Quality Care Amongst Clinical Commotion: Daily Challenges in the Care Environment

Quality Care Amongst Clinical Commotion: Daily Challenges in the Care Environment presented by Sherry Kwater, MSM,BSN,RN Chief Nursing Officer Penn State Hershey Medical Center Objectives 1. Understand the definition of quality and safety 2. Review the history of the Value Based Purchasing Quality Initiatives 3. Articulate your role in quality outcomes 4. Understand the healthcare team role and reactions to quality outcomes 1

What is Quality? Quality health care is the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge - Institute of Medicine (IOM) - Centers for Medicare and Medicaid (CMS) What is Patient Safety? Simply, The prevention of harm to patients Six Aims of a High Quality System l Safe avoiding injuries to patients from the care that is supposed to help them. l Effective providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse). l Patient-centered providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. l Timely reducing waits and sometimes harmful delays for both those who receive and those who give care. l Efficient avoiding waste, in particular waste of equipment, supplies, ideas, and energy. l Equitable providing care that does not vary in quality because of personal characteristics, such as gender, ethnicity, geographic location, and socioeconomic status. l (Institute of Medicine, 2001) 2

What is your role? Deliver the highest quality and safe care. Quality Reporting Voluntary Reporting Incentive Penalty Value Based Purchasing Value Based Payment Modifier The list goes on, 3

Value Based Purchasing (VBP) Centers for Medicare and Medicaid Services (CMS) commitment to transforming the quality of hospital care by realigning hospitals financial incentives Quality and Safety Agenda Final: 8/31/12 Federal Register Clinical Process : AMI (FY14 = 4) **AMI1/3/5 still req for JC HF (FY14 = 3) PN (FY13 =4) SCIP (FY14 = 9, FY15=8) **SCIP6 still req for JC, Jan13 elim VTE1 (chart review) Emergency Department FY 14 (Jan12 dc): 2 measures (chart review) Preventative: FY14 (Jan12 dc): 2 measures Pneumococcal & Influenza (chart review) Stroke NEW FY15 (Jan13 dc): 8 measures (chart review) VTE NEW FY15 (Jan13 dc): 6 measures (chart review) Perinatal NEW FY15 (Jan13 dc): 1 measure (chart review, but only aggregate submitted) Meaningful Use : Stage 1: 15 clinical measures Stroke, VTE, ED (straight from EHR/Cerner) Validation (CDAC audit): FY12: 800 hospitals; 12 cases/qtr; 75% CAARS pass FY13: no change FY14: 24 charts/qtr; add ED x2, vaccine x2, CLABSI FY15: Hospital Inpatient Quality Reporting Program HCAHPS: Patient Satisfaction (Press Ganey) 10 measures: 5 NEW FY15 (Jan13): 3 transition of care, 2 about you Healthcare Acquired Infections (NHSN): CLABSI (FY12; 1/1/11 dc) SSI (FY14; 1/1/12 dc) CAUTI (FY14; 1/1/12 dc) MRSA (FY15, 1/1/13 dc) C.Diff (FY15; 1/1/13 dc) Healthcare Professional flu vaccine (FY15; 1/1/13 dc) Outcomes data (claims): 30 day mortality: AMI, HF, PN 30 day readmissions : AMI, HF, PN Healthcare Acquired Conditions: 8 measures (claims) AHRQ IQI 2 measures; PSI 6 measures Composite QI 2 measures (claims) Medicare Spending per Beneficiary NEW FY14: 1 measure (claims) Elective TKA/THA 30 day Complications NEW FY15: 1 measure (claims) Elective TKA/THA 30 day Readmissions NEW FY15: 1 measure (claims) Hospitalwide all cause unplanned 30 day readmissions NEW FY15: 1 measure (claims) Structural Cardiac Surgery database Nurse Sensitive database Stroke database (FY13) Surgery database (FY14) Legend: yellow = manually abstracted, purple = claims, orange = other database, light blue = structural 4

Inpatient Quality 9 sets, 19 new measures AMI SCIP ED Throughput NEW 2012 (Also MU, prior Highmark) AMI 2 Aspirin prescribed at SCIP 1 Prophylactic antibiotic w/in 1 hour ED-1b Median time ED arrival discharge prior to surgical incision to ED departure for patients admitted to the hospital AMI 7a Fibrinolytic w/in 30 SCIP-2 Prophylactic antibiotic selection ED-2b Median time admit minutes of hospital arrival decision to ED departure for patients admit to the hospital AMI 8a PCI w/in 90 minutes of SCIP 3 Prophylactic antibiotics d/c w/in Stroke NEW 2013 hospital arrival 24 hours after surgery end (also MU, JC stroke cert) VTE NEW 2013 (also MU, partial prior Highmark) VTE-1 VTE Prophylaxis VTE-4 Patients receiving unfractionated heparin with doses/labs monitored by protocol VTE-3 VTE patients with anticoagulation overlap therapy AMI-10: Statin at discharge SCIP-4 Cardiac Surgery Patients with STK-1 VTE prophylaxis VTE-2 ICU VTE Prophylaxis Controlled 6AM postop glucose HF SCIP- 9 Postoperative Urinary Catheter STK-2 Antithrombotic therapy for VTE-5 VTE discharge Removal on Post Operative Day 1 or 2 ischemic stroke instructions HF 1 Discharge instructions SCIP-10: Perioperative Temperature STK-3 Anticoagulation therapy VTE-6 Incidence of potentially Management for afib/flutter preventable VTE HF 2 LVF assessment SCIP VTE 2 VTE prophylaxis within 24 STK-4 Thrombolytic therapy for Perinatal Care NEW 2013 hours pre/post surgery acute ischemic stroke HF 3 ACE-I or ARB for LSVD SCIP-Card-2 Periop BB admin for STK-5 Antithrombotic therapy by % of babies electively delivered patients on a BB Prior to arrival the end of hospital day 2 prior to 39 weeks gestation aggregate only reported PN Immunizations NEW 2012 STK-6 Discharged on Statin PN 3b Blood culture before first antibiotic IMM-1a Pneumococcal immunization STK-8 Stroke education PN 6 Antibiotic selection IMM-2 Influenza immunization STK-10 Assessed for rehab Inpatient Quality 11 eliminated/suspended AMI SCIP PN HF AMI 1 Aspirin at arrival (suspended 1/1/12) SCIP-6 Surgery Patients with Appropriate Hair Removal (suspended 1/1/12) PN 2 Pneumococcal vaccination status HF 4 Adult smoking cessation advice/counseling AMI 3 ACE-I or ARB for LSVD (suspended 1/1/12) SCIP VTE 1 VTE appropriate prophylaxis ordered (eliminated 1/1/13) PN 4 Adult smoking cessation advice/counseling AMI 4 Adult smoking cessation advice/counseling PN 5c Initial antibiotic w/in 6 hours of hospital arrival AMI 5 Beta blocker prescribed at discharge (suspended 1/1/12) PN 7 Influenza vaccination status HCAHPS Current NEW January 2013 Communization with nurses Transition of Care Communication with doctors The hospital staff took my preference and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital. Responsiveness of hospital staff When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. Pain management When I left the hospital, I clearly understood the purpose for taking each of my medications Communication about medicines About Me Cleanliness of hospital environment During this hospital stay, were you admitted to this hospital through the ED? Quietness of hospital environment In general, how would you rate your overall mental or emotional health? Discharge information Overall hospital rating Willingness to recommend this hospital 5

Inpatient Claims AHRQ AHRQ PSI Composite, aka serious complications PSI 3 Pressure ulcer rate PSI 6 - Iatrogenic pneumothorax rate PSI 7 Catheter related blood stream infection rate PSI 8 Postoperative hip fracture rate PSI 12 - Postoperative PE or DVT rate PSI 13 Postoperative sepsis rate PSI 14 - Postoperative wound dehiscence rate PSI 15 - Accidental puncture or laceration Medicare Spending per Beneficiary This measure assesses Medicare Part A and Part B payments for services provided to a Medicare beneficiary during a spending-per-beneficiary episode that spans from three days prior to an inpatient hospital admission through 30 days after discharge. The payments included in this measure are price-standardized and risk-adjusted AHRQ PSI-4: Death among surgical inpatients with serious treatable complications (eg: pneumonia, DVT/PE, sepsis, shock/cardiac arrest, or GI hemorrhage/acute ulcer) Mortality Readmissions 30 day mortality: AMI, heart failure, pneumonia 30 day readmissions : AMI, HF, PN Complications 30 day readmissions: Elective TKA/THA 30 day complications: Elective TKA/THA 30 day readmissions: Hospital wide all cause FY13 VBP 30% 70% FY14 VBP Patient Experience of Care Domain Clinical Process of Care Domain 1) Communication with Nurses 2) Communication with Doctors 3) Responsiveness of Hospital Staff 4) Pain Management 5) Communication about medicines 6) Hospital Cleanliness & quietness 7) Discharge Information 8) Overall Rating of Hospital Baseline: 4/1/10 thru 12/31/10 Performance: 4/1/12 thru 12/31/12 Experience of Care 30% Clinical Process of Care 45% 1) AMI-7a 2) AMI-8 3) HF-1 4) PN-3b 5) PN-6 6) SCIP1 7) SCIP2 8) SCIP 3 9) SCIP 4 10) SCIP 9 Urinary Catheter removed on postop day 1 or postop day 2 11) SCIP Card 2 12) SCIP VTE1 13) SCIP VTE2 Outcomes Domain Outcomes Baseline: 4/1/10 thru 12/31/10 Performance: 4/1/12 thru 12/31/12 1) AMI 30 day mortality 2) HF 30 day mortality 3) PN 30 day mortality Baseline: 7/1/09 thru 6/30/10 Perforrnance: 7/1/11 thru 6/30/12 6

FY15 VBP (finalized August 2012) Outcome 1) AHRQ PSI Composite Complication/patient safety for selected indicators 2) CLABSI Central Line Associated blood stream infections (NHSN) 3) AMI 30 day mortality 4) HF 30 day mortality 5) PN 30 day mortality Base & perforrnance varies Outcome 30% Efficiency 20% Efficiency MSPB 1 Medicare spending per beneficiary Baseline: 5/1/11 thru 12/31/11 Performance: 5/1/13 thru 12/31/13 Clinical Process of Care 1) AMI-7a 2) AMI-8 3) HF-1 4) PN-3b 5) PN-6 6) SCIP1 7) SCIP2 8) SCIP 3 9) SCIP 4 10) SCIP 9 11) SCIP VTE2 Baseline: 1/1/11 thru 12/31/11 Performance: 1/1/13 thru 12/31/13 Clinical Process of Care 20% Experience 30% Payment Reduction increases to 1.50% Patient Experience of Care 1) Communication with Nurses 2) Communication with Doctors 3) Responsiveness of Hospital Staff 4) Pain Management 5) Communication about medicines 6) Hospital Cleanliness & quietness 7) Discharge Information 8) Overall Rating of Hospital Baseline: 1/1/11 thru 12/31/11 Performance: 1/1/13 thru 12/31/13 FY16 VBP (finalized Aug13) Outcome 1) AHRQ PSI 90 2) CLABSI Central Line Associated blood stream infections (NHSN) 3) CAUTI (NHSN) 4) SSI (colon & hysterectomy) (NHSN) 5) AMI 30 day mortality 6) HF 30 day mortality 7) PN 30 day mortality Outcome 40% Efficiency Efficiency MSPB 1 Medicare spending per beneficiary Baseline: 1/1/12 thru 12/31/12 Performance: 1/1/14 thru 12/31/14 Base & performance varies Clinical Process of Care 1) AMI-7a 2) PN-6 3) SCIP 2 4) SCIP 3 5) SCIP 9 6) SCIP Card-2 7) SCIP VTE2 8) IMM2 Baseline: 1/1/12 thru 12/31/12 Performance: 1/1/14 thru 12/31/14 Clinical Process of Care 10% Experience Payment Reduction increases to 1.75% Patient Experience of Care 1) Communication with Nurses 2) Communication with Doctors 3) Responsiveness of Hospital Staff 4) Pain Management 5) Communication about medicines 6) Hospital Cleanliness & quietness 7) Discharge Information 8) Overall Rating of Hospital Baseline: 1/1/12 thru 12/31/12 Performance: 1/1/14 thru 12/31/14 FY17 VBP Measure Scoring (finalized Aug13) Patient & Caregiver Exp. of Care/Care Coordination Efficiency & Cost Reduction Safety 15% Clinical Care Process 10% Clinical Care Outcomes Payment Reduction increases to 2.0% 7

Meaningful Use Stage 2: Clinical Quality Eligible Hospitals and CAHs must report on 16 of the 29 approved CQMs Selected CQMs must cover at least 3 of the National Quality Strategy domains. These domains include: Domain Patient and family engagement Patient Safety Care Coordination Population and public health Efficient use of healthcare resources Clinical processes/effectiveness Last discussions I heard ED1, ED2, STK8, VTE5 VTE1, VTE2, VTE6 STK10, ED3 (new) STK2, STK3, STK4, STK5, STK6, VTE3, VTE4 So, SCIP is on the menu, but not on the table Hospital Readmissions Reduction Program Section 3025 of the 2010 Affordable Care Act (Public Law 111-148) requires the Secretary of Health and Human Services to establish a Hospital Readmissions Reduction Program whereby the Secretary would reduce Inpatient Prospective Payment System (IPPS) payments to hospitals for excess readmissions beginning on or after October 1, 2012 (Fiscal Year [FY] 2013). The Affordable Care Act further requires the Secretary to adopt the three National Quality Forum (NQF)-endorsed 30-day Risk-Standardized Readmission measures for acute myocardial infarction (AMI), heart failure (HF), and pneumonia (PN) for the Hospital Readmissions Reduction Program beginning October 2012. The Excess Readmission Ratios will be used to determine the payment adjustment for each eligible hospital. Hospital Readmissions Reduction Program If a hospital performs better than the average hospital that admitted similar patients (that is, patients with similar risk factors for readmission such as age and comorbidities), the ratio will be less than 1.0000. If a hospital performs worse than average, the ratio will be greater than 1.0000. # eligible # Predicted Expected Excess National Crude discharges readmissions Readmission Readmission Readmission Readmission (Jul08-Jun11) Rate Rate Ratio Rate AMI 310 48 16.6% 18.2% 0.9139 19.2% HF 542 126 23.5% 24.1% 0.9762 24.6% PN 424 74 17.9% 18.5% 0.9664 18.5% FY2013 Readmission Payment Adjustment Factor = 1.0000 8

Own the Quality and Safety Agenda Clinical Processes Clinical Outcomes Patient Experience Efficiency and Cost Reduction Safety Readmissions What is your role? Deliver the highest quality and safe care. Team Responsibilities Know your patient population Understand the quality and safety measures for that patient population Know how well you are performing compared to the benchmarks Make data transparent 9

Team Responsibilities Do a team huddle-assess on a shift / daily basis compliance with quality measures Address non-compliance Use checklists Hardwire improvements Reduce variation Identify improvement opportunities Improve the Quality and Safety Past to the Future Patient Experience 30% 70% Clinical Processes Patient & Caregiver Exp. of Care/Care Coordination Efficiency & Cost Reduction Safety 15% Clinical Care Process 10% Clinical Care Outcomes FY 13 FY 17 10

Questions? 11