1. No category

4/22/2012
The State of Quality &
Measurement in Indiana: Are We
Improving?
Katherine J. Wallace, RHIA
Director, Performance Improvement
Indiana Hospital Association
1
Objectives
• Review the current and future state of
health care measurement impacting our
hospitals’ financial state
• Examine Indiana’s standing nationally in
results for measures
• Review efforts taking place in Indiana to
improve efforts and if those efforts are
successful
1970’s
• Rising cost of medical care and fee-for-service
environment, risk management, medical
malpractice, and awareness that health careassociated infections can lead to litigation
• Hospitals began to track and reduce the
frequency of both endemic and epidemic
hospital infections
• Emerging pathogens and anti-microbial drug
resistance
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4/22/2012
1980’s
• 1984—Prospective reimbursement and
Diagnosis Related Groups as the basis for
payment
• Standard of hospital accreditation (The Joint
Commission) relevant to infection control
professionals and quality
• Theme of preventing infections and risk
stratification
1990’s
• “Quality assurance movement”
• Severity of illness and increasing risk among
hospital patients
• Blood-borne pathogens and occupational
infections received attention
• National Committee for Quality Assurance
(NCQA) reported data on managed care from
Health Plan Employer Data and Information Set
(HEDIS®)
2000’s
• Accountability
• Transparency
• Reflecting current evidence-based practice and
care
• Cost-effectiveness of prevention effectors
• Must include the entire health care delivery
system
• Public reporting of data via Web sites
• Value-based purchasing
• Health care reform
2
4/22/2012
IOM Reports That Have Influenced
Quality
• Crossing the Quality Chasm (2001):
Detailed investigation and recommendations.
(What is the problem?)
• Envisioning the National Healthcare
Quality Report (2001): Develops framework
for data collection. (How do we get
information about the problem?)
• Priority Areas for National Action (2003):
Identifies the focus of the assessment.
(Where do we begin?)
Major Conclusions: State of Quality
• Performance varies considerably
• The health care system is fragmented,
poorly organized, and does not make best
use of resources
• Increase of chronic illness has had a major
impact on the system
• System is confusing and too complex for
consumers
How is Success Defined? – 1980’s/1990’s
• Positive Margin
• Percent Market Share
3
4/22/2012
How is Success Defined? - 2012
• Top Clinical Performance
• High Marks on Patient Perception
• Low Readmissions
• Little to No Patient Harm
AND…..
• Positive Margin
• Percent Market Share
It is a Whole New World Out There!
Objectives
• Review the current and future state of
health care measurement impacting our
hospitals’ financial state
• Examine Indiana’s standing nationally in
results for measures
• Review efforts taking place in Indiana to
improve efforts and if those efforts are
successful
4
4/22/2012
Where Are We Now?
 57 total measures reported in 2011 for full
payment update:








AMI, HF, PN & SCIP inpatient – 27 (process)
30-day mortality & readmission -- 6 (outcome)*
Infection (CLABSI) – 1 (outcome)
Hospital-acquired conditions – 8 (outcome)*
HCAHPS
Outpatient – 7 (process)
Outpatient imaging – 4 (process)*
Registry participation response – 3
* Calculated from Medicare administrative/claims data
13
What Next?
New Inpatient Measures Collected in 2011 for
the 2012-2013 payment update:
 Central Line-associated blood stream infection
(CLABSI)
•
•
•
Chart-abstracted by hospital staff
New reporting system
Reported quarterly
 Hospital-acquired conditions
•
Calculated from Medicare claims
14
HAC Measures
8 measures required for 2012 payment update








Foreign object retained after surgery
Air embolism
Blood incompatibility
Pressure ulcer stages III & IV
Falls & trauma (Includes fracture, dislocation,
intracranial injury, crushing injury, burn &
electric shock)
Vascular catheter-associated infection
Catheter-associated urinary tract infection
Manifestations of poor glycemic control
15
5
4/22/2012
16
AHRQ Measures
Inpatient Quality:



Abdominal aortic aneurysm (AAA) mortality rate
Hip fracture mortality rate
Mortality for select medical conditions (composite)
Patient Safety:





Iatrogenic pneumothorax, adult
Postoperative wound dehiscence
Accidental puncture or laceration
Complication/patient safety for select indicators (composite)
Death among surgical patients with serious, treatable
complications


Post operative respiratory failure
Post operative PE or DVT
17
Other Measures
Composite medical conditions

Serious complications

Collapsed lung due to medical treatment

Serious blood clots after surgery

A wound that splits open after surgery on the abdomen or pelvis

Accidental cuts & tears from medical treatment

Pressure sores*

Infections from a large venous catheter*

Broken hip from a fall after surgery*

Bloodstream infection after surgery*
* Measure is included in the composite calculation but not reported separately
18
6
4/22/2012
19
Other Measures
Deaths for certain conditions






Deaths after admission for a broken hip
Deaths after admission for a heart attack*
Deaths after admission for congestive heart failure*
Deaths after admission for a stroke*
Deaths after admission for a gastrointestinal bleed*
Deaths after admission for pneumonia*
* Measure is included in the composite calculation but not reported separately
20
21
7
4/22/2012
Other Measures
Other complications & deaths



Deaths from serious treatable complications after
surgery
Breathing failure after surgery
Death after surgery to repair a weakness in the
abdominal aorta
22
23
2012-2014 IPPS Measures
2012 IPPS & OPPS final rules include final
measures for 2014 payment updates:

2012 Data Collection for 2014 payment update
•
•
•
•
•
ED Throughput (2)
Global Flu Immunization
Global Pneumonia Immunization
CDC NHSN Surgical site Infection (SSI)
CDC NHSN Catheter-associated urinary tract
infection
24
8
4/22/2012
2012-2014 IPPS Measures
2012 IPPS & OPPS final rules include final
measures for 2014 payment updates:

Participation in a systematic clinical database
registry for general surgery
• Jan – Dec 2012 time period
• Reported April – May 2013

Medicare Spending per Beneficiary (efficiency)
25
2012 IPPS Measures
10 ‘Topped Out’ Measures Suspended

AMI-1: Aspirin at arrival

AMI-3: ACEI or ARB at discharge

AMI-4: Smoking cessation

AMI-5: Beta blocker at discharge

HF-4: Smoking cessation

PN-2: Pneumococcal vaccination status

PN-4: Smoking cessation

PN-5c: Timing of initial antibiotic on arrival

PN-7: Influenza vaccination status

SCIP-Inf-6: Surgery patients with appropriate hair removal
26
Health Reform Law
For 2013, hospital value-based purchasing must
cover 5 specific conditions/procedures:
 Acute myocardial infarction
 Heart failure
 Pneumonia
 Surgeries, as measured by SCIP
 Healthcare-associated infections, as measured
by SCIP
2014 & beyond: measures must include efficiency
measures
27
9
4/22/2012
2015 IPPS Measures
2012 IPPS final rule includes 2013 Data Collection
for 2015 payment update:

Adds 3 Hospital-acquired infection measures
• MRSA bacteremia
• Clostridium difficile (C.Diff)
• Healthcare personnel influenza vaccination

Adds 14 chart-abstracted measures
• Stroke (8)
• VTE (6)
28
2011 Final Outpatient Rule
12 New Outpatient Quality Measures
 2012 payment update: Add 4 measures in 2011
•Imaging efficiency (3) – claims based
•Receipt of lab data electronically (attestation Aug 2011)
 2013 payment update: Add 8 measures in 2012
•ED efficiency (4)
•Patient left without being seen (attestation Aug 2012)
•Pain management (1)
•Stroke imaging (1)
•ED AMI care (1)
•Tracking clinical results between visits (attestation Aug 2012)
29
30
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4/22/2012
Quality Reporting Measures History
FFY 2005
payment
determination
FFY 2009
payment
determination
FFY 2007
payment
determination
10 Quality
Measures
37 Quality
Measures
21 Quality
Measures
FFY 2008
payment
determination
FFY 2006
payment
determination
10 Quality
Measures
87 Quality
Measures
57 Quality
Measures
FFY 2010
payment
determination
32 Quality
Measures
FFY 2013
payment
determination
FFY 2011
payment
determination
55 Quality
Measures
FFY 2012
payment
determination
FFY 2014
payment
determination
77 Quality
Measures
88 Quality
Measures
Quality Measure History
CMS Quality Measurement for Payment Update
Inpatient
Calendar
Year*
Abstract
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
10
10
21
24
26
26
27
27
29
25
Claims
2
3
16
14
24
24
25
Structural
1
3
3
3
4
Outpatient
Survey
(HCAHPS)
1
1
1
1
1
1
1
Abstract
5
7
7
7
14
21
22
Claims
4
4
7
7
7
IP & OP
Structural
TOTAL
1
1
2
4
10
10
21
32
37
55
57
77
87
88
*Year indicates when the measure is used for payment purposes
32
Implications of Hospital Measurement
& Public Reporting
•
•
•
•
Evidence-Based Care
Reputation
Reimbursement
Resource Use
11
4/22/2012
Pay for Performance Project Outcomes
• Annual estimate if all hospitals followed
standards of care
– For cardiac bypass
• 3,000 deaths avoided
– For pneumonia and cardiac bypass
•
•
•
•
$1 billion savings
6,000 fewer complications
6,000 fewer readmissions
½ Million fewer hospital days
Future CMS Agenda

HHS National Strategy for Quality Improvement in
Health Care
• Released March 21, 2011
•
http://www.healthcare.gov/center/reports/quality03212011a.html
•
Required by the Affordable Care Act
Purpose is to "establish a national strategy to improve the
delivery of health care services, patient health outcomes,
and population health“
Focus national, state and local efforts on common aims,
priorities and goals
Designed as an “evolving guide for the Nation” to improve
health and health care quality
•
•
•
35
Three Broad Aims
 Better Care
 Healthy People/Healthy Communities
 Affordable Care
36
12
4/22/2012
Focus on Six Priorities






Making care safer by reducing harm caused in care;
Engaging patients and family as partners in their care;
Promoting effective communication & coordination of
care;
Promoting the most effective prevention and treatment
practices for the leading causes of mortality, starting
with cardiovascular disease;
Working with communities to promote wide use of
best practices to enable healthy living; and
Making quality care more affordable for individuals,
families, employers and governments by developing
and spreading new health care delivery models
37
Measurement of Care Principle
 Develop national consensus on measures, data
sources and data collection
 Align measurement within value-based
purchasing programs
 Move toward measuring outcomes & patient
experience
 Minimize the burden of data collection by aligning
measures across programs
 Coordinate measurement with the private sector
 Integrate reporting with EHR meaningful use
38
Measure Applications
Partnership (MAP)
13
4/22/2012
Affordable Care Act of 2010
Law requires “pre-rulemaking process” for
HHS measure selection
 HHS must make public by Dec. 1 annually
measure list for consideration, including measures
suggested by the public
 Stakeholders provide input to HHS by Feb. 1
annually
 HHS publishes the rationale for selection of
measures not NQF-endorsed
 Assess impact of endorsed measures at least
every 3 years
40
2012 Measures for Consideration
366 new measures under consideration

23 CMS programs included
•
•
•
•
•
•


Acute care hospitals: 21 measures
Hospital VBP: 13
Inpatient Psych: 6
Inpatient Rehab: 8
LTAC Hospital: 8
Hospital EHR incentive: 39
95% of measures supported by external stakeholders
CMS to align measures across programs
41
14
4/22/2012
2012 Measures for Consideration
Acute Care Hospital
 Post-discharge transition composite measure (AMI,
HF, PN)
 Heart failure (5)
 Patients with an opiod given a bowel regimen
 Hip/knee complication
 Hip/knee readmission
 Hospital-wide readmission
 Safe surgery checklist
 Tobacco, alcohol & medication (8)
43
2012 Measures for Consideration
Value-based Purchasing (13)













Air embolism
AMI-10 Statin prescribed at discharge
Blood compatibility
Catheter-associated UTI
Central line-associated blood stream infection
Falls & trauma
IQI-91 Mortality for selected medical conditions (composite)
Manifestations of poor glycemic control
Medical spending per beneficiary
Pressure ulcer stages III & IV
PSI-90 Complication/patient safety for selected indicators
(composite)
SCIP-Inf-10 Surgery patients preoperative tempt management
Vascular catheter-associated infection
44
Health Reform
15
4/22/2012
Health Reform
Framework for Quality Measurement
 Value-Based Purchasing
 Reduce Avoidable Hospital Readmissions
 Reduce Hospital Acquired Conditions
 HITECH eMeasures Quality Reporting
 Accountable Care Organizations (ACO)
46
47
Health Reform
Hospital Value-Based Purchasing
 Final rule published 4-29-2011
 Tied to hospital performance on quality
measures
 Starts in FY 2013 based on 2011-2012
quality measure rates
 Includes phase-in period of years with
partial % of payments based on VBP
48
16
4/22/2012
CMS VBP Principles





Mix of standards, process, outcomes & patient
experience measures, including care transitions
& patient functional status
Move as quickly as possible to outcome &
patient experience measures
Align across Medicare/Medicaid public reporting
Minimize burden to providers
Align with meaningful use standards for EHR
49
CMS VBP Principles



“We believe that speed of implementation is a
critical factor in the success & effectiveness of
this program.”
Additional measures will be added to VBP
immediately after they are displayed on Hospital
Compare for one year, but without further
rulemaking.
Identified ‘topped out’ measures – 75th & 90th
percentiles were statistically indistinguishable
50
Health Reform Law
For 2013, hospital value-based purchasing must
cover 5 specific conditions/procedures:
 Acute myocardial infarction
 Heart failure
 Pneumonia
 Surgeries, as measured by SCIP
 Healthcare-associated infections, as measured
by SCIP
2014 & beyond: measures must include efficiency
measures
51
17
4/22/2012
VBP 2014 Measures (13 add’l)






AMI 30-day mortality
HF 30-day mortality
PN 30-day mortality
AHRQ indicator: Complication/patient safety for selected indicators
AHRQ indicator: Mortality for selected medical conditions
Hospital acquired conditions:
•
•
•
•
•
•
•
•
Foreign object retained after surgery
Air embolism
Blood incompatibility
Pressure ulcer stages III & IV
Falls & trauma
Vascular catheter-associated infection
Catheter-associated urinary tract infection
Manifestations of poor glycemic control
52
Accountable Care
ACO Final Rule Nov. 2




Can begin as an ACO in first 3 quarters of 2012
ACO can receive 50-60% of savings if they
exceed minimum quality standards
First year is pay-for-reporting experience; years 2
& 3 are a mix of pay-for-reporting & performance
33 quality measures
•
•
•
•
Patient/caregiver experience (7)
Care coordination/patient safety (6)
Preventive health (8)
At-risk population (12)
54
18
4/22/2012
ACO Final Rule Nov. 2

Data sources
•
•
•
•
CAHPS Survey (7)
Claims data (3)
EHR incentive program data (1)
Web interface with Group Practice Reporting
Option data collection tool (22)
55
HITECH eMeasures
HITECH Provisions




Shaped by The American Recovery and
Reinvestment Act (ARRA) of 2009
HITECH portion provides money to hospitals &
physicians to adopt EHRs with quality metrics
within the next 5 years
% of annual payment update for quality will
decrease
As much as 75% of annual payment update may
relate to adoption of EHRs
57
19
4/22/2012
HITECH Meaningful Use
Meaningful Use Goals:




Electronic exchange of health information to improve
quality of care
Reporting on clinical quality & other measures using
certified EHR technology
Hospitals must meet 14 core objectives for at least 90
days in the first payment year
MUST “Report clinical quality measures”
• For 2011 provide aggregate numerator,
denominator & exclusions through attestation
58
HITECH Meaningful Use
Meaningful Use Quality Reporting:
 Hospitals must report 15 measures in 3 sets
•
•
•




ED Throughput (2)
VTE (6)
Stroke (7)
No measures in current quality reporting program
Overlap with VBP measures in 2014-2015
113 Measures are ‘e-specified’ by NQF
Software certification must include measure
calculation by EHR for % reporting
59
What Should You Do?
 Monitor timelines & quality data collection
requirements closely through 2015
 Improve your baseline rates for hospital
acquired conditions and quality measures
 Prepare for more emphasis on infection and
public reporting of quality measures
 Continue efforts to automate quality data
collection and reporting with certified EHR
 Stay tuned to health care reform rules as
they are finalized
60
20
4/22/2012
Objectives
• Review the current and future state of
health care measurement impacting our
hospitals’ financial state
• Examine Indiana’s standing nationally
in results for measures
• Review efforts taking place in Indiana to
improve efforts and if those efforts are
successful
Value- Based Purchasing
62
Who is eligible for the VBP Program?
• Statutory definition of subsection (d) hospital found in Section 1886 (d)(1)(B)
Subsection D
Hospitals
• Hospitals subject to payment reductions under Hospital IQR
• Hospitals cited for deficiencies during the performance period that pose immediate jeopardy to
health or safety of patients
Exclusions under
Section
• Hospitals without the minimum # of cases or measures
1886(o)(1)(C)(ii)
Case/ Measure
Requirements
• Hospitals with at least 10 cases for at least 4 of the 12 applicable measures during the performance
period receive a Clinical Process of Care score
• Hospitals with at least 100 Hospital Consumer Assessment of Healthcare Providers and Systems
(HCAHPS) surveys during the performance period (July 1, 2011 – March 31, 2012) receive a Patient
Experience of Care score
63
21
4/22/2012
How Will Hospitals Be Evaluated under
the Hospital VBP Program in FY 2013?
12 Core Measures
(70% Weight)
Performance
attainment and
improvement
will determine
total hospital
reimbursement
1% Base DRG
Payments
HCAHPS Measures
(30% Weight)
Implementation FY 2013 (October 2012)
64
How Will Hospitals Be Evaluated under
the Hospital VBP Program in FY 2014?
13 Core Measures
(45% Weight)
Performance
attainment and
improvement
will determine
total hospital
reimbursement
HCAHPS Measures
(30% Weight)
1.25% Base DRG
Payments
Outcomes Measures
(25% Weight)
65
VBP Timeline
Jan
Feb
Mar
Apr
May
2012
Jun
Jul
Aug
Sep
Oct
Nov
Dec
13
Jan
FY 2013 Payment
Release simulated dry run report
FY2013 Clinical Performance
Period (7/1/11 - 3/31/12)
FY 2013 HCAHPS Performance
Period (7/1/11 - 3/1/12)
Provide hospitals with
ACTUAL incentive
adjustment for FY2013
Provide hospitals
with ESTIMATED
incentive
adjustment for
FY2013
Inquiry and appeals
period for FY2013
(30 days)
Fiscal Year 2015 Feedback
FY 2014 Performance
Adjust claims systems to accommodate the value-based incentive
FY 2014 Clinical Performance Period (4/1/12 - 12/31/12)
FY2014 HCAHPS Performance Period (4/1/12 - 12/31/12)
FY 2014 Outcomes (Mortality) Performance Period (7/1/11 - 6/30/12)
Release Medicare Spending per Beneficiary (MSPB)
Medicare Spending per
Beneficiary (MSPB)
Preview Period for 2015
Publish Proposed
IPPS Rule for FY
2015
Comment
Period - IPPS FY
2015
Publish Final IPPS
Rule FY 2015
22
4/22/2012
How Will Hospitals Be Evaluated?
67
Clinical Process of Care Measures
68
How Will Hospitals Be Evaluated?
Clinical Process of Care Domain
• Benchmark- score required to receive all
possible scoring points
– Mean performance score for the top 10% of all
hospitals during the baseline period
• Achievement – score below which no
scoring points will be awarded
– Median performance score for all hospitals
69
23
4/22/2012
Clinical Process Score
State Rankings - AMI
2
35
11
20
28
5
34
22
10
43
37
46
40
21
25
19 31
9
39
38
17
50
3
8
23
6
4
18
29
1
12
51 7
26
15
49
32
30
47
44
24
41
27
42
33
13
16
36
14
45
48
HANYS report- January 2012
Hospital Compare release
70
AMI Measures – FY2013
• AMI-7a Fibrinolytic Therapy Received
Within 30 Minutes of Hospital Arrival – *21,
29, 37, 40,
• AMI-8a Primary PCI Received Within 90
Minutes of Hospital Arrival Heart Failure –
24, 23, 9, 9
*State Ranking – January 2012, October, August, April 2011 Releases
Clinical Process Score
State Rankings –Heart Failure
4
37
43
29
33
25
50
14
38
18
41
24
7
11
32
17
48
51
19
12
21
16
13 28
46
3
22
30
15
8
45
1
34
40
2
31
47
23
9
36 20
44 35
26
39
5
49
42
6
10
27
HANYS report- January 2012
Hospital Compare release
72
24
4/22/2012
Heart Failure – FY 2013
• HF-1 Discharge Instructions – *28, 35, 9,
42
*State Ranking – January 2012, October, August, April 2011 Releases
Clinical Process Score
State Rankings - Pneumonia
5
19
35
42
13
23
14
34
2
29
25
7
21
30
33
47
37
3
48
26
44
50
20
28 16 15
27
24
43
18
45
17
41
36
6
40 12 22
11
1
10
8
38
32
46
39
9
51
4
31
49
HANYS report- January 2012
Hospital Compare release
74
Pneumonia – FY 2013
• PN-3b Blood Cultures Performed in the
Emergency Department Prior to Initial
Antibiotic Received in Hospital – *28, 28,
29, 31
• PN-6 Initial Antibiotic Selection for CAP in
Immunocompetent Patient – 38, 39, 41, 41
*State Ranking – January 2012, October, August, April 2011 Releases
25
4/22/2012
Clinical Process Score
State Rankings -SCIP
4
22
2
9
44
33
48
50
42
19
29
26
17
16
43
35
20
39
25
27
45
32
15
37
47
24
23 18 14
11
31
5
8
3
6
10
38
36
46
40
28
30 7
1
41
34
12
51
13
21
49
HANYS report- January 2012
Hospital Compare release
76
SCIP – FY 2013
•
•
•
•
•
•
•
SCIP-Inf-1 Prophylactic Antibiotic Received Within One Hour Prior to
Surgical Incision – *33, 31, 31, 25
SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients –
13, 19, 27, 24
SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within 24 Hours
After Surgery End Time –24, 23, 24, 23
SCIP-Inf-4 Cardiac Surgery Patients with Controlled 6AM
Postoperative Serum Glucose Surgeries – 19, 28, 31, 31
SCIP-Card-2 Surgery Patients on a Beta Blocker Prior to Arrival
That Received a Beta Blocker During the Perioperative Period – 25,
25, 21, 24
SCIP-VTE-1 Surgery Patients with Recommended Venous
Thromboembolism Prophylaxis Ordered – 32, 33, 39, 40t
SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous
Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to
24 Hours After Surgery – 30, 31, 36, 44
*State Ranking – January 2012, October, August, April 2011 Releases
SCIP-INF-9 – Post operative catheter removal post operative day 1 or 2 – added FY 2014
The Indiana Process Score Distribution
25
20
15
10
5
0
Process - April
Process - August
Process - Oct
Process - Jan
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99
3
21
17
16
11
9
2
1
0
2
5
10
21
19
10
9
6
2
1
1
1
7
18
17
14
15
9
2
2
1
2
5
13
15
15
17
7
7
3
1
78
26
4/22/2012
The Moving Target of Clinical Process
Measure Performance….
100
97
93
95
90
90
85
80
75
69
70
65
Percentile Rank
60
Overall Performance Rate
55
50
2006 Q4 2007 Q1 2007 Q2 2007 Q3 2007 Q4 2008 Q1 2008 Q2 2008 Q3 2008 Q4 2009 Q1 2009 Q2 2009 Q3 2009 Q4 2010 Q1 2010 Q2
79
Hospital Consumer Assessment of
Healthcare Providers & Systems
(HCAHPS)Providers and Systems
80
HCAHPS Composite Score
State Rankings
17
33
27
38
6
24
46
16
47
39
13
31
29
8
3
5
43
21
18
32
50
23
7
4
14
2
9
41
26
37 15
34
35
30
20
19
22
25
12
10
11 28
1
43
36
49
42
48
51
44
45
HANYS report- January 2012
Hospital Compare release
81
27
4/22/2012
HCAHPS Survey – Patient Perception
Composite
Question summary
Nursing
Communication – 8, 7, 7, 5*
Doctor
Communication – 16, 15, 16, 15
Responsiveness
of staff –10, 13, 12, 12
Pain Management –6, 7, 7, 8
Communication
of Medications – 22, 22, 23, 23
ALWAYS, Usually, Sometimes, Never
ALWAYS, Usually, Sometimes, Never
ALWAYS, Usually, Sometimes, Never
ALWAYS, Usually, Sometimes, Never
Doctor listen carefully
Doctor explanations are clear
Did you need help in getting to bathroom?
Staff helped with bathroom needs
Call button answered
Did you need medicine for pain?
ALWAYS, Usually, Sometimes, Never
ALWAYS, Usually, Sometimes, Never
ALWAYS, Usually, Sometimes, Never
ALWAYS, Usually, Sometimes, Never
ALWAYS, Usually, Sometimes, Never
ALWAYS, Usually, Sometimes, Never
Pain well controlled
Staff helped with pain
Were you given any new meds?
Staff explained medicine
Staff clearly described side effects
Did you go home, someone else's home, or to
another facility?
ALWAYS, Usually, Sometimes, Never
ALWAYS, Usually, Sometimes, Never
ALWAYS, Usually, Sometimes, Never
ALWAYS, Usually, Sometimes, Never
ALWAYS, Usually, Sometimes, Never
Own home, Someone else's home, another
facility (screening question)
Discharge Information – 17, 14, 19, 16 Staff discussed help need after discharge
Cleanliness (10, 10, 10, 9) and
Quietness (21, 21, 24, 24) of Hospital
Environment
Overall Rating –4, 4, 6, 6
Response Scale
Nurse courtesy and respect
Nurses listen carefully
Nurse explanations are clear
Doctor courtesy and respect
Written symptom/ health info provided
YES, No
YES, No
Area around room kept quiet at night
ALWAYS, Usually, Sometimes, Never
Room and bathroom kept clean
ALWAYS, Usually, Sometimes, Never
Hospital Rating Question
Willingness to Recommend –10, 9, 10, 10 Willingness to Recommend
0 to 10 point scale (percent 9 and 10
reported)
DEFINITELY YES, Probably Yes, Probably No,
Definitely No
82
*State Ranking – January 2012, October, August, April 2011 Releases
How Will CMS Calculate the Patient
Experience of Care (HCAHPS) Score?
Greater of
improvement or
achievement scores
for each of the eight
HCAHPS dimension
(80 points)
Consistency score
(20 points)
Patient
Experience of
Care Score
(100 points)
83
How Will Hospitals Be Evaluated?
Patient Experience of Care Domain
• Benchmark- score required to receive all
possible scoring points
– Mean of the top 10% performance of top box
scores
• Achievement – score below which no
scoring points will be awarded
– Median of top box scores
84
28
4/22/2012
•
•
•
How Will CMS Calculate the Patient
Experience of Care (HCAHPS) Score?
If all dimension rates are
greater than or equal to the
Achievement Thresholds: 20
Consistency Points
If any individual dimension
rate is less than or equal to the
worst-performing hospital
dimension rate from the
Baseline Period: 0 Consistency
Points
If the lowest dimension rate is
greater than the worstperforming hospital’s rate but
less than the Achievement
Threshold: 0-20 Consistency
Points awarded based on
consistency formulas
Domain
>50th
Percentile
Domain
>50th
Percentile
Domain
>50th
Percentile
Domain
>50th
Percentile
Domain
>50th
Percentile
20
Consistency
Points
Domain
>50th
Percentile
Domain
>50th
Percentile
Domain
>50th
Percentile
85
53 .
The Indiana HCAHPS Score
Distribution
25
20
15
10
5
0
HCAHPS - April
HCAHPS - Aug
HCAHPS - Oct
HCAHPS - Jan
0-9
0
0
0
0
10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99
6
20
14
12
11
10
6
0
3
6
18
12
20
7
12
4
2
3
4
16
17
14
12
14
4
1
4
5
15
14
17
11
10
8
2
3
86
The Exchange Function
• The total amount of value-based incentive payments
in aggregate be equal to the amount available for
value-based incentive payments
• High performance hospitals can earn back more than
their reduction.
• Funding for ‘incentive’ created by increasing amount
of hold back each year.
• FY 2013
1%
• FY 2014
1.25%
• FY 2015
1.5%
• FY 2016
1.75%
• FY 2017
2% Max
87
29
4/22/2012
VBP Current Estimate Payment
Percentages Score State Rankings
5
34
30
44
45
50
31
36
37
40
IN= 98.21%
9
49
15
6
23
10
13
46
1
33
48
28
14
39
21
26
29
16
22 27
42
8
32
38
3
7
18
4
24
12 2
19
41
20
47
17
35
xx
25
11
43
HANYS report- January 2012
Hospital Compare release
88
Sample Hospital VBP Score
VBP Trends - FFY 2013
Program - Current Estimate
Score
Process Domain
Patient
Experience
Domain
Hospital
Compare's
(1st quarter
2011)
Hospital
Compare's
(2nd quarter
2011)
Hospital
Compare's
(3rd quarter 2011)
Hospital
Compare's
(4th quarter
2011) *
Collection Dates: Collection Dates:
Collection Dates:
Collection Dates:
July 2009 - June
2010
Oct. 2009 - Sept.
2010
Jan. 2010 - Dec.
2010
Apr. 2010 - Mar.
2011
31.82%
48.18%
59.09%
64.55%
15 of 86
560 of 3054
15 of 85
509 of 3044
Rank within State
Rank within U.S.
34 of 82
20 of 84
1356 of 3063 766 of 3062
Score
Rank within State
Rank within U.S.
20.00%
18.00%
20.00%
21.00%
73 of 82
79 of 84
79 of 86
77 of 85
2030 of 3063 2348 of 3062 2288 of 3054 2235 of 3044
Score
Rank within State
Total
Rank within U.S.
Performance
Linear Payout Function Factor
Score
VBP Payment Percentage
Net VBP Gain/Loss
28.27%
39.13%
51 of 82
37 of 84
1704 of 3063 1103 of 3062
3.24
2.93
91.68%
114.59%
($32,500)
$57,000
47.36%
31 of 86
838 of 3054
2.63
124.57%
$95,900
51.48%
31 of 85
801 of 3044
2.43
125.04%
$97,800
Indiana VBP Scores
30
25
20
15
10
5
0
Overall - April
Overall - Aug
Overall - Oct.
Overall - Jan
0-9
0
0
0
0
10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99
14
21
19
15
6
4
1
2
0
7
19
24
15
10
6
1
2
0
4
14
23
16
17
8
2
2
0
4
8
23
16
18
9
4
3
0
90
30
4/22/2012
The Indiana Experience –2012 Release
Hospitals January
Total
Winners
Losers
85
48
37
$ Contributed to $ Paid Out of
Net Return VBP Pool VBP Pool January
January
January
$
20,798,379
$ 9,209,132.23
$11,589,247
20,426,948
$
371,431
$11,805,183
$2,596,051
$8,621,765 ($2,967,482)
91
The Indiana Experience – January 2012
Release
• Scores ranged from 17 to 89
• Associated payment returns from 41% of
withhold to 216% of withhold
• Losses ranged from $2,127 to $393,142 in
the first year
• Gains ranged from $63 to $302,571 in the
first year
92
Publication
• Hospital scores will be published on
Hospital Compare:
– Measure scores
– Condition-specific scores
– Domain-specific scores
– Total performance scores
• Hospitals will have 30 calendar days to
review and submit corrections
93
31
4/22/2012
Reducing Readmissions
94
ACA 3025- Readmissions Reduction
Program
• Reduces all Medicare payments to hospitals
with higher than expected 30‐day
readmission rates
• Effective October 1, 2012 – Federal Fiscal
Year 2013
• Rates from Hospital Compare measures
• Secretary has discretion to expand program
to all discharges
95
Overview of the CMS Methodology
• What is the current focus? (FY 2013)
– Heart Failure patients
– Heart Attack patients
– Pneumonia patients
• What will be added in the future? (FY 2014)
–
–
–
–
Chronic Obstructive Pulmonary Disease
Coronary Artery Bypass Graft
Percutaneous Transluminal Coronary Angioplasty
Other vascular procedures
96
32
4/22/2012
Overview of the CMS Methodology
• What hospitals are included?
– All acute care PPS hospitals
– Critical Access Hospitals are excluded
– Hospitals must have 25 discharges within a disease category
over the 3 year reporting period for public reporting via hospital
compare
– FY 13 includes discharges from July 1, 2008 through June 30,
2011
• Maximum Payment Reduction for facilities:
– 1% in FY 2013
– 2% in FY 2014
– 3% in FY 2015
97
Observed to Expected Ratio (O/E)
• O/E less than 1=
– Lower than expected readmission rate
– Better quality
• O/E greater than 1=
– Higher than expected readmission rate
– Lower quality
98
Sample Medicare Readmission
Reduction Analysis
Calculation of Excess Payments Due to
Readmissions
Number of Patients
Number of Readmissions
Hospital 30-Day Readmission Rate
U.S. 30-Day Readmission Rate
Statistical Relationship to U.S. Average *
Excess Readmission Ratio [A / B]
Excess Readmission Factor [C - 1, if C is > 1]
Medicare Inpatient Operating Payments by
Condition (MedPAR FFY 2010)
Estimated Excess Payment [D * E]
Heart Attack Heart Failure
350
701
64
143
18.3%
20.4%
19.8%
24.8%
Pneumonia
507
88
17.3%
18.4%
No Different Better than No Different
than U.S.
U.S. National
than U.S.
National Rate
Rate
National Rate
0.92
0.00
0.82
0.00
0.94
0.00
$1,717,000
$2,087,400
$1,312,600
$0
$0
$0
Time Period Reflected: July 1, 2007 –June 30, 2010
Actual FFY Period: July 1, 2008 – June 30, 2011
33
4/22/2012
What is higher than expected?
• A hospital’s risk-adjusted readmission rate
will be compared to the unadjusted/raw
U.S. average rate
• The result of this calculation will be an
Excess Readmission Ratio.
• If a hospital performs worse than average,
the ratio will be greater than 1.0 and the
hospital will be subject to a payment
penalty.
The Anticipated Indiana Experience –
Year 1 – August 2011 Release
• 43 hospital with no projected loss
• 38 hospitals with projected losses year one
ranging from $1400 - $753,200
–
–
–
–
–
–
Thirteen hospitals over $100,000
Nine hospitals between $50,000 - $100,000
Five hospitals between $25,000 - $50,000
Eight hospitals between $5,000 - $25,000
Three hospitals between $1,000 - $5,000
Zero hospitals under $1,000
101
Readmission Policy Issues
• Methodology not yet finalized
– No differentiation in planned, potentially preventable,
and unrelated readmissions for HF and PN
– Current methodology combines three years worth of
data into one measure so very difficult to make
progress in one year
– Hospitals do not have control over every factor that
affects readmissions – e.g., personal, physician,
community factors, and socioeconomic conditions
102
34
4/22/2012
ACA 3026 – Community–Based Care
Transition Program (CCTP)
• Develop a CCTP for hospitals with high
readmission rates
• The CCTP provides funding to test models
for improving care transitions for high risk
Medicare beneficiaries
• Part of larger Partnership for Patients
initiative through the US Department of
Health and Human Services
• $500 million is available for qualifying acute
care hospitals and community based
organizations
103
The Indiana Experience
• Four hospitals are in the 4th quartile in all
three patient populations
• Additional 13 hospitals are in the 4th
quartile in two of the three patient
populations
– 7 Acute Myocardial Infarction
– 8 Heart Failure
– 11 Pneumonia
Feb. 2012 4th Quartile Hospitals
104
Reduce Hospital Acquired
Conditions
105
35
4/22/2012
Medicare Recognized Hospital-Acquired
Conditions (HAC)
•
•
•
•
•
•
•
•
•
•
Object Left in Surgery
Air Embolism
Blood Incompatibility
Stage III and IV Pressure Ulcers (Decubitus Ulcers)
Falls and Trauma
Catheter-Associated Urinary Tract Infections (UTIs)
Vascular Catheter-Associated Infection
Glycemic Control (Diabetic Ketoacidosis/Nonketotic
Hyperosmolar Coma)
Surgical Site Infections – Orthopedic, CABG, and Bariatric
surgeries; and
Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE)
106
HAC Medicare Payment Impacts
• Current: reduces payments to hospitals for certain
cases where one of the conditions recognized was
not present on admission (POA) and, therefore,
considered to be acquired in the hospital.
• Beginning in FFY 2011: CMS will publicly report
eight of these HAC categories under the inpatient
quality reporting program. (Available March 31,
2011)
• Beginning in FFY 2015: hospitals in the bottom
quartile of risk-adjusted HAC rates will be subject
to a 1.0% payment penalty under Medicare as
mandated by the Affordable Care Act (ACA) of
2010.
107
HAC - The Anticipated Indiana
Experience
• Review of October 1, 2008 through June
30, 2010 data show that eleven Indiana
hospitals would be at risk for a 1% penalty
in FFY 2015.
108
36
4/22/2012
Sample
Hospital Acquired Conditions
Foreign
Blood
Pressure
Object
Air Embolism Incompatibili Ulcers Stages
Retained
ty
III and IV
After Surgery
Number of HAC
Occurrences (Numerator)
Number of Eligible
Discharges (Denominator)
Vascular
Catheter- Manifestatio
Catheter- Associated ns of Poor
Associated Urinary Tract Glycemic
Infection
Infection
Control
Falls and
Trauma
Overall
0
0
2
3
6
0
2
1
2,651
8,879
8,879
8,879
8,879
8,879
8,879
8,879
Hospital HAC Rate
(per 1,000 discharges)
Hospital's National
Quartile Ranking
0.000
0.000
0.225
0.338
0.676
0.000
0.225
0.113
1st
1st
4th
4th
3rd
1st
3rd
4th
3rd
Indiana HAC Rate
(per 1,000 discharges)
National HAC Rate
(per 1,000 discharges)
0.074
0.002
0.004
0.065
0.519
0.251
0.274
0.051
1.240
0.090
0.003
0.001
0.134
0.565
0.367
0.317
0.050
1.527
Rate per 1,000 Discharges
1.577
Bottom Quartile,
1.844
Total Medicare HAC Rate
2.000
14
1.577
1.527
Elkhart General
Healthcare
System
National Rate
1.500
1.000
0.500
0.000
In Summary…
Number of hospitals who experienced
losses in one, two, or all three programs
Program Loss
Number
VBP
14
VBP/HAC
3
VBP/Readmission
19
VBP/HAC/Readmission
1
HAC/Readmission
2
HAC
5
Readmission
14
VBP – Jan. 2012 Release
Readmissions – Aug. 2011 Release
HAC – Apr. 2011 Release
110
The Stakes are Increasing!
Potential Negative Impacts to Base DRG Payments….
Fiscal Year
VBP
Readmissions
HAC
Total
2013
1.00%
1.00%
-
2.00%
2014
1.25%
2.00%
-
3.25%
2015
1.50%
3.00%
1.00%
5.50%
2016
1.75%
3.00%
1.00%
5.75%
2017
2.00%
3.00%
1.00%
6.00%
111
37
4/22/2012
Physician Documentation
Improvement & Coding
How You Can Support
Accuracy in Reimbursement and Profiling of
Severity & Mortality for Your Organizations
Documentation Improvement
• Concurrent chart review
• Promote accurate documentation, provide
physician education on documentation
requirements for coding
• Promote accurate coding according to
regulatory compliance standards accepted
by CMS
Impact of Documentation
• Hospital & Physician Performance
– Severity of Illness
– Risk of Mortality (Actual vs Expected)
– Actual vs. Expected Readmission Rates
– Utilizations of Resources
– Pay for Performance
38
4/22/2012
Improved Documentation
• Reflect the patient’s true severity of illness
(SOI)
• Reflect the patient’s true risk of mortality
(ROM)
• Explain the length of stay (LOS)
• Explain resources consumed
SOI/ROM
Severity levels have weights, used to provide
comparisons in profiling by severity-adjusted
statistics.
Level
Severity
Level
Mortality
1
Minor
1
Minor
2
Moderate
2
Moderate
3
Major
3
Major
4
Extreme
4
Extreme
Cardiac Case Study
• 70 year old male presents with c/o chest
heaviness, SOA, and neg. cardiac profile.
• Documented PMH: Diabetes, renal
insufficiency, hx tobacco abuse
• Procedure: L & R heart cath with
arteriography
• Principal Dx: CAD with unstable AP
• DRG: Circ d/o except AMI with cath & with or
without complex diagnosis (124 or 125?)
39
4/22/2012
Secondary Dx Impact on APR-DRG
Option 1
Option 2
Option 3
Option 4
DRG 125
Circ. d/o w/
cath w/o comp dx
RW=1.0530
DRG 125
Circ. d/o w/
cath w/o comp dx
RW=1.0530
DRG 124
Circ. d/o w/
cath w/ comp dx
RW= 1.4099
DRG 124
Circ. d/o w/
cath w/ comp dx
RW= 1.4099
UAP w/ CAD;
T2DM; RI; HTN
NOS; Hx tobacco
APR-DRG
wt=0.4655
UAP w/ CAD; T2DM
uncontrolled; RI;
HTN, malignant
ess.; hx tobacco;
COPD exac;
hypoxemia
APR-DRG
wt= 0.5523
UAP w/ CAD; T2DM
uncontrolled; malig
HTNive HD w/ CKD
(NOS) & HF (comp);
COPD exac;
hypoxemia; hx tob.
APR-DRG
wt=1.5914
UAP w/ CAD; T2DM
uncontrolled; malig
HTNive HD w/ CKD
IV & dcmp sys CHF;
COPD exac; hx tob.;
acute resp failure;
mech vent <96 hrs.
APR-DRG
wt=3.4451
SOI=1
ROM=1
SOI=2
ROM=2
SOI=3
ROM=3
SOI=4
ROM=4
Impact of Complete Documentation
MS DRG 195 w/o
MCC/CC
PDx: Pneumonia
Organism,
Unspecified
MS DRG 193 with
MCC
PDx: Pneumonia
Organism,
Unspecified
SDx: COPD with
SDx: COPD
Exacerbation
Malnutrition, protein
calorie
Pressure Ulcer, Stage
Decubitus Ulcer
IV
Have reached the
highest MS-DRG
APR-DRG: 139
APR-DRG: 140
APR-DRG: 141
APR-DRG: 142
SOI Level:
1
SOI Level:
2
SOI Level:
2
SOI Level:
3
APR Weight: 0.4060 APR Weight: 0.6329 APR Weight: 0.6329 APR Weight: 0.9814
ROM Level: 1
ROM Level: 1
ROM Level: 2
ROM Level: 2
MS DRG 194 with CC
PDx: Pneumonia
Organism,
Unspecified
SDx: COPD with
Exacerbation
MS DRG 194 with CC
PDx: Pneumonia
Organism,
Unspecified
SDx: COPD with
Exacerbation
Malnutrition, protein
calorie
MS DRG 193 with
MCC
PDx: Pneumonia
Organism,
Unspecified
SDx: COPD with
Exacerbation
Malnutrition, severe
protein calorie
Pressure Ulcer, Stage
IV
APR-DRG: 143
SOI Level:
3
APR Weight: 0.9814
ROM Level: 3
Peer Group Mortality Peer Group Mortality Peer Group Mortality Peer Group Mortality Peer Group Mortality
Rate: 0.3%
Rate: 0.3%
Rate: 2.3%
Rate: 2.3%
Rate: 9.2%
Changes SOI & MSChanges SOI & MSDRG
Changes ROM
DRG
Changes ROM
Sensitivity to Illness Burden
Sensitivity to Illness Burden & Risk
of Mortality: An Example
SECONARY DIAGNOSIS
MEDICARE DRG
APR DRG
APR DDRG SOI
APR DRG ROM
APR DRG Relative Weight
MORTALITY RATE
(APR DRG ADJUSTED)
Principal DX: Congestive Heart Failure
CASE 1
CASE 2
COPD, atrial fibrillation
127 Heart Failure & Shock
194 Heart Failure
1 minor
1 minor
0.07847
1.7%
COPD, atrial fibrillation,
respiratory failure acidosis,
decubitus ulcer,
malnutrition, cardiogenic
shock
127 Heart Failure & Shock
194 Heart Failure
4 extreme
4 extreme
2.9128
36.3%
40
4/22/2012
The Impact of Coding
• Expected ROM and SOI are dependent
upon comprehensive capture of thorough
documentation and subsequent coding of
the conditions
Organizational Strategies
• Pay attention to the data reported to
government agencies—others use it
• Hardwire for information, gathering, retrieval,
reporting, and validation
• Develop interfaces to support practice
• Ongoing education and information— sharing
is essential
• Participate in national and state quality
initiatives that meet your needs
Objectives
• Review the current and future state of
health care measurement impacting our
hospitals’ financial state
• Examine Indiana’s standing nationally in
results for measures
• Review efforts taking place in Indiana
to improve efforts and if those efforts
are successful
41
4/22/2012
National Partnership for Patients
• National program launched on April 12, 2011
• Focus on two aims by 2013:
– Reduce hospital readmissions by 20%, and
– Reduce hospital-acquired harm by 40%
• Up to $1 billion in funding for the program
• CMS expects to save $35 billion in health
care costs
124
Help patients heal without
complication
• By the end of 2013, preventable
complications during a transition from one
care setting to another would be decreased
so that all hospital readmissions would be
reduced by 20 percent compared to 2010.
– more than 1.6 million patients will recover
from illness without suffering a preventable
complication requiring re-hospitalization within
30 days of discharge.
125
Keep hospital patients from getting
injured or sicker
• By the end of 2013, preventable
hospital-acquired conditions would
decrease by 40 percent compared to
2010.
– Achieving this goal would mean
approximately 1.8 million fewer injuries
to patients, with more than 60,000 lives
saved over the next three years.
126
42
4/22/2012
Impact of Partnership for Patients
• Large scale funded national initiative
• Aims aligned with Indiana priorities
• Takes statewide and regional
improvement efforts to scale
• Encourages local adaptation with the
discipline of organized effort and
measurement
Indiana/HRET HEN Summary
• 120 Indiana hospitals aligned with IHA/HRET
• Includes:
–
–
–
–
26 critical access hospitals
8 psychiatric hospitals
5 rehabilitation hospitals
4 long term acute hospitals
• Other HENs in Indiana include: Ascension
(18), VHA (3), NAPH (1), UHC (1), Ohio
Children’s Hospital collaborative (1), Joint
Commission Resources (1)
128
Are you interested in improvement
support from AHA/HRET/IHA? - Feb.
100
90
80
70
60
Want Help
50
Maybe
40
No Help
30
20
10
0
READ
Falls
CAUTI
PU
SSI
ADE
VTE
CLABSI
OB
VAP
43
4/22/2012
IHA’s Plan
Design
HRET (Prime Contractor)
HRET National Education:
•Access to National Programs
•4 groupings of 10 topics
•Plus HCAHPS,TeamSTEPPS
(AHRQ funded activities)
• Fellowship Programs
• Stand-alone programs (Webinars
educational sessions, etc)
•Learning networks
IHA (Subcontractor)
Direct and Shared Services Support:
• Regional coalitions and affinity groups
• Administrative/organizational support
• Local support and facilitation
Technical Assistance:
•Purdue Healthcare TAP and CMSA
•Individual hospital plans/assessments
•Statewide coaching network
•Communities of Practice (Lean, Med Safety)
HRET Support:
•Measurement warehouse
•Best practice clearing house
•Access to national experts
•Partially defray data collection costs
Indiana Education:
•State and regional education:
• Key topics from needs assessment
•Tools training (Lean certification,
medication safety, etc)
130
•Leadership for cultural improvement
Ten regional coalitions cover
Indiana: only state in the country with
this model
Members agree not to compete on
patient safety
Create layered model of regional
coalitions and affinity groups –
Indiana’s “transformation grid” to
support dissemination
Benefits:
• Innovate at the front lines
• Align with state and national
efforts, and standardize when
beneficial
• Model builds local and hospitalspecific capacity for improvement
and innovation
• Encourages safety leadership at all
levels across multiple professions
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Leading Transformation in Indiana
Assessing and
Organizing
Building Lasting
Capacity
Individual hospital plan
based on the needs
assessment
Medication Safety Webbased CEU/certification (10
per hospital)
Safety Coalition and affinity
group support
Lean leadership overview
(2 per hospital)
HRET content offerings
Lean certification (2 green
belts, 1 black belt per
hospital)
IHA/Purdue coaching
Innovation and Transforming
Care
Joint programs with Health
Care Excel and other HENs
Leadership for Safety
(CEOs, Trustee, and Safety
Leaders)
Driving
Improvement
HAI Focus (CLABSI, CAUTI,
SSI, VAP)
IHA – Sepsis mortality
Obstetric Adverse Events
(IHA/ISDH/FSSA/March of
Dimes – with IHI support)
Transforming Care at the
Bedside – Pressure Ulcers,
Falls, Teamwork)
Medication Adverse Events
and Readmissions
+
Culture/Leadership/Teamwork
All Cause Harm
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Education by Topic
CAUTI: HRET CUSP: CAUTI
CLABSI
SSI
VAP
Readmissions
Adverse Drug Events
Obstetric Harm
Harm from Falls
Pressure Ulcers
HRET “Stay FIT”:
– Safe Surgery
VAP
– On the CUSP:
CAUTI/CLABSI
HRET: Reducing
RED
IHA: CAUTI First
Focus
Sepsis Mortality
Reduction
(Coalitions)
Link to IN – APIC
NHSN training
IHA: ADEs and
Readmissions
Mini-collaborative
HRET: Reducing
EEDs (CMS first
focus)
IHA: Reducing
EEDs (partners)
HRET: “PIVOT”
Collaborative
IHA: Transforming
Care at the
Bedside elements
VTE
Additional Topics
•
•
•
•
•
•
Leadership Systems
Culture of Safety
Teamwork and Communications
Lean Training
Innovation and Transformation
Preventing All-Cause Harm
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System-Level Redesign
Every system is perfectly designed
to achieve exactly the results it
gets. *
New levels of performance can
only be achieved through
dramatic system-level redesign.
*Don Berwick
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Four Levels of Change Required
• Changes at Level A: experience of the
patients and communities
• Changes at Level B: “microsystems” of
care
• Changes at Level C: health care
organizations
• Changes at Level D: health care
environment
Berwick DM. A user's manual for the IOM's 'Quality Chasm'
Report. Health Affairs. 2002; 21(3):80-90.
136
Transformation is Personal!
• Stories are important means of
demonstrating urgency
• Involve patients and families
• Connect health care workers at the
level of the heart
• Berwick: Changes at Level A are the
“true north” of improvement
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4/22/2012
Indiana Sepsis Mortality Rates
Septicemia Mortality Rates - Impact of 3 Regional Coalitions
25.00%
23.00%
21.00%
19.00%
17.00%
15.00%
13.00%
11.00%
9.00%
7.00%
5.00%
1Q2008
2Q2008
3Q2008
Coalition A
4Q2008
1Q2009
Coalition B
2Q2009
3Q2009
4Q2009
Coalition C
1Q2010
2Q2010
3Q2010
4Q2010
1Q2011
2Q2011
3Q2011
Statewide
Next Steps
• Creating individual hospital plans
• Scheduling Purdue Executive Sessions
and Lean training
• National collaborative launch
• National webinars
• Coaching calls (National and Indiana)
• Measurement (baseline and monthly)
• Communications and web sites launch
Indiana’s Bold Aim:
To make
Indiana the
safest place to
receive health
care in the
United States,
if not the
world
Inaugural Indiana Patient Safety Summit - March 2010
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4/22/2012
“A rising tide
lifts all boats.”
Model for Managing Change
Vision
Skills
Incentives
Resources
Action Plan
CHANGE
Skills
Incentives
Resources
Action Plan
CONFUSION
Incentives
Resources
Action Plan
ANXIETY
Resources
Action Plan
GRADUAL
CHANGE/DE-ENERGIZED
Action Plan
FRUSTRATION
Vision
Vision
Skills
Vision
Skills
Incentives
Vision
Skills
Incentives
Resources
FALSE
STARTS/CYNICISM
FOUNDATION SKILLS
Influencing, Enhancing Participation, Proactivity, Tolerating Ambiguity,
Communication/Connection-Building, Surfacing Assumptions
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4/22/2012
Contact
Kathy Wallace
Director, Performance Improvement
Indiana Hospital Association
[email protected]
(317) 423-7740
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