Quality In an Age of New Health Care Models - NACHC...Journal of Participatory Medicine: December...

Module I:

Quality in A Rapidly-Evolving

Environment

“The Quality Management (QM) Plan” - NACHC Monograph - Download via NACHC Web Site

Dale S. Benson, MD, CPE, FACPE - FQHC Physician Executive (40 yrs.) - NACHC “Lifetime Achievement Award”

- Co-Author: The QM Plan

“The Patient Will See You Now” John Krueger, M.D.

Journal of Participatory Medicine: December 28, 2011

“As I listened to patients talk, I discovered that many considered our health care system to be completely out of step with their lives. Patients spoke of their sense that health care just no longer cared.”

Chinese curse: “May you live in interesting times…”

Multiple new initiatives

For Community Health Centers (CHCs), significantly greater: Visibility / Opportunity Accountability (Must optimize quality)

Like an iceberg – must get below surface to create improvements

New technologies and reporting mandates

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Drivers (2009) American Recovery and Reinvestment Act - “Stimulus Bill”

(2010) Patient Protection & Affordable Care Act - “Health Care Reform”

Multiple new FQHC initiatives (Health and Human Services (HHS), States, etc.) Programs: HIV strategies; Behavioral Health Integration; Etc. Technology: Meaningful Use Models: Patient Centered Medical Homes (PCMHs)

“Improving the quality of health care while controlling costs is the fundamental issue for the current generation.”

- Atul Gawande, M.D., MPH Harvard School of Public Health

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To… From…

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Need: Standardization Terminology Models Methods

Reduced sense of fragmentation Longstanding programs Increasing new initiatives

Overarching “organizing principle / instrument”?

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A good Quality Program does this at operational level

Can be “plug-and-play” Standardized Metrics Common functional “Categories”

Quality Management = unifying principle The QM Plan (Monograph) approach

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Major initiatives, models, and mandates impacting CHCs: The Triple Aim The Patient Centered Medical Home model Practice Transformation initiatives Meaningful Use Accreditation Patient safety Risk Management Federal Tort Claims Act (FTCA)

Common concern with / approach to Quality

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“Triple Aim” IHI / Donald Berwick, M.D.

1. Health of a defined population 2. Experience of care for individuals in population 3. Per capita cost of providing care for population

All 3 dimensions affect one another Thus, must optimize performance in all 3

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Patient Centered Medical Home (cont’d)

Basic model – around since the 1960s

Many organizations promoting the new model Multiple names -

same animal

A focus on QM

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HRSA

6 PCMH Domains:

Enhanced access and continuity

Identifying and managing patient populations

Planning and managing care

Providing self-care and community support

Tracking and coordinating care

Measuring and improving performance

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• NCQA (“PCMH 2014”)

6 Standards

Patient-Centered Access Team-Based Care Population Health Management Care Management and Support Care Coordination and Care Transitions

Performance Measurement / Quality Improvement

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The Joint Commission

5 PCMH Operational Characteristics

Patient-centeredness Comprehensive care Coordinated care Superb access to care System-based approach to quality and safety, including:

a) Performance improvement b) Clinical practice guidelines usage

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Practice Transformation Safety Net Medical Home Initiative’s Change Concepts for Practice

Transformation:

Engaged Leadership QI Strategy

Empanelment Continuous, Team-based Healing Relationships

Patient-centered interactions Organized, Evidence-based Care

Enhancing Access Care Coordination

Laying the Foundation

Building Relationships

Reducing Barriers to Care

Changing Care Delivery

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Meaningful Use

From American Recovery and Reinvestment Act (ARRA) / Stimulus Bill (HITECH program)

Goal: Ramp up use of HIT - Nationwide: Improve Quality

Meaningful use = “Carrot-and-stick” incentives Bonuses for meeting specified milestones Financial penalties for long-term lack of compliance

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Accreditation

HRSA initiative – Full accreditation for CHCs The Joint Commission (TJC) Accreditation Association for Ambulatory Health Care (AAAHC)

Formal QM structures and activities = required

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Patient Safety

“To Err is Human” (1999, Institute of Medicine) - Up to 98,000 deaths and 1,000,000 cases of harm per year

IOM: Many errors from fragmented health system

Leading cause of outpatient medical error = misdiagnosis

Clearly a QM issue

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Risk Management (RM)

Program expectation and accreditation requirement

Clearly part of QM

Details don’t need to be in QM plan

Can have RM (and UR) systems referenced in QM Plan

NOTE: Formal documentation may be required by: States Managed care plans

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Federal Tort Claims Act (FTCA) Saves CHCs $88 Million / yr. No-cost malpractice coverage (annual FTCA judgment fund) “Deemed” by HRSA to be PHS (Federal) employees: Eligible officers, board members, employees, or qualified contractors

Focus = Risk reduction and patient safety Strongly involves quality assessment / improvement (QM)

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Quality Management today

Broad Aim

Ongoing excellence (quality & safety), at most reasonable cost: BEST HEALTH CARE VALUE

(Important corollary: “As quality goes up, cost comes down.”)

Ultimate Goal Care = safe, effective, patient-oriented, timely, efficient, equitable. - “Crossing the Quality Chasm” (2001: IOM)

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Quality Management today (cont’d)

Comprehensive: Clinical / Managerial / Administrative / Facility

Meets requirements of all major external organizations

Ultimate Question:

“Does this impact / potentially impact the patient’s health?”

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So… WHY worry about QM??

Funding agents (NOT optional) HRSA / BPHC States and local municipalities Private grants, etc.

Accrediting / certifying bodies (NOT optional) The Joint Commission (TJC) Accreditation Association for Ambulatory Health Care (AAAHC) National Committee for Quality Assurance (NCQA)

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Improve clinical outcomes Committed to improving the

lives of our patients Great care enhances likelihood

of great outcomes QM = better care

Improve financial outcomes Reduce health care costs Optimize CHC financial health

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Because we have to…

Because we want to! Make a real difference in improving the health of our patients.

Because… It’s the right thing to do.

SO, in a time-strapped environment, here’s the “Quality Challenge”…

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Quality takes effort and time…

But it will be worth it.

The Quality Challenge:

An interdependent group of items, people,

and/or processes delineated by the

initial input and the ultimate output.

1. Highly interdependent processes As part of a whole, contribute synergistically

2. System output /”outcome” Product – direct or indirect – of every process

3. System outcome quality Depends on quality of every component

Strategic Quality Triad Relates directly to the Triple Aim

Quality’s “3 Strategic Goals”:

World-class Patient Satisfaction (Experience of care)

World-class Outcomes (Health of individuals and populations)

World-class Efficiency (Cost of care)

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World-Class Patient Satisfaction “The degree to which the health care services and resulting health

status meet the expectations of (that is, please) the patient.” Art of care & amenities of care

We want patients who are always satisfied, often delighted – and sometimes dazzled!

(Both Experience and Outcome of care)

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World-Class Outcomes

“The degree to which health care services and resulting health status meet the needs of patients”

The essence of quality; ultimate reason to be a health care professional What patients most want (they don’t come to enjoy our processes…) Measures of effectiveness - “Change health status for the better?” We want outcomes that are defined, measurable,

and spectacular!

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World-Class Efficiency “Making the best use of available resources”

Efficiency and quality mutually enhance one another

Clinical efficiency (“appropriateness”) “If care is not necessary, it is bad care.”

- Alan Korn, M.D.

Production (process) efficiency (elimination of waste, duplication, rework) “85% of problems in health care delivery from dysfunctional processes”

We want efficiency that is breathtaking!

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Managing Quality Three fundamental Phases

Phase 1: Quality Assessment “Monitoring and evaluation”

Phase 2: Quality Improvement “Problem resolution”

Phase 3: Tracking and reporting “Follow-up, and communication of results”

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Phase 1: Quality Assessment

Assessment first

Don’t jump directly to Improvement (Phase 2)

Improvement action without initial assessment = “tampering” Can actually make problems worse

Assessment “well done” = Improvement “well done”

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Phase 1: Quality Assessment (cont’d)

A leadership / management responsibility

Must determine where your attention is most needed…

TJC: “High volume, high risk, problem prone” issues

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Phase 1: Quality Assessment (cont’d) Monitoring the metrics

Need standard terminology We use “metrics” (Others use “measures” / “indicators” / etc.)

Definition: Metric “A carefully defined program measure – usually process or outcome – that is actively and continuously reviewed (monitored) to determine the level of performance for that particular item.”

Metrics = pre-selected measures of quality Selected by leadership Several kinds

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Phase 1: Quality Assessment (cont’d) (Monitoring the metrics)

Process and Outcome Metrics

“Process” Metrics Analytic measurements describing what is actually happening in a process. Used to identify /prioritize improvement actions.

“Outcome” Metrics Measure the actual or potential change in health as a result of one or more processes.

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Examples of process metrics:

PROCESS PROCESS METRIC (Clinical) Preventing population flu Administering flu vaccine (Organizational) Measuring employee satisfaction Using agreed-upon questionnaire

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Types of outcome metrics

Disease-Specific Outcomes (actual change in health) Microbiologic; physiologic; biochemical; symptoms/signs

General Health Outcomes (actual change in health) Ability to function; sense of well-being

Patient Experience Outcomes (potential change in health) Patient satisfaction Patient compliance

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Phase 1: Quality Assessment (cont’d) Program vs. Function Related Metrics

Examples of program-related metrics

Pediatric health HIV/AIDS Women’s health Pharmacy / Lab Dental School-based clinics Homeless care

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Phase 1: Quality Assessment (cont’d)

Examples of function-related metrics

Appropriateness of diagnostic / treatment procedures Provider / support staff performance Continuity of care Patient safety Patient experience / patient adherence Medical record system Lab quality control and infection control

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Internal vs. External metrics

Internal metrics Established by Centers themselves to identify opportunities for

improvement

External metrics Developed by outside parties

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Phase 1: Quality Assessment (cont’d) (Monitoring the metrics) A Sample Metric

Metric Name: Pediatric Dental Visit Referrals

Performance Goal: 100% of children 3-8 referred to dentist within 12 mos. Quality Action Point: 75% Data Source: Pediatric Chart Audit (age 3-10) – 10 charts / mo. Review Frequency: Every 6 months Responsible Manager: Pediatric Medical Director

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External metrics

Developed by experts / tested clinically

Possibility for benchmarking

Relevant to Center’s uniquenesses (mission, patient population)

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External metrics – sources: UDS clinical measures (process / outcome) HEDIS metrics Professional societies National Quality Forum (NQF) National Guidelines Clearinghouse (AHRQ) Etc.

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Points to Remember:

Leadership / Management drives metrics

Leaders / managers develop metrics, provide data

QM Committee ensures metrics being monitored / evaluated

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Points to Remember (cont’d):

Rule of Thumb: Start simple (few metrics), build slowly

Begin with required metrics, “low hanging fruit”

Plug in new metrics over time

Ultimate objective: A balanced, comprehensive set of metrics that effectively and routinely

monitor your entire health program

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Phase 2: Quality Improvement Resolving the problem

2nd phase of QM process

3 main categories of improvement methodology: 1. Process Improvement 2. Reengineering 3. Root Cause Analysis

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Phase 2: Quality Improvement (cont’d) Resolving the problem: #1 = Process Improvement

If process results not acceptable, must change the process

“A process will produce exactly what it is designed to produce - no more and no less.”

- Donald Berwick, M.D. Co-Founder, IHI

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Phase 2: Quality Improvement (cont’d) (#1 = Process Improvement)

Multiple “Process Improvement” models

Slightly different emphases, BUT…

All address the same things: Fact-finding and Improvement

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Phase 2: Quality Improvement (cont’d) “Process Improvement”

The Key:

First understand…

Phase 2: Quality Improvement (cont’d) “Process Improvement”

Then…

Develop / test potential improvements


Major “Process Improvement” Models

PDSA

Nolan Accelerated Model

Six Sigma

Lean

Etc.

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Plan – Do – Study – Act (“PDSA”) Model • Relevant to virtually all process improvement methodologies


Nolan Accelerated Improvement Model

From Thomas Nolan, PhD – Institute for Healthcare Improvement (IHI)

Teams answer 3 fundamental questions: 1. “What are we trying to accomplish?” 2. “How will we know when a change is actually an improvement?” 3. “What changes can we make that will result in improvement?”

(Then… “PDSA”)

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Variation – measured on control charts

Common cause: Usual results , due to process design < 3 standard deviations To decrease variation / increase average, improve the process

Special cause: Unusual / unexpected results, not generally from the process > 3 standard deviations “Process improvement” not likely to eliminate Must find / remediate “special cause”

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Phase 2: Quality Improvement (cont’d) Resolving the problem: #2 = Reengineering

When needed:

1. When major process improvement is required

2. When specific processes are fundamentally dysfunctional

3. When normal process improvement is unsuccessful

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Phase 2: Quality Improvement (cont’d) (#2 = Reengineering)

To decrease chances for error – increase potential for efficiency:

Press “Delete” and start over!

Appoint and train Reengineering Team / Assign Facilitator

Can be major effort – often results in dramatic improvement

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Phase 2: Quality Improvement (cont’d) Resolving the problem: #3 = Root Cause Analysis

In-depth analysis of adverse incidents / sentinel events

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Phase 2: Quality Improvement (cont’d) (#3 = Root Cause Analysis)

Use “5 Why’s”

Ask: “Why did this happen?”

Take answer and ask “Why?” again

By 5th “Why”, should be very close to root cause

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Phase 3: Tracking & Reporting

Principle: All assessment and improvement activity is tracked, reported, and followed up until actual improvement is fully realized

Begins with QM Committee review of data Data / reports then to Director of Quality

Data / reports then collated and forwarded to CEO

CEO then reports to Board (or Board QM Committee)

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Tracking and Reporting (cont’d)

Included in reports:

Identification of metrics used

Specific data results Relative to pre-established Quality Action Points

Improvement activities initiated

Ongoing QM results

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The Quality Umbrella

Primary Care PCMH

Mean’l. Use

HIV Accreditation

Etc......

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So, How Do We Get There??

Quality is complex

Quality can be confusing

Quality requires leadership

Thus, Quality Management requires a PLAN Required by critical internal / external entities

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Characteristics of the QM Plan

Plan = Program!

“Say what you do, and do what you say.”

Board approved

Reviewed / updated annually

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Characteristics of the QM Plan (cont’d)

The Plan should be complete, rational, and succinct

Complete = Describe everything you do regarding quality

Rational = Structure, parts, and activities make sense / fit together

Succinct = Organize tightly 8-10 pages / 12 pt. type Use Appendix as needed

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Characteristics of the QM Plan (cont’d)

The Plan should address 3 fundamental topics:

1. Program structure Roles / accountability

2. How to manage quality Assess / improve / track

3. QM’s relationship to programs / initiatives EX: PCMH

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Structuring the QM Program

4 Principles

1. Develop a functional definition of quality

2. Ensure accountability at all levels

3. Clearly differentiate responsibilities

4. Recognize and optimize the key role of practitioners

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• Structuring the QM Program (cont’d)

#1: A functional definition of quality

In order to monitor, measure, and improve quality, must first define it.

Board must approve the definition.

Once defined, structure all quality-related activities around that.

No “required” definition.

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A functional definition of quality

A useable operational definition:

“Quality is the degree of excellence of the organization’s processes, practitioner and support staff performance, decisions, and human interactions.” - Dale Benson, M.D.

Focus = “degree of excellence” (not “outcomes”)

Isolates 4 specific areas to monitor / measure / improve

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Structuring the QM Program (cont’d) #2. Ensure accountability at all organizational levels

Board of Directors

CEO

Director of Quality

CMO

QM Committee

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Governing Board in QM

• Assumes fiduciary role

• Reviews and approvesQM Plan every 3 yrs.

• Receives / acts onreports

• Assures availability of resources / systems

• If desired, may create Board QM Committee

Structuring the QM Program (cont’d) (#2. Ensure accountability at all organizational levels)

CEO

Accountable to Board for overall CHC quality Directly, or Through Board QM Committee

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Director of Quality

Responsible for general functioning of the QM program QM Committee(s) report to him / her

Reports directly to CEO NOTE: Should not report to CMO

Staffs Board QM Committee

May also coordinate Risk Management / Utilization Review

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CMO Medical Director, Director of Clinical Quality, etc. Reports to CEO NOT accountable for organization-wide QM program CEO responsibility

IS accountable for provider performance assessment / improvement Coordinates peer review activities

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Quality Management Committee

Large organizations may have several (by program, etc.)

Meets regularly / Reports to Director of Quality

Front-line employees with no leadership / management responsibility Broadly-representative / cross-functional / Front-line providers OK

Monitors the QM program (full, or program-specific)

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QM Structure

Governing Board

Board QM Committee

CMO Director of Quality

Quality Management Committee

CEO

Structuring the QM Program (cont’d) #3. Clearly differentiate responsibilities Leadership: Those with decision making authority They (not QM Committee) are responsible for quality / QM 5 Tasks:

• Choose metrics to monitor, with goals • Determine thresholds for each metric • Provide data to the QM Committee • Manage improvement activity • Responsible for resolving identified quality problems

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Structuring the QM Program (cont’d) (#3. Clearly differentiate responsibilities)

The Quality Committee

5 tasks… Ensures that: QM activity routinely carried out Selected metrics being monitored Data being collected Metrics below thresholds move to

improvement phase Identified quality problems are resolved

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Structuring the QM Program (cont’d) (#3. Clearly differentiate responsibilities)

SUMMARY of Principle #3

The QM Committee is not responsible for QM program Leadership and management are

The QM Committee is not responsible for solving quality problems Leadership and management are

QM Committee supports leadership / management and ensures the Quality program is working and generating appropriate results

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Structuring the QM Program (cont’d) #4. The practitioner role must be effective and efficient

Practitioners critical to CHC quality

Must actively ensure quality

Monitor / measure / improve practitioner-related processes

Monitor / measure / improve performance, decisions, interactions

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Structuring the QM Program (cont’d) (#4. The practitioner role must be effective and efficient)

Components of practitioner quality / QM Use clinical guidelines Do peer chart reviews (contribute greatly to quality) Review data Participate on Center and clinical improvement teams Have membership on QM Committees

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Structuring the QM Program (cont’d) (#4. The practitioner role must be effective and efficient)

Key Role of the CMO… Must ensure:

Broad practitioner participation in QM activities

That practitioner component of QM program is efficient

That practitioner component of QM program is effective

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Structuring the QM Program (cont’d)

4 Principles: REVIEW

Your QM program should be structured to:

1. Start from a functional definition of quality

2. Ensure accountability at all levels

3. Clearly differentiate responsibilities of leadership / management from those of QM Committee

4. Recognize and optimize key role of practitioners

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A QM Framework for Integrating Programs / Models

Our template must:

Be an organizing / unifying force among programs / initiatives

Be aligned with fundamental PCMH principles

Be aligned with Quality Assessment & Improvement principles

Be consistent with the Triple Aim

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A QM Integrating Framework (cont’d)

PCMH-based “Quality Categories”

8 broad Categories

Underlie PCMH-based Template Foundation for program-specific “Metric Paks”

Align closely with PCMH concepts Thus, good for both primary care and population-specific programs

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A QM Integrating Framework (cont’d)

Understanding “Quality Categories” For each (as found in NACHC’s Monograph, “The QM Plan”): Definition Key underlying concepts

Includes one business quality Category Potential for significant savings / new revenues Enables all patient care

QM objective = At least 1 metric / Category / program

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The “Quality Categories” (All underlying concepts shown in NACHC “QM Plan” Monograph)

1. Access and Cycle Time 2. Comprehensive, Coordinated, and Integrated Care 3. Clinical Quality / Safety 4. Prevention / Health Promotion 5. Patient / Community Relationships 6. Health Information Technology (HIT) 7. Patient Experience / Loyalty 8. Business Process Quality

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Generating Category-based Metrics

Develop specific metrics within each “Category”

Ideally, start with 1 – 2 metrics per Category

Add metrics within each Category as QM program matures

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PCMH-based “Metric Paks”

Definition: A group of metrics (internal or external) covering each of the 8 broad Quality Categories, as applied to a specific program or initiative.

Examples (from Monograph):

Primary Care Metric Pak HIV Metric Pak Behavioral Health Metric Pak Meaningful Use Metric Pak

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Metrics Arrayed by PROGRAM / INITIATIVE

(see Monograph)

“Primary Care” METRIC PAK

Once your Plan and QM program are successfully moving

forward, don’t forget to:

CELEBRATE !

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“The Patient Will See You Now” John Krueger, M.D.

Journal of Participatory Medicine: December 28, 2011

“The patient will see you now. Are you ready?”

Quality In an Age of New Health Care Models - NACHC...Journal of Participatory Medicine: December...

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