Bending the Healthcare Cost Curve The Value of a Comprehensive CQI Database Bryan V. May, MD, MBA Chair, Quality Committee American Anesthesiology of the Southeast Charlotte, North Carolina
The Changing Landscape of Healthcare
Concerns About the Future of Healthcare Cost of healthcare continues to rise Quality of Care delivered is variable Little transparency regarding quality or outcomes Current quality measurements tools Are they having an impact?
U.S. Healthcare Spending as a Percentage of GDP Source: Centers for Medicare and Medicaid Services
U.S. Healthcare Spending as a Percentage of GDP Source: Organization for Economic Cooperation and Development, OECD Health Data, 2008
Medicare Cost and Non-Interest Income by Source as a Percentage of GDP Source: 2012 Annual Report of the Board of Trustees - CMS
The Changing Landscape of Healthcare CMS Value Based Purchasing Program Volume to value transition from fee for service Patient Experience Process of Care Clinical Outcomes Domains FY 2013 Weights Patient Experience of Care Clinical Process of Care 30% 30% 70% 45% Outcomes N/A 25% FY 2014 Weights
The Changing Landscape of Healthcare CMS Value Based Purchasing Program Volume to value transition from fee for service Patient Experience Process of Care Clinical Outcomes Efficiency Measures Domains FY 2013 Weights Patient Experience of Care Clinical Process of Care FY 2014 Weights 30% 30% 20% 70% 45% 30% Outcomes N/A 25% 30% Efficiency N/A N/A 20% FY 2015 Weights
The Changing Landscape of Healthcare Better health outcomes Superior service Lower overall costs
Concept of Value in Healthcare Quality and Safety = Value Cost per unit
How are we currently measured? CMS HCAHPS Studer, Press Ganey, PRC, HealthStream Social Media
A Data Driven Quality System How do we design a data driven CQI system to help clinicians improve clinical outcomes wile at the same time, reduce costs? Define relevant parameters Patient Satisfaction (Patient focused) Efficiency/Timeliness (Value/Productivity) Practitioner Performance (Individual Accountability) Clinical Outcomes (Systems issues)
A Data Driven Quality System How do we design a data driven CQI system to help clinicians to improve clinical outcomes and reduce costs? Continuous real-time feedback loops Clinicians CQI Committee Department Chiefs Medical Directors Hospital Administration Patient Safety Managers and Officers
A Data Driven Quality System Steps in data collection, entry and reporting
Feedback Reporting: January 2010 August 2013
CQI Data Audit Process First Level Review and Data Abstraction by QA RN Reconciliation audit to assure all cases are captured Incomplete fields on data record are identified Inter rater reliability Audit Minimum of 30 cases per QA RN reviewed annually. (2003 reviews with 99.5% accuracy) Data Validation Audit Minimum of 50 cases per facility reviewed annually. (3453 reviews with 99.55% accuracy)
Checklists DO Work!
Why Checklists Work Help improve the effectiveness of individuals or groups performing complex tasks Ensure effective communication amongst team members especially when each person (group) is performing subtasks for the procedure. Help catch errors or omissions Ensure both routine procedures and emergency responses are handled appropriately
Experience With a Checklist Power on stall Familiarize the student with: The warning signs of a stall at the takeoff condition Reaction of the airplane when stalled Recovery techniques required
Experience With a Checklist Engine Failure in Flight Airspeed to 60 KIAS Carb Air Hot Best field SELECTED Primer in and LOCKED Fuel Valve ON Mixture RICH Magnetos BOTH or START Attempt RESTART
Experience With a Checklist
Data Collection Through Checklists Incorporates both positive and occurrence based measures Allows completion in seconds Results are available almost immediately
Data Reporting and Utilization Feedback Loops and Reporting Constant measurement and re-measurement Peter Drucker - If you can t measure it, you can t manage it. Hawthorne Effect What you measure, improves! Benchmarking facilitates positive competition Alerts that focus on key metrics Real time reporting that enables quick analysis, intervention and re-measurement Implement best practices
Improving Clinician Performance Systems approach: Analysis of aggregate data and EBM guide the development of: System-wide best practice Organizational practice change Systems approach to error reduction Decreased variability Measure data against evidence based protocols Individual Accountability: Measures, benchmarks and real time feedback loops assure individual accountability and facilitate clinician practice change
Immediate Clinician Feedback Loop Critical Alert Email automatically generated Involved parties are notified as soon as the case is closed
Benchmark Reporting
How Many Think We Are Average?
Benchmark Reporting
Benchmark Reporting: 2012 Data
Trending Reports - Continuous Hawthorne Effect
Introduction of CVL Protocol Checklist December 2008 80,000 catheter related infections/yr 28,000 deaths/yr *Estimated Average cost $45,000 ($11,971-$54,000) Up to $2.3 Billion/Yr 66% reduction at 16 to 18 months after implementation
Putting EBM to Work
Putting EBM to Work Central venous line protocol checklist introduced December 2008
Sustained Improvement
Bending the Healthcare Cost Curve Peri-operative Myocardial Infarction 2012 SAC total cases 122,857 SAC Incidence MI measured: 0.01% = 16 cases per year Published Benchmark Incidence Post-Op MI 0.19% = 233.42 cases per year Cost per MI $38,501* 233.42 cases /year benchmark $8,987,222.98 16 cases/year SAC @ $616,016.00 = $ 8,371,206.98 Annualized Cost Savings *Obtained from Milliman Research Report Benefit Designs for High Cost Medical Conditions, April 22, 2011.
Bending the Healthcare Cost Curve Peri-operative Stroke 2012 SAC cases 122,857 SAC incidence of Post-Op Stroke measured via Quantum: 0.02% = 23 cases/ year Published Benchmark Incidence Post op stroke : 0.05-7% = 614.285 cases/year (using 0.5% for calculation) Average Cost per post op stroke - $15,000* 614.285 cases/year benchmark $9,214,257 23 cases/year SAC @ $345,000/year = $8,869,257 Annualized Cost Savings *Perioperative stroke in noncardiac, nonneurosurgical surgery. Anesthesiology. 2011 Oct;115(4):879-90
Bending the Healthcare Cost Curve MEDICATION ERRORS 2012 SAC Total cases 122,857 SAC Incidence of Medication Errors: 0.01% (14 cases per year) Published benchmark incidence: 0.75% Cost per medication error: $4,685* Cases / year at benchmark / 921 cases = $ 4,316, 888 year Cases/year SAC/ 14 cases = $18,740 = $ 4,251,298 Annualized Cost Savings *Obtained from Quality Progress Journal, 2007 January, Hospital Reduces medication Errors Using DMAIC and QFD
Bending the Healthcare Cost Curve DENTAL INJURY/LOSS 2012 SAC cases 80,315 (Peds patients excluded) SAC Incidence of Dental Injury 0.04% (29 cases per year) Published benchmark incidence 0.02% -- 0.07% (Average 0.05%) *Cost per dental injury $6,025 per claim Cases / year at benchmark (0.05%) / 40 cases = $ 241,000.00 year Cases / year SAC (0.04%) / 29 cases = $ 174,725.00 = $66,275.00 Annualized Cost Savings *Obtained from ASA Closed Claims Database
Efficiency Measures OR Utilization Lower Healthcare Costs and Higher Customer Satisfaction Through Improved Efficiency Using Medicare fee schedule total revenue loss per cancelled case was $4,550 or $1440 to $1700 per hour of delay* Anesthesiology 2005; 103:855-9
Bending the Healthcare Cost Curve
Patient Satisfaction/Experience
Patient Satisfaction/Experience HealthStream Confirms QCNS 2012 Patient Satisfaction Results %s reflect combined 2 top box scores QCNS: 8400 patients surveys received between June and Sept. CL/CI: 95% +.82 HealthStream: 610 patient surveys received between June and Sept. CL/CI: 95% +.21
Thank You GO TIGERS!
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