety and quality of the care, treatment, and services they provide. The best way to achieve better care is by first measuring the performance of processes that support care and then by using that data to make improvements. PI PI DNV National Integrated Accreditation for Healthcare Organizations (NIAHO ) The governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring that the organization implements and maintains an effective quality management system. This quality management system shall ensure that corrective and preventive actions taken by the organization are implemented, measured and monitored. 5

6 Hospital Compare NDNQI Nurse Indicators CMS Core Measures (chart abstraction) Medicare (claims data) (AHRQ) STS Society of Thoracic Surgeons HCAHPS ACC/NCDR National Cardiovascular Disease Registry CDC National Healthcare Safety Network CMS Core Measures Medicare Claims Data CDC National Healthcare Safety Network HCAHPS 6

7 U.S. News WhyNotTheBest.org Consumer Reports Leap Frog healthgrades.com AMI-2 AMI-7a AMI-8a AMI-10 HF-1 HF-2 HF-3 PN-3b PN-6 SCIP-Inf-1 SCIP-Inf-2 SCIP-Inf-3 SCIP-Inf-4 SCIP-Inf-9 SCIP-Inf-10 SCIP-Card-2 SCIP-VTE-1 SCIP-VTE-2 CAC-1 CAC-2 Hospital Compare Data Elements CAC-3 MORT-30-AMI MORT-30-HF MORT-30-PN READM-30-AMI READM-30-HF READM-30-PN PSI-03 PSI-04 PSI-06 PSI-07 PSI-08 PSI-11 PSI-12 PSI-13 PSI-14 PSI-15 PSI-90 IQI-11 IQI-15 IQI-16 IQI-17 IQI-18 IQI-19 IQI-20 IQI-91 OP-2 OP-3 OP-4 OP-5 OP-6 OP-7 OP-8 OP-9 OP-10 OP-11 OP-12 OP-13 OP-14 OP-17 OP-18/ED-3 OP-20 OP-21 OP-22 OP-23 ED-1 ED-1b ED-2 ED-2b HAC (x8) HAI (x4) HCAHPS (x10) IMM-1a IMM-2 Medicare Spending Medicare Volume Hospital Compare AMI-2 AMI-7a AMI-8a AMI-10 HF-1 HF-2 HF-3 PN-3b PN-6 SCIP-Inf-1 SCIP-Inf-2 SCIP-Inf-3 SCIP-Inf-4 SCIP-Inf-9 SCIP-Inf-10 SCIP-Card-2 SCIP-VTE-1 SCIP-VTE-2 CAC-1 CAC-2 Hospital Compare VBP Data Elements CAC-3 MORT-30-AMI MORT-30-HF MORT-30-PN READM-30-AMI READM-30-HF READM-30-PN PSI-03* PSI-04 PSI-06* PSI-07* PSI-08* PSI-11 PSI-12* PSI-13* PSI-14* PSI-15* PSI-90 IQI-11 IQI-15 IQI-16 IQI-17 IQI-18 IQI-19 IQI-20 IQI-91 OP-2 OP-3 OP-4 OP-5 OP-6 OP-7 OP-8 OP-9 OP-10 OP-11 OP-12 OP-13 OP-14 OP-17 OP-18/ED-3 OP-20 OP-21 OP-22 OP-23 ED-1 ED-1b ED-2 ED-2b HAC (x8) HAI (1/4) HCAHPS (8/10) IMM-1a IMM-2 Medicare Spending Medicare Volume Hospital Compare 7

8 ISO 9001 ISO 9001 Quality Management Systems Requirements ISO 9001 Plan Do Check Act 8

9 ISO 9001 Say what you do. [Plan] Do what you say. [Do] Prove It. [Check] Improve It. [Act] ISO 9001 Required Documented Procedures: Quality Manual (ISO ) Control of Documents (ISO ) Control of Records (ISO ) Customer Satisfaction (ISO ) Internal Audit (ISO ) Control of Nonconforming Products (ISO ) Corrective Action (ISO ) Preventative Action (ISO ) ISO

10 ISO 9004 Managing for the Sustained Success of an Organization A Quality Management Approach ISO 9004 To achieve sustained success, top management should adopt a quality management approach. The organization's quality management system should be based on the principles described in Annex B. These principles describe concepts that are the foundation of an effective quality management system. To achieve sustained success, top management should apply these principles to the organization's quality management system. The organization should develop the organization's quality management system to ensure the efficient use of resources, decision making based on factual evidence, and focus on customer satisfaction, as well as on the needs and expectations of other relevant interested parties. 10

11 FY2013 Value-Based Purchasing Clinical Process of Care Measures (n=12) Heart Attack (n=2) Heart Failure (n=1) Pneumonia (n=2) Surgical Care Improvement Program (n=7) Patient Experience of Care Measures (n=8) HCAHPS Nurse Communication Doctor Communication Responsiveness of Hospital Staff Pain Management Communication about Medications Cleanliness and Quietness Discharge Information Overall Rating FY2013 Value-Based Purchasing Clinical Process of Care Measures FY2013 Base* Goal^ AMI-7a Fibrinolytic therapy received within 30 minutes of hospital arrival AMI-8a Primary PCI within 90 minutes of hospital arrival HF-1 Discharge instructions PN-3b Blood cultures performed in the ER prior to initial antibiotic received in hospital PN-6 Initial antibiotic selection for community-acquired pneumonia in immunocompetent patient SCIP-Inf-1 Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time SCIP-Inf-4 Cardiac Surgery Patients with Controlled 6:00 a.m. Postoperative Serum Glucose SCIP-VTE-1 Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery SCIP Card-2 Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period. * Threshold ^ Benchmark FY2013 Value-Based Purchasing HCAHPS Clinical Process of Care Measures FY2013 Base* Goal^ Communication with Nurses 75.18% 84.70% Communication with Doctors 79.42% 88.95% Responsiveness of Hospital Staff 61.82% 77.69% Pain Management 68.75% 77.90% Communication About Medicines 59.28% 70.42% Cleanliness and Quietness of Hospital Environment 62.80% 77.64% Discharge Information 81.93% 89.09% Overall Rating of Hospital 66.02% 82.52% * Threshold ^ Benchmark 11

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13 Sentara Norfolk General* * The fine print: Please note that the estimate contained in this tool may not match your final FY 2013 VBP incentive from CMS. While this tool displays the most recently available data from Hospital Compare, the data reflects your organization's performance period between January 1, 2011 to December 31, 2011 and a baseline period of January 1, 2009 to December 31, The actual performance period that CMS used to compute your assessment is July 1, March 31, 2012 with a baseline of July 1, March 31, Please note that this timeframe is both more recent, and shorter overall. Source: The Advisory Board Company (est. change in Medicare Revenue ($16,585) 13

14 FY2015 Value-Based Purchasing Clinical Process of Care Measures (20%) Patient Experience of Care Measures (30%) Outcome Measures (30%) Efficiency (20%) FY2015 Value-Based Purchasing Clinical Process of Care Measures (20%) Heart Attack (AMI-7a Fibrinolytic agent w/in 30 min) Heart Failure (AMI-8a PCI w/in 30 min) Pneumonia (PN-3b Blood culture before antibiotic) Pneumonia (PN-6 Most appropriate antibiotic for pneumonia) Surgery (SCIP-1 Prophylactic antibiotic at right time) Surgery (SCIP-2 Appropriate prophylactic antibiotic) Surgery (SCIP-3 Prophylactic antibiotic d/c d w/in 24 hrs) Surgery (SCIP-4 Day 1 and 2 6 a.m. blood glucose control) Surgery (SCIP-9 Postop Urinary Catheter Removal) Surgery (SCIP-Card-2 Appropriate beta blocker pre-post surgery) Surgery (SCIP-VTE2 Appropriate VTE prophylactics pre/post surg) 14

15 FY2015 Value-Based Purchasing Patient Experience of Care Measures (30%) HCAHPS Nurse Communication Doctor Communication Responsiveness of Hospital Staff Pain Management Communication about Medications Cleanliness and Quietness Discharge Information Overall Rating FY2015 Value-Based Purchasing Outcome Measures (30%) 30-Day AMI Mortality 30-Day HF Mortality 30-Day Pneumonia Mortality FY2015 Value-Based Purchasing Efficiency (20%) Medicare Spending per Beneficiary 15

16 FY2015 Value-Based Purchasing Clinical Process of Care Measures (20%) Base Goal AMI-7a Fibrinolytic therapy received within 30 minutes of hospital arrival AMI-8a Primary PCI within 90 minutes of hospital arrival PN-3b Blood culture before 1 st antibiotic received in hospital PN-6 Initial antibiotic selection for CAP immunocompetent pt SCIP-1 Abx w/in 1 hr before incision or w/in 2 hrs if Vanco/Quinolone is used SCIP-2 Received prophylactic Abx consistent with recommendations SCIP-3 Prophylactic Abx discontinued w/in 24 hours of surgery end time or hrs for cardiac surgery SCIP-4 Controlled 6 AM postoperative serum glucose cardiac surgery SCIP-9 Postoperative Urinary Catheter Removal on Post Operative Day 1 or SCIP-Card-2 Pre-admission beta-blocker and perioperative period beta blocker SCIP VTE2 Received VTE prophylaxis within 24 hrs prior to or after surgery FY2015 Value-Based Purchasing Patient Experience of Care Measures (30%) Floor Base Goal Communication with nurses Communication with doctors Responsiveness of hospital staff Pain management Communication about medications Cleanliness and quietness Discharge information Overall rating of hospital FY2015 Value-Based Purchasing Outcome Measures (30%) Base Goal MORT-30-AMI 30-Day Mortality acute myocardial infarction (AMI) survival rate MORT-30-HF 30-Day Mortality heart failure (HF) survival rate MORT-30-PN 30-Day Mortality pneumonia (PN) survival rate Base Goal CLABSI Central-Line-Associated Bloodstream Infection Base Goal AHRQ PSI AHRQ Patient Safety Indicator Composite Score

17 FY2015 Value-Based Purchasing AHRQ Patient Safety Indicator Composite Score PSI 03 PSI 06 PSI 07 PSI 08 PSI 12 PSI 13 PSI 14 PSI 15 Pressure Ulcer Rate Iatrogenic Pneumothorax Rate Central Venous Catheter-Related Blooodstream Infection Rate Postoperative Hip Fracture Rate Postoperative Pulmonary Embolism/DVT Rate Postoperative Sepsis Rate Postoperative Wound Dehiscence Rate Accidental Puncture or Laceration Rate 17

18 Contact Info Brent Ibata, PhD JD MPH Director of Operations Sentara Heart Hospital (757)