Military Health System Enterprise Dashboard as of August 2015
MHS Performance Dashboard STRATEGIC ALIGNMENT THRESHOLDS COMPONENT PERFORMANCE PERFORMANCE MEASURE DEV. MHS PERFORMANCE AIM OBJECTIVE STATUS RED GREEN BLUE A N AF NCR MD PSC AS OF Medically Ready Force (PLS1) eadiness Ready Medical Force (PLS2) etter ealth Healthy People (PLS3) Improve Healthy Behaviors (IP5) Improve Clinical Outcomes and Consistent Patient Experience (PLS4) Report as of 22 JUL 2015 Individual Medical Readiness (IMR) I 87% <75% 85% 90% 85% 90% 89% N/A N/A Mar 15 Jun 15 TBD --- --- --- --- --- --- --- --- --- --- --- TBD --- --- --- --- --- --- --- --- --- --- --- HEDIS Cancer Screening Index I 79% 50% 70% 90% 89% 95% 73% 77% 34% Mar 15 Jun 15 Risk Adjusted Mortality (All Cause) E 6.5 TBD TBD TBD 2014 Q4 Jun 15 Inpatient: Recommend Hospital (Satisfaction) I 74% <71% 73% 75% 71% 74% 78% 84% 73% Dec 14 Jun15 Overall Satisfaction w/healthcare (Outpatient) I 93% Service Specific Service Specific Service Specific 92% 96% 96% 92% 92% Dec 14 Jun 15 **HAI (CLABSI) I 7 N/A N/A 0 3 3 1 0 N/A May 15 Jun 15 DATA ENTRY etter are ower Cost Improve Safety (IP9) Improve Condition- Based Quality Care (IP7) Improve Comprehensive Primary Care (IP8) Optimize & Standardize Access & Other Care Support Processes (IP10) Improve Stewardship (PLS5) **PSI 5 - Retained Surgical Item or Unretrieved Device Fragment Count (Per Year) National Surgical Quality Improvement Program (NSQIP) (30 Day) All Case Morbidity Index I 11 N/A N/A 0 10 1 0 0 N/A Jun 15 Jun 15 I N/A 10th percentile 11th - 89th percentile 90th percentile Multiple scores per service N/A Jun 14 Jun 15 CAUTI Wrong Site Surgery **HEDIS Diabetes Index I 70% 50% 70% 90% 70% 81% 75% 85% 20% Mar 15 Jun 15 **HEDIS Appropriate Care Index (Low Back Pain, Pharyngitis, URI) NPIC Post-Partum Hemorrhage* E 5.3% NPIC Vaginal Deliveries w/coded Shoulder Dystocia Linked to a Newborn 2500 grams w/birth Trauma* I 57% 50% 70% 90% 40% 65% 62% 62% 30% Mar 15 Jun 15 I 17.8.% HEDIS (30-Day) Mental Health Follow-Up I 86% HEDIS All Cause Readmission E 1.45 ORYX Transition of Care Index (Asthma, VTE, Inpt Psy(2)) 2σ above NPIC avg.(3.3%) 2σ above NPIC avg.(12.5%) 50th percentile (74%) 50th percentile (0.79) within 2σ of NPIC avg. (3.3%) within 2σ of NPIC avg. (12.5%) 75th percentile (81%) 75th percentile (0.73) 2σ below NPIC avg.(3.3%) 2σ below NPIC avg.(12.5%) 90th percentile (85%) 90th percentile (0.68) 4.5% 5.8% 6.0% 2.8% N/A 2014Q3 Jun 15 13.4% 22.6% 18.0% 33.3% N/A 2014Q3 Jun 15 100% 100% 72% 100% 20% Mar 15 Jun 15 1.46 1.39 1.27 1.80 N/A Nov 14 Jun 15 I 54% 60% 75% 100% 44% 56% 50% 63% N/A 2014 Q4 Jun 15 AHRQ Prevention Quality Indicator (PQI) Index I 94% 70% 80% 90% 94% 94% 98% 100% N/A 2014 Q3 Jun 15 PCM Continuity I 61% 55% 65% 81% 61% 63% 61% 54% N/A Apr 15 Jun 15 PCM Empanelment E <1,100:1 1,100:1 >TBD Primary Care Leakage I 25.3% >24% 24% to > 20% 20% 23.0% 26.8% 28.1% 26.5% N/A Feb 15 Jun 15 **Avg. No. of Days to Third Next Available Future Appointment (Primary Care) **Avg. No. of Days to Third Next Available 24 Hour Appointment (Primary Care) **Percent of Direct Care Enrollees in Secure Messaging **Satisfaction with Getting Care When Needed (Service Surveys) PMPM Total Purchased Care Cost Private Sector Care Cost per Prime Enrollee OR Utilization I 7.3d >7d 7.0d 2.2d 6.4d 7.0d 7.9d 11.1d N/A Jun 15 Jul 15 I 1.5d >1d 1.0d 0.8d 1.5d 0.9d 1.8d 1.9d N/A Jun 15 Jul 15 TBD 36% TBD TBD TBD 27% 41% 43% 38% N/A May 15 Jul 15 I 85% Service Specific Service Specific Service Specific 82% 90% 90% 80% 90% Dec 14 Jun 15 I E I E $342 4.6% >2.8% yearly growth 2.8% to > 0% yearly growth 0% yearly growth 2.6% 2.0% 5.4% -7.3% 5.0% Sep 14 Jun 15 $-47.7M -2.5% Service Specific Service Specific Service Specific -7.0% -0.8% 0.3% -3.6% N/A Dec 14 Mar 15 $169 2.7% >2.8% yearly growth 2.8% to > 0% yearly growth 0% yearly growth 6.5% 5.8% 4.2% -0.8% 5.3% Sep 14 Jun 15 **Total Enrollment I 3.59M 0% to < 5% yrly 0.1% <0% yrly growth growth 5% yrly growth -0.5% 2.6% -1.5% 1.2% N/A May 15 Jun 15 Pharmacy Percent Retail Spend I 50.6% >40% 40% to > 35% 35% 51.8% 53.5% 48.4% 39.7% N/A Feb 15 Jun15 Productivity Targets I 89% Service Specific Service Specific Service Specific 89% 91% 91% 71% N/A Mar 15 Jun 15-2 -
Partnership for Improvement: Virtuous Cycle MHS Performance Dashboard A Set Our Priorities E Report How We re Doing 4 Priorities, 9 Measures by 2016 B Provide Useful Information MTF Ranking (Access) D Share With Each Other Access Driver Diagram Avg Days to SMS % PC Leakage Avg Days to Acute Avg Days to Acute PC Leakage Routine EST Registered (Jan- April Avg Days to Routine SMS % Care Care (Jan- April 2015) (as of June (May 2015) 2015) Facility Service PDMIS Parent Facility Name EST Registered (as of June 2015) Composite Score (as of 30 June Goal is 24% or 2015) (as of 30 June 2015) (May 2015) 2015) less Quartile Score Quartile Score Quartile Score Quartile Score Air Force 0074 14th MED GRP- COLUMBUS 0.9 4.7 44% 21% 3 3 2 3 11 Air Force 0366 59th MDW- 359 MDG- JBSA- RANDOLPH 1.2 5.7 55% 3 2 3 3 11 Air Force 0395 62nd MED SQ- MCCHORD 1.1 4.9 30% 19% 3 3 2 3 11 Air Force 0805 52nd MED GRP- SPANGDAHLEM 1.1 4.1 43% 3 3 2 3 11 Air Force 0808 31st MED GRP- AVIANO 1.2 6.6 63% 3 2 3 3 11 Air Force 7234 MENWITH HILL 0.7 3.5 41% 3 3 2 3 11 Army 0610 AHC BG CRAWFORD SAMS- CAMP ZAMA 0.9 4.5 32% 3 3 2 3 11 Navy 0030 NH TWENTYNINE PALMS 1.0 4.2 38% 24% 3 3 2 3 11 Navy 0038 NH PENSACOLA 0.8 3.4 62% 28% 3 3 3 2 11 Navy 0056 JAMES A LOVELL FHCC 1.1 2.8 46% 18% 3 3 2 3 11 Navy 0092 NHC CHERRY POINT 0.9 3.6 51% 29% 3 3 3 2 11 Navy 0103 NAVAL HEALTH CLINIC CHARLESTON 1.0 4.3 50% 30% 3 3 3 2 11 Navy 0127 NH OAK HARBOR 0.7 4.6 35% 23% 3 3 2 3 11 Navy 0280 NHC HAWAII 1.1 4.8 37% 23% 3 3 2 3 11 Navy 0617 NH NAPLES 0.9 5.8 65% 3 2 3 3 11 Navy 0618 NH ROTA 0.8 5.5 72% 3 2 3 3 11 Navy 0621 NH OKINAWA 0.9 4.2 37% 3 3 2 3 11 Navy 0622 NH YOKOSUKA 1.0 3.1 36% 3 3 2 3 11 Air Force 0015 9th MED GRP- BEALE 1.9 6.5 51% 23% 2 2 3 3 10 Air Force 0018 30th MED GRP- VANDENBERG 1.8 6.6 55% 23% 2 2 3 3 10 Air Force 0051 78th MED GRP- ROBINS 1.9 4.8 49% 27% 2 3 3 2 10 Air Force 0083 377th MED GRP- KIRTLAND 1.7 4.3 50% 25% 2 3 3 2 10 Air Force 0097 97th MED GRP- ALTUS 1.3 5.2 53% 18% 2 2 3 3 10 Air Force 0106 28th MED GRP- ELLSWORTH 1.0 3.5 44% 26% 3 3 2 2 10 Air Force 0799 470th MED FLT- GEILENKIRCHEN 1.4 4.6 42% 2 3 2 3 10 Air Force 0804 18th MED GRP- KADENA AB 1.7 5.9 49% 2 2 3 3 10 Air Force 0806 86th MED GRP- RAMSTEIN 1.9 6.5 49% 2 2 3 3 10 Air Force 0814 423rd MDS- RAF ALCONBURY 1.2 4.2 28% 3 3 1 3 10 Army 0060 ACH BLANCHFIELD- CAMPBELL 1.5 4.9 29% 19% 2 3 2 3 10 Army 0075 ACH LEONARD WOOD 2.0 4.7 29% 20% 2 3 2 3 10 Army 0131 ACH WEED- IRWIN 1.2 3.2 25% 19% 3 3 1 3 10 C Find Out What Works Component Lessons Learned Simplify appointment types (2) Extend hours options Template management to match demand Use of extended team members Utilize mobile technology - 3 -
Partnership for Improvement: Virtuous Cycle STEP A. Set Our Priorities B. Provide Useful Information C. Find Out What Works D. Share With Each Other E. Report How We re Doing WHAT WE ARE DOING 4 x 9 x 2016 At the March R&A, leadership approved 4 improvement priorities with 9 associated measures, each with specific performance thresholds. The 4 priorities are: Improve Access Reduce Patient Harm Improve Quality Outcomes for Condition Based Care Increase Direct Care Primary Care Capacity We have learned that the Components need more than high-level run charts to drive improvement, so we are experimenting with new ways to provide more useful information. For example, the Access SMEs have developed an MTF Ranking Report that identifies best performers as well as MTFs that may need help. Army, Navy, Air Force, and NCR are capturing Component Lessons Learned for each of the 4 improvement priorities. This knowledge fosters the identification and transfer of best practices. To facilitate a discussion of what we are doing to improve across the enterprise, we are testing the use of Driver Diagrams. These diagrams define the primary improvement levers and organize improvement initiatives in a manner that help us communicate and share what we are doing collectively. Each month, the MDAG receives an updated MHS Performance Dashboard showing the latest performance of the Enterprise and of each Component. This same dashboard is reviewed quarterly at the R&A. - 4 -
Sharing with Each Other: Driver Diagrams There have been two MDAG Performance Updates since the 24 June R&A. During this period, leadership has requested briefing materials that clearly define the efforts that are being taken to drive improvement across the enterprise. We are testing the use of driver diagrams to meet the requests of leadership. These diagrams identify the primary levers and initiatives that the SME communities have identified to foster improvement. If leadership finds the Improve Access driver diagram helpful, the P4I-SC will work with appropriate SME groups to draft driver diagrams for the other Process Improvement Priorities and present them at the 30 September R&A. - 5 -
Improve Access Background Access to Care is strategically important because it strengthens patient partnerships and decreases the likelihood that patients will seek alternative care venues. In turn, we should see an increase in continuity of care and patient satisfaction, and a reduction in purchased care costs. Pt Identifies Need for Medical Help Pt Contacts Direct Care System (Phone, Secure Messaging, NAL, TOL) Measure: Secure Messaging Patient Requests Appt at preferred Date and Time Measure: Third Available (24 hr and Future Appt) Clerk Schedules Appointment Pt Goes to Clinic Pt Waits for Doctor Pt Sees Provider & is treated Current State: Air Force & Navy have the highest percent of enrollees registered in secure messaging; overall 35% of enrollees registered; thresholds not yet approved by governance. Navy has the best performance on average number of days to third next 24 hour; over 50% of appointments are available on a 24-hour basis. Overall performance on average number of days to third next future exceeds goal of 7 days or less To date, no component has met the FY15 goal of a 2% annual improvement against previous Service performance on Patient Satisfaction with Getting Care When Needed Patient Satisfied Measure: Satisfaction w/ Getting Care MEASURE PERFORMANCE MHS A N AF NCR-MD PSC % of Direct Care Enrollees in Secure Messaging 35% 27% 42% 40% 39% NA Average Number of Days to Third Next 24 Hour 1.5d 1.5 1.0 1.7d 2.1d NA Average Number of Days to Third Next Future 6.6d 6.5d 6.6d 6.5d 11.3d NA Satisfaction with Getting Care When Needed 85% 82% 90% 90% 80% 90% Goals/Targets % of Direct Care Enrollees in Secure Messaging (data as of 31 Mar 15): 50% (Exploratory Measure pending Governance approval) Average Number of Days to Third Next -24 Hour (data as of 30 Apr 15): 1 day (or less) Average Number of Days to Third Next Future (data as of 30 Apr 15): 7 days (or less) Satisfaction with Getting Care When Needed (data as of FY15Qtr1): 2% improvement in each Service (data currently in Carepoint has not been validated by DHA/Decision Support) - 6 -
Improve Access Top 3 Initiatives 1. Focus on PCM Continuity 2. Promote Secure Messaging utilization to reduce Face to Face Appt Demand 3. Implement Simplified Appointing, including matching appointment supply to patient demand preference by appointment type and time of day Primary Drivers Improved supply of visits Alternative to inperson visits Initiatives PCM Continuity Simplified Appointing Match appointment supply to patient demand by appointment type and time of day Open access model ( see today s patient today ) Extended hours options and integration with inhouse ER/UC Provider Availability and appropriate panel size Template Management (Appts/Day/PCM)* Primary Care utilization rate Improve Access Measures % of Direct Care Enrollees in Secure Messaging Average Number of Days to Third Next 24 Hour Average Number of Days to Third Next Future Satisfaction with Getting Care When Needed Decrease demand Use of technology Transparency Secure messaging utilization to reduce need for face to face appointments T-Cons (both proactive outreach and response) Use of extended team members (BH, Pharmacy, PT, educators/dm/cm) Proactive management of high utilizers (ER, visits, CHUP, etc.) Pre-visit planning ** Nurse run protocols for common acute conditions (for walk-ins) Clinical Practice Guidelines Project ECHO Nurse advice capability Tricare OnLine for appointing Relay Health to communicate with team Mobile technology support (mcare) Virtual Face to Face with PCM On-call (pending) * Duty Day; goal is 18 **Pre- visit planning by team allows more issues to be accomplished in one visit - 7 - Transparency of access measures to MTFs Transparency of access measures to patients Approved 3 Aug at Tri- Service PaAent Centered Care Integrated Board
Improve Quality Outcomes for Condition Based Care Background (Why are you talking about this?) We monitor LBP imaging to ensure it is ordered appropriately IAW the CPG. We monitor treatment of pharyngitis and URI to ensure we are prescribing antibiotics appropriately to young patients. High quality care for diabetic patients improves their quality of life by reducing the risk of short and long-term complications associated with persistently high blood glucose. Overall, evidence-based care improves outcomes and reduces costs. Patient presents to system Preliminary diagnosis established Diagnostic testing performed Measure: HEDIS Appropriate Care Index Treatment plan established Treatment delivered according to evidence based guidelines Biological indicator of illness improves Measure: HEDIS Appropriate Care Index & HEDIS Diabetes Index Disease progress slowed down Measure: HEDIS Diabetes Index Patient feels better and has better function Patient stays better Current State (Where do things stand today?) HEDIS Appropriate Care Index:. Current performance for MTFs obtaining 4 or 5 index points for the index measures is 33.5%. The Navy, Air Force and NCR-MD are at the threshold level while the Army and MCSC are below the threshold. The desired performance is for MTFs to obtain 4 or 5 index points for each measure thus reaching the top 2 levels of performance (HEDIS 90th and 75th Percentile) for the index measures HEDIS Diabetes Index: The Navy and NCR-MD have reached the target. Army and Air Force are at the threshold level. Purchased care is below the threshold. The desired performance is for MTFs to obtain 4 or 5 index points thus reaching the top 2 levels of performance (HEDIS 90th and 75th Percentile) for the index measures. MEASURE PERFORMANCE MHS A N AF NCR-MD PSC HEDIS Appropriate Care Index* 57% 40% 65% 62% 62% 30% HEDIS Diabetes Index* 70% 70% 81% 75% 85% 20% Goals/Targets (What specific outcomes are required? What by when?) HEDIS Appropriate Care Index: goal 70% (Green) HEDIS Diabetes Index: goal 70% (Green) *As of Mar 15-8 -
Improve Quality Outcomes for Condition Based Care: Army Medicine HEDIS Appropriate Care Index Measures remain in exploratory development status; unique to MHS without civilian benchmark. Individual measures w/i index specifically defined by NCQA s HEDIS criteria. Current Condition: Acute Condition Management Measures LBP 67.2%, 10 th percentile Child with pharyngitis 72.2%, 10 th percentile Children URI treatment 91.2%, 75 th percentile 22 Facilities are at the 75 th percentile in at least one measure Analysis: Musculoskeletal injury is most common complaint in SCMH. LBP imaging metric is being elevated as a primary indicator of readiness within PCSL Pharyngitis, URI treatment, and immunizations becoming the PCSL pediatric safety/ quality measures. Actions for Improvement: LBP imaging: CPG utilization and same day access to SCMH Internal PT consultants will shift toward appropriate and effective care. Child Quality Measures: standardization of a peer review process which creates a forum to educate and discuss CPG and standards of care will improve quality. - 9 -
Improve Quality Outcomes for Condition Based Care: Army Medicine HEDIS Diabetes Index Measures remain in exploratory developmental status; unique to the MHS without civilian benchmark. Individual measures w/i index specifically defined by NCQA s HEDIS criteria Current Condition: Diabetes Index (31,162 total diabetics 2.5% prevalence) A1c testing in the last 12 months 90.5%. 25 th percentile A1c <9 77.0%. 50 th percentile A1c<8 65.76% 75th percentile A1c <7 48.4%. 90th percentile Analysis: The data suggest that diabetes is not a readiness issue, however prevention of DM and management of those with DM is critical. Actions for Improvement: At MTF level, clean up action lists and engage patients to have labs drawn at our facilities to ensure appropriate credit. AMH OPORD shifts to a virtual population health model, which is augmented by AMH staff and will expand the capacity of AMH towards improving health. Aggressive efforts to synchronize multiple programs towards healthier weight and capitalize on internal specialty consultants (IBHC/Pharm D/ Nutrition). Significant IRIS incentives for individual weight reduction. - 10 -
Improve Quality Outcomes for Condition Based Care: Navy Current Condition: HEDIS Appropriate Care Index 67% 50 th percentile (Target 70%) LBP 75.05%, 25 th percentile (75.83% = 50 th percentile) Children with pharyngitis 78.25%, 25 th percentile (83.23% = 50 th percentile) Children URI treatment 94.68%, 75 th percentile (94.97% = 90 th percentile) Current Condition: HEDIS Diabetes Index - 82% (Target = 70%) A1c testing in the last 12 months 92.16%, 50th percentile (92.7%=75 th percentile) A1c <8 67.10%, 75 th percentile Analysis: As of Feb 15, Navy is meeting the goal for both the Appropriate Care and Diabetes Indices. All three appropriate care measures were new in 2014, and it typically takes two years for a measure to mature to a point where we can trend and analyze the data. Actions for Improvement: Monthly distribution of trended data to Regions, MTFs and Specialty Leaders. Sharing of best practices and lessons learned from Top and Bottom performers. Required action plans for improvement from all MTFs who have metrics identified as outliers. Explore if challenges lie in obtaining data results in the EHR. - 11 -
Improve Quality Outcomes for Condition Based Care: Air Force Current Condition: Where do things stand today? (As of 30 Jun 2015) HEDIS Appropriate Care Index: (yellow) 62% AF HEDIS Diabetes Index: (green) 75% AF Analysis: What are the causes of the problem? Is there a root cause? (2014Q4 data) Working to understand performance through indices (developed with complex methodology and made up of known individual HEDIS components) Appropriate Care Index: 2 of 3 components responsible for low performance (LBP has 47/71 and pharyngitis has 60/71 MTFs < 50 th percentile); components relatively new without much historical content DM Index: 1 out of 2 components responsible for low performance (HgA1C screening has 45/75 MTFs <50 th percentile); Narrow distribution: only 2.1% difference between 90 th percentile and 50 th percentile for HgA1C screening MTFs affiliated with VA lab sharing data not captured Pts with Other Health Insurance (~10% of DM pts) negatively affect measure (~10% lower A1C screening avg) Actions for Improvement: What are we doing to address the causes of the problem? Systematically share leading practices and address outliers through performance management process Based on AFMS-specific Outlier definition (2/3 recent quarters <25 th percentile; >25 pts): 6/71 MTF outliers for HgA1C screen; 9/71 MTF outliers for LBP; 25/71 MTF outliers for Pharyngitis will help target MTF-specific interventions Develop education for MTF staff for LBP and Pharyngitis measures Reinforce clinical practice guidelines, proper coding, and standard clinical processes in MTFs Implementation of AF Medical Home will reinforce education efforts -- Request assistance with VA data capture/sharing - 12 -
Improve Quality Outcomes for Condition Based Care: DHA NCR MD Current Condition Analysis 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% HEDIS Appropriate Care Index (Prime) NCR MD, 62% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% Diabetes Care Index (Prime) NCR MD, 85% Although performance is above target for these measures, opportunity exists for improvement in measures beyond the chosen index measures. Practice variation exists across the NCR market and a consistent market-wide Healthcare Effectiveness Data and Information Set (HEDIS) monitoring program does not exist to monitor the various HEDIS measures. Actions for Improvement HEDIS Best Practice Repository (NCR emsm market-wide) Objective: Tracker for best practices that are identified and fully implemented across the emsm; to standardize improvements across all metrics as much as possible. Best Practices Breast Cancer Screening Colorectal Cancer Screening - 13 - Well-Child Visits Interdisciplinary HEDIS council or committee? 2 facilities not 2 facilities not 2 facilities not Utilizing performance improvement processes (e.g., FOCUS-PDCA or LSS)? ü ü ü Open access for self-referral for cancer screening? 1 facilities not 1 facility not Track and capture external work (e.g., HAIMS) HAIMS HAIMS Communication with due/overdue patients? Telecon Telecon ü Utilize Secure Messaging for wellness screening or appointment needs? ü ü 5 facilities not Provider Report Card for HEDIS performance? ü ü ü Coordinate with TRICARE/member services to conduct routine non-user list review and scrub? 2 facilities not 2 facilities not Are Well Child and Immunization Schedules synchronized? ü Monitor/assess No-show visits for improvement opportunities? ü ü ü Standardized Secure Messaging education and appointment reminders Pilot Data Source: CarePoint, P4I Dashboard High Reliability Culture of Quality and Patient Partnership Initiative The initiative includes a component for improving performance in HEDIS measures specifically: Establish consistent market-wide HEDIS monitoring program by June 2015, driving market strategy to improve systems through evidence-based practice and robust process improvement. Breast Cancer Screening was the first marketwide effort to improve performance on a HEDIS measure and improved by over 5% from Dec 13 to Jan 14 as a market.
Reduce Patient Harm Background (Why are you talking about this? CLABSI and unintended retained foreign objects (URFOs) are potentially preventable AEs which increase patient suffering and cost of care. Evidence supports the use of care bundles to reduce the risk of CLABSI and standard intraoperative procedures to reduce the risk of URFO. By placing emphasis on processes that have been proven to reduce patient harm, we will ensure that the MHS consistently delivers safe, high quality care. Patient presents for help Team performs diagnostic evaluation Need for specific intervention identified Team provides service according to protocol Patient monitored following service delivery Assess safety outcomes Patient with health needs met Measure: HAI CLABSI & PSI 5:Retained Surgical Item or Unretrieved Device Fragment Count Current State (Where do things stand today?) CLABSI: a statistically significant decline across MHS, FY12-FY14. For the most part, we are performing as predicted when compared to a reference ICU population from CDC. URFO: On a rolling basis Year over Year decrease in coded RFO with 55 in CY 2013 and CY 44 in 2014 Quarterly basis since last report 1 additional PSI-5 coded MEASURE PERFORMANCE MHS A N AF NCR-MD PSC HAI CLABSI* 7 3 3 1 0 N/A PSI-5: Foreign Body Retention** 11 10 1 0 0 N/A *CY2015 includes only 3 months from Jan 2015 to Mar 2015 Goals/Targets (What specific outcomes are required? What by when?) **Rolling 12 months; thru Q4CY14 HAI CLASBI: 0 PSI-5 Retained Surgical Item or Unretrieved Device Fragment Count: 0 Source: NHSN Contents confidential and privileged IAW 10 USC 1102. Do not disclose. - 14 -
Reduce Patient Harm: Army Medicine Current Condition: CLABSI Army currently has 21% improvement since PfP started in 2012. 7 facilities have improved enough to be potential mentors of other facilities. 2 facilities have room for improvement with 6 total CLABSI. Only 1 facility has not improved from their baseline since the initiation of PfP. Analysis: Increased attention to the CLABSI bundles has resulted in a decrease in total CLABSI across the Army. Actions for Improvement: Aggressive bundle management; require lower performing facilities to revalidate their use of the CLABSI bundles. All CLABSI are reported to the NHSN database for surveillance, and tracking will continue to be required of all facilities. - 15 -
Reduce Patient Harm: Army Medicine Current Condition: PSI 5 Foreign Body Retention Jan Dec 2014 Army had 9 total Unintended Retained Foreign Objects (URFO) Most Common was surgical sponges (4), the rest were a wide variety of items in non-operating room settings 4 URFO discovered in the first quarter of 2015 Analysis: This is not only an issue in surgical, but also procedural settings across Army. Although surgical count policies and universal protocol policies have existed for years, there still continues to be significant deviation from the standard particularly in non-operating room settings. Actions for Improvement: RCA required of all URFO and lessons shared across the Army and the MHS. Surgical counts policy revised and published. Now being revised to incorporate recent national Assoc of Operating Rm Nurse changes. - 16 -
Reduce Patient Harm: Navy CLABSI CLABSI Navy actively monitors infection prevention and control measures; 10 MTFs with ICUs. Data from this 12 month period reflects a small number of infections at the two MEDCENs. Attack rate over time averages 2.2-2.5%. Generally in the 75th-90th percentile. Analysis: Monthly tracers performed in all ICUs to assess the CLABSI bundle use; data reviewed monthly with MTFs. Actions for Improvement: Continue to monitor and report. Continued emphasis on Hand hygiene, Essentris documentation and observational procedural tracers. - 17 -
Reduce Patient Harm: Air Force Current Condition: Where do things stand today? (As of 30 Jun 2015) HAI CLABSI (data from NHSN): 10 actual events in 2014; overall AF Rate 1.56 CLABSIs/1000 Line Days-- higher than Nat l Pooled mean (0.9) PSI 5: Retained Foreign Objects (RFO); reported 0 in 2015 (from P4I) Analysis: What are the causes of the problem? Is there a root cause? HAI CLABSI: Although total number of events is low, AF CLABSI rate is higher than national average Despite training, MTFs have not consistently applied evidence based bundles to reduce HAIs AF remains concerned that our data is incomplete/inaccurate (underreporting) due to a shortage of skilled staff within MTFs (NHSN data is self-reported, must be tabulated manually, and requires a time-intensive surveillance process within the MTF) PSI 5: P4I methodology is based on administrative coding (vs PSR) AFMS has devoted considerable efforts through its PS Program to preventing RFOs. Overall numbers are down since 2012. While overall numbers are low, under-reporting is a concern retained foreign objects are rarely coded during an admission Data from discharge codes and from the PSR are very different PSR is likely more accurate in this instance, though self-reporting is inherently subject to underreporting bias. Actions for Improvement: What are we doing to address the causes of the problem? HAI CLABSI: Re-assess how we have POM d/staffed the IP career field (currently out of hide ) AFMOA/CC reiterate use of standard bundles with MTF Commanders Implement 100% MTF NHSN participation (AFMOA has conducted training to improve compliance and reporting) Request MHS specific NHSN training MTF leaders will be asked to validate compliance with approved 6-step CLABSI bundle. Focus improvement efforts at big 3 Med Ctrs with most line days/clabsis PSI 5: Develop a coding instruction package on RFO to enhance accuracy of capturing events discovered during an admission. Awaiting study results to determine whether administrative data or PSR data is more accurate for this measure - 18 -
Reduce Patient Harm: DHA NCR MD Current Condition 0 0 Analysis Taken in context of volume the NCR is performing well, with zero CLABSI events in this period. However, we recognize there are other aspects of patient safety that demand attention. During CY 2013 2014, 149 incidents of patient harm and 3,412 medication errors occurred across the NCR. The market experienced a year-over-year increase in Adverse Drug Events (ADEs), Falls, and Wrong Site Procedures. These outcomes are inconsistent with the principles of an HRO and impact patient choices as they seek healthcare. The staff and leadership in the market facilities are focused collectively on embracing high reliability principles that are successful in improving the system s ability to provide high quality care, reduce harm events, and foster resiliency in implementing harm mitigation strategies. Actions for Improvement Specifically related to CLABSI, the NCR has Adopted central line insertion bundle (evidence based best practice) Instituted a daily rounds check list to assess ongoing need for central line Instituted chlorhexidine bathing. In order to consistently provide excellent care with each and every patient encounter, the NCR will focus on specific patient safety and quality initiatives: Implement Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) training across the NCR by June 2015, promoting a culture committed to team communication and resilience, to contain and prevent adverse events Expand the Partnership for Patients (PfP) program to outpatient facilities and monitor trends through April 2016, increasing awareness to eliminate harm events. Currently, the NCR emsm is the only market shifting PfP to ambulatory care settings The NCR has established a Quality Working Group (QWG), with full representation from market facilities, that collaboratively partners to build trust and foster transparency regarding quality and patient safety. The NCR also conducted immersive interviews and stakeholder conversations to engage patients and foster a partnership to improve the patient experience. These efforts were shared with the market facilities and representatives from DHA during the NCR s inaugural Quality Summit on April 28th, 2015. Data Source: CarePoint, P4I Dashboard - 19 -
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Percent MTF Enrollees Registered in Secure Messaging The percent of MTF enrollees registered in Secure Messaging (SM) is growing by approximately 1% per month; active promotion at the MTF and enterprise level should increase the percent of MTF enrollees registered for and using SM % Enrollees Registered in Secure Messaging 60% 50% 40% 30% 20% 10% 0% Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 Component End FY14 Apr-15 Growth (% Pts) Army 22% 27% 5% Navy 33% 42% 9% Air Force 36% 40% 5% NCR MD 34% 39% 5% Total 30% 35% 5% Army Air Force Total Navy NCR MD Goal (Pending Approval) Why is it important? Secure messaging provides enhanced, virtual access and advice from PCMs and PCMH teams; registering MTF enrollees is the first step in increasing utilization of secure messaging to reduce face-to-face utilization. Increasing percent registered users first and second, utilization is expected to reduce demand for face-to-face encounters. What are we measuring? We are measuring the total number of unique Prime Enrollees registered in Secure Messaging compared to the total number of MTF Prime enrollees. NOTE: This measure is currently exploratory. What is our current and desired performance? As of 30 Apr 15, 36% of MTF enrollees are registered in secure messaging; the proposed goal is at least 50% (pending approval.) What are the causes of the gaps in performance / What are the causes of success? PCMH and MTF staff must actively promote secure messaging. MTFs with high rates of registered enrollees ensure PCM promotion directly to the patient and facilitate enrollment at each visit by providing opportunities to enroll prior to leaving the MTF after an appointment. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? MTFs should continue to promote secure messaging and encourage PCMs to speak to enrollees directly. In addition, MHS Review Action Plan 7 includes enterprise-level promotion activities to promote secure messaging. - 21 - Working Group: Tri-Service PCMH Advisory Board Measure Advocate Name: Regina Julian Phone number: 703-681- 6216 Monitoring: Monthly Date Source: Relay Health (unique users); M2/CHCS (eligible enrollees) Thresholds: Pending Governance Approval: Green: >50% Red: <50% Blue: > 75%
Average Number of Days to Third Next 24-Hour Appointments Performance has improved 22% in one year and should continue to improve with implementation of Simplified Appointing Guidance 4.0 Avg # of Days to Third Next 24-hour Appt 3.5 3.0 2.5 2.0 1.5 1.0 0.5 Service May 14 Apr 15 12-month Change Air Force 2.28 1.69-26% Army 1.89 1.45-23% Navy 1.13 1.00-11% NCR MD 2.80 2.05-27% Direct Care Average 1.88 1.46-22% - May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 Air Force Army NCR MD Navy Direct Care Average Goal Top 10% Performers Why is it important? The average number of days to the third next available 24-hour appointments views access prospectively. Beneficiaries continue to report that PCM continuity and access to appointments within 24-hours are their top concerns at MTF site visits/patient listening tours. What are we measuring? We are measuring the average number of days to the third next acute (OPAC and ACUT) appointments in primary care. Measure being modified through governance approval process What is our current and desired performance? Current average performance is 1.46 days compared to a goal of 1.0 days or less; performance has improved 22% in one year. What are the causes of the gaps in performance / What are the causes of success Performance gaps are caused by a mis-alignment of appointment supply and demand, not using demand management and team-based workflow. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? PCMHs can use demand management tools/ techniques to reduce face to face appointment demand (group appointments, secure messaging, t-cons and nurse run clinics), ensure that Service-approved number of appointments are template per available PCM, and that the proportion of 24-hour and routine appointments are matched to patient demand. - 22 - Working Group: Tri-Service PCMH Advisory Board Measure Advocate Name: Regina Julian Phone number: 703-681- 6216 Monitoring: Monthly Date Source: CHCS (TOC) Thresholds: Blue: <.8 days Green: <1 day Red: >1 day
Average Number of Days to Third Next Future Appointments Performance has improved 2% in one year and remains within Access Standards of 7 days or less Avg # of Days to Third Next Future Appt 12.0 10.0 8.0 6.0 4.0 2.0 - May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Air Force Army NCR MD Navy Direct Care Avg Green - Goal Blue - Top 10% Performers Service May 14 Apr 15 12-month Change Air Force 7.44 6.45-13% Army 6.25 6.48 4% Navy 6.31 6.55 4% NCR MD 8.60 11.3 31% Direct Care Average 6.71 6.55-2% Why is it important? The average number of days to the third next available future appointments views access prospectively. Future appointments with a MTF enrollees PCM supports PCM continuity and a focus on prevention/better health. What are we measuring? We are measuring the average number of days to the third next future (ROUT and EST) appointments in primary care; EST is most prevalent appointment type What is our current and desired performance? Current average performance is 6.55 days compared to a goal of 7 days or less; performance has improved 2% in one year; performance is within access standards and emphasis has been on improving access to care within 24 hours What are the causes of the gaps in performance / What are the causes of success Performance gaps are caused by a mis-alignment of appointment supply and demand, not using demand management and team-based workflow. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? PCMHs can use demand management tools/techniques to reduce face to face appointment demand (group appointments, secure messaging, t-cons and nurse run clinics), ensure that Service-approved number of appointments are template per available PCM, and that the proportion of 24-hour and routine appointments are matched to patient demand. - 23 - Working Group: Tri-Service PCMH Advisory Board Measure Advocate Name: Regina Julian Phone number: 703-681- 6216 Monitoring: Monthly Date Source: CHCS (TOC) Thresholds: Blue: < 2.2 days Green: <7 days Red: >7 days
Satisfaction with Getting Care When Needed (Service Surveys) This measure indicates an average assessment of access to outpatient care experience from the beneficiary s perspective, based on self-reported responses to Service-unique surveys. First quarter results compared to the Services FY 2014 baseline indicates mixed results at this time 8% 6% 4% 2% 0% - 2% - 4% - 6% - 8% FY12Q1 FY12Q2 FY12Q3 FY12Q4 FY13Q1 FY13Q2 FY13Q3 FY13Q4 FY14Q1 FY14Q2 FY14Q3 FY14Q4 FY15Q1 FY15Q2 FY15Q3 FY15Q4 Army Navy Air Force NCR TROSS DC TROSS PC FY14 Actual (Red) FY15 Target (Green) FY15 Target (Blue) Why is it important? Access to comprehensive, quality health care services is important to achieve the best health outcomes and healthy life for all MHS beneficiaries. What are we measuring? Outpatient Satisfaction with Care ( Percent Satisfied is identified as those patients who select a score of 4 or 5, on a 0-5 scale where 5 is best, for Rate Ability to See Provider When needed). What is our current and desired performance? FY14 Services and NCRMD average is 84% and FY2015 goal will be a 2% increase in each Service s FY 2014 average. What are the causes of the gaps in performance/what are the causes of success? (1) High volume of patients who require care for limited resources to support the request; (2) More work needed to improve patient appointment templates/provider availability. (1) Modeling is underway to examine the impact of the implementation of the MHS First Call Resolution and Do Not Call Back Policy. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? (1) Book appointments in accordance with access to care and referral management protocols; (2) Share best practices among facilities with the highest access to care; (3) Generalized evidence from national surveys indicates typical drivers of satisfaction tend to be accessspecific: getting/timeliness of appointments. NOTE: the Joint Outpatient Satisfaction Survey (JOES) will create a consistent, standardized survey and methodology - 24 - Metric Direction Fiscal Year FY12 (Actual) FY13 (Actual) FY14 (Actual) FY15 Target- Green Services and NCRMD Average Satisfaction with Getting Care When Needed Air Force (SDA) Army (APLSS) Higher is Better NCRMD Navy (APLSS (PSS) +TROSS) Note: * Ratings for FY14Q1-FY14Q2 using the old TROSS survey instrument. ** Ratings for FY2014Q1-Q4. FY14Q3-Q4 include data from the new TROSS survey instrument Thresholds: TROSS DC Blue: >= 2% above Green target Green: >=2% above FY 2014 baseline Red: < Service s FY 2014 average TROSS PC 85% 87% 83% 86% 77% 70% 85% 85% 88% 82% 90% 79% 70% 85% 84% 89% 82% 91% 79% 71%* 85%* 91% 84% 93% 81% FY15 Target- 93% 86% 95% 83% Blue FY15Q1 82% (n/ 90% 80% 85% (+1%) 90% (+1%) 83% 90% (Actual) c) (-1%) (+1%) TROSS FY14 77% 75% 77% 79% 76%** 85%** (Actual) HCSDB FY14 74% 69% 71% 80% DC= 71% PC= 82% (Actual) Working Group: MHS Survey Work Group Measure Advocates: Name: Dr. Rich Bannick/Dr. Kim Aiyelawo, Dr. Mel Gliner, Dr. Sharon Beamer, Lt.Col. Stephanie McCue Phone number: 681-3636 Monitoring Data Source: Service/DHA surveys, May 6, 2015
HEDIS Appropriate Care Index Steady trend below threshold over time Month- Year Navy Army Air Force NCRMD TRO Oct-14 64% 40% 63% 61% 29% Nov-14 64% 40% 63% 61% 30% Dec-14 64% 40% 62% 60% 30% Jan-15 64% 40% 62% 61% 30% Feb-15 64% 40% 63% 60% 30% Mar-15 65% 40% 62% 62% 30% Note: Higher is better. Working Group: PCMH Measure Advocate Name Phone number Monitoring : CAC / CMSP Date Source: MHS PHP P4I Thresholds: Blue: 90 % of Possible Index Points Green: 70% of Possible Index Points 75 th Red: 50% of Possible Index Points What are we measuring? The measures included in the index are appropriate use of imaging studies for low back pain, use of antibiotics for upper respiratory infection (URI) and treatment of pharyngitis with antibiotics and strep test. Index points for the measures are based on HEDIS national benchmarks. Data is displayed as percent of possible index points obtained all 3 measures. Why is it important? Over use of antibiotics has been directly linked to the prevalence of antibiotic resistance. Overuse of imaging studies unnecessarily exposed patients to radiation. Overuse of antibiotics and imaging studies wastes resources. What is our current and desired performance? Currently The desired performance is for MTFs to obtain 4 or 5 index points for each measure thus reaching the top 2 levels of performance (HEDIS 90 th and 75 th Percentile) for the index measures. Current performance for MTFs obtain 4 or 5 index points for the index measures 33.5%. The Navy, Air Force and NCR-MD are at the threshold level while the Army and MCSC are below the threshold. What are the causes of the gaps in performance / What are the causes of success? Causes for gaps include inconsistent use of evidence based practice guidelines and incomplete documentation. Use of Tri-Service Work Flow AIM form for treatment of LBP has proven to be successful when implemented. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? Maximize use of available electronic tools in workflow processes to support evidence based guideline compliance - 25 -
HEDIS Diabetes Index Performance rates reveal minimal variation but the Navy and Army rates have decrease over the past 2 months Month- Year Navy Army Air Force NCRMD TRO Oct-14 82% 72% 77% 84% 20% Nov-14 82% 73% 76% 84% 20% Dec-14 83% 73% 76% 85% 20% Jan-15 84% 74% 77% 84% 20% Feb-15 83% 71% 75% 82% 20% Mar-15 81% 70% 75% 85% 20% Note: Higher is better. Working Group: PCMH Measure Advocate Name Phone number Monitoring: CAC / CMSP Date Source: P4I MHS PHP Thresholds: Blue: >90 % of Possible Index Points Green: >70% of Possible Index Points Red: >50% of Possible Index Points What are we measuring? The measures included in the index are diabetes A1C screening and A1C good control (<8.0) for patients with an A1C screening for direct care and just diabetes A1C screening for purchased care as laboratory results are not available in the claims system data used for purchased care. Index points for the measures are based on HEDIS national benchmarks. Data is displayed as percent of possible index points obtained both measures. Why is it important? The MHS has approximately 137,000 enrolled diabetics. Diabetes is the seventh leading cause of death in the United States. Many complications from diabetes, such as amputation, blindness and kidney failure, can be prevented if detected and addressed in the early stages. What is our current and desired performance? The desired performance is for MTFs to obtain 4 or 5 index points thus reaching the top 2 levels of performance (HEDIS 90 th and 75 th Percentile) for the index measures. The Navy and NCR-MD have reached the target. Army and Air Force are at the threshold level. Purchased care is below the threshold. What are the causes of the gaps in performance / What are the causes of success? A1C in good control data is only available for laboratory test completed in the direct care facilities unless patient brings results to MTF provider. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? Action lists identifying patients needing diabetes A1C screening are available to clinic staff. Data internally transparent in CarePoint to support MTFs with collaborative learning from others. - 26 -
Central Line Associated Bloodstream Infections (CLABSI) Counts (ICU): Enterprise View A statistically significant reduction in the reported burden of CLABSI has been observed from CY12-14 Month-Year MHS 2012* 51 2013 39 2014 31 2015** 7 Note: As of 5/20/15 *Reporting mandated Q2 of Calendar Year 2012. **CY2015 includes only 3 months from Jan 2015 to Mar 2015. Working Group: PSIC Measure Advocate Name TBD Phone number Monitoring: PSAC/ICPC/PSIC Date Source: NHSN Thresholds: Blue: Zero Green: NA Red: NA Why is it important? CLABSI are potentially preventable adverse events which increase patient suffering and cost of care What are we measuring? ICU counts of CLABSI What is our current and desired performance? Year over year decrease in CLABSI. Goal of zero CLABSI What are the causes of the gaps in performance / What are the causes of success? Significant improvement since CY 2012 associated temporally with PfP and the use of IHI bundles. A good measure of compliance with CLABSI bundle and CLIP adherence is not possible until validated reports of best practices are query-able via reports from ESSENTRIS. Success is associated with meticulous attention to infection prevention continuously on every patient with a central line placed. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? Embed IHI bundles into Essentris notes now as soon as possible. Disseminate data to lowest level (to include importance of bundles).perform audits on each event and share lessons learned internally and correct any process deficiencies by during tracers. Ensure line necessity assessment is imbedded into Essentris notes now versus waiting for Essentris 2.0 and imbed into multi-disciplinary rounds discussions/documentation. Consider required Essentris training and competency must be performed and documented in personnel records regarding nursing, physician, corps staff documentation. This must include utilizing Invasive Device Flowsheet (IDF) properly rather than documentation of central lineassociated behaviors only in free text Progress Notes. - 27 -
Central line Associated Bloodstream Infection (CLABSI) Rates (ICU): Enterprise View A statistically significant reduction in the reported burden of CLABSI has been observed from CY12-14 Month-Year. Working Group: PSIC Measure Advocate Name TBD Phone number Monitoring: PSAC/ICPC/PSIC Date Source: NHSN Thresholds: Blue: Zero Green: NA Red: NA What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more?? Embed IHI bundles into Essentris notes now as soon as possible. Disseminate data to lowest level (to include importance of bundles).perform audits on each event and share lessons learned internally and correct any process deficiencies by during tracers. Ensure line necessity assessment is imbedded into Essentris notes now versus waiting for Essentris 2.0 and imbed into multi-disciplinary rounds discussions/ documentation. Ensure adequate Essentris IT experts to optimally cover all MTFs utilizing Essentris, install the most current version efficiently, and educate infection preventionists how to run queries for reports relevant to central line insertion practice (CLIP) adherence, central line days, and best practice adherence. - 28 - MHS Device Days Incidence 2012* 51 22,777 2.24 2013 39 20,960 1.86 2014 31 21,341 1.45 2015** 7 4,800 1.46 Note: As of 5/20/15 *Reporting mandated Q2 of Calendar Year 2012. **CY2015 includes only 3 months from Jan 2015 to Mar 2015. Why is it important? CLABSI are potentially preventable adverse events which increase patient suffering and cost of care What are we measuring? ICU rates of CLABSI at the Enterprise level What is our current and desired performance? Current CLABSI rate is similar to CY 2014 but may not be stable given a single quarter of data for CY2015. Desired performance :Goal of zero CLABSI What are the causes of the gaps in performance / What are the causes of success? Significant improvement since CY 2012 associated temporally with PfP and the use of IHI bundles.
Central line Associated Bloodstream Infection (CLABSI) Counts (ICU): Component View A statistically significant reduction in the reported burden of CLABSI has been observed from CY12-14 - 29 - Month- Year Navy Army Air Force NCRMD 2012* 8 31 0 12 2013 6 14 7 12 2014 5 14 8 4 2015** 3 3 1 0 Note: As of 5/20/15 *Reporting mandated Q2 of Calendar Year 2012. AF began reporting in CY2013 **CY2015 includes only 3 months from Jan 2015 to Mar 2015. Working Group: PSIC Measure Advocate Name TBD Phone number Monitoring: PSAC/ICPC/PSIC Date Source: NHSN Why is it important? CLABSI are potentially preventable adverse events which increase patient suffering and cost of care What are we measuring? ICU counts of CLABSI at the Component View. Thresholds: Blue: Zero Green: NA Red: NA What is our current and desired performance? Current CLABSI is similar to CY 2014 but may not be stable given a single quarter of data for CY2015. Desired performance. Goal of zero CLABSI What are the causes of the gaps in performance / What are the causes of success? Significant improvement since CY 2012 associated temporally with PfP and the use of IHI bundles. A good measure of compliance with CLABSI bundle and CLIP adherence is not possible until validated reports of best practices are query-able via reports from ESSENTRIS. Success is associated with infection prevention continuously on every patient with a central line placed. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? Embed IHI bundles into Essentris notes now as soon as possible. Disseminate data to lowest level (to include importance of bundles). Perform audits on each event and share lessons learned internally and correct any process deficiencies by during tracers. Ensure line necessity assessment is imbedded into Essentris notes now versus waiting for Essentris 2.0 and imbed into multi-disciplinary rounds discussions/ documentation. Ensure adequate Essentris IT experts to optimally cover all MTFs utilizing Essentris, install the most current version efficiently, and educate infection preventionists how to run queries for reports relevant to central line insertion practice (CLIP) adherence, central line days, and best practice adherence.
Central line Associated Bloodstream Infection (CLABSI) Rates (ICU): Component View A statistically significant reduction in the reported burden CLABSI has been observed from CY12-14 Month-Year Navy Army Air Force NCRMD 2012* 2.22 2.32 0.00 3.38 2013 1.72 1.16 2.28 5.20 2014 1.34 1.16 2.08 2.31 2015* 3.65 1.01 1.09 0.00 Note: As of 5/20/15 *Reporting mandated Q2 of Calendar Year 2012. AF began reporting in 2013 **CY2015 includes only 3 months from Jan 2015 to Mar 2015. Working Group: PSIC Measure Advocate Name TBD Phone number Monitoring: PSAC/ICPC/PSIC Thresholds: Blue: Zero Green: NA Red: NA - 30 - Date Source: NHSN Why is it important? CLABSI are potentially preventable adverse events which increase patient suffering and cost of care What are we measuring? Rates of CLABSI in ICUs at the Component View What is our current and desired performance? Current CLABSI is similar to CY 2014 but may not be stable given a single quarter of data for CY2015. Desired performance. Goal of zero CLABSI What are the causes of the gaps in performance / What are the causes of success? Significant improvement since CY 2012 associated temporally with PfP and the use of IHI bundles. A good measure of compliance with CLABSI bundle and CLIP adherence is not possible until validated reports of best practices are query-able via reports from ESSENTRIS. Success is associated with to infection prevention continuously on every patient with a central line placed. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? Embed IHI bundles into Essentris notes now as soon as possible. Disseminate data to lowest level (to include importance of bundles).perform audits on each event and share lessons learned internally and correct any process deficiencies by during tracers. Ensure line necessity assessment is imbedded into Essentris notes now versus waiting for Essentris 2.0 and imbed into multi-disciplinary rounds discussions/documentation. Ensure adequate Essentris IT experts to optimally cover all MTFs utilizing Essentris, install the most current version efficiently, and educate infection preventionists how to run queries for reports relevant to central line insertion practice (CLIP) adherence, central line days, and best practice adherence
Central-line Associated Bloodstream Infections (CLABSI) MHS ICUs have performed the same as or better than predicted by CDC/NHSN risk-adjusted methodology Why is it important? CLABSI are potentially preventable adverse events which increase patient suffering and cost of care What are we measuring? Standardized Infection Ratio (SIR) = Observed # of CLABSI / Expected (Predicted) # of CLABSI What is our current and desired performance? Performance is no different than predicted. Desired performance is statistically significantly below predicted What are the causes of the gaps in performance / What are the causes of success? Significant improvement since CY 2012 associated temporally with PfP and the use of IHI bundles. Multiple instances of exemplary performance for the SIR across the 3 settings listed. Diligent attention to best practice details for prevention of CLABSI by nursing, physician, and infection prevention personnel. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? Embed IHI bundles into Essentris notes now as soon as possible. Disseminate data to lowest level (to include importance of bundles).perform audits on each event and share lessons learned internally and and correct any process deficiencies by during tracers. Ensure line necessity assessment is imbedded into Essentris notes now versus waiting for Essentris 2.0 and imbed into multi-disciplinary rounds discussions/documentation. Ensure adequate Essentris IT experts to optimally cover all MTFs utilizing Essentris, install the most current version efficiently, and educate infection preventionists how to run queries for reports relevant to central line insertion practice (CLIP) adherence, central line days, and best practice adherence. Consider Mandatory Essentris training and competency must be performed and documented in personnel records regarding nursing, physician, corps staff documentation. This must include utilizing Invasive Device Flowsheet (IDF) properly rather than documentation of central line-associated behaviors only in free text Progress Notes. - 31 - QTR/CY MED SIR MED/SURG SIR Trauma SIR 2012Q1 0.615 1.264 0.367 2012Q2 1.867 0.929 0.594 2012Q3 0 1.323 1.142 2012Q4 0.601 0.621 1.609 2013Q1 0.399 0.59 0 2013Q2 0.511 1.039 0.376 2013Q3 3.407 0.547 0.809 2013Q4 0.465 0.544 0 2014Q1 0.988 0.846 0.331 2014Q2 1.129 0.724 0 2014Q3 1.078 0.988 0.908 2014Q4 0 0.211 0.688 2015Q1 0.429 1 0 Working Group: PSIC Measure Advocate Name TBD Phone number Monitoring: PSAC Date Source: NHSN Thresholds: Note: As of 5/20/15 Blue Statistically significantly less than 1 Green: Statistically no different than (1) predicted Red: Statistically significantly Greater than 1
PSI 5 Retained Surgical Item or Unretrieved Device Fragment Count Over CY 2014 there have been 11 Coded PSI 5 events Year- Quarter Navy Army Air Force NCRMD 2012-3 4 13 1 2012-4 5 10 1 2013-1 3 8 1 2013-2 5 8 2 2013-3 5 7 3 Why is it important? Retained Surgical Items/ Unretrieved Device Fragment are potentially preventable adverse events which increase patient suffering and cost of care What are we measuring? The number of hospital discharges with a retained surgical item or unretrieved device fragment(secondary diagnosis ) fragment among surgical and medical patients ages 18 years and older or obstetrics patients What is our current and desired performance? 11 PSI-5 codes were recorded in CY 2014. Current performance unclear if not validated. Desired performance is Zero events ; What are the causes of the gaps in performance / What are the causes of success? Human factors(instrument use); use of counts not optimized relative to manual assessment What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? Consider policies to ensure a procedure count was done both pre and post procedure, and use of radio-opaque tailed sponges in all OB procedure cases, this has led to a major turnaround and sustained compliance performance. Educated MTF units and training programs to ensure compliance with applicable use of instruments. Consider PSI 5 as a subset of all URFO reporting to better characterize epidemiology of RFO 2013-4 3 7 3 0 2014-1 3 7 3 0 2014-2 0 9 1 0 2014-3 1 9 0 0 2014-4 1 10 0 0 Note: As of 6/2/15. Working Group: PSIC Measure Advocate TBD Phone number Monitoring: PSAC Date Source: PSI 5 Coded data in MHSHP Thresholds: Blue: 0 Green: N/A Red: N/A - 32 -
Enterprise Risk Areas At the 24 June R&A, MHS leadership requested further analysis of the following measures to determine if potential enterprise risk exists Per Member Per Month (PMPM) Cost Pharmacy % Retail Spend HEDIS All Cause Readmissions ORYX Transition of Care ORYX - 33 -
Recent Performance Background Recent years PMPM has managed to achieve targets Primarily related to limited cost and utilization growth Sequestration, limited pay raises for Military, and no COLA for Civilians Labor is approximately 70% of DC costs Private sector care costs also contained due to sustainable growth formula Private sector insurance premiums also low by normal standards FY15 goal is <= 2.0% growth Task: Excluding Retail Pharmacy determine if MHS will achieve goal or not Provide Mitigation Strategies to Address the Drivers - 34 -
PMPM Fiscal Quarter Year over Year Growth Trend Significant portion of growth related to Compound Pharmacy 3.5% 2.8% 2.0% Excluding Retail Rx still above goal Note: MHS Target is based on the external benchmark of the Kaiser Family Foundation and the Health Research & Educational Trust annual Employer Health Benefits Survey Family Premium increase less 1% point per agreement with USD(P&R) and is based on YTD performance as opposed to quarterly as shown on graph. - 35-35
Prime Enrollees MTF and MCSC FY2015 Q1/Q2 YTD Performance Data is valid through FY15Q1, FY15 Q2 is preliminary with missing data MSM Name (All) MSM (All) With Retail Parent Name (All) FQ (Multiple Items) Pharmacy growth FM (All) Service (Multiple Items) rate is 10.6% Ben Grp (All) Enrollment Site Parent (Multiple Items) Region (Multiple Items) PMPY Analysis FY PMPY FY2014 FY2015 Drivers of change Utilization and Unit Cost - Monthly basis PMPM Inpt 823 817-0.8% 18% % Total $ Value RWP/1k Inpt FY2014 FY2015 % Chng Outpt 2,457 2,601 5.8% 59% Inpt Util -6% (26) Total RWP 5.80 5.62-3% Rx 738 1,026 39.0% 23% Inpt Cost 4% 19 (7) DC 2.15 2.07 4,018 4,443 DC Cost 2% 7 PC 3.66 3.55 10.6% PC Cost 3% 12 Avg Cost 11,821 12,103 2% Mkt 0% (0) DC Cost 13,533 13,810 2% FY2014 FY2015 PC Cost 10,816 11,106 3% Inpt Mkt 37.0% 36.9% Outpt Mkt 42.8% 42.2% % Total $ Value RVU/100Outpt FY2014 FY2015 % Chng Rx Mkt 65.8% 65.5% Outpt Util 15% 62 Total RVU 117 123 5% Outpt Cost 19% 81 DC 50 52 % Total $ Value Excluding Retail DC Cost 3% 11 PC 67 71 PMPY Increase 425 153 PC Cost 4% 16 Avg Cost 87 89 2% Inpt -2% (7) (7) -4% Mkt 13% 55 DC Cost 227 229 1% Outpt 34% 143 143 94% PC Cost 135 137 1% Rx 68% 288 16 10% % Total $ Value Script/10Rx FY2014 FY2015 % Chng Summary Drivers of change % Total $ Value Rx Util 3% 13 Total Script 114 117 2% DC Unit 6% 26 Rx Cost 65% 275 DC 75 76 1% PC Unit 72% 306 DC Cost 2% 8 PC 27 26-2% Mkt 10% 43 PC Cost 64% 272 TMOP 12 14 14% Util 12% 50 TMOP Cost 1% 6 Avg Cost 54 73 37% Mkt -3% (11) DC Cost 29 30 3% PMPM 335 370 PC Cost 129 216 67% Retail RX 64% TMOP Cost 43 46 8% Eq 2,159,366 2,130,786 PMPY Increase W/O Retail Rx 3.8% Declining Enrollment Excluding Retail 153 (7) -4% 143 94% 16 10% Outpatient represents almost entire growth when Retail Pharmacy is excluded - 36 - Growth rate without Retail Pharmacy (Compounding issue) is 3.8% vs goal of 2.0% 36
PMPM Equivalent Lives Trend TRICARE Prime enrollment decreasing MTF holding stable for now Further Active Duty End-Strength cuts still coming - 37 -
Enrollee Ambulatory Utilization Trend Utilization is growing at 5% between FY2014 and FY2015-38 -
Direct Care Ambulatory Trend Expenses are growing, while workload is declining for the first six month of FY15 compared to FY14. Overall DC unit cost growth for Enrollees is around 391% - 39 -
Enrollee Ambulatory Market Trend Prime represented 76% of DC workload in FY2013 and represents 78% in FY2015 Based on increased productivity from Modernization Study, Prime recapture was expected to be accomplished at Marginal costs, but with declining workload, it is currently occurring at Average Direct Care cost which is raising the PMPM costs. - 40 -
Areas of Risks Impacting PMPM, outside of Compound Pharmacy Risk Mitigation Strategy Mitigation Tools Execution Level 1) Eligible Population and Lower Risk Enrollees Directed Enrollment from MCSC to MTF Army: limited trial campaign at select locations Navy: Mandatory enrollment campaign Air Force: pursuing enrollment recapture at currency platforms DHA: (Still Reviewing) Service/MTF 2) Ambulatory Utilization is Increasing Use Medical Home and Standardized Care Practices Army: Enforce CPGs and Recapture from network (PT) Navy: Secure Messaging emphasis Air Force: (Still reviewing) DHA: (Still Reviewing) Service/MTF 3) Direct Care Ambulatory unit costs are rising, while productivity gains from Modernization should see reduced unit cost Efficient use of Providers in Proper locations Army: Match staffing with workload Navy: Increasing Provider Productivity, OR Initiatives Air Force: (Still reviewing) DHA: (Still Reviewing) Service/MTF - 41 -
Pharmacy Percent Retail Spend Enterprise Risk Scan Excluding Compounds William Davies DHA Pharmacy Operations Division
Pharmacy Percent Retail Spend (presented at June 2015 R&A) Component Performance Negatively Impacted By Uncontrolled Pharmacy Compound Spend Why is it important? Measure encourages MTFs to channel or recapture pharmacy workload to the MTF pharmacy or mail order. What are we measuring? Retail Pharmacy Spend divided by Total Pharmacy Spend. Total costs are full costs (net cost to the Government) at each point of service. What is our current and desired performance? All Services have been experiencing increases in FY15, in FQ2 all Components exceeded 40% FY15 target. What are the causes of the gaps in performance / What are the causes of success? Increases largely due to increased utilization of compound drugs in the retail. Previously stable markets lost control due to Compounding. What could we do to close the gap / If there is no gap, what could we do to continue to succeed or improve even more? May 2015 mitigation strategy having desired effect. Components educating providers on behavioral seeking aspects of compounding. Implementation of mandatory maintenance medications out of retail for under 65 in Fall of 2015. Working Group: Pharmacy Work Group Measure Advocate Name: Dr. George Jones Phone number: 703-681-2890 Data Source: M2, 01 June 2015 (P4I accessed 1JUN15) - 43 -
Performance to Target: Pharmacy Percent Retail Spend (Excluding Compounds) SUMMARY OF Pharmacy % RETAIL SPEND AIR FORCE ARMY NAVY DHA MONTH FY 2015 With Compounds Without Compounds With Compounds Without Compounds With Compounds Without Compounds With Compounds Without Compounds October 46.70% 40.80% 46.10% 38.60% 48.50% 42.70% 38.70% 34.20% November 46.80% 40.60% 48.60% 39.20% 49.60% 42.50% 39.20% 34.40% December 47.60% 40.70% 51.40% 39.70% 53.20% 42.80% 39.60% 34.00% January 49.00% 40.70% 53.10% 39.20% 54.80% 41.60% 39.60% 33.70% February 52.90% 41.00% 59.00% 39.50% 60.20% 42.30% 43.10% 35.60% March 54.60% 40.70% 62.10% 38.80% 61.20% 41.20% 42.70% 33.60% April 59.60% 40.40% 70.70% 38.60% 69.60% 41.50% 43.00% 32.10% TOTAL 51.60% 40.70% 57.80% 39.00% 58.20% 42.10% 40.90% 33.90% Performance with all compound spend removed metric at target or improving. May 2015 compound mitigation strategy reduced monthly spend to $10 million vs $216 million in prior FY15 months Low number of appeals and subsequent low approval indicates success Minimal impact on pediatric population Mitigation strategy: Prior authorization with screening on ingredient pricing Network pharmacy agreement addendum required to remain in network Active monitoring KEY FY15 Target Red >40% Green 40-35% Blue <= 35% KEY FY16 Target Red >35% Green 30-35% Blue <= 30% Metric measures distribution of spend across pharmacy points of service; does not articulate savings or changes in spend. - 44 -
Specialty vs. Non-Specialty - Pharmacy Spend Excluding compounds FY15 Total Spend (1 st 6 months) Specialty vs. Non- specialty 22% 78% Non- specialty Specialty 0.7% 99.3% FY15 Total Spend (1 st 6 months) by Point of Service 59% 23% 18% Mail Order MTF Retail 37% 23% 41% Total Spend 30dEq Rxs Specialty Non- specialty Spend by Quarter, FY13 1 st 6 months FY15 FY13 ($M) FY14 ($M) FY15 ($M) 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q Non-specialty 1331 1349 1348 1388 1335 1335 1399 1364 1386 1471 Specialty 299 304 315 332 332 372 413 425 417 403 Percent Specialty (excluding compounds, paper claims, COB) 18.3% 18.4% 18.9% 19.3% 19.9% 21.8% 22.8% 23.8% 23.1% 21.5% Based on 4QFY14 Specialty Agent Reporting List; adjusted for refunds & copays - 45 -
Enterprise Risk Examples Specialty Drugs Four Classes Represent 71% of all Specialty Expenditures (CY14) Targeted Immunomodulatory Biologics (TIB) Multiple Sclerosis Medications (MS) Oncological Medications Hepatitis C Medications Preferred TIB medication (Humira) 2.6 times higher in retail Hepatitis C medication (Harvoni) $6K more per course in retail Acute care drug not part of FY15 NDAA Specialty drug growth expected to continue Management strategy shifting to Mail and MTF where appropriate, requires balancing of resources - 46 -