J Michael Henderson Chief Quality Officer Cleveland Clinic Health System

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1 Quality Data Public Reporting J Michael Henderson Chief Quality Officer Cleveland Clinic Health System

2 Public Quality Data Reporting What & Why? Hospitals & Physicians NSQIP option

3 WHAT: Quality Data Reporting HHS: Hospital Compare, and others State Reporting: 26 have Scorecards Commercial: Leapfrog Thomson Reuters Consumer Reports Healthgrades

4 There is only one public reported Scorecard that counts HHS Quality data source Hospital Compare But another is emerging Physician Compare

5 Implications: Hospitals probably look more than patients? driving Hospital PI Will drive Value Based Purchasing

6 37 measures Medical, 29 Surgical 1 measure 71

8 Hospital Compare: Patient Safety Measures 1 Patient Safety Indicators (10) Inpatient Quality Indicators (9) 2 8 metrics/1,000 discharges 3 Central line associated blood stream infections

9 Hospital Compare: display of Safety measures

10 How is HHS looking at Cost? Medicare Spend Per Beneficiary 3 Phases: 1. 3 days prior to admission 2. Index admission days post disrge Data is shown as a ratio: Hospital Spend National Median

11 Does your Hospital participate in Registries? NSQIP to be added Oct 2012

12 A whole new look!! July 19 th 2012

13 WHY: Quality Data Reporting 1. Transparency 2. Reputation 3. Reimbursement 4. Drive Performance Improvement

14 Institute of Medicine Focused patients (and country) on Patient Safety

15 What do patients want? 1. Don t hurt me 2. Heal me 3. Be kind to me It s all about TRANSPARENCY

16 REPUTATION Increasing focus on Hospital Compare data to establish credibility US News and World Report Leapfrog Thomson Reuters Consumer Reports

17 REPUTATION: Heart Failure 30 day mortality and readmissions % d Mortality 6 H Hopk G M Gen o Mayo C Cle C A UCLA ol Colu F UCSF m Brigh e Duke n Penn 30 % d Readm 20 H G o c A ol F m e n

18 Penn Duke Brigh UCSF CLABSI Standard Infection Ratio 2 1 Do not report National Hopkins Mass G Mayo CC UCLA Col/Pres 0

19 Medicare Spend Per Benificiary Ratio to National Median National Hopkins Do not report Mayo Mass Gen CC UCLA Col/Pres UCSF Brigh Duke Penn 0.9

20 Reimbursement: Value Based Purchasing Process of Care + HAI, PSI Patient Exp Outcomes (mortality) MSPB

21 Performance Improvement Driven by Data 1. National Scorecard data 2. Hospital level data 3. Real-time data Yearly Monthly Weekly

22 If you can t measure it you can t manage it

23 Physician Quality Reporting Incentive CMS: - Physician Quality Reporting System (PQRS) - Meaningful Use - Maintenance Of Certification (MOC) - eprescribe - Physician Feedback/Value Modifier Program The Joint Commission - OPPE requirement for privileges Commercial: - Profiling from beneficiary Claims Data

24 What do Hospital and Physician Quality Data Reporting have in common? Pay For Reporting Pay For Performance

25 NSQIP OPTION

26 Beginning October 2012, Hospital Compare will include new surgical outcomes measures submitted on a voluntary basis by hospitals participating in the American College of Surgeon s National Surgical Quality Improvement Program database (ACS NSQIP ).

28 Why do this? NSQIP drives improved care for patients Clinical better than Administrative Data Change the approach for quality reporting ACS Inspiring Quality

29 NSQIP on Hospital Compare What to expect: 3 Measures: Lower Extremity Bypass Surgery Colon Surgery Surgery > 65 years Combined death & serious morbidity Will report as: Better than average Average Worse than average Not available

30 ACS-NSQIP Measures Option Cleveland Clinic data Rate Odds ratio Comment Elderly (>65) Colon Surgery Lower Ext Bypass 13.4% 0.80 Better than average 21.2% 1.09 Average 14.9% 1.23 Worse than average

31 Next Steps 170 NSQIP/Non-NSQIP Hospitals inquired and/or expressed interest All should explore and understand this option

32 Hospital Compare to do 1. Review your measure results as contained in your SAR 2. Commit to being a Quality Leader and showing your data on Hospital Compare 3. Electronic submission for all: Addendum to your contract Exhibit Form Measure Selection Deadline: August 13th

33 Takeaways Transparency: data should be reported Data drives PI: accountability Hospital and Physician reporting NSQIP reporting heralds a new era

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

CCHS: Quality and Patient Safety J Michael Henderson, MD Guido Bergomi Outline Integrated Quality & Safety structure Quality Goals and Performance Improvement Quality data sources Quality Reporting The