Quality Measures in Healthcare Facilities for Patient Family Advisory Council members Maura Collins Feldman Director, Hospital Performance Measurement & Improvement June 11, 2014
Today s Agenda What are quality measures? Types of quality measures What are quality measures used for? Where do I find quality measures? Additional quality resources Next Steps & Discussion 2
Quality Measures what are they? In healthcare, quality can encompass the patient s experience when receiving the care, if the facility is using the right treatment and procedures while providing care, and the outcome of the care received how successful was the treatment and procedure that the patient received. The Center for Medicare and Medicaid Services (CMS) define quality measures as: tools that help us measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide highquality health care and/or that relate to one or more quality goals for health care. These goals include: effective, safe, efficient, patient-centered, equitable, and timely care 1 1 http://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/qualitymeasures/index.html?redirect=/qualitymeasures/ 3
Quality Measures types of measures There are three general types of quality measures: Process measures describe whether the right treatment and procedure was followed or completed correctly. These measures inform us if something was completed For example, for patients that have had surgery, were they given an antibiotic prior to surgery to prevent infection Outcome measures report the result of the treatment, procedure, and care that patients receive at a facility. Readmission measures are typically included as an outcome measure. For example, how many surgery patients experienced an accidental puncture or laceration during their surgery Patient experience measures describe the patients perspective on the care they received from individual providers and/or facilities where they received care 4
What are quality measures used for? To track and drive improvement facilities use their internal performance on quality measures to make changes to improve care they provide To understand the care being provided patients/consumers can assess the quality of care at different facilities when selecting where to receive their care To determine or impact facility payment public and private insurers use performance on quality measures as a component of facility payment whether it be a bonus for good performance, a change (positive or negative) on facility rates, or non-payment (i.e. Serious Reportable Events in MA) 5
Where do I find quality measures? There are numerous sources of publicly reported health care data, some sources are mandatory through legislation (i.e. CMS) and others are voluntary Publicly reported data utilizes aggregated data Many of the sources also provide benchmark data to better understand the context of the facility s performance My focus today is on the available national resources for quality measures There are many local organizations involved in quality work; those resources are available as links at the end of my presentation 6
National Quality Forum (NQF) NQF is a national non-profit organization that endorses measures that are considered to be the gold standard for healthcare measurement in the US; it recommends measures for use in payment and public reporting, and works to accelerate quality improvement priorities.* * http://www.qualityforum.org/what_we_do.aspx 7
Hospital Compare Hospital Compare is a CMS-sponsored site that provides information on hospital performance and recommended patient treatments. http://www.medicare.gov/hospitalcompare/ search.html 8
Hospital Compare Search Results 9
Hospital Compare Hospital Profile 10
Measures on Hospital Compare Hospital Compare enables users to review individual facility quality measures or comparing multiple facilities. For process measures, Hospital Compare has a section dedicated to timely and effective care. The measures that fall under this umbrella are related to care provided for heart failure, heart attack, pneumonia, surgery, emergency department, preventive (immunization for pneumonia and flu), children's asthma, stroke care, blood cot prevention and treatment, and pregnancy and delivery care. For outcome measures, Hospital Compare has section dedicated to readmissions, surgical complications, health-care associated infection. The readmission measures that are currently displayed include both all-cause and condition-specific, i.e. unplanned readmission for pneumonia patients. Patient experience measures are also available on hospital compare. They include measures of satisfaction with nurse communication, doctor communication, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness and quietness of the hospital environment, and overall rating of the hospital and willingness to recommend the hospital. 11
Other Quality Facility Compare Websites CMS has comparative quality websites for physicians, nursing home, home health, and dialysis. In addition, information on psychiatric care, surgical outcomes, and cardiology measures can be found on the Hospital Compare website They utilize aggregated data Many of the sources also provide benchmark data to better understand the context of the facility s performance 12
Other Quality Facility Compare Websites CMS has comparative quality websites for physicians, nursing home, home health, and dialysis. In addition, information on psychiatric care, surgical outcomes, and cardiology measures can be found on the Hospital Compare website They utilize aggregated data Many of the sources also provide benchmark data to better understand the context of the facility s performance 13
Nursing Home Compare Profile 14
Agency for Healthcare Research & Quality The Agency for Healthcare Research and Quality (AHRQ) is an agency within the U.S. Department of Health and Human Services (HHS). AHRQ develops quality and performance measures, provides patient resources, and publicly reports data. http://www.ahrq.gov 15
The Joint Commission (TJC) The Joint Commission is an independent, not-for-profit organization that accredits and certifies health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization s commitment to meeting certain performance standards.* * http://www.jointcommission.org/about_us/about_the_joint_commission_main.aspx 16
The Leapfrog Group The Leapfrog Group was started by a group of large employers who wanted to influence the quality and affordability of healthcare based on their healthcare service purchases.1 This is a voluntary program for hospitals to participate in. The data hospitals submit is publicly reported on Leapfrog s website and allows for consumers to compare facilities. Their website is: http://www.leapfroggroup.org/ 1 http://www.leapfroggroup.org/about_leapfrog 17
Centers for Disease Control & Prevention The Centers for Disease Control and Prevention (CDC) has many resources of both data and background on issues facing the healthcare system today. Of particular interest for hospitals is the CDC s National Healthcare Safety Network. It is the nation s most widely used healthcareassociated infection tracking system. NHSN provides facilities, states, regions, and the nation with data needed to identify problem areas, measure progress of prevention efforts, and ultimately eliminate healthcare-associated infections.* http://www.cdc.gov/nhsn/ 18
Additional Quality Resources Massachusetts Quality Resources Executive Office of Health and Human Services (EOHHS) where you can find information on Serious Reportable Events at MA facilities: http://www.mass.gov/eohhs/gov/departments/dph/programs/hcq/serious-reportable-eventsres.html Massachusetts Health Quality Partners where primary care quality and patient experience information can be found: http://www.mhqp.org/default.asp?nav=010000 National Quality Resources National Patient Safety Foundation: http://www.npsf.org/ http://www.cdc.gov/nhsn/ 19