Hospital Acquired Conditions: using ACS-NSQIP to drive performance. J Michael Henderson Jackie Matthews Nirav Vakharia

Transcription

1 Hospital Acquired Conditions: using ACS-NSQIP to drive performance J Michael Henderson Jackie Matthews Nirav Vakharia

2 Your Team: Quality & Patient Safety Institute Cleveland Clinic Mike Henderson: Chief Quality Officer Jackie Matthews: Senior Director, Quality Reform and Reporting Nirav Vakharia: Associate Staff, Medicine and Quality & Safety

3 Why this topic? Complications Hospital Acquired Conditions

4

5 Hospital Acquired Conditions From a reporting & Payment perspective the focus is changing: 1. Patient Safety Indicators: Administrative data 2. Hospital Acquired Infections: Surveillance data

6 Patient Safety Indicators Inclusions in PSI 90 reporting PSI CMS UHC 3 Pressure Ulcer Rate X X 6 Iatrogenic Pneumothorax Rate X X 7 Central Venous Catheter-Related Blood Stream Infection Rate X X 8 Postoperative Hip Fracture Rate X X 9 Postoperative Hemorrhage or Hematoma Rate X 10 Postoperative Physiologic and Metabolic Derangement Rate X 11 Postoperative Respiratory Failure Rate X 12 Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate X X 13 Postoperative Sepsis Rate X X 14 Postoperative Wound Dehiscence Rate X X 15 Accidental Puncture or Laceration Rate X X

7 Hospital Acquired Infections Central line associated blood stream infection Catheter associated urinary track infection Surgical site infections - Colon / hysterectomy / total joints.. C. difficile infection MRSA

8 Why are HACs important? 1. For Patients 2. For Reputation 3. For Payment

9 What have you been doing with NSQIP? 1. Detailed clinical data on complications 2. Driving improvement How to use NSQIP in context of HACs 1. Identify HAC gaps from Admin data 2. Focus improvement to close gaps

10 Hospital Acquired Conditions Message YOUR hospital needs help You can help drive improvement with NSQIP

11 Today s Session 1. Big Picture context 2. Payment programs tied to HACs 3. NSQIP to help drive improvement 4. Case Studies: breakouts

12

13 Overview of Federal Pay for Performance Programs Nirav Vakharia, MD Cleveland Clinic

14 TRIPLE AIM: KEY STRATEGIES Better Health for the Population Better Care for Individuals Lower Cost Through Improvement

15 Learning Objective Review major federal / public programs driving transition to value

16 Value = Quality Cost

17 Which is the better value? $1.99 / pound $2.49 / pound

18 Which is the better value? $1.99 / pound $2.25 / pound

19 Value = Quality Cost Could anything go wrong?

20 Incentives Moral The right thing to do True north Social Cultural Peer pressure Acceptance Financial Discounts Bonuses Fines

21 Unintended Consequences Incentive Paying villagers for each rat tail Unintended Consequence Encourage rat farming Requiring strong, complex passwords for online accounts Mandatory bicycle helmet policy for Australian children Paying healthcare providers for each procedure that they do Writing down passwords on paper Less children riding bicycles Unnecessary procedures

22 Incentives Moral The right thing to do True north Social Cultural Peer pressure Acceptance Financial Discounts Bonuses Fines Healthcare Do what s best for the patient. Healthcare Public reporting Healthcare Performancebased payments

23 Public (CMS) P4P Programs Hospital Value Based Purchasing Readmissions Reduction Hospital Acquired Conditions Physician Physician Quality Reporting System (PQRS) / Value Based Modifier Both Meaningful Use Accountable Care

24 Promoting Value in Healthcare Population Health Public Program Accountable Care PQRS Value Modifier Measured Group(s) Both Physicians Episodes of Care Readmissions Hospitals Discrete Hospitalizations Value Based Purchasing Hosp. Acquired Conditions Hospitals

25 Value Based Purchasing What: 20+ measures, currently process and patient experience How: achievement and improvement both influence Total Performance Score Why: - CMS: budget neutral - Providers: Financial: +/- 2% DRG base rate adjustment Social: publicly reported

26 Value Based Purchasing

27 Readmission Reduction What: 30 day readmission rates How: comparing expected to actual readmission rates, total hip/knee, COPD and CABG coming online Why: - CMS: overall cost saving - Providers: Financial: up to 3% penalty on DRG base rate Social: publicly reported

28 HAC Penalty Program What: patient safety indicators and hospital acquired infections Why: - CMS: reduce preventable harm, overall cost saving - Providers: Financial: up to 3% penalty on DRG base rate Social: publicly reported

29 HAC Program Domains

30 PQRS / Value Based Modifier PQRS Quality Measures Value = Outcomes Cost All Cause Readmissions Preventable Admissions $$ at Risk Up to 2% of Medicare Part B billing Overall Cost

31 Financial Incentive Public (CMS) P4P Programs Hospital (Part A) Value Based Purchasing (2%) Readmissions Reduction (3%) Hospital Acquired Cond. (3%) Physician (Part B) Physician Quality Reporting System (PQRS) / Value Based Modifier (2%)

32 Social Incentive

33 Social Incentive

34 Social Incentive

35 Social Incentive

36 Incentives Moral Do what s best for the patient. Social Public reporting Financial Performancebased payments Could anything go wrong?

37 Questions?

38 Hospital Acquired Condition Programs Jacqueline Matthews, RN, MS Senior Director, Quality Reform & Reporting Quality & Patient Safety Institute

39 Focus on Patient Safety 1999: To Err is Human IOM publication - At least 44,000 (as many as 98,000) people die in hospitals each year from preventable medical errors 2001: Crossing the Quality Chasm IOM publication First Aim for Improvement: Safe Care. 2002: Serious Reportable Events published by NQF 2010: Adverse Events in Hospitals: National incidence among Medicare Beneficiaries OIG Report - Estimated 13.5% hospitalized beneficiaries experienced adverse events 2011: Partnership for Patients Collaborative Initiated by CMS

40 2008 CMS Hospital Acquired Condition (HAC) Goal Reduce preventable hospital acquired conditions by 40% - Preventing 1.8 million injuries - Averting 60,000 deaths of hospital inpatients over the next 3 years

41 CMS Hospital Acquired Conditions Programs HAC- Present On Admission (POA) Program FY2009 HAC Reduction Program FY2015

42 Hospital-Acquired Conditions (HAC) and Present on Admission (POA) Indicator Reporting (HAC-POA) The purpose of the HAC-POA program is to evaluate the HAC-POA payment policy related to preventable HACs. Are high cost or high volume or both, Assignment to higher MS-DRG when present as a secondary diagnosis, and Could reasonably have been prevented through evidence-based guidelines.

43 HAC- POA Measures Foreign Object Retained after surgery* Air Embolism* Blood incompatibility* Pressure ulcer stage III & IV* Falls and trauma* Vascular catheter associated infection* Catheter associated urinary tract infection* Manifestations of poor glycemic control* Surgical Site Infection Mediastinitas after CABG Surgical Site infection after certain Ortho Procedures Surgical Site Infection Following Bariatric Surgery for Obesity Deep Vein Thrombosis and Pulmonary Embolism Following Certain Orthopedic Procedures Iatrogenic Pneumothorax with Venous Catheterization

44 Goal of HAC-POA Reporting To accurately document hospital acquired conditions Accurately report if HACs were present on admission or developed during the hospitalization No additional payments for cases with these conditions that occurred during hospitalization

45 Medicare Payments for Selected HACs HAC Catheter Associated UTI SSI: Following certain Ortho procedures Number Pts Payments without Condition $27,347 $50,089 Payment with the conditions $33,261 $61,260 Amount difference $5,914 $11,172 Total Increase in Payments $16,458 $2,167

46 HAC-POA DRG Demotion Policy Hospitals do not receive the higher payment for cases when selected conditions is acquired during hospitalization Case is paid as though the secondary diagnosis is not present.

47 Cleveland Clinic Experience HAC-POA DRG Demotions

48 HAC-POA Public Reporting 2010 CMS approved reporting of HACs on Hospital Compare 8 HACS were publicly reported for 2 years Utilized for other Report Cards - Healthgrades - Leapfrog - US News and World Report

49 HAC- POA Current Status Active program with spill-over to private payers & Medicaid. Minimal direct financial impact Public Reporting of HAC-POA rescinded

50 Hospital Acquired Condition Reduction Program Regulated in the Healthcare Reform Act Starts in FY2015 (October 2014) Utilizing different metrics then HAC-POA program - Hospital Acquired Infections - Patient Safety Indictors Penalty program only for worse performing hospitals

51 HAC Reduction Penalty Hospitals in worse performing quartile face 1% reduction in payments (IME & DSH) Reduction applied after VBP and Readmission Reduction Programs Hospital Compare reporting in December 2014

52 Hospitals Affected by HAC Reduction Program Provided with permission from AAMC

53 HAC Domains and Measures Domain 1 AHRQ Patient Safety Indicator (PSI) 90 Composite PSI-90 Composite: PSI-3: Pressure Ulcer Rate PSI-6: Iatrogenic Pneumothorax Rate PSI-7: Central Venous Catheter-related blood stream infection Rate PSI-8: Hip Fracture Rate PSI-12: Postoperative PE/DVT Rate PSI-13: Sepsis Rate PSI-14: Wound Dehiscence Rate PSI-15: Accidental Puncture Rate Domain 2 CDC Measures 2015: CAUTI CLABSI 2016 (1 Additional measure): Surgical Site Infection (Colon/Abd Hysterectomy 2017 (2 Additional Measures) MRSA C DIFF

54 Hospital Acquired Condition Program Framework Domain 1 Weighted 25% Domain 2 Weighted 75%

55 FY 2015 CMS Preliminary Analysis of Hospital Acquired Conditions Reduction Program Cleveland Clinic Hospitals Worst 25th Quartile (Scores > 7) CC Marymount Euclid Hillcrest South Pointe Medina Lutheran Fairview Lakewood Florida The 75th percentile of the Total HAC Score is 7.0 for the FY 2015 CMS conducted a preliminary analysis of the HAC Reduction Program using currently available historical data as a proxy for the actual data that will be used to determine hospital performance under the program. C:\Documents and Settings\matthej1\Local Settings\Temporary Internet Files\Content.IE5\16PGSMDK\FY2015-NPRM-Table- 17[1].zip

56 Questions?

57

58 How ACS-NSQIP Can Help to Improve HACs J Michael Henderson

59 What are the goals? 1. Reduce morbidity for patients 2. Reduce HACs for reporting (reputation) 3. Reduce HACs for payment programs

60 Where are the greatest opportunities? 1. For patients: define by center 2. For reporting & Payment: - Hospital Acquired Infections CLABSI, CAUTI, SSI (CORS, GYN, Joints, CABG) cdiff, MRSA - Patient Safety Indicators (PSI 90) Pneumothorax, post op DVT/dehiscence/sepsis, accidental laceration, pressure ulcers, hip#, CLABSI

61 An approach Identify gaps from public reported data: Hospital Compare Drive improvement from clinical registry data: NSQIP for many of the reporting/payment metrics

62 GAPS Patient Surveys Cleveland Clinic Performance 2013 Timely, effective care Readmissions, complications, death Use of medical imaging Medicare payment Total At or above national average Worse than national average GAPS : Patient Safety Indicators (PSI 90) Hospital Acquired infections

63 July 2014 Semi Annual Report 435 Hospitals: Multiple models Still morbidity / opportunity for improvement

64 Limitations with Data 1. Hospital Compare - Mix of Administrative / abstracted / surveillance - Some audit - Available for all hospitals 2. NSQIP - Clinical abstracted data: sample methodology - Audit - Limited to ~ 450 hospitals

65 What can you do? Work with Hospital Team Recognize strengths/ weaknesses of different types of data Engage frontline caregivers in performance improvement

66 Improvement Opportunities Centers: Just do it projects Are you working with your hospital quality improvement team or in a NSQIP silo? Broader Horizons: - NSQIP Collaboratives - CMMI Partnership-for-Patients - Joint Commission Center for Transforming Healthcare

67 Examples Reducing SSIs Preventing pneumothorax Post-op VTE prevention Accidental puncture or laceration

68 CORS SSI project Bundle1: Nursing driven Bundle 2: +/- Buy in Bundle 3:? Commitment

69 Preventing Pneumothorax Patient Safety Training and competency Privileging

70 Post-op VTE prevention Gap identified by 2 sources: - Patient Safety Indicators (administrative data) - NSQIP (clinical data) Project Plan: 1. Standardize assessment and order sets 2. Root cause analysis on events Data for the work : Internal / Administrative / NSQIP

71 Accidental Puncture/Laceration Don t forget that documentation is important too! This PSI depends on accurate documentation by your surgeons in their op note

72 Why are Hospitals working on HACs? Penalty Program Performance Gaps All Hospitals scored on HAIs 65% PSIs 35% 60% AMCs in lowest quartile Penalty (1%) starts Oct 2014

73 Summary HACs are here to stay Hospitals have a huge focus on HACs Multimodality approach to reducing HACs NSQIP is one of the useful tools to help drive a hospital program

74