Tmp Cms Quality Lunch & Learn Final

SWO-HFMA : Lunch and Learn

Quality of Care

Cost Leadership, Methodology and Technology

October 30, 2009

Presenters: Sunil Rao, MD, MBA, Chief Medical Officer, TMP

Jeff Burke, MBA, Managing Partner, TMP

2www.T-M-Partners.net

You will Learn

1. The importance of Quality to national healthcare reform

2. The financial impact Quality can have on every part of your hospital

3. The connection between “Meaningful Use”, the ARRA and EHR use; and the reporting of CMS Quality Core Measures

4. How to move from "just reporting" quality measures to a Quality Management Program for Improved Patient Outcomes based on methods and technology

5. The importance of real time data and process improvement methodologies to the critical issue of improving quality of care processes in healthcare

6. The critical part that (IT) information technology plays in the sustaining platform for continuous improvement

www.T-M-Partners.net

Agenda

• What is Quality in Healthcare?• Why is Quality so Important?• Finance and Executive Buy-in• Methodologies• Technologies• Q&A

Thoughts for Today

• Consider these issues:• Is Quality Improvement a “Burning Platform”?• In the long run, everything is focused on improving Quality• CMS says, Quality will improve their financial health• CMS may not care about your bottom line• CMS will pay the winners and penalize the others• ARRA will pay to accelerate IT adoption, but only based on Quality• Methods and Technologies can help• You need a Quality Improvement Roadmap and CEO Backing

Agenda

Healthcare IndustryKey Quality Drivers

• Patient-Centered Quality Care• Quality is a Board Level issue• Compliance is Required• CMS Pays for Performance

Cost of Compliance

Net Profit

QualityPatient

If Quality Outcomes had been improved by 2% in 2004, the national savings would have been:

• 5,700 avoidable death• 1 million hospital days• $1.4 billion

Better patient care costs hospitals less and improves patient outcomes

Elimin

The Industry Today

The Goal

Talking About Quality June 2009

Health Care Today | Misuse

Definition of Misuse

Committee on Quality of Health Care in America, Institute of Medicine. To Err is Human: Building a Safer Health System. Washington: National Academies Press, 1999.

“Misuse” of care is another way of describing medical errors, which can be defined as either the failure to properly carry out appropriate treatment plans or the use of inappropriate plans.

Deaths Due to Preventable Errors

Committee on Quality of Health Care in America, Institute of Medicine. To Err is Human: Building a Safer Health System. Washington: National Academies Press, 1999.

Deaths Due to Health Care-Associated Infections

Klevens RM, Edwards JR, Richards CL, Jr., et al. "Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002." Public Health Reports, 122: 160-166, 2002.

Health Care Today | Overuse

Definition of Overuse

When treatments are given without medical justification, such as antibiotics for simple infections, or when an equally effective option could have been followed that would have cost less or caused fewer side effects.

Unnecessary—and Possibly Harmful—Services

Fisher ES, Goodman DC, Chandra A. Disparities in Health and Health Care among Medicare Beneficiaries: A Brief Report of the Dartmouth Atlas Project. Princeton, NJ: Robert Wood Johnson Foundation, 2008.

Health Care Today | Overuse

Health Care Today | Underuse

Definition of Underuse

When patients do not receive medically necessary care, or when proven health care practices are not followed, e.g., when people who have heart attacks are not given beta-blocking drugs.

Recommended Care

McGlynn EA, Asch SM, Adams J, et al. "The Quality of Health Care Delivered to Adults in the United States." The New England Journal of Medicine, 348: 2635-2645 (26): 1, 2003.

Deaths Due to Improper Care

Essential Guide to Health Care Quality. Washington: National Committee for Quality Assurance, 2007. (No authors given.)

Agenda

News about Quality Every Day

CMS chief says Medicare should consider cost to determine coverageCMS Director Dr. Barry Straube is expected to play a critical role in ensuring that health care spending is closely linked with the quality of care as White House officials and lawmakers scramble to pass a health care reform bill. Straube says cost should be considered in deciding which treatments should be covered by Medicare in order to address rising health care costs.

www.T-M-Partners.net 18

The Wall Street Journal (10/27/09)

The HFMA believes that achieving the nation’s health goals requires effective reform of the payment system

“Payment reform will strengthen, if not codify, the relationship between payment and quality, with a significant amount of revenue at risk if quality goals are not achieved.”

Catherine Jacobson, FHFMA, CPA, Chair HFMA

Breaking Barriers

Why is Quality so Important?

• In the long run, everything is focused on improving Quality• CMS says, Quality will improve their financial health• Meaningful Use = CMS Quality Core Measures (Plus other items)

• CMS• Pay for Reporting• Pay for Performance• Value Based Purchasing

• ARRA• Certified EHR• Meaningful Use

CMS has been pursuing this since

before 2005

ARRA raises the ante and pays for

faster action

Quality is worth

What is your Plan?

What Does VBP Mean to CMS?

Transforming Medicare from a passive payer to an active purchaser of higher quality, more efficient health care

Tools and initiatives for promoting better quality, while avoiding unnecessary costs

Tools: measurement, payment incentives, public reporting, conditions of participation, coverage policy, QIO program

Initiatives: pay for reporting, pay for performance, gainsharing, competitive bidding, bundled payment, coverage decisions, direct provider support

Premier Hospital Quality Incentive Demonstration

CMS/Premier HQID Project Participants Composite Quality Score: Trend of Quarterly Median (5th Decile) by Clinical Focus Area

October 1, 2003 - September 30, 2006 (Year 1 and Year 2 Final Data, and Yr 3 Preliminary)

8%92.5

3%93.5

4% 98.2

AMI CABG Pneumonia Heart Failure Hip and Knee

Clinical Focus Area

4Q03 1Q04 2Q04 3Q04 4Q04 1Q05 2Q05 3Q05 4Q05 1Q06 2Q06 3Q06

Health Care Today | Variations in Care

Overall Improvement is Slowing

National Healthcare Quality Report. Rockville, MD: Agency for Healthcare Research and Quality, 2008. (No authors given.)

FY 2010–FY 2011 FY 2012 and Beyond

Efficiency measuresOutcomes measuresEmergency care measuresCare coordination measuresPatient safety measuresStructural measures

Performance areas to address measure gapsExpect need for new measure development

Additional Measure Topics for FY 2010 and Beyond

HACs Selected During IPPS FY 2008 Rulemaking

• Foreign object retained after surgery• Air embolism• Blood incompatibility• Catheter-associated urinary tract

infection• Vascular catheter-associated infection• Surgical site infection – mediastinitis

after CABG• Pressure ulcers• Falls – specific trauma codes

HAC, POA

• “Since 2008, hospitals that cannot document certain conditions as POA have faced Medicare payment reductions. Medicare has also stopped paying for … Never Events. Next on the radar screen; Preventable Readmissions.

• “Financial leaders should engage with clinicians to work toward avoiding preventable complecations – something both groups want. And we need to develop costing capabilities so we know what these events are costing us.

• “It isn’t about the lost revenue anymore; it’s about preventing the complications and the associated costs in the first place.”

• Catherine Jacobson, FHFMA, CPA, Chair HFMA• Letter from the Chair, HFM Magazine, October 2009

ARRA – Hospital HITMedicare Funding Is Provided to Encourage the Adoption of HIT

ARRA Provisions

• Hospitals Using Certified EHR During A Reporting Year Are Eligible.

• Payment for Qualified Facilities Is Based on the “Medicare Share.”

• Payments Are Phased Over Four Years Beginning in 2010.

• Non-Adopting Hospitals Face Reduction to Three-Quarters of Their Medicare Market Basket Update, Starting in 2015

Base payment is $2M plus $200 per discharge for additional discharges from 1,150 to 23,000th

Reduced using a ratio based on Medicare utilization adjusted for charity care.

• Early adopters will receive payments from Medicare during the implementation corridor, 2010 to 2015.

• Laggards will see reductions in Medicare payments beginning 2015.

• Monitor the Office of the National Coordinator for HIT to stay abreast of standards, specifications and certification criteria.

• Instead of bolting EHR on top of existing processes, facilities should re-engineer patient care and billing workflows to increase efficiency and quality.

Implications for Hospitals

ARRA – Hospital HIT

Year 1 Year 2 Year 3 Year 4

“Meaningful” users of HIT will receive additional payments from Medicare…

Percentage of HIT Medicare Share Payments Received Based on When Eligible

…while non-adopters will have their Medicare market basket update reduced

Percentage of Market Basket Update Received by Non-Adopters

2010 - 2013

2014 2015 2016Eligible in:

2015 2016 2017

Meaningful Use

• “CMS is expected to publish a formal definition of meaningful use, for the purposes of receiving the Medicare and Medicaid incentive payments, by December 31, 2009.”

• “Meaningful use of EHRs, we anticipate, will also enable providers to reduce the amount of time spent on duplicative paperwork and gain more time to spend with their patients throughout the day.

• “Meaningful use, in the long-term, is when EHRs are used by health

care providers to improve patient care, safety, and quality.

A Message from Dr. David Blumenthal, National Coordinator for Health Information Technology

2009 2011 2013 2015

HIT-Enabled Health Reform

HITECH Policies 2011 Meaningful

Use Criteria (Capture/share

data)2013 Meaningful

Use Criteria(Advanced care processes with

decision support)

2015 Meaningful Use Criteria (Improved Outcomes)

Meaningful Use is Being Defined and Will Follow an “Ascension Path” Over Time*

*Report of sub-committee of Health IT Policy Committee

Policy Committee Recommendations for the Definition of Meaningful Use

Cost of Poor QualityGeneric Model

Direct poor-quality cost• A. Controllable poor-quality cost

(1) Prevention cost --- Work to avoid an error (2) Appraisal cost --- Work to assess error (3) No-value-added cost --- Rework, Fix it

• B. Resultant poor-quality cost (1) Internal error cost --- LOS, Denials, HAC/POA (2) External error cost --- Malpractice, UnPaid Care

Indirect poor-quality cost• A. Patient-incurred cost --- Time, Emotion, Money

B. Patient-dissatisfaction cost --- ReputationC. Lost-opportunity cost --- Time and Capacity LostD. Loss-of-reputation cost --- Repeat, Referral, Payer

Cost of Poor QualitySpecific Direct Costs (Unpaid)

Selected HACMedicare Data

(FY 2007)CC/MCC

(ICD-9-CM Codes)

Selected Evidence‑Based Guidelines

Foreign Object Retained After Surgery

● 750 cases● $63,631/hospital stay

998.4 (CC)998.7 (CC)

NQF Serious Reportable Adverse Eventwww.ahrq.gov/qual/nqfpract.htm

Air Embolism ● 57 cases● $71,636/hospital stay

999.1 (MCC) NQF Serious Reportable Adverse Eventwww.ahrq.gov/qual/nqfpract.htm

Blood Incompatibility

● 24 cases● $50,455/hospital stay

999.6 (CC) NQF Serious Reportable Adverse Eventwww.ahrq.gov/qual/nqfpract.htm

Vascular Catheter-Associated Infection

● 29,536 cases●$103,027/hospital stay

999.31 (CC) Available at the Web site:http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html

Surgical Site Infection

● 69 cases●$299,237/hospital stay

519.2 (MCC) Available at the Web site:http://www.cdc.gov/ncidod/dhqp/gl_surgicalsite.html

Poor Quality Impacts

Patient•Medical Error, Harm, HAC, LOS, inefficiencies•www.hospitalcompare.hhs.gov

Finance•Rework, Uncompensated Care, Error, Coding•CMS Reimbursement, RAC

Staff•Quality of work, Satisfaction, Administrative burdens•Fewer resources and capacity for excellence

Strategy•No capacity for strategic projects, Growth Inhibitor•Competitive Advantage, Board of Directors

Agenda

SummaryTop 10 Things to do

1. Establish Executive Priority

2. Assess your current situation

3. Start Fast

4. Identify the Baseline

5. Align Incentives

6. Establish a repeatable approach (Program)

7. Data Flow

8. Work Flow

9. Cash Flow

10.Repeat

Better patient care costs hospitals less and improves patient

outcomes.

Can you identify quality problems and fix them

promptly?

Do you have the:Methods

·6σ, Lean, Value Stream

Experienced People·External change agents

Technology·Data, Workflow, Portals

Quality is Worth It!

• CEOs• Quality Scores of You and Your Competition

• CFOs• Cost of Bad Quality• Cost of Compliance & Reporting

• COO, CNO• Nurse Staffing Shortages• Administrative burdens

Net Profit

To maximize CMS Reimbursement, and your bottom line, you need to proactively identify

Quality Improvement opportunities now.

Establish Executive Priority

• How important are Quality of Care, Core Measure Scores, and Patient Safety to the overall executive leadership?

• How fast does the board know about the last “Never Event”?• Do you look at the public quality core measures of your competition?• In relation to the many other issues, how does this stack up?• What is the “Burning Platform” for this to take precedence?• What is it worth to improve? Budget? ROI?

CEO & Board

Executives & Directors

Clinical & Quality Staff

Competitive AdvantagePatient Satisfaction

Budget, Cost, Compliance, Revenue, ROI

Best Practices, Improved Process Efficiencies

Dr. Sunil Rao

• A Physician’s View• Evidence Based Medicine = Best Practice• Learn and Improve• Benchmark Performance

• Quality Feedback • On errors in real time• A Desire to follow proper procedure

• Physician’s need for Core Measure data• In the simplest format possible • With easy accessibility • Up to date and relevant

How We Get There | Performance Measurement and Public Reporting

Doctors and Performance Data

Audet AJ, Doyt MM, Shamasdin J, et al. Physicians' Views on Quality of Care: Findings from the Commonwealth Fund National Survey of Physicians and Quality of Care. New York: The Commonwealth Fund, 2005.

Doctors and Process-of-Care Data

Doctors and Clinical Outcomes Data

Doctors and Quality Data

Flash Poll

Is there a CEO or Board Level mandate to improve Quality?

Does this relate to Core Measure scores or your reporting process?

Improving Health Plan Performance with Public Reporting

• Health plans that willingly allow public reporting perform at a higher level than those that choose not to do so.

• In 2006, publicly reporting health plans outperformed non-publicly reporting plans on 37 of 40 measures.

The State of Health Care Quality 2007. Washington: National Committee for Quality Assurance, 2007. (No authors given.)

Quality Reporting

• National IT Coordinator David Blumenthal, MD, emphasized that quality measures are at the heart of his office’s strategy for using IT to transform the U.S. healthcare system

• “The key to Meaningful use is to know how to measure for performance and to be able to give feedback to providers”

• “just the act of measuring will continually cause us to improve”

• “Providing better information is the foundation for change”

A Message from Dr. David Blumenthal, National Coordinator for Health Information Technology at a National Quality Forum

Improving Process

• Real Time Analysis

• Real Time Alerts• Trending Reports• Rapid Changes

to process of care

• More people involved

• Access to useful real time data

• Incentives for change

Moving from Reporting to Quality Management

• How does your Quality process stack up?• Retrospective Review of Quality Data?• Concurrent Review of Core Measures?• Ability to drill down and analyze Core Data?• Process changes easily deployed?• Strategic Quality Goals being met?

ReportingManual

Meet MinimumLate

Staff Limited

EfficientBetter Data

Real Time AccessWorkflow

Notifications

ConcurrentAnalysis:

• Timeliness of Data• Usefulness of Data• Extend to include

• More Core Measures• More Reports

• Include more people

FinancialImpact

• Patient Satisfaction

• Core Measure Scores

• Efficient Reporting

• Pay for Performance

• CompetitiveAdvantage

Level 4

Level 5

Level 3

Level 2

Level 1

Return On Investment

• Cost of Compliance = $500K+• FTEs for growing requirements• Cost of training and change• Buying EHR/IT

• Risk = $ Millions• 4% of Annual Payment (P4R + P4P)• Cost of Uncompensated Care, Poor Quality• Risk of being Slow or Late to Move

• Quality Benefits = Priceless• ARRA/MU Incentive, CMS Bonus• Real-Time Visibility of Quality Measures• Competitive Advantage (Hospital Compare)• Patient And Employee Satisfaction

ROI = 5x Data Flow + Work Flow= Cash Flow

Sample ROI Model

Your Hospita l's Fina ncia lOve rvie w of S a vings Num be rs Im pa ct S ca le Authority

A nnual Net P atient Revenues $527,284,629 FY 2007 from A HD.comA nnual M edicare P aym ent $263,275,743 $5,265,515 2% Fines or poss ible B onusA nnual Inpatient Claim s 38,000 7,600 20% Num ber of I/P Reports per yearA nnual Outpatient Claim s 402,000 80,400 20% Num ber of O /P Reports per yearA pprox im ate Num ber of P atient Claim s per Y ear 440,000 88,000 20% Tota l Num be r of Re ports pe r ye a r to CM S

Am ount a t RIS K w ith CM S Qua lity Da ta 4.00% $10,531,030 2% Fines for non-com pliance Reporting P rocess 2% B onus for P erform ance

Cost of Q I Nurse S a la ry 68,000$ 300 Days per year

Curre nt 18 Reports per day per Q I nurseReports per Day I/P 25 $95,704 1.4 Required FTE sReports per Day O /P (and others pending) 268 $1,012,444 14.9 Required FTE s

P ropose d 50 Reports per day per Q I nurseReports per Day I/P 25 $34,453 0.51 Required FTE sReports per Day O /P (and others pending) 268 $364,480 5.36 Required FTE s

Ne t Im pa ct on S ta ffing a nd P roductivity $709,215 Im prove d Re ports / Da y/ Q I Nurse

Additiona l Im prove m e nts Im provem ents listed as a % of NPR (Notes below)Quality M easures in Real-Tim e 0.07% $369,099 Fas ter correc tion of Quality Issues (2)Im proved Com petit ive A vantage from Quality 0.05% $263,642 B etter "Hospital Com pare" pos it ion (3)A bility to secure P 4P B onus 0.03% $158,185 B onus based on bes t in c lass reporting and quality (4)A bility to rapidly change processes in support 0.03% $158,185 P rocess Changes rapidly deployed to s taff (5)

Tota l Additiona l Be ne fit from Autom a tion $949,112

Total V alue of Cash F low at Risk $12,189,357 as a percentage of Net P atient Revenues 2.31%

Agenda

• What is Quality in Healthcare?• Why is Quality so Important?• Executive Buy-in• Methodologies• Technologies• Q&A

How do you move forward?Some things you will need

• Methodologies for solving problems• Executive Workout, Assessments• Six Sigma, Lean, Continuous Improvement• Requirements Definition, Program/Project Leadership

• Additional Resources• Add Capacity to deliver multiple projects• Dedicated and Experienced Team

• Standard Technology Platforms• Complementary to existing and planned platforms• Any Real Time Data, Any Hospital Process or Measure

People

Technology

Methods Your

Success

Assess your current situation

• How well are you reporting CMS Core Measures?

• Are the scores as high as possible? • How do you plan to improve them?• Do you have real time quality measures for

action?• What other quality measure or process is

more important right now?• Executive Quality Dashboards in need?

It is up to every hospital to

Analyze their specific

measures, Improve the

quality of care processes that

these measures represent and

Control the processes

onward so as to ensure quality of

CMS, You and Six Sigma

Define CMS P4R, VPB

Measure Core Measures, Never Events, HAC/POA

Analyze Concurrent Chart Review, Quality Analytics

Improve Process of Care, Outcomes, Evidence Based Medicine

Control Continuous Improvement, Automation, IT systems

It is up to you to Analyze the Data,

Improve your Quality of Care Processes, and

Control IT

CMS continues to Define and Measure

CMS ComplianceMore important than ever before…

• CMS Core Measure Reporting Process• Approaching over 100 required reports of clinical quality• Abstraction From Many Sources• Manual Data = Error• Time & Cost of Each Report

Cost of Compliance

“Meets minimum is not enough”

Changes and mounting requirements = Unfunded Mandates

Define

Measure

Its Not Just sending data

• Data is 3 months old• Vendors don’t help with abstraction• No Reuse of Quality Data• Multiple Reports = Multiple Abstractions

Reporting Data does NOT improve Quality

The tracking and reporting of Core Measure performance is a huge amount of work which occupies multiple clinical staff members

Analyze

Agenda

Flash Poll

• Are you buying a large new HIS appliction to solve all your issues? (Rip & Replace)• We will not even touch on EHR Systems

• Do you have access to Real Time Quality Data?• We will address how you can get to more data and use it

• Do you want to make better use of exisiting IT applications?• We can discuss Composite Healthcare Applications• Complementary to existing application investments

Applying Technology to Obtain Benefits

• Real-Time Quality Measures for Improvement

• Get Data from Any System• Populate Any Form or Dashboard• Reduce Cost of Data Abstraction

• Improving Processes• Eliminate Administrative Tasks• Reduce Task and Process Times• Notify, Escalate, Manage by Exception

• Increase Net Income• Reduce Uncompensated Care• Reduce the Cost of Compliance• Improve Quality, Satisfaction, Profits

Data Flow

Work Flow

Cash Flow

Analyze

Improve

Control

Quality Management Functions

• Real Time Quality Data• Abstraction• Workflow Processes• Notification and Control• Quality Dashboards• Management Platform

• Alerts, Reports, Charts, KPIs, Never Events

Quality DBMS

(PN, AMI, SCIP, HF, OP)

CNO Executive Dashboard

• Board of Directors Report

• Concurrent Review

• Drill Down

Quality Database

• Quality Reports• Charts• Benchmark Data

Abstraction & ReportingWorkflow

• Data Drop Starts Workflow

• Data is checked against Rule Sets

• Processes Launched

• Tasks Assigned• QI Staff Notified• Alerts

Quality Reporting

• CMS Quality Reports• PN• HF• AMI• SCIP• OP

• Extendable• Meaningful Use• JCAHO• HB 197• Any Report

• Easily analyze data and see trends

• Make well-informed decisions

• Create, publish, and share reports

• Provide insight into operational, clinical, and financial data with scorecards and

dashboards

BI can help simplify the integration of information from clinical and line-of-business systems, with personalized

views for caregivers, staff, and administrators.

Business Intelligence (BI) in

Portal Solutions for Health Business Intelligence provides

health professionals with the tools to:

Technology StrategySummary

Action Result Technology

GetData

Real Time Abstraction Interface Engines, HL7, other

Analyze Data Quality Database Business Intelligence & Analytics

DeliverData

SecurePortals Dashboards, Reporting, Benchmarking

Improve Processes Automated Workflow Forms, Tasks, Alerts, Escalate Notification

Real Time Quality Data

and other Technology can

help you improve Quality of Care at your

Hospital.

It is up to you to Analyze the

Data, Improve your Quality of Care Processes.

Agenda

Quality Roadmap

• COPQ• Quality Reporting

To Be• EHR and Meaningful

Use• High Quality Scores• Better Outcomes

• Patient Satisfaction

• Risk of Inaction• Investment Loss

• Too Early, Late, Slow

Drivers• CMS & ARRA Spending

• Payers will follow• Patient Demands• Board of Directors

• Mounting Requirements• More Reporting• EHR is required

• Buy an EHR, Invest in IT

• Analysis, Consulting• Training and Process

Change• ComplianceBenefits

• ARRA Payments• CMS P4P Bonus

• Better Patient Care• To 10% in Quality

• Higher Reimbursement• Net Income

• As Is• To Be

Assess

Tmp Cms Quality Lunch & Learn Final

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