Richard L. Gilbert, MD, MBA. Chairman/CEO, Southeast Anesthesiology Consultants. Charlotte, NC

Transcription

1 Can a Data Driven Continuous Quality Improvement (CQI) System Change Physician Practice to Reduce Medical Errors, Improve Outcomes, and Lower Healthcare Costs? Richard L. Gilbert, MD, MBA Chairman/CEO, Southeast Anesthesiology Consultants Charlotte, NC The Eighth National Quality Colloquium at Harvard University

2 Disclaimer SAC has commercialized its CQI process as: Quantum Clinical Navigation System

3 Since 1997, SAC has developed, field tested and refined a data driven CQI program to reduce costly medical errors Real time measurement of over 50 clinical indicators (efficiency, practitioner performance, clinical outcomes and patient satisfaction) Provides a continuous real time feedback loop to providers, CQI committees, Department Chiefs, Exec Committee, Hosp Admin Analysis of aggregate data & EBM guide development of system-wide best practices and systems approach to error reduction Performance measures/benchmarks to assure individual accountability and facilitate clinician practice change Facilitates improved individual practitioner performance, identifies systems opportunities to reduce variability which positions HealthCare providers to prospectively exceed benchmarks for CMS, SCIP, PQRI, HCAHPS, P4P

4 Quantum Quality Management Pays Presentations to ASA, MGMA, CMS, National P4P Symposiums, E-Health, Health Leaders, Fortune 500 Companies, have outlined the opportunity to reduce costly medical errors, achieve efficiency, assure patient satisfaction

5 What is Driving HealthCare Reform? How do we generate clinician buy in? How do we change clinician practice? How do we develop a system to achieve systemic opportunities to decrease error? How do we assure individual accountability? What are the opportunities for stakeholders?

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7 What is driving HealthCare Reform? 18.4% 20.0% 10.0% 13.4% 14.9% 15.3% 15.5% 15.7% US Health Expenditures as a Share of GDP 0.0% Healthcare costs are rising rapidly Advisory Board Value Gap *Health Care Advisory Board, Recovering Healthcare Value, 2005, page 24.

8 What is driving HealthCare Reform? Catalyst for Change Numerous studies have highlighted the high rate of medical errors and the need for fundamental changes in the health care delivery system to eliminate gaps in quality. One early catalyst for growth in pay for performance was the Institute of Medicine (IOM) report To Err is Human in 1999, which estimated 98,000 preventable deaths due to medical errors of commission each year. IOM outlined the need to focus on Safe, Timely, Efficient, Effective, Equitable and Patient Centered (STEEEP) care Source: Accenture, Achieving High Performance in HealthCare: Pay for Performance ( Accenture Report ).

9 HealthCare Reform Pay for Performance JCAHO-CMS- Core Measures CMS- SCIP- 2% withhold LOS, DRGs Malpractice premiums PQRI- 2%

10 HealthCare Reform Customer Satisfaction/Certificatio n HCAHPS -Hospital Consumer Assessments of Healthcare Providers & Systems 2002 Clinical Advisory Board- surgeon s top ten prioritiesskilled anesthesiologists, OR turnover Press Ganey, PRC, JD Powers, Health Grade, HealthStream JCAHO- Credentials - OPPE (On-going Professional Practice Eval), FPPE (Focused Professional Practice Eval)

11 What is Driving HealthCare Reform? The Challenge The primary problem is not the absence of knowledge regarding comparative effectiveness, but the absence of the necessary mechanisms to put this knowledge to work. -G. Caleb Alexander, et al. Does Comparative Effectiveness Have a Comparative Edge? JAMA, JUNE 17, 2009

12 How do we Generate Clinician Buy-in? Committed Leadership SAC Executive Leadership SAC CQI Committee CQI ADMINISTRATORS Site CQI COMMITTEE MDs,CRNAs QA NURSING IT INFRASTRUCTURE

13 How do We Generate Measure a spectrum of relevant parameters- Buy-in? Patient Satisfaction (Patient Focused) Efficiency/Timeliness (Value/Productivity) Practitioner Performance (Individual Accountability) Clinical Outcomes (Systems Issues) Real time clinician entered metrics, not claims based or retrospective chart review Timely communication of practitioner results Uniform clinical definitions: apples to apples measurements Ease of implementation and ease of use

14 How do we Generate Clinician Buy-in? Field tested wide spectrum of clinical settings; >100K patients annually Opportunity to achieve substantive improvements in patient satisfaction, efficiency, quality of care Practitioner/Site specific information Ability to benchmark and achieve objective comparisons Communicate expectations/ Encourage positive incentives Transparency virtually 100% data capture; Comprehensive Audit process assures veracity of data

15 How Do We Change Clinician Practice? Constant Re-measuring; Reporting (Hawthorne Effect) Benchmarking facilitates appropriate competitive forces Alerts allow focus on key metrics Real time reporting enables quick analysis; intervention, remeasurement We implement Best Practices-review of data in aggregatealong with EBM

16 Quantum M-5 Process Improvement MONITOR Sustain Improvement/Continuous Reassessment i) Did Intervention Work? Yes; No ii) Trending; Benchmarks iii) Critical Alerts iv) Reports Clinical Navigation METRICS What is Important to Measure? Definitions Quality i) Practitioner Performance ii) Systems Issues iii) Patient Satisfaction iv) Operations Efficiency New Priority-add Ingrained practice change- delete System MEASURE Deviations from Standards Analyze Data; Trend; Benchmark i) Root Cause Analysis of Deviation ii) Audits- Data Veracity iii) +/- feedback loops MOTIVATE Leadership Sets Expectations i) Culture of Continuous Quality Improvement ii) Generate Buy-In; Veracity of Data iii) Accountability - positive, negative incentives iv) Scorecards, Mentoring, Collegial Intervention v) Hawthorne Effect MAKE IT HAPPEN Implement Best Practices i) Evidence Based Medicine ii) Data Analysis iii) Decrease Defects by Decreasing Variability iv) Implement Systems Change-SOPS, Time Out, Site Verification v) Implement Practitioner Practice Change- Mentoring, Case Conference

17 Challenge How Do We Change Clinician Practice? We create constant real time positive & negative feedback loops-foster change in physician practice This process results in individual and organizational physician practice change; systems approach to decreasing errors yet preserves individual accountability

18 Electronic Clinical Alert

19 CQI Management Report identify variability

20 OPPE- Quantum for Credentialing Real Time DATA DUMP Sent to CMC Credentialing Department with CQI Data for all physicians to support Ongoing Professional Practice Evaluation (OPPE) initiative.

21 Quantum For Credentialing OPPE/FPPE Data from CQI Report is compared against group average (benchmark) A focused review is required for any clinician who does not meet established benchmarks, Educational activities (mentoring, case studies, presentations, etc) are assigned. Performance for all clinicians is reviewed on an ongoing basis.

22 Antibiotic Protocol Clinician Process Compliance Patient Population 45,574 Aug % (3448) Sep % (3689) Antibiotic Administration Protocol August June modified tool to include checklists Oct % (3398) Nov % (3101) Dec % (3120) Jan % (3147) Feb % (4260) Mar % (4816) Apr % (4546) May % (4563) Jun % (4664) % 98.00% 96.00% 94.00% 92.00% 90.00% 88.00% 86.00% 84.00% Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09

23 Antibiotic Administration Results Confirmed by Anesthesia Business Consultants Apr-09 May-09 Jun-09 Quantum* ABC** *14,289 Antibiotics ordered. Confidence Level/Interval CQI Results 99% **15,984 Antibiotics ordered. Confidence Level/Interval ABC 99%+ 0.20

24 ROI - Proper Antibiotic Administration Protocol Proper Antibiotic Administration Savings Incidence SSI 3-5% *Cost $3,000; 7-9 hospital days Appropriate Administration of Antibiotics DECREASES SSI 40-80% *Benchmark AB giving appropriately timing 50-75% SAC: 100,000 patients/year Incidence SSI avg: 4,000 TOTAL Cost: $12 Million/year If AB delivered 100% on time, decrease SSI by 60%(40%-80% = 60%) Cost savings: $7.2 Million Benchmark Antibiotics administers appropriately 62.5% (50-75% average 62.5%) = $4.51 Million savings If SAC administers AB 90% appropriately = $6.48 Million savings Estimated savings with protocol compliance= $2.03 MM per year Estimated National Savings with protocol compliance = $528 MM/year *Cost & Benchmark source: Barnard, Bonnie MPH, CIC Fighting Surgical Site Infections

25 Monitoring Practitioner Performance Mentoring- ( OPPE )

26 Overall Surgical Patient Satisfaction 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% ROI Hospital/Physicians 99.74% 99.58% 99.72% 99.62% 99.65% 99.70% 99.76% 98.80% *Confidence Level 95%, Confidence Interval 5.00

27 Patient Satisfaction Results Confirmed by Press Ganey Overall Anesthesia Care CQI Program Results* Would Recommend Press Ganey Results** *29,722 patient surveys received. Confidence Level/Interval CQI Results 99%+.52 **163 patient surveys received. Confidence Level/Interval Press Ganey 95%+6.56

28 2001 N= (0.01%) 2002 N= (0.01%) 2003 N= (0.01%) 2004 N= (0.01%) Hospital- Transfusion Error Systems Process N= (0%) N=26865 N=27470 N=26128 Improvement 0 (0%) 0 (0%) 0 (0%) 2009 YTD N=15234 Several patients received albumin although there was documentation on the medical record that they requested no blood products. Root Cause Analysis Undertaken Recognition of albumin as a blood product Easy access to albumin since it was contained on the anesthesia cart Need for increased communication between anesthesia care team before administering albumin. Process Improvement Education; albumin red label blood product- unsuccessful (monitored) New Process Improvement albumin removed from OR; triple signature checklist Quantum-Ongoing Monitoring 0 (0%)

29 **B Blocker protocol Changed 2009 Event 2005 n=73,093 Educational seminar Protocol developed 2006 n=76,414 Monitoring Drivers of Postop Cardiac Events ( Process, 2007 n=87,211 Diabetic Protocol implemented June n=88,458 Outcomes ) Tool revamped to Identify risk factors /protocol checklist 2009 YTD n=48,411 Beta Blocker** Compliance N/A 2.07% (1,584)* 38.46% (9,445) 90.98% (15,362) 92.89%(5,103) MI 0.02% (11) 0.02% (16) 0.01% (13) 0.02% (19) 0.01% (7) Cardiac Arrest 0.07% (52) 0.10% (78) 0.11% (99) 0.08% (73) 0.08% (37) BP Changes 6.01% (4,391) 9.19% (7,021) 13.82% (12,057) 15.06% (13,319) 15.48% (7,492) EKG Changes 0.68% (499) 0.66% (505) 0.31% (266) 0.37% (323) 0.39% (191) Post op Normothermia Diabetic Protocol Compliance 0.38% (303) 29.84% (22,804) 80.77% (54,799) 91.89% (81,282) 87.50% (49,599) N/A N/A 52.89% (403) 74.10% (7,000) 83.39% (5,589) *BP Protocol data collection started in June 2006

30 Lowering Health Care Costs Post Operative MI Myocardial Infarction # Patients % Patients SAC % National Benchmark* % Number of patients undergoing anesthesia annually: SAC- 95,205 patients/year US approx. 40 million patients/year. Average cost to traditional health insurer for first 90 days after heart attack per patient $ 38,501** Total SAC patients $ 731,519 Total National Benchmark $ 7,894,75 Estimated savings to health plans/patients resulting from SAC reduced events $7,163,236 Estimated national savings if benchmark reduced to SAC benchmark levels $2.618 Billion *Benchmark Source: Chung, Dorothy and Stevens, Robert, Evidence-based Practice of Anesthesiology, page 379. ** Cost Source: NBER Working Paper No. 6514, nber.org/digest/oct 98, National Bureau of Economic Research.

31 Lower HealthCare Costs Financial Model #2: Stroke # Patients Post-Op Stroke % Patients SAC % National Benchmark* % Number of patients undergoing anesthesia annually: SAC-95,205 patients/year US approx. 40 million patients/year. *Nt l Avg is <1%, so.5% is used for calculation. Cost at discharge for inpatient care per patient $ 9,882** Total SAC patients $ 187,758 Total National Benchmark $4,703,832 Estimated savings to health plans/patients resulting from SAC reduced events $4,516,074 Estimated national savings if benchmark reduced to SAC benchmark levels $1.897 Billion *Benchmark Source: Fleisher, Lee; Evidence-based Practice of Anesthesiology, page 163. **Cost Source: Neurology, Vol 46, Issue 3, , 1996, American Academy of Neurology, Inpatient costs of specific cerebrovascular events at five academic medical centers

32 Monitoring Practitioner Performance MD Performance-Skill/Technical Ability CHS Medical Staff Survey 2005, 2007 Anesthesiologis ts: 29.7% Skill or Technical Ability 0.7%0.4% 69.2% Very Satisfied 69.2% Satisfied 29.7% Dissatisfied 0.7% Very Dissatisfied 0.4% Mean 2005,2007 Score: 3.68 HealthStream Survey-99% Satisfied or Very Satisfied

33 Medicare Hospital Reporting Program Total Medicare Hospital ROI SCIP-antibiotics, normothermia, beta blockers, peri-op glucose Market Basket** Deduction for Not reporting 2.0%*** Year 1 Year 2* Year 3* $600,000,000 $630,000,000 $661,500,000 $12,000,000 ($3,000,000) $12,600,000 ($3,150,000) *Incorporates a 5% increase each year in Medicare reimbursement. **Includes total Medicare Reimbursement for Sample hospital network. *** SCIP Initiatives approximately ¼ overall reporting requirements. $13,230,000 ($3,307,500)

34 Lowering HealthCare Costs Through Improved Efficiency 2007 Advisory Board High Performance Operating Room Practice-wide, less than one fourth of one percent of cases are cancelled because of NPO violations or Abnormal Labs. Case Cancellations 1.0 % 0.9% 0.8% 0.7% 0.6% 0.5% 0.4% 0.3% 0.2% 0.1% 0.0% 0.24% 0.25% 0.13% 0.09% 0.12% 0.11% 0.09% 0.06%

35 Journal Articles The February issue of the journal Anesthesiology features a new report based on data collected over a three-year period. Findings from the report, Intraoperative Awareness in a Regional Medical System: A Review of Three Years Data, show that the incidence of intraoperative awareness may be as low as 1 in 14,000 surgeries. Pollard, Beck, et.al. Anesthesiology February 2007

36 Lowering HealthCare Costs Reduced Malpractice Premiums the group s s commitment to quality assurance and patient satisfaction has returned r benefits in many areas, not the least of which is a reduction in professional liability coverage premiums discretionary credits associated with the comprehensive quality/patient satisfaction programs maintained by Southeast primary professional liability coverage increased from 5%...to 15% this year. total loss-free discount for the group amounts to an 11.1% credit against the t total annual premium we attribute an 8% to 10% overall net premium reduction in in recognition of the impact of Southeast Anesthesia s s quality assurance and risk management programs -Lawrence Jones, Sr. VP/ Manager, Special Risk Division

37 Continuous CQI Program Part of the solution for Healthcare Reform? Quantitative real time clinical data in aggregate along with EBM guides an organization to develop, implement and monitor best practices/systems to reduce variability/ costly errors Facilitates, improvement and monitoring of individual practitioner performance to reduce costly medical errors Real Time monitoring enhances ability to proactively make interventions to achieve continual improvement, to exceed benchmarks and to succeed in the Realm of P4P

38 Opportunities for Stakeholders Hospitals/Medical Staff/Payors Reduce Medical Errors and Costly Complications- LOS/DRG/POA Assure compliance with best practice processes Medical Staff Credentials, OPPE, FPPE, Sentinel events CMS SCIP Initiatives/ Core Measures/POA,P4P PQRI Reporting MD P4P Patient Customer Satisfaction -HCAHPS, PRC, Press Ganey Operations Efficiency Malpractice Premium Reduction