Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Understanding the Quality
Landscape in Psychiatry
Richard J Goldberg, MD, MS, FAPA
Psychiatrist-in-Chief,
Rhode Island Hospital and
The Miriam Hospital
Professor, Department of Psychiatry &
Human Behavior,
The Warren Alpert Medical School of
Brown University
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Unsettling News…
•Most Americans do not
receive optimal medical care.
•Many receive ineffective or
unnecessary care.
•Significant variation in
delivery processes and
outcomes.
IOM, 2006
Wennberg JE, et al. Dartmouth Inst.
For Health Policy, 2008.
•No evidence that not-for-
profit or academic centers
have better quality
Jha AK, et al. NEJM; 353(3):265-74, 2005
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Traditional Quality Metrics
• Research dollars
• Staff pedigree
• “Top” residents
• Clinical volumes
• Objective data of
outcomes?
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Examples of Shortcomings
in Psychiatry Quality:
A Minority of Practices:
• Follow accepted guidelines
Bauer M. Harvard Rev Psychiatry 135-153, 2002
• Provide science-based knowledge treatment for substance use McGlynn EA, et al. NEJM; 348(26):2635-45, 2003
• Provide minimally adequate care Kessler RC, et al. JAMA; 289:3095-3105, 2003
• Adopt effective treatments; e.g.,
• CBT for suicide attempters
• Supported employment for schizophrenics
• Collaborative care for geriatric depression Pincus HE, et al. Am J Psychiatry 2007;164:712-719
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
2006: Institute of Medicine 5 years after “Crossing the Quality Chasm”
• Improving our nation’s general health care system depends upon equally attending to quality problems in health care for M/SU conditions
• Unipolar major depression and drug and alcohol use and dependence are the leading cause of death and disability among American women and the second among men
Michaud CM, et al. JAMA 285(5):535-539; 2001
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Compared to Other Medical Specialties:
Psychiatry Has Lagged in Quality Reporting
• Need for more linkages across clinicians,
disciplines, settings, and systems
• Less widespread use of IT
• Differently structured market place with
relative insulation from market pressures
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
No Shortage of “Advice” from IOM
• 6 Aims for High Quality Care
• 10 Rules to Guide Redesign
• 6 Critical Pathways for achieving the prescribed Aims and Rules
• 5 Practices Essential to undertaking and sustaining quality improvement
• 4 Practices and 4 Mechanisms to bridge the separation between providers
IOM. Improving the Quality of Health
Care for Mental and Substance-Use Conditions, 2006
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
How the World of Quality
Appears to Clinical Staff
TJC CQAIMH ECHO …and,
HQA PQRI IHI new
NCQA CARF Leapfrog indicators
AHQR CAHPS HBIPS monthly
CMS QMIS NQF
HEDIS NQMC ORYX
NPSG NREPP DNV
QIO AQA NIATX
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
THE QUALITY PYRAMID
Safety
Accreditation Indicators
Patient Experience
Pay for Performance
Outcomes
High
Value Care
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
THE QUALITY PYRAMID
High
Value Care
Outcomes
Pay for Performance
Patient Experience
Accreditation Indicators
Safety
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
The Joint Commission:
Patient Safety Advisory Group
• Sentinel Events: an unexpected occurrence
involving death or serious injury, or risk thereof.
• Review of 3548 events in 2005:
– Suicide 13.1%
– Medication errors 10.1%
– Falls 5.3%
– Restraint death/injury 3.9%
– Elopement 1.9%
• APA SAFE MD: 2009 scholarly guidance
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
The Joint Commission:
National Patient Safety Goals (2002)
• Evidence-based, practical
– Patient identification
– Caregiver communication
– Medication safety and reconciliation
– Infection reduction
– Patient involvement in care
– Risk identification
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
THE QUALITY PYRAMID
Safety
Accreditation Indicators
Patient Experience
Pay for Performance
Outcomes
High
Value Care
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Psychiatry Quality
Inpatient Measures: TJC • Nat’l Assoc. of Psychiatric Health Systems
Nat’l Assoc. of State Mental Health Program Directors Developed measures for 2008 (submitted to NQF)
• Hospital-Based Inpatient Psychiatric Services (HBIPS): 7 Core Measures – Admission screening for violence, SI, trauma, strengths
– Hours of restraint use
– Hours of seclusion use
– Discharges on multiple antipsychotics
– Justification for multiple antipsychotics
– Discharge plan
– Discharge plan communicated
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Outpatient Quality Measures
• National Committee for Quality Assurance (NCQA)
– Accredits MCOs, BHCOs, and Health Plans
– Healthcare Effectiveness Data and Information Set (HEDIS)
– HEDIS measures endorsed by NQF and Ambulatory Quality Alliance (AQA) 2004: AAFP, ACP, AHIP, AHRQ.
• 71 measures
• Some pertain to psychiatry
– F/U of children on ADHD medication
– Depression medication use
– Use of SA and MH services
– Elderly:
» Use of high-risk medication
» Potentially harmful drug-disease interactions
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Measure
Defined
Sample
Defined
Data
Source
Provid
er
1st
Qtr
FY
10
2ns
Qtr
FY 10
3rd
Qtr
FY 10
4th
Qtr
FY
10
Sentinel Events
Suicide
Severe medication
errors
Falls with injury
Elopement
Assault
High Risk Marker
Suicide assessment
Patient Experience
Overall Press
Ganey
TJC 7 Core Measures
Admission
screening
Physical Restraints
Seclusion
>2 antipsychotics
on discharge
Antipsychotics
justified
Discharge plan
created
Discharge plan
communicated
HEDIS Outpatient Measures
Other Measures
Access to care
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
THE QUALITY PYRAMID
Safety
Accreditation Indicators
Pay for Performance
Outcomes
High
Value Care
Patient Experience
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Level 3: Quality of the
Patient Experience
“
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Patient Centered Care
• Picker Foundation and Commonwealth Fund (1987): 8 dimensions of measurable patient-centered care:
– Access
– Respect for patient values, preferences
– Coordination of care
– Information, communication, education
– Physical comfort
– Emotional support, alleviation of fear/anxiety
– Involvement of friends and family
– Transition and community
Cleary PD, et al. JAMA 1997;278:1608-12
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Consumer Assessment of Healthcare
Providers and Systems (CAHPS)
• Agency for Healthcare Research and Quality
(AHRQ): (lead Federal agency in developing and
distributing standardized, evidence-based
surveys)
– launched CAHPS in mid-1990s based on work by the
Picker Foundation and Commonwealth Fund
– NCQA and CMS require CAHPS
– No application for psychiatry
www.cahps.ahrq.gov
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Quality of The Patient Experience
• ECHO (The Experience of Care and Health
Outcomes Survey):
– A registered CAHPS instrument
(public domain, validated, and usable for
comparisons)
– Designed for MH/SU outpatient areas.
http://www.cahps.ahrq/gov/CAHPSkit/files
http://www.hcp.med.harvard.edu/echo/home
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Press Ganey
• National patient satisfaction survey vendor
• Health industry’s most widely used approach to
collecting data on patient perspectives
– Data can be compared with prior years and
with comparable hospitals
• Inpatient domains include:
– Admission, unit, meals, nursing, psychiatry,
treatment team, program, discharge
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
This is Incorrect…
“Total Quality Management is 70 percent
attitude and 30% quality control.”
From Labovitz G, Chang YS, Rosansky V. Making Quality Work: A Leadership Guide for the
Results-Driven Manager, 1993. Wiley.
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
THE QUALITY PYRAMID
Safety
Accreditation Indicators
Patient Experience
Pay for Performance
Outcomes
High
Value Care
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Electronic Prescribing (eRx)
Year Incentive Penalty
2009 2%
2010 2%
2011 1%
2012 1% -1%
2013 0.5% -1.5%
2014 0 -2%
Incentive payment is the % of all Medicare Part B (FFS)
allowed charges during the reporting period.
http://www.cms.gov/PQRI/03_EPrescribingProgram
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Physician Quality
Reporting Initiative (PQRI)
•2006 Tax Relief and Healthcare
Act
•Some of the 186 measures pertain
to behavioral health
•Documenting 3 in 80% of
applicable visits qualifies for 1.5%
bonus on allowable Medicare
charges.
• Document DSM-IV criteria
for new episode MDD
• Document suicide risk at
each visit
• Maintaining anti-depressants
for 12 weeks
• Assessing pain
• Asking about tobacco use
• Counseling for smoking
cessation www.cms.hhs.gov/PQRI
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Pay For Performance
• Of the hundreds of PFP
programs,
few are in Behavioral Health
– Mostly in primary care,
mostly depression
Bremer RW et al. Psychiatry Serv 2008; 59:1419-29
• On the threshold of an explosion
of PFP
• Potential for non-incentivized
activities to be neglected
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Some Problems with PFP
• Incentives must be
meaningful
• Socioeconomic
penalty factor
• Professionalism
• Issue of how much
MDs control (e.g.,
pt. self-care)
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
THE QUALITY PYRAMID
Patient Experience
Outcomes
Pay for Performance
Accreditation Indicators
Safety
High
Value Care
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Emerging Quality Outcomes
in Surgical Care
• If you were going to have a knee replacement, you would want to know: How many procedures your surgeon had done
Time under anesthesia
Complication/infection rates
Post op days in hospital
Rehab days to recovery
6 month/1 year outcomes
Time to return to PGA tour
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Some Things You
Might Want to Know
• If you’re a 60 year old woman with 2 episodes
of major depression, now entering a third:
How often have you treated people like me?
Do you use evidence based methods?
For your practice:
• Rates of recovery/remission?
• Times to recovery/remission?
• Success in maintenance of recovery/remission?
• Success in getting patients back to work/family
• Quality of life
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
We should provide evidence-based care…
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
From Process to Outcome…
• The routine use of clinical outcomes measures is vital to determining what works and what does not work and to improve quality and reduce costs.
Berwick DM, et al. Med Care 2003;130-138
• Programs should move away from measures that focus on individual processes (e.g., whether 2 antipsychotics are prescribed) toward broader measures of quality, e.g., clinical outcomes The Commonwealth Fund Commission on a High Performance Health System, 2008
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Inherent Limitations of Process
(care segment) Indicators – Do not necessarily cover the
most important issues, but those with easily available consensus data
– Limited number:
• limits conclusions of overall quality
• does not appear to diffuse to overall quality
• focuses provider attention on limited scope
– There can be wide quality variation even if compliance with a few measures is uniform
– Can inhibit innovation
– May overwhelm providers
– Show problems but do not
suggest solutions
– Will inevitably lead to
micromanagement
Improving Mental Healthcare: A Guide to
Measurement-Based Quality Improvement. Richard
Hermann. APA Press, Washington, DC, 2005.
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Measuring Outcome:
Not the Standard of Care
in the Treatment of Depression
Survey of 314 Psychiatrists:
– 6.5% use scales almost all the time
– 11.4% use scales frequently
– 21.3% sometimes use scales
– 60.8% rarely or never use scales Zimmerman M, et al. J Clin Psychiatry 2008; 69: 1916-1919.
35
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Six Potential Obstacles
in Measuring Outcome
1. Patient acceptance
2. Clinician acceptance
3. Clinical utility
4. Cost
5. Clinical heterogeneity
6. Data aggregation
= Data aggravation
36
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Using Scales to Assess Outcome
Impractical to use the Ham-D in clinical practice
Use of a self-report scale
• Consider patient time
• Clinically Useful Depression Outcome Scale
(CUDOS) *
*CUDOS scale development and the following slides on Outcomes were developed by
Mark Zimmerman, MD, and are used here with permission
37
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
15 Desirable Features of a
Self-report Depression Outcome Scale
• Brief
• Acceptable to patients
• Covers all DSM-IV diagnostic criteria for major
depressive disorder
• Reliable (internal consistency and test-retest reliability)
• Convergent validity
• Discriminant validity
• Indicator of symptom severity
• Indicator of remission status
38
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
15 Desirable Features of a Self-report
Depression Outcome Scale
• Case-finding capability as a screening instrument
• Assesses psychosocial function
• Assesses quality of life
• Assesses suicidal thoughts
• Sensitive to change
• Easy to score
• Inexpensive
• Published in scientific literature
39
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Major Advantages of the CUDOS
• Covers the DSM-IV symptom criteria
• Assesses psychosocial function and quality of life
• < 2 minutes to complete (mean=103 seconds)
• <10 seconds to score
• Reliable, valid, sensitive to change
• Can be used to determine remission
• Free
Zimmerman, M., Posternak, M.A., & Chelminski, I. Using a self-report depression scale to
identify remission in depressed Outpatients. Am J Psychiatry 2004;161:1911-1913.
40
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Patient Acceptability of
Measurement-based Care
50 depressed outpatients in ongoing treatment
who completed CUDOS:
Measure of perceived burden and acceptability:
– 98% none-minimally burdensome
to complete
– 94% willing to complete at every visit
Zimmerman et al., Annals of Clinical Psychiatry, 2008
41
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
The Problem with Paper
Six Potential Obstacles in Measuring Outcome
1. Patient acceptance
2. Clinician acceptance
3. Clinical utility
4. Cost
5. Clinical heterogeneity
6. Data aggregation
– Data aggravation
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
How Might Outcome Data Be Used?
Evaluate efforts to improve outcome (quality)
Compare:
Institutions
Practices
Clinicians
The issue of case-mix severity will have to be
addressed.
48
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
How Can Outcomes Data Improve Outcome,
Treatment Efficiency, or Costs?
Examples of outcomes that could be assessed:
– Response
– Remission
– Treatment drop-out
– Disability days
– Work absenteeism/presenteeism
49
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Questions That Could Be Asked
If We Tracked Outcomes
• Do changes in formulary or co-pays affect response and remission rates?
• Do changes in insurance benefit impact outcome?
• Should visit frequency be decreased/increased for patients receiving
medication management?
• Does outcome tracking improve early identification of poor treatment
outcomes, thereby reducing emergency and hospital services?
• Does measurement based care result in improved outcome?
• Does measurement based care improve compliance and outcome?
50
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
How Do You Get Clinicians to Adopt a
Measurement-based Care Approach?
• Demand
• Educate and engage
• Incentives
– Improve referral stream
– Eliminate oversight
– Augment reimbursement
– Subsidize EMR management
51
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
THE QUALITY PYRAMID
Safety
Accreditation Indicators
Patient Experience
Pay for Performance
Outcomes
High
Value Care
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Evolving Towards High Value Care
• The goal is value: defined as better health per dollar spent
• Care is organized around medical conditions and care cycles
• Risk-adjusted outcomes and costs measured for each condition
• Rewards tied to results, not compliance
Outcome measurement is the only convincing way to make the case for more generous reimbursement for non-procedure based services
Porter ME and Teisberg EO. JAMA 2007;297:1103-1111
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
Challenges to the AMC
• One of NIMH 4 major objectives:
“Improve understanding of factors that affect access, quality and costs, and
means by which new evidence is disseminated and implemented.”
• Creates potential new and powerful alliance between academic talent and
quality initiatives
• Most academic programs lack mechanisms to encourage faculty engaged in
QI activities
Insel TR. Arch Gen Psychiatry 2009;66:128-133
Shojania KG, et al. JAMA 2009;301:766-768
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital
What if We Don’t?
Our inability to transform care based on outcomes will lead to
blunt approaches to cost cutting and limitations of services.
Rhode Island Hospital/Hasbro Children’s Hospital,
The Miriam Hospital, Bradley Hospital, Newport Hospital