Office of Quality and Performance SD Fihn MD MPH December 12, 2008 2 3 Office of Quality and Safety Associate Deputy USH for Quality & Safety (10 G) William E. Duncan, MD, PhD, MACP Chief Quality & Performance Officer (10Q) Stephan D. Fihn, MD, MPH, FACP Assistant Deputy USH for Quality & Safety Peter Almenoff, MD, FCCP Special Advisor Ashish Jha, MD, MPH Chief Patient Safety Officer (10Q) James P. Bagian, MD, PE Quality and Safety Analytics VHA Quality and Safety Advisory Committee Office of Quality & Performance National Center for Patient Safety IPEC Marta Render, MD OPES* Eileen Moran, MS IPEC = Inpatient Evaluation Center; OPES- Office of Productivity, Efficiency & Staffing 4 5 OQP Team Leadership Joe Francis, Roxane Rusch, Mark Enderle Programs Evidence-Based Practice: Carla Cassidy Performance Measurement: Tammy Czarnecki Analysis: Steve Wright C&P: Kate Enchelmayer Accreditation: Dody Tyler Pt. Experience: John Elter Staff Collaborations: PCS, 10N, Public Health, ONS, ORD 6 Figures Total budget ~$38 million (minus IT) ~$30 million in contracts EPRP, SHEP, TJC, CARF, URAC, CPGs, VetPRO Pending -- Protected Peer Review ~40 employees 61 presently authorized Located in Washington DC, Durham, Providence, Iowa, Tucson, Seattle, Detroit, Fayetteville AR 7 8 Major Functions/Programs Evidence Based Practice Performance Measurement Continuous Improvement and Practice Optimization Utilization Management Risk Management Peer Review Professional Credentialing and Privileging Analytic Resources Accreditation 9 10 Evidence Based Practice Cataloguing clinical evidence Clinical practice guideline development and adoption with companion tools Collaborative with Dept. of Defense Collaborations and partnerships Health Services Research and Development Inter-Agency liaisons 11 Current Clinical Practice Guidelines Post Deployment Health Uncomplicated Pregnancy Major Depressive Disorder PTSD Psychosis Substance abuse disorder Medically Unexplained Symptoms Opioid Use in Chronic Pain Mild TBI Post Operative Pain Bio/Chem/Rad/Blast Injury Tobacco Use Cessation Obesity Amputation Disease Prevention Heart Failure Hypertension Ischemic Heart Disease Dyslipidemia Diabetes Mellitus Pre End Stage Renal Disease COPD Stroke Rehabilitation Acute Stroke Rehabilitation Dysuria Asthma (Adult and Pediatric) GERD Glaucoma Erectile Dysfunction Low Back Pain 14 in process of update 12 Future Course Expansion of evidence program Partnerships Beyond CPGs Department-wide evidence base Creation of coordinated evidence-driven products CPGs new formats Clinical pathways QI initiatives Clinical reminders Decision support Clinical Guidelines Evidence Formulary Clinical Processes Appropriateness Measures Decision Support Performance Measures Clinical Reminders 13 Performance Measurement Evidence-based measurement Leverage of electronic data sources Goal and target setting Inter-agency collaboration Initiatives in support of transparency and interoperability Enhanced performance reporting 14 VA Perspective VA early adopter of PMs initiated in1996 Initially manual abstraction of clinical data from randomly selected records (EPRP) Has evolved to include data from additional sources including Austin, PBM, DSS, VISTA Multiple domains other than clinical Reliance largely on audit/feedback Performance contracts with senior leadership Integral to transformation 15 Performance Improvement Prevention Index 1996: Influenza & pneumococcal vaccination Breast, cervical, colorectal, prostate cancer screening Screening for tobacco and problem alcohol use; counseling for tobacco cessation 2004: Added hyperlipidemia screening Prostate Ca screening education/counseling Similar story for most original PMs 16 Performance Measurement Current System Performance Measures: (Does not include self report/transformational measures) Mission Critical (ECF plan): 50 clinical, 2 satisfaction & 1 access Non-mission critical performance measures: 17 clinical, 27 access, functional status, & 2 non-clinical 157 Supporting Indicators 94 clinical, 27 non-Clinical, 10 functional status, & 10 access Performance is >90% on nearly 50% of measures 17 Limitations of Current PM System Data for many measures, including HEDIS and ORYX, obtained via EPRP which is dependent on manual review of medical records. Expensive Lag between collection and feedback. Relatively small samples of patients inadequate to compare important subgroups such as sex, ethnic group, mental health patients, disabled, etc. Introducing new measures cumbersome Reliant upon the quality of documentation and the abstractors ability to accurately identify documentation. Focuses attention on mechanics of measurement rather than improvement. Measurement criteria often change noncomparable data over time. Aggregate measures difficult to interpret and may lead to inaccurate conclusions about overall performance. Measures lacking in many critical areas such acute care, population health and use of community resources. Adequate mechanisms for collection of data sometimes lacking 18 Framework for adopting PMs Performance Measures Magnitude of effect Cost Clinical burden Opportunities for improvement IT Support Reliability & validity of measure Relevance to strategic goals Clinical Guidelines 19 ProClarity Cube Dozens of pre-built Graphical views for the field VA staff that have ProClarity Desktop Professional have the ability to link to our cube and build their own custom views to meet specialized business processes. 20 Inpatient Composites AMI (11) CHF (4) Diabetes (7) Ischemic heart disease (3) Prevention (7) Pneumonia (9) Surgical Quality (SCIP) (8) Behavioral health screening (3) Tobacco follow-up (3) Outpatient Composites 9 Composite Measures 21 Greater than 2 SD from the Mean Within 2 SD of the Mean 22 2SD below the Mean 23 Other Composites- Under Discussion Access measures: Create groupings for MH, new patient wait time, established patient wait time? Patient Satisfaction: Inpatient & outpatient together or separate? Incorporate satisfaction into disease- specific composites? Access? 24 Performance Alerts Subscriber-driven Performance Alert System designed to notify Senior and Line managers of possible issues related to performance measure groupings i.e. Cardiology, Diabetes Mellitus, Surgical Infection Prevention, Mental Health and so on.. 25 Performance Measurement Planned Actions: Reestablish commitment to evidence, value to pt care Systematic, critical review of existing measures Migration from manual sampling to automated, longitudinal measures on all patients Resource survey underway Potential e-measures for 09: Mental heath, diabetes Development of meaningful patient-centered measures Longitudinal (cohort) measures: CHF Incorporating preferences 26 Analysis and Reporting Current emphasis on data collection and reporting minimal analysis. OQP budget >2/3s devoted to data collection Major effort to automate reporting with dashboards and proclarity cubes Insufficient investment in directed, in-depth analyses of quality issues 27 28 SHEP: Transition to CAHPS SHEP is transitioning from Picker Dimensions of Care to the Consumer Assessment of Healthcare Plans and Systems (CAHPS) NRC-Picker and CAHPS SHEP are being parallel administered for 4 th quarter FY08 to determine: Correlation of new questions with old dimensions Continuity of performance measures Includes assessment of internal consistency, item response theory, construct validity, factor analysis, and calibration 29 Implications for QuERI Research expertise/consultation critical New PMs Evidence development (ESPs) QI tools identification, grading, cataloguing SHEP new modules, health status Analytic support, e.g., surgical complexity, adjusted outcomes Suggestions?