CMS DATA FOR THE PUBLIC What We Intend To Do About It! Stephen Sibbitt, MD, FACP Chief Medical Officer Scott & White Memorial Hospital

CMS DATA FOR THE PUBLIC What We Intend To Do About It! Stephen Sibbitt, MD, FACP Chief Medical Officer Scott & White Memorial Hospital

What does this metric suggest to you? Good Performance? Great Performance?

Now, what if you knew that the metric was % Safe Landings for East-West Airlines?

Safety Metric: % Safe Landings East-West Airlines Would you fly this Airline? Would you fly any airline less than 100% on this metric?

Actual Measure is AMI Composite Core Measure for SWMH Is less than 100% acceptable?

What would our patients think? Good Performance? Great Performance? Most Trusted and Most Valued?

Publically Reported Data Increasing ability for our patients, our payers, and regulatory services to view our quality data. CMS encourages participation in reporting of Core Measures and HCAHPS survey results TJC and RHQDAPU (Reporting Hospital Quality Data for Annual Payment Update) require reporting Intended to equip consumers with quality of care information to make more informed decisions about their health care, while encouraging hospitals and clinicians to improve the quality of inpatient care provided to all patients 2.0 percent reduction in Medicare annual payment, for nonparticipants

So what is available to the public? Publically Reported Data Hospital Compare Core Measures (SCIP, AMI, HF, Pneumonia) Readmission Rates (AMI,HF, Pneumonia) Mortality Rates (AMI,HF, Pneumonia) HCAHPS (survey of patient s hospital experience)

The HCAHPS (Hospital Consumer Assessment of Health Plans) Survey. A nationally standardized survey developed by CMS and AHRQ. Captures patients perspectives of their hospital care. Questions focus on aspects of the care experience that are particularly meaningful to patients, including: Communication with doctors and nurses, Responsiveness of hospital staff, Quality of discharge instructions, Hospitals scores publicly reported

HCAHPS Quarterly Trend Would you recommend this hospital to your friends and family? SWMH Top Box quarterly percentage Quarter to Date Percentile Rank compared to All DB n = The total number of respondents for the question during the quarter

HCAHPS Quarterly Trend How often did doctors treat you with courtesy and respect? Quarter to Date

HCAHPS Quarterly Trend How often did doctors listen carefully to you? Quarter to Date

HCAHPS Quarterly Trend How often did doctors explain things in a way you could understand? Quarter to Date

HCAHPS Quarterly Trend Did you get information in writing about what symptoms or health problems to look out for after you left the hospital? Quarter to Date

So what is available to the public? Publically Reported Data www.medicare.gov Home Health Santa Fe Rehab

Set Aggressive & Achievable Goals - 2010 We have set an aggressive institutional goal to reduce our mortality index by 25% over the next year. We must all hold ourselves accountable and responsible to this goal.

Communicate the Data Hospital Quality & Patient Safety Council (HQPSC) SWMH Quality Dashboard provided to HQPSC Members Physician Members responsible to communicate to their department s Sr. Staff and Residents.

Review Data Identify Opportunities for Improvement Partner Caregivers.Create Best Practice Teams CORE Measures SCIP Pneumonia HF AMI CAC VAP CAUTI CLIP Pressure Ulcer Prevention Palliative Care Reduce Readmissions CDAP Mortality Review

Mortality: Observed mortality remains significantly below expected, and statistically no different than top 10 % of U.S. hospitals, and noticeable decline over past 2 years. We will continue to improve!

Accountability Expect Performance Improvement