1 Quality / Performance Improvement Mike Holland Vice President, Lean Healthcare NEXT LEVEL Partners, LLC

1

Quality / Performance Improvement

Mike Holland

Vice President, Lean Healthcare

NEXT LEVEL Partners, LLC

2

Highlights

Quality / Performance Improvement

• 20 questions for 10% of exam

• 8 knowledge areas

3

American Reinvestment &

Recovery Act (ARRA)Provide incentive payments for Meaningful Use of

Certified EHR technology

Stage 1 Components:

Electronically capture health information in a coded format

Use that information to track key clinical conditions

Communicate that information for care coordination purposes

Initiate the reporting of clinical quality measures and public health information

4

American Reinvestment &

Recovery Act (ARRA)Meaningful Use Priorities

Improve quality, safety, efficiency, and reducing health disparities

Engage patients and families in their health care

Improve care coordination

Improve population and public health outcomes

Ensure adequate privacy and security protections for personal health information

Engage decision support for national high-priority conditions

5

Hospital Hospital

23 Meaningful Use Functional Measures23 Meaningful Use

Functional Measures

Measures with a denominator of unique patients

regardless of whether the patients

records are maintained using

certified EHR technology5 measures

Example: Maintain active medication list





Example: Maintain active medication listMeasures with a denominator based on counting actions for patients whose



Example: Record and chart changes in vital

signs

Measures with a denominator based on counting actions for patients whose



Example: Record and chart changes in vital

signs

Stage I - Functional Measures (Final Rule)

Stage I - Functional Measures (Final Rule)

Eligible Professional


Functional CapabilityYes/No Attestation

Only9 measures

Example: Implement drug-drug and drug-allergy interaction

checks


Only9 measures


checks

24 Meaningful Use Functional Measures24 Meaningful Use

Functional Measures





Example: Maintain active medication list





Example: Maintain active medication listMeasures with a denominator based on counting actions for patients whose


certified EHR technology

10 measuresExample: Record and chart changes in vital

signs

Measures with a denominator based on counting actions for patients whose


certified EHR technology

10 measuresExample: Record and chart changes in vital

signsFunctional CapabilityYes/No Attestation

Only8 measures


checks


Only8 measures


checks

15 Meaningful Use Clinical Quality

Measures


Measures

Stage I - Clinical Quality Measures (Final Rule)

Stage I - Clinical Quality Measures (Final Rule)

Hospital

Hospital

Eligible

Professional


Functional reports will be developed by Cerner as part of each solution’s departmental reports. Clients who have implemented

the corresponding solution will receive the reports as part of that solution.


Measures per EP


Measures per EP

Stage I Eligible Professional

Meaningful Use Clinical Quality

Measuresor

Chronic Condition Management

Core Measures 3

Alternate Core Measures 3

Additional Measures for Selection by

Specialty 17

Stage I Eligible Professional

Meaningful Use Clinical Quality

Measuresor

Chronic Condition Management

Core Measures 3

Alternate Core Measures 3

Additional Measures for Selection by

Specialty 17

Cerner Millennium® Core Measure solutions requires a subscription and services

for implementation.

Please note – this does not cover the 2012 future e-submission capabilities

based on pending definition and requirements.

Cerner Millennium® Stage I Eligible Professional

Meaningful Use solution and Cerner Millennium®

Chronic Condition Management solution

require a subscription and services for

implementation.

Stage I Hospital Meaningful Use Clinical Quality

Measures

Stage I Hospital Meaningful Use Clinical Quality

MeasuresCore Measures:

Stroke7 measures

Core Measures: Stroke

7 measures

Core Measures: VTE

6 measures

Core Measures: VTE

6 measures

Core Measures: ED Throughput

2 measures – Reports Only

Core Measures: ED Throughput

2 measures – Reports Only

Cerner Corp. All rights reserved

6

Quality and PI Knowledge Areas

Benchmarking techniques

Medical staff peer review and discipline process

Risk management principles and programs

Performance and process improvement (e.g. CQI, TQM, QA/QI, PI)

Customer satisfaction principles and tools

Clinical methodologies, evidence-based medicine, population health, pay for performance

Utilization review and management regulations

National quality initiatives (e.g. patient safety)

7

Why the focus on Quality & Performance Improvement?

Accreditation guidelines

Growing consumerism

Efficiencies and cost savings

Improved patient outcomes

Transparency

National reporting, e.g. HHS Hospital Compare http://www.hospitalcompare.hhs.gov

Quality & PI

8

Quality & PI

Organizations that support quality initiatives:

The Joint Commission (TJC)

CMS Core Measures (NHQM, HOP)

Institute of Medicine (IOM)

Leapfrog Group

NQF ( National Quality Forum)

AHRQ (Agency for Healthcare Research and Quality)

IHI (Institute for Healthcare Improvement)

Baldrige National Quality Program

9

The Joint Commission (TJC):

Requires organizations to systematically monitor, analyze, and improve patient outcomes

TJC National Patient Safety Goals

• Improve the accuracy of patient ID

• Improve the effectiveness of communication among caregivers

• Improve the safety of using high-alert medications

• Eliminate wrong-site, wrong patient and wrong procedures surgery

• Improve the safety of using infusion pumps

• Improve the effectiveness of clinical alarm systems

• Reduce the risk of healthcare acquired infections

Quality & PI

10

The Joint Commission & Medical Records

The record must contain sufficient information to identify the patient and to support the diagnosis and treatment, and it must furnish adequate documentation of results.

Requires that the medical history, diagnostic and therapeutic orders, all reports, consultations, tests, progress notes, and clinical resume are entered and signed by the attending physician.

Quality & PI

11

Core Measures The Joint Commission Measures CMS/Premier Core Measures

• AMI

• CHF

• Pneumonia

• SCIP (hip and knee replacement, vascular surgery, CABG, other cardiac surgery, hysterectomy, colon surgery)

• Stroke

• VTE

• Readmission and Mortality (HF, AMI, Pneumonia)

• Children’s Asthma Care

HHS Website – Hospital Compare

12

HCAHPS

Hospital Consumer Assessment Health Plans Survey

Looks at satisfaction with:

• Communication

• Pain management

• Environment

• Education of patient

13

IOM ReportsEmphasis on Patient Safety

1999 – To Err Is Human

2001 – Crossing the Quality Chasm Between 44K and 98K people die as the result of medical errors that could

have been prevented

Medical errors

• Failure of planned action as intended

• Use of wrong plan to achieve outcome

Common problems

• Drug and blood reactions

• Restraint deaths

• Falls, burns and pressure ulcers

• Mistaken identity

Most high risk areas

• ICUs, ORs and EDs

14

Institute for Healthcare Improvement (IHI)

100,000 Lives Campaign inspired by IOM reports

• Saved 124,000 lives in 18 months

Dec ‘06 – Dec ’08 5 Million Lives Campaign

IHI Improvement Map

IHI.org

15

Leapfrog

Leapfrog Group’s inception 2000 – built on fact that provider performance transparency is critical to optimal functioning in marketplace

Save lives by reducing preventable medical mistakes NQF endorsed practices CPOE Evidence-based Hospital Referrals (EHR) ICU Physician Staffing Never Events (Pressure Ulcers, wrong surgical site, etc.) Mortality by Surgeon Surgeon Volumes

16

HEDIS

Healthcare Effectiveness Data and Information Set

Report card primarily from the consumers’ perspective on health plan performance

Assists employers with health plan selections, etc.

Measures were developed by the National Committee for Quality Assurance (NCQA

Rate health plans on quality of care, access to care, and member satisfaction with the plan

Used by more than 90 percent of America’s health plans

17

Pay for PerformanceP4P

Model built on defined measures, data collection, and public reporting

Payment incentives aimed at quality, efficiency, and patient satisfaction

Focus on value while taken into account the relationship between quality and cost

18

Baldrige Criteria

Enhance the competitiveness, quality and productivity of US organizations for benefit to all residents

Categories (7)• Leadership, Strategic Planning, Focus on Patients,

Measurement & Analysis, Staff Focus, Process Management and Performance Results

Measurement of processes that have• Approach

• Deployment

• Learning

• Integration (horizontal vs. vertical alignment)

19

Processes and Progress are measurable

Quality tools improve the reliability of collecting data

Better decisions can be made with proper analysis

Individual success improves when allowed to participate in decision making

Empowerment and fear are mutually exclusive

Serving the customer is paramount to survival

Customers provide feedback (expectations)

Acting on feedback improves customer satisfaction

Quality & PI Themes

20

Aids in identifying, evaluating, and reducing risks that could be encountered by staff, patients, and visitors

Reduces the legal and financial exposure of the organization, while TQM/CQI improves processes that may have been poorly designed, and as a result increase risk to the patient

Common risk management concepts: near miss, root cause analysis, sentinel events, safety, etc.

In some organizations, the risk management function overlaps or is included with the corporate compliance function

QI/PI perspective – is there a trend or disequality? RM perspective – is an accident waiting to happen?

Risk Management

21

Ownership of the medical record rests with the hospital or with the physician who keeps patient records

The owner of the record thus has the right of physical possession and control

Neither the patient nor an authorized representative has the right to physical possession of original medical records

The physician or hospital can transfer a copy

The hospital or physician has a legal obligation to make available to the receiving physician or hospital all information that is necessary for the care of the patient

Risk Management and Medical Records

22

Establish a mission and culture that are committed to excellence Nurture commitment to quality principles and lead by example Ensure the safety systems are in place Hold people accountable to be technically competent to meet the

needs of patients Identify gaps between actual and desired performance Provide a framework to identify, debate, and resolve issues

limiting clinical capability Provide training in in use of tools and statistical concepts for

accurate data collection Select problems to address Understand fluctuation with a goal to reduce variation As variation is reduced, the quality becomes more consistent and

patient outcomes and satisfaction improve

Quality & PILeadership Role

23

Quality and PIMedical Staff Roles

Create and maintain the bylaws that help govern the health care organization’s setting

Provide the medical oversight for quality care, services offered, types of treatment

Establish medical privileging and credentialing of staff

Provide ongoing evaluation of the competencies related to the medical community

24

Quality & PI

Common Process Improvement Methods Total Quality Management (TQM) and Continuous Quality

Improvement (CQI) – often used interchangeably

Six Sigma – reduce variations

LEAN thinking – remove waste

Plan-Do-Check-Act Cycle – study the process, put plans into action, observe key learnings, and repeat the cycle with needed modifications

Rapid Cycle Improvement (Kaizen) – improve performance by incremental process changes

Review the teachings of Deming, Phillip Crosby, Juran, Ishikawa

25

TQM/CQI focus is on the system and processes, rather than the individual

PDCA cycles encourage analysis of data to assess interrelated parts of the system and how they function

As one part of a system is improved, the relationship or functioning between parts of the system can be improved

Focus on interdependencies and hand-offs

Quality & PI

26

Pareto charts – arrange data by relative importance

Scatter diagrams – relationship between two qualitative variables

Check sheets – collection of data that help summarize information

Control charts – determine upper and lower limits of expected common cause variation

Cause and Effect diagrams – AKA Fishbone diagrams

Histograms – graphical display of a set of numbers and their variation

Quality & PITools

27

Quality and PI

Examples of quality data use:

Reporting on data related to adverse effects, outcomes, incidents, complaints and malpractice

Patient and family satisfaction survey

Total costs per patient or per episode

Compliance/Variation with clinical practice guidelines

Number of rules/alerts acted upon or ignored

28

Quality and PI

Examples of quality in clinical performance

Using patient management protocols to guide clinical care

Using functional protocols to ensure safe, reliable, patient centered care elements

Continuously improving clinical care

Strengthening illness prevention and health promotion

Supporting a culture of clinical improvement

29

“…total score-able offsets put forward by the [U.S. Presidential] Administration to nearly

$950 billion over 10 years…”- June 13, 2009 White House release in response to how the government plans to cover the cost of health care reform

(billions of dollars)

Additional CMS Savings

$110 billion in Productivity

Improvements over 10 years

30From NATIONAL AND LOCAL IMPACT OF LONG-TERM DEMOGRAPHIC

CHANGE ON INPATIENT ACUTE CARE, Solucient, 2005

Rough estimate of this impact on your hospital(s) over 10 years:

100 Bed Hospital = $1M / year

250 Bed Hospital = $2.5M / year

500 Bed Hospital = $5M / year

1,000 Bed Hospital = $10M / year

50% of the productivity improvements are imposed upon all acute care hospitals in the US (will likely be more)

The improvement expectations will be imposed proportionate with hospital size (# registered beds)

The impact of $110B in Productivity Improvements on every hospital assuming…

Currently ~575,000 registered beds in US

Prepared for this?

31

This will require disruptive change to the way we lead our

healthcare organizations!

Quality and Costs

32

Quality & PI

Need more in-depth resources?

Applying Quality Management in Healthcare: A Process for Improvement, Diane L. Kelly, Dr.P.H.

Continuous Quality Improvement in Health Care, Curtis P. McLaughlin and Arnold D. Kaluzny

Crossing the Quality Chasm: A New Health System for the 21st Century, Committee on Quality of Health Care in America, Institute of Medicine

Error Reduction in Health Care, Patrice L. Spath

To Err is Human: Building a Safer Health System, Linda T. Kohn, Janet M. Corrigan, Molla S. Donaldson, Committee on Quality of Health Care In America, Institute of Medicine.

33

Quality & PI

Test QuestionsThe primary purpose of the quality assurance/risk

management program is to:

A. Comply with licensure and accreditation standards as required by state and federal legislation

B. Monitor medical staff practices in order to control the increases in malpractice rates

C. Identify potential problems that will keep the hospital from becoming a party to litigation

D. Monitor, control, and direct the institution’s efforts towards achieving delivery of the optimal level of care

34

Quality & PI

Test QuestionsIn consultation with the board, the administrator has decided

that an effort must be made to increase the level of involvement among management personnel in quality assessment and assurance. Which one of the following options is most likely to achieve the desired results?

A. Send all key management personnel to quality assessment workshops over the next year

B. Delegate quality assessment function in question to the medical records committee

C. Delegate quality assessment education functions to the utilization review coordinator

D. Develop an in-house program using trained key personnel for presenting and discussing quality assurance and its implication for the organization.

35

Quality & PI

Test QuestionsThe governing body of a healthcare institution meets its

responsibility for the quality of patient care by:

A. Delegating accountability for patient care to the committee appointed by the governing body, which provides a formal administrative liaison between the governing body, the administration, and the medical/professional staff.

B. Delegating to the chief executive officer the responsibility for developing criteria for making certain that an effective medical/professional audit is carried out.

C. Establishing, maintaining, and supporting through medical/professional staff and management staff an ongoing program of review and evaluation of patient/client care and action on findings

D. Establishing an effective system for utilization review, medical/professional audit activities, and credentialing of the medical/professional staff.

36

Quality and PI

Test Questions

Which of the following statements most accurately describe how the Baldrige Quality Program criteria relates to the health care sector?

A.Addresses key areas of running a successful health care organization and is compatible with other performance improvement initiatives, i.e. Magnet status, Joint Commission and Institute For Healthcare Improvement initiatives

B.Valuable framework for measuring performance and planning in an uncertain environment

C.Criteria helps health care organizations achieve and sustain the highest national levels of patient safety and patient loyalty, health outcomes, physician/staff satisfaction, revenue and market share, and community services

D.All of the above

37

Quality and PI

Test Questions

All of the following are commonly recognized to be a right of each patient except:

A.Right to considerate and respectful care

B.Right to receive a reasonable response to his/her requests

C.Right to communicate with a caregiver in the language of the patient’s choosing

D.For dying patients, the right to receive effective pain management

38

Quality and PI

Test Questions

The governing authority assures itself about the quality of care by:

A.Holding the CEO of the health facility accountable.

B.Making the president of the medical/professional staff an ex officio member of the governing authority

C.Approving the process and then following up regularly and continuously to see that it is being used

D.Reviewing tabulated results of incidence reports

39

Quality & PI

Test Questions

Which PI tool would best show process problems, in ranking order of the most frequent, down to the least frequent, in descending order from left to right?

A. Histogram

B. Pareto Chart

C. Scatter diagrams

D. None of the above

40

Quality & PI

Test QuestionsWhich of the following statements most accurately

describes the HEDIS, Health Plan Employer Data and Information Set?

A. HEDIS indicators can easily be adopted for use by acute care hospitals

B. HEDIS quality indicators evaluate preventive services, prenatal care, acute and chronic illness, and mental health and substance abuse programs

C. HEDIS was developed primarily to meet the needs of patients and their families

D. Financial performance has no bearing on HEDIS indicators

41

More Question Areas

Benchmarking techniques and their use

Performance improvement tools and their use

Board role for Quality of Care – Medical Staff

Ultimate responsibility for Credentialing

Functions of a Quality Council or Performance Improvement Council

Understanding Patient Rights and Responsibilities

Utilization review concepts

Overview of the Joint Commission Standards on Medical Documentation

Documents

1 Quality / Performance Improvement Mike Holland Vice President, Lean Healthcare NEXT LEVEL Partners, LLC