A Short History of Healthcare in A Short History of Healthcare in

the 21st Centurythe 21st Century The Regulatory Environment, Public The Regulatory Environment, Public Reporting and Pay-for-Performance Reporting and Pay-for-Performance

(P4P)(P4P)

Gene Peterson Gene Peterson Preston SimmonsPreston Simmons

Center for Clinical ExcellenceCenter for Clinical ExcellenceUniversity of Washington Medical CenterUniversity of Washington Medical Center

SIP #5SIP #5July 19, 2005July 19, 2005

Goals for TodayGoals for Today

History of the regulatory environmentHistory of the regulatory environment History of the quality movementHistory of the quality movement What are we as a hospital reporting now?What are we as a hospital reporting now? Where is this going in the future?Where is this going in the future? Will there be individual physician profiling Will there be individual physician profiling

on the same measures?on the same measures?

One role of the Health Care Leader is to manage the One role of the Health Care Leader is to manage the Environment of CareEnvironment of Care

Complex UndertakingComplex Undertaking ““Regulatory Environment”, Spiegel and Kavaler, Regulatory Environment”, Spiegel and Kavaler, Risk management in Risk management in

Health Care Institutions Health Care Institutions , ,

A flavor for regulations. Who regulates the industry ( just a few A flavor for regulations. Who regulates the industry ( just a few examples)examples)

Federal, State and LocalFederal, State and Local WACWAC RCWRCW CMS CMS Specific regulations on how health care organizations are builtSpecific regulations on how health care organizations are built NFPANFPA National Environmental Policy ActNational Environmental Policy Act OSHAOSHA WISHAWISHA EPAEPA Shoreline ActShoreline Act Department of HealthDepartment of Health L&IL&I DSHS- Licensing DivisionDSHS- Licensing Division JCAHOJCAHO ADAADA Department of Construction and Land UseDepartment of Construction and Land Use Etc. …………………………..Etc. …………………………..

F:/PUBLIC/SAFETY/SAFETYHEALTH/SMC-STRUCTURE&COMMUNCIATIONS

Safety Fairs Meetings ICES Newsletters Safety Audits

ENVIRONMENT OF CARE STRUCTURE AND COMMUNICATIONS

PATIENTS, VISITORS

STAFF, PROPERTY AND EQUIPMENT

BOARD

LEADERSHIP

Safety Hotline E-Mail Orientation Training

ENVIRONMENT OF CARE

KEY SUPPORT ELEMENTS Environmental Health and Safety (EH&S) Risk Management Employee Health Employee Safety Committee Infection Control Quality Improvement Management Safety Officer Key Departments

KEY PROCESS SUBCOMMITTEES Medical Equipment Emergency Preparedness Hazardous Materials and Waste Security/ Public Safety Fire Prevention Safety Utility Management Education and Communication Work Place Violence

The good news is that we have proven structures to comply

1997- National Patient Safety 1997- National Patient Safety FoundationFoundation

1999- To Err is Human1999- To Err is Human

The First Institute of Medicine Report Alerted the Public and Congress of 45,000-98,000 Deaths due to “errors” in healthcare- first real public attention to medical failures

2001- Crossing the Quality Chasm2001- Crossing the Quality ChasmThe Second IOM Report

SafeEffectivePatient CenteredTimelyEfficient Equitable

2002-JCAHO Six National Patient 2002-JCAHO Six National Patient Safety GoalsSafety Goals

Patient identificationPatient identification Communication among caregiversCommunication among caregivers High-alert medicationsHigh-alert medications Eliminate wrong-site, wrong-patient, Eliminate wrong-site, wrong-patient,

wrong-procedure surgerywrong-procedure surgery Infusion pumpsInfusion pumps Clinical alarm systemsClinical alarm systems

2002-Leapfrog Three Leaps2002-Leapfrog Three Leaps

Computerized Physician Order EntryComputerized Physician Order Entry ICU Care StandardsICU Care Standards Volume MeasuresVolume Measures

CABGCABG PCIPCI AAAAAA PancreatectomyPancreatectomy EsophagectomyEsophagectomy Neonatal CareNeonatal Care

2003- National Voluntary Hospital 2003- National Voluntary Hospital Reporting Initiative-CMSReporting Initiative-CMS

Hospitals are given the chance to voluntarily Hospitals are given the chance to voluntarily report outcome datareport outcome data

No take always but a reporting bonusNo take always but a reporting bonus Process measuresProcess measures

Acute Myocardial InfarctionAcute Myocardial Infarction Heart Failure Heart Failure Community Acquired PneumoniaCommunity Acquired Pneumonia

The Medicare Prescription Drug, The Medicare Prescription Drug, Improvement, and Modernization Act of Improvement, and Modernization Act of

20032003 Instructs the Center for Medicare Services to Instructs the Center for Medicare Services to contract with the Institute of Medicine of the contract with the Institute of Medicine of the National Academy of Sciences to:National Academy of Sciences to:

catalogue, review, and evaluate the validity of catalogue, review, and evaluate the validity of leading health care performance measures;leading health care performance measures;

catalogue and evaluate the success and utility of catalogue and evaluate the success and utility of alternative performance incentive programs in alternative performance incentive programs in public or private sector settings; andpublic or private sector settings; and

The Medicare Prescription Drug, The Medicare Prescription Drug, Improvement, and Modernization Act of Improvement, and Modernization Act of

20032003

Identify and prioritize options to implement Identify and prioritize options to implement policies that align performance with payment policies that align performance with payment under the Medicare program that indicate—under the Medicare program that indicate—

the performance measurement set to be used the performance measurement set to be used

the payment policy that will reward the payment policy that will reward performanceperformance

the key implementation issues (such as data the key implementation issues (such as data and information technology requirements) and information technology requirements) that must be addressedthat must be addressed

Who is supporting this idea…Who is supporting this idea…

An open letter in Health Affairs Co-authored by Berwick, An open letter in Health Affairs Co-authored by Berwick, Eddy,…support this idea. They argue that the government Eddy,…support this idea. They argue that the government needs to become involved in pay-for-performance efforts:needs to become involved in pay-for-performance efforts:

The human and financial costs of medical care and The human and financial costs of medical care and substandard care have been exhaustively documented.substandard care have been exhaustively documented.A robust inventory of measures and standards for quality A robust inventory of measures and standards for quality improvement has been developed and continues to grow.improvement has been developed and continues to grow.The strategic concept of paying for performance-a The strategic concept of paying for performance-a bedrock principle in most industries- has begun to emerge bedrock principle in most industries- has begun to emerge in health care in a variety of experiments in both private in health care in a variety of experiments in both private and public sectors.and public sectors.

Health Affairs, Vol 22(6) November/December 2003, pages 7-9.

2004- Leapfrog partners with the 2004- Leapfrog partners with the National Quality Forum - Thirty National Quality Forum - Thirty

LeapsLeaps

AwarenessAccountabilityAbilityAction

2004- Leapfrog adds process and 2004- Leapfrog adds process and outcomes measuresoutcomes measures

Society for Thoracic Surgery (STS) for CABGSociety for Thoracic Surgery (STS) for CABG American College of Cardiologist National American College of Cardiologist National

Cardiac Data Registry (ACC-NCDR) Cardiac Data Registry (ACC-NCDR) (Washington Data COAP)(Washington Data COAP)

Vermont Oxford Data Base for NeonatesVermont Oxford Data Base for Neonates Beta Blockade for AAABeta Blockade for AAA

2004- Institute for Healthcare Improvement2004- Institute for Healthcare Improvement

•Deploy Rapid Response Teams •Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction •Prevent Adverse Drug Events•Prevent Central Line Infections •Prevent Surgical Site Infections •Prevent Ventilator-Associated Pneumonia

  

AVERAGE FOR ALL REPORTING HOSPITALS IN THE UNITED STATES

72% 

AVERAGE FOR ALL REPORTING HOSPITALS IN THE STATE OF WASHINGTON

72% 

UNIVERSITY OF WASHINGTON MEDICAL CTR

39% 

 

   

 

* Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved a 89% rate or better.

2004- CMS Displays Quality Data from National 2004- CMS Displays Quality Data from National Hospital Voluntary Reporting Initiative Hospital Voluntary Reporting Initiative

www.hospitalcompare.hhs.govwww.hospitalcompare.hhs.gov

Patients with pneumonia receiving antibiotics within 4 hours

HEALTH GRADES

2005 Surgical Care Improvement 2005 Surgical Care Improvement Project (SCIP)Project (SCIP)

Preventing Surgical Complications in four broad Preventing Surgical Complications in four broad areas where the incidence and cost of areas where the incidence and cost of complications are high:complications are high:

Surgical site infections Surgical site infections Adverse cardiac events Adverse cardiac events Venous thromboembolism Venous thromboembolism Postoperative pneumonia Postoperative pneumonia

SCIP Steering Committee SCIP Steering Committee OrganizationsOrganizations

Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality American College of Surgeons American College of Surgeons American Hospital Association American Hospital Association American Society of Anesthesiologists American Society of Anesthesiologists Association of periOperative Registered Nurses Association of periOperative Registered Nurses Centers for Disease Control and Prevention Centers for Disease Control and Prevention Centers for Medicare & Medicaid Services Centers for Medicare & Medicaid Services Department of Veterans Affairs Department of Veterans Affairs Institute for Healthcare Improvement Institute for Healthcare Improvement Joint Commission on Accreditation of Healthcare Joint Commission on Accreditation of Healthcare

Organizations Organizations

2006-Leapfrog-Hospital 2006-Leapfrog-Hospital Rewards ProgramRewards Program

These represent 33% of the admissions and 20 % of the spending by commercial payers

Coronary artery bypass graft (CABG) Percutaneous coronary intervention (PCI) Acute myocardial infarction (AMI) Community acquired pneumonia (CAP)Deliveries/newborns

Hospital Rewards Program Quality Measures: CABG

Measure Source Weight

CABG mortality LFG Survey 34.00%

CABG volume LFG Survey 12.00%

Prophylactic antibiotic received within one hour prior to surgical incisision

JCAHO Core Measure 3.50%

Prophylactic antibiotic selection for surgical patients - CABG

JCAHO Core Measure 3.50%

Prophylactic antibiotics discontinued within 24 hours after surgery end time - CABG

JCAHO Core Measure 3.50%

Process of Care -- 80%+ adherence to at least two: •CABG using internal mammary artery •Aspirin at discharge •Beta-blocker within 24 hours after surgery •Beta-blockers prescribed at discharge •Lipid-lowering therapy prescribed at discharge •Extubation within 24 hours after surgery

LFG Survey 18.50%

Computerized physician order entry (CPOE) system

LFG Survey 8.33%

ICU physician staffing (IPS) LFG Survey 8.33%

Leapfrog Quality Index (NQF Safe Practices) LFG Survey 8.33%

REWARDING SUPERIOR QUALITY CARE: THE PREMIER HOSPITAL QUALITY INCENTIVE DEMONSTRATION

CENTERS FOR MEDICARE & MEDICAID SERVICES

FACT SHEET

March 2005

Overview

CMS is pursuing a vision to improve the quality of health care by expanding the information available about quality of care and through direct incentives to reward the delivery of superior quality care. Through the Premier Hospital Quality Incentive Demonstration, CMS aims to see a significant improvement in the quality of inpatient care by awarding bonus payments to hospitals for high quality in several clinical areas, and by reporting extensive quality data on the CMS web site.

Quality of Care

Under the demonstration, top performing hospitals will receive bonuses based on their performance on evidence-based quality measures for inpatients with: heart attack, heart failure, pneumonia, coronary artery bypass graft, and hip and knee replacements.

Financial Awards

CMS will identify hospitals in the demonstration with the highest clinical quality performance for each of the five clinical areas. Hospitals in the top 20% of quality for those clinical areas will be given a financial payment as a reward for the quality of their care. Hospitals in the top decile of hospitals for a given diagnosis will be provided a 2% bonus of their Medicare payments for the measured condition, while hospitals in the second decile will be paid a 1% bonus. The cost of the bonuses to Medicare will be about $7 million a year, or $21 million over three years.

Improvement Over Baseline

In year three, hospitals that do not achieve performance improvements above demonstration baseline will have adjusted payments. The demonstration baseline will be clinical thresholds set at the year one cut-off scores for the lower 9th and 10th decile hospitals. Hospitals will receive 1% lower DRG payment for clinical conditions that score below the 9th decile baseline level and 2% less if they score below the 10th decile baseline level.

2005-Other Reports2005-Other Reports

Washington Clinical Outcomes Washington Clinical Outcomes Assessment Project (COAP)Assessment Project (COAP)

SCOAPSCOAP American College of Surgeons National American College of Surgeons National

Surgical Quality Improvement ProjectSurgical Quality Improvement Project

UWMC Operating PlanUWMC Operating Plan

2001- Through CQI produce measurable 2001- Through CQI produce measurable improvements in clinical care service and improvements in clinical care service and operating performance. CORMoperating performance. CORM

2002-Lay the foundations for improving patient 2002-Lay the foundations for improving patient safety. CORMsafety. CORM

2003- Make measurable progress toward 2003- Make measurable progress toward becoming the #1 AMC resource on patient becoming the #1 AMC resource on patient safety by building the culture of a high reliability safety by building the culture of a high reliability organization…(Increase reporting by 50% and organization…(Increase reporting by 50% and decrease harm events in 3 areas)decrease harm events in 3 areas)

UWMC Operating PlanUWMC Operating Plan

2004- Achieve measurable improvements in 2004- Achieve measurable improvements in patient safety and quality. (Six JCAHO National patient safety and quality. (Six JCAHO National Safety Patient Goals, Identify and adopt an Safety Patient Goals, Identify and adopt an integrated quality model, Identify a balanced set integrated quality model, Identify a balanced set of key organizational and clinical quality of key organizational and clinical quality metrics.)metrics.)

2005-Provide the safest clinical care available. 2005-Provide the safest clinical care available. Presented in a PASCO format (Increase Presented in a PASCO format (Increase reporting by 30%, decreased falls by 50%, reporting by 30%, decreased falls by 50%, reduce DVT by 50%)reduce DVT by 50%)

2006 UWMC Operating Plan 13 of 2006 UWMC Operating Plan 13 of 25 Elements are Quality and safety 25 Elements are Quality and safety

ElementsElements

Critical Test ResultsCritical Test Results

Medication ReconciliationMedication Reconciliation

Hand HygieneHand Hygiene

Falls With InjuryFalls With Injury

AMIHeart FailureCommunity Acquired PneumoniaCentral Line InfectionsSurgical Site InfectionsVentilator Associated PneumoniaVenous ThromboembolismRapid Response Teams

These are organizational These are organizational performance measures. What performance measures. What about physician performance about physician performance

measures?measures?

When will P4P role down to physicians on When will P4P role down to physicians on the surgical side?the surgical side?

New York Times Friday April 15, 2005

Sample Outpatient Health Sample Outpatient Health Outcomes/Safety DataOutcomes/Safety Data

Women’s Health- Breast and Cervical Women’s Health- Breast and Cervical Cancer ScreeningCancer Screening

Diabetes Care- Eye exams, HbA1c, Diabetes Care- Eye exams, HbA1c, cholesterol screening, ACE inhibitorscholesterol screening, ACE inhibitors

Use of Optimal Medications- Asthma, Use of Optimal Medications- Asthma, Otitis Media, Acute BronchitisOtitis Media, Acute Bronchitis

Pharmacy Measures- Formulary Pharmacy Measures- Formulary Compliance, Generic useCompliance, Generic use

Service MeasuresService Measures

P4P OptionsP4P Options

FinancialFinancial Non FinancialNon Financial

Financial StrategiesFinancial Strategies

Quality BonusesQuality Bonuses Compensation at RiskCompensation at Risk Performance Fee SchedulesPerformance Fee Schedules Quality grantsQuality grants Reimbursement for Care PlanningReimbursement for Care Planning Variable Cost Sharing for PatientsVariable Cost Sharing for Patients

Non Financial StrategiesNon Financial Strategies

Performance ProfilingPerformance Profiling Publicizing PerformancePublicizing Performance Technical Assistance for Quality Technical Assistance for Quality

ImprovementImprovement Practice SanctionsPractice Sanctions Reducing Administrative RequirementsReducing Administrative Requirements

DiscussionDiscussion