CCHS: Quality and Patient Safety J Michael Henderson, MD Guido Bergomi
Outline Integrated Quality & Safety structure Quality Goals and Performance Improvement Quality data sources Quality Reporting The Future
Strategic Planning Clinical Quality The Enterprise Quality Goal is to move public reported quality metrics to the top decile nationally through: Integrated infrastructure Annual Quality Goals Continuous quality improvement Optimal use of data
Quality Structure Board of Trustees Executive Leadership Oversight Quality Leadership Team Content Experts Develop Plan Functional Clinical Units Frontline Caregivers Implementation
Central Resources (Content Experts) Local Implementation (Function) CENTRAL Resources LOCAL Implementation Quality and Patient Safety Institute (QPSI) Accreditation Quality Regulation Clinical Risk Management Patient Safety Infection Prevention Performance Improvement Hospitals and Clinical Institutes Quality Director Physician Lead Nursing Director Administrator
Execution of Quality Goals Set Goals Communication & Education Performance Improvement Data Review
CCHS 2013 Quality Goals Domain Measure 2013 Targets Patient Safety Indicators < 83 / month Safety HA Pressure Ulcers II-IV < 0.13% Never Events: Wrong Site, Retained FB, Falls with injury Hospital Acquired Infections Zero CLABSI < 1/1k ICU CaUTI: 1.9/1k SSI: NHSN SIR < 1
Communication and Education
Continuous Improvement Model Create the Culture Set Goals Measure Performance Improve Reward and Recognize Improve Quality and Performance Define Plan Implement Transition
Quality Data Management Dashboard Patients All In Patients Hospital At discharge
Data Review & Accountability Board of Trustees and Executive Management To the frontline Caregiver
Project Portfolio Management Portfolio Summary: Active Projects Quality Project Portfolio Review Review date: 11/1/2012 Program Name QI FTE Number Projects % Earliest Start Latest End Lowest Rating QPSI Operations 4.8 18 48% 9/12/11 12/31/14 G Core Measures 0.4 13 59% 12/13/11 12/31/12 G Hospital Acquired Infections (HAI) 0.5 12 47% 9/2/11 3/1/13 Y Never Events 0.6 5 66% 1/1/12 12/31/12 G Patient Safety Indicators (PSI) 0.9 12 37% 7/11/11 7/1/13 Y Readmissions 0.8 7 65% 3/17/11 3/31/13 G Totals 8.0 67 54% 3/17/11 12/31/14 Y FTEs include QI (7.0), and Safety (1.0). Two additional QI FTE started late-october and are onboarding; their hours are not reflected above.
Examples Patient Safety Indicators documentation Central Line Associated Blood Stream Infections clinical processes Readmission rates models of care
250 200 150 CCHS Patient Safety Indicators # 100 50 0 J F M A M J J A S O N D J F M A M J J 2011 2012
CLABSI 1. Insertion Bundle 2. Line Maintenance 3. Line Removal
ICU CLABSI Rate 4 Per 1000 line days 2 0 1 2 3 4 1 2 3 4 1 2 2010 2011 2012
Web Tool for Data Management Realtime: reports and patient level data Management tool Data for PI
30 day HF Readmissions 30% 25% 20% 15% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2010 2011 2012
Quality Data Sources For reporting and Improvement: - Administrative (documentation/ coding) - Abstracted (Core Measures) - Quality Databases (STS, NSQIP, NDNQI) - Clinical (eg Event reporting)
Type of Hospital, Location, Use of Registries HCAHPS Process Measures 30d Deaths & Readmissions AMI, HF, PN PSIs, HACs, HAIs Mammograms, CT scans, MRIs Medicare Spend per Beneficiary 7 Medical, 29 Surgical conditions 10 38 20 10 1 79
Where is CMS Going? 1. $$$s tied to quality metrics: - VBP, HACs, Readmissions. - Medicare Spend per Beneficiary 2. Physician Quality Reporting: - Multiple programs - Incentives, then penalties
Medicare Spend Per Beneficiary Required for inclusion in VBP Phases: 1. 3 days prior to admission 2. Index admission 3. 30 days post discharge Exclusions / Risk adjustment On HospitalCompare website
Physician Quality Data Reporting
CMS Physician Quality Payment Reform Initiatives 2008 2009 2010 2011 2012 2013 2014 2015 2016 Physician Quality Reporting System (PQRS) Incentive 2%-0.5% PQRS Mandated eprescribing Incentive 1% eprescribing Penalty 1-1.5% erx Mandated EHR Incentive Program (Meaningful Use) MU Mandated Maintenance of Certification Incentive 0.5% Incentive Accountable Care Organization?? Penalty Reporting Physician Feedback Reports No $$ Physician Compare Website MD Value Modifier
Physician Quality Reporting Emphasis moving to individual physicians Initial incentives for reporting data Moving to penalties for not reporting or poor performance Data flows through different routes
Physician Quality Reporting Physician Quality Reporting System Physician Payment Value Modifier Ongoing Professional Performance Evaluation Meaningful Use Tools Metrics Quality Alliance ACOs and Value Based Operations Commercial Payers Communication Chronic Disease Management Maintenance of Certification
Physician Quality Reporting Components: Set priorities in these 3 areas Metrics Tools Communication
CCHS Quality Programs SUMMARY Integrated infrastructure Set goals / measure performance Optimal use of data sources Engagement at all levels New horizons