ACMQ Annual Meeting 2010

Donald Fetterolf, MD, MBA, FACPPresident, American College of Medical Quality

Introduction to Quality Improvement

Abstract and Learning Objectives

Abstract: The American College of Medical Quality is committed to furthering a basic understanding of how to advance the quality of medicine using well established tools and techniques for continuous quality improvement. In this lecture, we will present an overview of basic tools used in the field, including an overview of the history of continuous quality improvement, basic techniques piloted by Deming, and some more advanced tools and their use in a medical management setting. The presentation would be a good introduction for students, medical directors new to QI analysis and similar individuals.

Learning Objectives: The listener will develop an appreciation for the unfolding history of the field of medical

quality management. The listener will become familiar with basic tools used in creating an approach to

continuous quality improvement. The group will collectively consider application of more advanced tools in the medical

management setting. The group will generally discuss common issues and experiences in the use of these tools

and lessons learned.

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Outline

Introduction

Historical perspective

Designing a Framework for Strategies for Quality Management

Making the business case for medical quality

References

Historical Perspective

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The Evolution -- Definitions of Medical Quality

Many writers borrowed heavily from concurrent activities in business, engineering and statistical quality control programs in manufacturing.

Shewhart - Bell Labs 1920’s & 30’s Deming/Juran - Industrial Quality Management Systems -

CQI/TQM and the movement from QA to QI. Crosby -- Conformance to requirements Donabedian – Early basic thinking in medical QI Couch – Quality = The attribute of a product, service, or outcome

that is the extent to which achievable value is actually achieved. Value is usually defined in terms of consumer expectations, whether explicit (i.e. wants), or implicit (i.e. needs)

Eddy – Attributes of quality indicators and HEDIS Berwick – Institute for Healthcare Improvement (IHI) Provider

participation, continuous improvement. The IOM report. Six Sigma, Toyota Production System, ISO9000 and others ACMQ – Core Curriculum for Medical Quality Management

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Historical Perspective

Quality has had an evolutionary course that has paralleled similar developments in the business world. The relationship to the business world and business thinking is important:

Stage 1: Quality Assurance, The Era of Inspection CPCs, sentinel event monitoring, outlier review, inspection

Stage 2: Statistical Quality Control and CQI Deming tools, control charts, multivariate normal distributions

Stage 3: Outcomes Focused Analysis Prevention, functional status, patients perceptions,

Stage 4: Big Management Rise of the QI bureaucracy: NCQA, JCAHO, URAC, CMS

Stage 5: Fluid Change, a Cacophony of Quality

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First Generation CQI

Physician Credentialing Institutional Credentialing Procedure Specific Credentialing UM/QI Process Adequacy Technology Assessment Process Adequacy Adverse Occurrence Monitoring Sentinel Event Monitoring External Accreditation

The Era of Inspection

Questions answered:Did the horse get out of the barn?Who left the barn door open?

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"QA" Approach

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Second Generation CQI

Diagnosis-Specific Admissions Variations Targeted Surgical Variations Targeted Ambulatory Surgery Variations Physician Statistical cost/mortality profiling Pharmaceutical Profiling

The Era of Statistical Quality Control

Questions Answered:How many horses get out per year?Can we make repeated door structural changes to reduce the

number of escapes over time?

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"QI" Approach

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Third Generation CQI

Selected Claims-Based Outcomes Member Satisfaction/Perception of Health Clinical Outcomes Measures Disease Specific Patient Perceptions Linkage to Disability/Absenteeism Life Event Risk Intervention Analysis Conventional Medical Outcomes Social - small area analysis Dartmouth Study Functional Status and Well Being Health Risk Appraisal Cost Effectiveness Analysis (CEA)

The Era of True Outcomes Measures

Questions Answered:Can we reduce the reasons why the horse would want to leave the

barn and instead want to stay and work for me?

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Fourth Generation CQI

Big Systems Integrated Care Management Delivery Systems Multispecialty Group Practice PHO, PHCO, IPA, CHIN, and Others

New Methods, Tools, and Concepts “Data Driven” Information Systems Statistical Quality Control - Shifting the Bell Curve

Comparing Across Plans, Hospitals, Companies and Individuals Best Practice Analysis

The Era of Big Management

Questions Answered:If we hire consultants and build big farm coops, will fewer horses escape?Can data mining and predictive modeling reduce the number of horse escapes?

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Fifth Generation CQI

Government Agency Participation CMS, AHRQ, State DOH, State DOI

Pseudo-governmental Participation NQF, IOM, PROs, QIOs

Accreditation Bureaucracies JCAHO, URAC, NCQA, AAAHC

Integrated Care Management Delivery Systems PHO, PHCO, IPA, CHIN, and Others Health plans, HMOs, Group practice.

Other Players Consultants

Accenturisms -- Buzzwords and Buzzwords for The Next Big Thing P4P, Transparency, Accountable Networks, EMR, Medical Home

The Era of Confusion and Cacophony

Question: Our system of evaluation for accountable providers transparently creates acceptable deliverables to reduce equine elopement.

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External Organizations Concerned about Health Care Quality

Governmental Centers for Medicare and Medicaid Services

(CMS) Peer review organizations (“PROs”) Quality Improvement Organizations (“QIOs”) State departments of health and insurance State health care cost control councils Centers for Disease Control

Accreditation National Committee for Quality Assurance

(NCQA); includes use of Health Plan Employer Data Information Set (HEDIS) and Consumer Assessment of Health Plans Survey (CAHPS) tools

Joint Commission for the Accreditation of Healthcare Organizations (JCAHO)

American Accreditation Healthcare Commission (“URAC”)

Accreditation Association for Ambulatory Health Care (AAAHC)

Business Business Health Care and Purchasing Coalitions Washington Business Group on Health Pacific Business Group on Health Leapfrog Group Local business groups and councils Regional employer coalitions Tech councils National Business Coalition on Health Drug companies and their spin off organizations

Others Americas Health Insurance Plans (AHIP) Blue/Cross Blue Shield Association (BCBSA) and

the TEC American Board of XYZ Council for Affordable Quality Healthcare (CAQH) Doctors Office Quality Project (DOQ) Institute of Medicine (IOM) National Quality Forum (NQF) Organized medical associations (e.g. AMA) Professional organizations (e.g., American Heart

Association) and Specialty societies The BIG UNIVERSITY “experts” Benefit management consultant “experts”

Question: How much money is being spent on the development and delivery of the medical quality initiatives that are present or being planned for the future? How much will you need to know about business in quality?

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Theories and Ideas Too!

CQI Six Sigma Hoshin Planning ISO 9000 Toyota Production System The Intergalactic Business Group on Health’s RFP

Analytic Quality Statistic

Takeaway point: The language of business is pervasive in the language of medical quality.

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Basic Tools in QI Management

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Shewhart Cycle

Plan Do Check/

Study Act

Plan

Do

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ActContinuousImprovement

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ACMQ Core Curriculum

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Selection Grid

Reference: Morgenstern, p.3-3

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Seven Helpful Charts

Reference: Walton

Flow Chart Histograms Pareto Charts Run (Trend) Charts Control Charts Scatter Diagrams Cause and Effect

Diagrams

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Histograms

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Histograms

“Bar Graphs” Show relative amounts of things in a group Can show trends over time Special forms: Pareto charts

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Histogram

Reference: Core Curriculum

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Histogram

Reference: Core Curriculum

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Results of the Study

Results of the Study

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Pareto Charts

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Pareto Charts

Pareto charts are a type of histogram that arranges the bars on the chart from highest to lowest value.

The focus then in QI processes is to concentrate on the highest sources of an issue first and eliminate them as problems.

A concurrent line often shows an accumulated total for each subsequent bar in the graph, reflecting total cumulative impact.

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Pareto Analysis

Reference: Core Curriculum

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Pareto Chart

Reference: Morgenstern

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Process Flowcharts

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Flow Charts

Clarify the process Identify observation points Address

logical inconsistencies redundancy timing

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Process Flowchart

Reference: Core Curriculum

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Types of Flowcharts

Process Flowchart Interrelationship Diagraphs CPM/PERT Charts Affinity Diagrams Activity Network Diagram Process Decision Program Chart Others

Reference: Brassard, and others

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Interrelationship Diagraph

Reference: Brassard

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Clean up the Mess!

Look for redundant functions; create simpler models to do the task.

Measure each step for efficiency improvement and possible error reduction.

Redesign the program to reduce the number of nodes and handoffs

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CPM/PERT Charts(Critical Path Method/Program Evaluation Review Technique)

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Run Charts and Control Charts

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Run Charts

“Line charts” Used to measure relative changes in a value over time Specialized forms for more sophisticated analyses

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Run Chart

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Radar Chart

Radar Chart

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Shewhart:

A phenomenon will be said to be controlled when, through the use of past experience, we can predict, at least within limits, how the phenomenon may be expected to vary in the future. Here it is understood that prediction within limits means that we can state, at least approximately, the probability that the observed phenomenon will fall with the given limits…”

Reference: Montgomery

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Control Chart

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Dynamic Chart Terms

Median position = average; horizontal line showing the average value

Run = two or more consecutive data points on the same side of the median

Upper control limit, lower control limit = limiting horizontal lines drawn above and below the median, which show the limits of where the system is “in control” or “out of control”

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Types of Control Charts

X-R Average and Range XmR Average/Moving Range

Control=x+/-2.66R p-Chart Control=p+/-3 √p(1-p)/n

p=defects/total occurrences c-Chart Control=c+/-3 √c

c=number of defects/total observations u-Chart Control=u+/-3 √u/n

u=defects for all subgroups/total observations in all subgroups

Reference: Carey and Lloyd

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Control Chart Concerns

Number of data points in a run Up to 8/5; 9 to 20/6; 21 to 100 /7

Too few or too many runs? Run = 2+ data points on one side of median

Trends Zig Zag or “sawtooth” patterns Normal vs special cause variations Bell curve on the side Divide control chart into zones of concern - action

limits vs warning limits

Reference: Carey and Lloyd.

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Time Series Analysis Techniques

Run Chart (Shewart Model) Running Average (>6 mo) CUSUM Plot (sensitive to small changes in σ Exponentially Weighted Moving Average

(EWMA) Current items weighted more. Autoregressive integrated moving average

model (ARIMA), when series are autocorrelated.

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Cusum Plot

A Cusum plot allows you to evaluate an important result before it reaches statistical significance!

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CUSUM Plot

Calculate the target mean Create running sum of differences of each variable

from the mean

Note upper and lower control limit formulas exist

C = Σ(xi-avg)

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CUSUM Plot

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Scatter Diagrams

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Scatter Plots

Plot two or more variables simultaneously (up to six!) Two by two plots usually Association testing Correlation coefficient calculations

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Analysis of Variation

CV of Paid vs LOS for 90% Impact DRGs

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Reference: ACPM Presentation 2/2003

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Linear Regression

Creates a line from a series of data in a scatter plot. The sum of the squared differences of each data point

from the line is minimized. It is possible to have more than two variables (multiple

regression) It is also possible not to be linear (nonlinear

regression)

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Other Regression Things

Correlation -- R2 or R value or Pearson Correlation Coefficient. R2 close to 1 shows high correlation.

Autocorrelation -- Durbin Watson Statistic -- 0 - 2 - 4 scale

Forecasting by extrapolation lagged variables, cycles, etc. exponential smoothing software Forecast Pro for Windows

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Cause and Effect Diagrams

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Ishikawa (“Fishbone”) Cause and Effect Diagram: PT Referral Costs

ElevatedReferral

Costs

SpecialistsPhysical therapists

PCPsGreed, personal gain

Staff do referralsOpen ended referrals

No guidelinesNo feedback

High ProfitLow prior control

Benefit designMedical policy

Equipment costsIn house expenses

Environment Equipment

Procedures People

Reference: Carey and Lloyd

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Wishbone Diagram

Reference: Core

Curriculum

Reference: Core Curriculum

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CQI: Closing the Loop

Is That Really All There is to It?

Formal programs for organizing the use of quality tools exist.

“Continuout Quality Improvement” Six Sigma Lean Six Sigma Toyota Production System ISO 9000; ISO 9001

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DMAIC Problem-Solving Model

DMAIC equals Define, Measure, Analyze, Improve and Control.

Step 1 - Define the problem. Step 2 - Measure. Step 3 - Analyze. Step 4 - Improve. Step 5 - Control.

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Clinical Study Format

Problem identification Determine the guidelines Establish the criteria Design the study

(population, sample, data collection techniques) Data analysis Identify deficiencies Develop recommendations for problem resolution Feedback to appropriate providers, depts, committees,

individuals Reevaluate problem to determine if corrective actions have

been implemented/problem resolution occurred

Thanks to: NCQA

Six Sigma

Six Sigma is a business management strategy, initially implemented by Motorola, that today enjoys widespread application in many sectors of industry.

Six Sigma seeks to improve the quality of process outputs by identifying and removing the causes of defects (errors) and variation in manufacturing and business processes.[1] It uses a set of quality management methods, including statistical methods, and creates a special infrastructure of people within the organization ("Black Belts","Green Belts", etc.) who are experts in these methods.[1] Each Six Sigma project carried out within an organization follows a defined sequence of steps and has quantified financial targets (cost reduction or profit increase).[1]

66Reference: Wikipedia, accessed July, 2009

LEAN

Lean manufacturing or lean production, which is often known simply as "Lean", is a production practice that considers the expenditure of resources for any goal other than the creation of value for the end customer to be wasteful, and thus a target for elimination. Working from the perspective of the customer who consumes a product or service, "value" is defined as any action or process that a customer would be willing to pay for. Basically, lean is centered around creating more value with less work. Lean manufacturing is a generic process management philosophy derived mostly from the Toyota Production System (TPS) (hence the term Toyotism is also prevalent) and identified as "Lean" only in the 1990s.[

67Reference: Wikipedia, accessed July, 2009

MAKING THE BUSINESS CASE FOR HEALTHCARE QUALITY IMPROVEMENT

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The Issue: Making the Business Case

Making the business case to someone or some entity that you should be paid for your valuable services is difficult for anyone. Money is tight everywhere.

You were trained as a clinician, not a business person. So, how do you put a price on quality or clinical improvement? What is the strategy to convince a potential nonclinical payer of diabetic education services that they are worth it?

Do your services create a “value proposition” for your services? How do you construct the approach and the arguments for the government, health plans and clinics that create a compelling case in your favor in the mind of a business person?

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Introduction: Case Study

The CEO of your company has made friends with the Vice President of marketing of a national company that claims that it can provide [what your area does] effectively using a cool web based tool his company has designed. The two have gone golfing, have had dinner together, and have had several “high-level” discussions about having the vendor replace your program staff with the vendor's web site. Two of your organization’s senior vice presidents, in totally unrelated areas and who have no knowledge of clinical issues, think the proposal might be a viable option. The vendor claims that he can give your company an “8 to1 return on investment,” and will ”guarantee” it.

You are now approached by the CEO, who admits that he might dissolve your area, but offers to give you 20 minutes to talk him out of it. He is interested in the value/return that you get now.

What do you tell him? Your answer should address both an analytic approach and recognition of the various political factors that may influence your choices.

Paraphrased and restated from Fetterolf, AJMQ Jan/Feb 2003.

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Wisdom from CMO’s:Stay Focused on the Important Stuff

Lower/maintain PMPM costs for your clients Reduce administrative overhead Generate more revenue Measurably improve patient care quality Improve relationships with business contacts – “co-

opetition”

Have real impact, not inconsequential activities

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The Business Case for Medical QualityComponents of the Business Case for a QI Unit

Government mandates Basically, you have to…

Demands by the payer/business/consultant community Financial effect

Lower quality is more expensive Logical requirements for quality oversight Demands of business partners Trade off between value of accreditation and lower

costs Estimated economic impact from econometric attempts

NCQA Quality dividend calculator Social goals

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Conclusions and Summary

The basic ingredients of a good quality program have not changed much over 20 years.

People still need to use them however. From simple charts to complex analyses, QI will

continue to make things better wherever it is applied.

Questions?

References on Next Slides

References

Basic References on Medical Quality

American Journal of Medical Quality Carey, R. and Lloyd, R.. Measuring Quality Improvement in

Healthcare. New York. Quality Resources. 1995. An old but great reference. Lots of terms and a standardized approach.

Couch, JB. Health Care Quality Management for the 21st Century. Tampa, FL. Hillsboro Printing Co for the American College of Physician Executives. 1991. The last really good book on the subject before the ACMQ one.

Dlugacz, Yosef. Measuring Health Care. Jossey Bass.2006 Langley, G. et. al.. The Improvement Guide: A Practical Approach to

Enhancing Organizational Performance. Josey-Bass Publishers. 1996. McLaughlin, C. and Kaluzny, A. "Continuous Quality Improvement in

Healthcare." 1999. This is a college type textbook. Nash, D and Goldfarb, N (Ed) "The Quality Solution: The Stakeholder's

Guide to Improving Health Care." 2006. A solid reference also. Varkey, P. Ed.. Medical Quality Management: Theory and

Practice. Boston, MA. Jones and Bartlett Publishers. 2009. ACMQ just published. 76

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--Baker, Judith. Activity-Based Costing and Activity-Based Management for Health Care. Aspen Publishers. 1998. --Berwick, D. Curing Health Care. New Strategies for Quality Improvement. San Francisco. Jossey-Bass. 1990. --Blissenbach, H. "Use of Cost-Consequence Models in Managed Care." Pharmacotherapy. (15)5. 1995. pp. 59s-61s.--Carey, R. and Lloyd, R. Measuring Quality Improvement in Healthcare. New York. Quality Resources. 1995. --Corrigan, J.; Greiner, A.; and Erickson, S. "Fostering Rapid Advances in Health Care: Learning from System Demonstrations." 2002. --Coddington, D. Making Integrated Health Care Work. Center for Research in Ambulatory Health Care Administration. Englewood, CO. 1996.--Couch, JB. Health Care Quality Management for the 21st Century. Tampa, FL. Hillsboro Printing Co for the American College of Physician Executives. 1991. --Crosby, P. Quality is Free. New York. New American Library. 1979. --Crosby, P. Quality Without Tears. New York. McGraw Hill Book Company. 1984. --Donabedian, A. Explorations in Quality Assessment and Monitoring. Volume II. The Criteria and Standards of Quality. Health Administration Press. Ann Arbor. 1982.--Drummond, M. and McGuire, A. Economic Evaluation in Health Care. Merging Theory with Practice. Oxford University Press. 2001. --Drummond, M., O'Brien, B., Stoddart, G. and Torrance, G. Methods for the Evaluation of Health Care Programmes, 2nd Ed.. New York. Oxford Medical Publications. 1998. --Fetterolf, D. "Commentary: Presenting the Value of Medical Quality to Nonclinical Senior Management and Boards of Directors." American Journal of Medical Quality. (18)1. Jan/Feb 2003. pp. 10-14.

Bibliography – Additional Reading

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--Fetterolf, D. and West, R. “The Business Case for Quality: Combining Medical Literature Research with Health Plan Data to Establish Value for Non-Clinical Managers.” American Journal of Medical Quality. (19)2. March/April 2004. pp. 48-55.--Gafni, A. "Willingness to Pay in the Context of an Economic Evaluation of Healthcare Programs: Theory and Practice." Am. J. Man. Care. (3(suppl))S21-S32. 1997. --Galvin, R. "The Business Case for Quality. Developing a business case for quality will require a deliberate approach, with all economic parties at the table.." Health Affairs. Nov/Dec 2001. pp. 57-58.--Gladowski,P., Fetterolf, D, Beals, S., Holleran, MK, and Reich, S. “Analysis of a Large Cohort of HMO Patients with Congestive Heart Failure.” American Journal of Medical Quality. (18)2 April 2003.--Gold, M. et. al. Cost Effectiveness in Health and Medicine. (Report of the U.S. Public Health Service Panel on Cost Effectiveness in Health and Medicine.). Oxford University Press. 1996. --Haddix, A., Teutsch, S., Shaffer, P. et al. Prevention Effectiveness: A Guide to Decision Analysis and Economic Evaluation. New York/Oxford. Oxford University Press. 1996. --Hubbell, W. "Combining Economic Value Added and Activity Based Management." Journal of Cost Management. Spring 1996. pp. 18-29.--Kohn, L., Corrigan, J., and Donaldson, M.. To Err Is Human - Building a Safer Health System. Washington, DC. National Academy Press. 1999. pp. 1-13.

Bibliography

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--Luehrman, T. "What’s It Worth? A General Manager’s Guide to Valuation." HarvardBusiness Review. May-June 1997. pp. 132-142.

--Millenson, M. America's Health Care Challenge: Rising Costs. A report commissioned by the American Association of Health Plans. Washington, DC. AAHP. 1/22/2002. --National Academy of Sciences "Priority Areas for National Action: Transforming Health Care Quality 2003." 2003. --NCQA. The Business Case for Health Care Quality. 2002. -- Santerre, R. and Neun, S. Health Economics: Theories, Insights, and Industry Studies. Irwin. Chicago. 1996.--Stephens, K. et al. "What is Economic Value Added? A practitioner's view. (corporate performance measure)." Business Credit. (99)4. pp. 39(4).--Torrance, G. "Preferences for Health Outcomes and Cost-Utility Analysis." The American Journal of Managed Care. (3(Suppl)). 1997. pp. S8-S20.--Walton, M. The Deming Management Method. New York, NY. Perigee Books. 1986. --Weinstein, M., Siegel, J., et al. "Recommendations of the Panel on Cost-Effectiveness in Health and Medicine." JAMA. (276)15. October 16, 1996. pp. 1253-1258.Wessels, WJ. Economics. Second Edition 1993. --Wessels, WJ. Economics. Barron’s Business Review Series. New York. 1993.

Bibliography

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Slide Set Information

Author: Don Fetterolf, MD, MBA, FACP Fetterolf Healthcare Consulting Phone: 412-638-2891 Email: donfetterolf@gmail.com

filename: 100217 ACMQ QI v1.ppt date: February, 2010. date of this printout: February 21, 2010