Enhancing The Intersection Between Production and Promoting Quality Improvement: Focus on Quality

Enhancing The Intersection Between Production and Promoting Quality Improvement: Focus on Quality Nina Brown, MPH, CHES National Health Care for the Homeless Council Regional Training Regional Meeting: Albuquerque, New Mexico November 11, 2011 Public Health Analyst, Office of Quality and Data U.S. DHHS/HRSA/BPHC 1

Learning Objectives At the end of this presentation participants will be able to: 1. Understand the role of quality within healthcare delivery system reform; 2. Understand the importance of using data in Quality Improvement efforts; 3. Locate data within EHB and the HRSA website to assist in Quality Improvement activities; 4. Be able to access and utilize BPHC s Quality Improvement resources. 2

HCH Grantee Patients - 2010 Health Center Snapshot No. of Patients Patients 805,064 Female Patients Male 44% Patients 56% Age 65 and Over 3% Age <= 19 16% Age 20-64 81% 3

HCH Grantee Patients - 2010 More Than One Race 3% White 41% Hispanic 21% American Indian/Alaskan Native 1% Asian 2% Black/African American 31% Native Hawaiian/Other Pacific Islander 1% 4

HCH Grantee Patients - 2010 1% 5% 2% 13% 100% and Below 101%-150% 79% 151%-200% Over 200% Unknown 5

Health Care Delivery System Reform Current system lacks a single entry point Affordable Care Act Allows Health Care to move towards a patient-centered, clinically integrated, accountable system. Modernization of Health Information Technology (HIT) Development of new patient care models o ACOs Strengthen Quality Infrastructure o National Quality Strategy Supportive services delivered at home and in the community 6 Source: The Heller School for Social Policy and Management. Foundations and Healthcare Reform 2010 Policy Brief. July 14, 2010

QI Critical for Delivery System Redesign IOM s top challenges for delivery system redesign: Use of performance measures/outcomes for continuous quality improvement and accountability What is quality health care? Safe, effective, patient-centered, timely, efficient, equitable Includes other services that are provided Source: Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21 st Century. March 2001, National Academies Press. 7 7

National Trends Growing awareness of the need to improve quality, costs, and outcomes Patient and provider experience Push to measure quality and increase accountability HIT enables increasing opportunities for integration, public reporting PCMH is becoming the de facto blueprint for delivery system redesign Primary care currently only accounts for 4 percent of total health care spending 8

The Take Home Message: Quality vs. Productivity Delivery reform focus on quality Visits are smarter and more coordinated HIT and Patient Centric models of care Good for patients and good for the system HRSA has no minimum annual Productivity Requirements Team based care 9

BPHC QI Strategy Framework Inputs/ Resources Activities Output Impact Outcome (HCs providing care that is...) HRSA Health Centers HC Partners Other HHS & Fed. Agencies Local & National Stakeholders Recruit and Retain Approp. Workforce Develop TA & QI Support Infrastructure Facilitate HIT Adoption & Integration Strengthen Eval. & Innovation Infrastructure Facilitate Communication & Collaboration Skilled Workforce Available HIT Adopted & Used Meaningfully Eval. & Innovations Sustained Collaborations & Partnerships Strengthened Health Centers Transformed for QI (PCMH) Care & Services Coordinated Regionally QI Efforts Aligned Locally & Nationally Safe Effective Efficient Patient- Centered Timely/ Accessible Equitable 10 10

BPHC Quality Strategy 1. Develop and enhance access points 2. Transform HC care delivery system PCMH HIT Meaningful Use 3. Recruit, develop, retain skilled workforce 4. Integrate Health Centers into local health systems Specialists, ER, Hospitals ACOs Public Health 5. Align policies and programs where possible 11

Primary Health Care 2011 Strategic Priorities Grantee Satisfaction BPHC External Technical Assistance & Training Strategy Employee Satisfaction BPHC Internal Staff Training & Development Timeliness/Quality Service Area Definition & Overlap/Collaboration Impact Quality Strategy (including Meaningful Use & Patient- Centered Medical Home) Recovery Act Close-Out 12

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Quality Improvement 1. QI infrastructure Protected staff time QI committee Board Policies and procedures 2. Written QI Plan 3. Evidence of Implementation 14

QI Planning Critical to Meeting Quality Goals Delivery system redesign Clinical quality Patient experience Staff satisfaction Financial sustainability Leveraging resources and coordinating beyond your four walls 15

Benefits of an Effective QI Plan Roadmap for HC organization Leadership, focus, & prioritization Efficient coordination of staff & resources Better outcomes, patient experience, staff satisfaction Satisfy external requirements HRSA, state or multipayer pilot Third-party quality accreditation and recognition 16

HRSA Program Requirements Ongoing QI/QA Plan encompassing management and clinical services, maintaining confidentiality of patient records Focused responsibility for QI Periodic assessments of appropriate service use and quality Conducted by physicians or licensed health professionals under the supervision of physicians Based on systematic collection and evaluation of patient records Identify and document the necessity for change in the provision of services and result in the change being implemented 17

QI Program Flow 1. QI teambuilding throughout your center and QI Committee responsibilities 2. Self-assessment of areas to target 3. Goal setting Concrete goals Progress measures 4. Identify strategies for improvement Philosophy of organizational change Specific changes to structures and process of care 18

QI Program Flow 5. Data collection and analysis Use data to fuel QI by closing the feedback loop 6. Periodically evaluate, celebrate, and disseminate 7. Integrate with operations and other qualityrelated activities 19

Teambuilding Quality as an integral part of the organizational culture Buy-in at all levels Board, management, staff and patients Resources Staff time, meetings, information systems Provide education and training 20

QI Infrastructure QI Committee QI Plan & Health care plan QI calendar Clinical practice guidelines Policies & procedures Peer review Chart audits Patient satisfaction surveys Tracking systems Credentialing and privileging Data sources 21

Self-Assessment Revisit mission statement and vision Review past needs assessments and consider how the needs of the patient population have evolved Compare capacity and ability to supply quality services to the need Identify areas for improvement: high risk, high volume, low performance 22 22

Setting Goals Compare yourself to your prior performance Compare yourself to others EHB benchmarked performance reports Short and long-term time goals Aspirational Goals 23

DATA DATA DATA 24

Monitoring Quality of Care Uniform Data System (UDS) Clinical Measures Current Measures New in 2011 Low birth weight Entry into prenatal care Childhood immunization Pap tests Adult hypertension (blood pressures) Adult diabetes (HbA1c levels) Child & adolescent weight assessment & counseling Adult weight screening & follow up Tobacco use assessment & counseling Asthma therapy (pharmacologic) 25

Collecting Your Data Data collected depends on expectations of 3 rd parties Process vs. performance: Measure should reflect 3 things: WHAT you do HOW you do it HOW EFFECTIVE you are Include measures that you Aspire to achieve. Challenges Ease and access of use EHR Levels differ Free Text 26

Using Data is a Team Effort! Staff on the floor are part of the process. They need to understand the process. Aligned process that ties into your strategic plan Involve your Medical Director Critical in gaining understanding of data and system level performance Picture: 3 individuals holding hands united 27

Using Your Data Start with the end in mind Collect it ONCE and use it MANY times Try using data that are shared and accessed easily Data need to be structured the same way Weekly, quarterly pull of data if possible Linking data Ex. Meaningful Use data are standardized, but the data entry isn t Training of staff 28

Using Your Data Align How to prevent failure Identify the failure Bring into balance Balanced Measures Strategic plan Align measures Plan Do Study Act (PDSA) Scorecards: Determining who s responsible for what measure 29

Using Your Data Measure the process to drill down to the outcome Achieve your goals Through processes and structure using root cause analysis (contributing and restricting factors) Case studies help! Select 20 patients & the data points that stand out Stories personalize the data Utilize your consumer board members to help you know if the process is working. 30

Data Sources for Quality Improvement Public site for UDS data: http://bphc.hrsa.gov/healthcenterdatastatistics/ index.html HRSA Data Warehouse: http://datawarehouse.hrsa.gov/ Reports Available in EHB Health Center Trend Report (National/State/Grantee) Health Center Summary Report (National/State/Grantee) Performance Profile (National/State) -- Number & Percent of Health Centers 31

EHB Reports This graphic highlights the EHB home page and directs participants to the area they can access reports within EHB. It is denoted by a red circle 32

UDS Health Center Performance Comparison Report This graphic shows the report that grantees can access within EHB. The report shows the specific grantee and how their clinical performance compares to their state and national. It also shows comparison amongst grantees of different sizes and special populations. 33

UDS Health Center Performance Comparison Report This is a continuation of the previous report. It highlights how the grantee compares on costs to their state and national. It also shows comparison amongst grantees of different sizes and special populations. 34

UDS Health Center Performance Comparison Report This is a continuation of the previous report. It highlights how the grantee compares on costs to their state and national. It also shows comparison amongst grantees of different sizes and special populations. 35

UDS Health Center Trend Report This is an EHB report that shows the three year trend for the specific grantee on key performance measures. 36

Plan Your Quality Intervention Establish project-specific QI team that represents all staff integral to the service or issue Utilize QI tools and techniques to understand the problem that you are facing Flow charts, root cause analysis, cause and effect diagrams, facilitated brainstorming Identify potential solutions to make improvement to the systems of care, both short and long term Develop timeline for reporting findings and improvement strategies 37

Evaluation of the Intervention Document and track progress in activity logs, workplans, meeting minutes If historical data are available, trend analysis Display and distribute data to communicate findings and results. Plan to inform CQI committee and staff of results Graphic presentation of data readings over time Report progress to the rest of the organization on a regular basis Celebrate and share beyond your four walls 38

HIT and Quality 39

Role of HIT in QI Neither necessary nor sufficient, but can really make QI a lot easier Can t just use EHRs like paper charts Interoperability and standard terminology and codes Consensus-based quality measures: e- specification HIT adoption: what is needed for MU? UDS and Patient Experience 40

Key Features of EHR for QI Population management/registries Clinical quality dashboards Decision support Integration with other clinical record systems (lab, oral, BH) Health Information Exchange, e-prescribing Patient self-management support Enhanced access and communication with patients Reporting quality measures 41

Benefits of HIT Provider-to-provider communication Safety enhancements: drug interactions, handwriting foibles Better prepared providers, with the right information and evidence-based practice guidelines or clinical protocols Family and personal health history collected and used Information on the whole person: what about oral and behavioral health? Patient encounters with providers can be more productive 42

How HRSA Supports You! 43

BPHC Quality Initiatives in Health Centers National Quality Recognition PCMH & PCMH Supplemental Accreditation CMS Advanced Primary Care Demonstration Project Resources 4 Readiness FTCA Health Information Technology (HIT) HCCNs and Beacon Communities Meaningful Use Quality Guidance 44

National Quality Recognition Goal: 100% of Health Centers strive to receive national quality recognition, starting with 25 percent of grantees by 2013 Where are we? Accreditation (~25%) Patient Centered Medical Home Recognition (16 grantees representing 46 sites) o Enhance access & continuity o Track and coordinate care o Identify and manage patient populations o Provide self care support & community resources o Track and coordinate care 45

National Quality Recognition Additional NQR Initiatives FY2011 PCMH Supplemental Funding o 904 Grantees Awarded CMS Advanced Primary Care Demonstration o 500 sites to be selected PCMH Supplemental, NOI Requirement 46

FTCA Federal Tort Claims Act Deeming Health centers and free clinics New 2012 deeming requirements o FTCA Policy Manual (PIN 2011-01) http://bphc.hrsa.gov/policiesregulations/policies/ pdfs/pin201101manual.pdf ECRI Institute resources: Free and available to all! o https://www.ecri.org/pages/default.aspx 47

New Application Requirements Minutes from last six QI/QA committee meetings Remove patient names and other identifiers Minutes from the last six Board meetings that reflect Board approval of QI/QA activities Remove all information not related to QI/QA activity Board-approved Credentialing and Privileging policies Must be signed and dated by the Board 48

New Application Requirements (continued) Clinical policies and procedures for the following activities: q Referral Tracking q Hospitalization Tracking q X-Ray Tracking q Lab Result Tracking 49

Additional Application Requirements A complete initial or redeeming application must include: 1. An Application Form completed in EHB 2. An approved Quality Improvement/Quality Assurance Plan, including governing board signature and approval date 3. Summary of professional liability history for cases filed or closed within the last 5 years, if applicable v Name of provider(s) involved v Area of practice/specialty v Date of Occurrence v Summary of allegations v Status and outcome of claim 50

Additional Application Requirements (continued) 4. Explanation of any NO responses 5. Deeming applications for any sub-recipients (as documented on the organization s most recent approved scope from FORM 5B - see subrecipient submission instructions. ) 51

Additional Application Requirements (continued) 6. Credentialing list (in an excel spreadsheet) of all licensed and/ or certified health care personnel employed and/or contracted by the health center, with the following information: o o o o o o o o Name & Professional Designation (e.g., MD/DO, RN, CNM, DDS) Title/Position Specialty Employment Status (full-time employee, part-time employee, contractor, volunteer) Date of Hire Initial Credentialing Date (the first time the individual was credentialed by your organization) Most Recent Credentialing Date Next Expected Credentialing Date 52

Health Information Technology Health Information Technology Coordinating adoption, meaningful use, health info exchange Health Center Controlled Networks o 3 or more health centers o Increased buying power o Collaboration to improve access to care, enhance quality of care, and achieve cost efficiencies. Supplemental funding for health centers in Beacon communities o Part of the HITECH Act o Comprised of different health care systems, clinicians, payers, employers, patient advocates, and IT leaders 53

Adoption and Meaningful Use of HIT Goal: 100% of Health Centers meaningfully use a certified EHR system 50.7% report having EHR in use at all sites for all providers, and 14.1% report having EHR in use at some sites or for some providers. Where are we? Baseline data collection EHR questions in UDS, HCs participating in HCCNs Other data sources REC program, GW/NACHC Survey, NAMCS survey Strategy Support for and TA from HCCNs/PCAs/NACHC. Partnerships/Collaborations CMS EHR Incentive Program ONC REC Program, State HIE Program, Beacon Communities, Community College Program 54

Other Focus Areas Patient experience measurement The role of mental health and substance abuse services in the medical home SAMHSA/HRSA Center for Integrated Health Solutions Integration with local health care, public health, and social services landscape Telehealth National priorities: tobacco, healthy weight, HIV, oral health Supporting Affordable Care Act implementation and delivery system reform 55

Conclusion Focus on quality Support for planning and implementation of Quality Improvement strategies QI Plan Learning Series Further guidance Resources and technical assistance Third-party quality recognition Invest in your QI infrastructure Clinical quality and beyond Effectively use your data to achieve your goals Focus on implementation This work never ends 56

Resources Technical assistance through HRSA, NCAs Third-party quality recognition Accreditation: http://bphc.hrsa.gov/policiesregulations/ accreditation.html o AAAHC, TJC NCQA recognition: http://bphc.hrsa.gov/policiesregulations/ policies/pal201101.html Comparison chart: http://bphc.hrsa.gov/policiesregulations/policies/ qualrecogn.pdf 57

QI Resources HRSA FTCA website http://bphc.hrsa.gov/ftca/ index.html BPHC QI Plan Learning Series and Modules http://bphc.hrsa.gov/policiesregulations/quality/index.html BPHC Office of Training and Technical Assistance http://bphc.hrsa.gov/technicalassistance/tatopics/ qualitymanagementimprovement/index.html HRSA Office of HIT and Quality http://www.hrsa.gov/ quality/toolsresources.html HIV/AIDS bureau http:// nationalqualitycenter.org/ Safety Net Medical Home Initiative http:// www.qhmedicalhome.org/safety-net/qistrategy.cfm 58

PCMH Resources Agency for Healthcare Research and Quality (AHRQ) PCMH Resource Center: http://www.pcmh.ahrq.gov/portal/server.pt/ community/pcmh home/1483 o Clinical Practice Guidelines: http://www.ahrq.gov/clinic/ cpgsix.htm o US Preventative Services Task Force: http:// www.uspreventiveservicestaskforce.org/tools.htm o Consumer Assessment of Healthcare Providers and Systems (CAHPS patient experience survey): https:// www.cahps.ahrq.gov/default.asp o Innovations Exchange: www.innovations.ahrq.gov/ o Patient Health literacy toolkit: literacy/ http:// http://www.ahrq.gov/qual/ Patient-Centered Primary Care Collaborative (PCPCC): http://www.pcpcc.net/content/pcmh-outcome-evidence-quality 59

Contributors Emily Jones, MPP Public Health Analyst Quality Branch, BPHC/OQD Harriet McCombs, Ph.D Senior Public Health Analyst Quality Branch, BPHC/OQD Christopher Gibbs, JD, MPH Public Health Analyst FTCA Branch, BPHC/OQD Michael Witte, MPH Public Health Analyst HIT Branch, BPHC/OQD 60

Contact Information Nina Brown, MPH, CHES Public Health Analyst Office of Quality and Data Quality Branch Bureau of Primary Health Care Health Resources and Services Administration 301-443-1921 nbrown2@hrsa.gov 61