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Chapter Ten

Performance Standards and Measures

Health Care Information Systems: A Practical Approach for Health Care Management

Karen A. WagerIFrances Wickham LeeIJohn P. Glaser

Health Care Information Systems: A Practical Approach for Health Care Management, 4th editionK. WagerIF. LeeIJ. Glaser

  • To explain the significant role of health information in national private andpublic quality improvement initiatives
  • To compare and contrast licensure, certification, and accreditation processes
  • To discuss the role of the Joint Commission and the National Committee forQuality Assurance in ensuring the quality of care in the US
  • To understand performance measurement development in the US
  • To identify the roles of specific public and private organizations in thedevelopment and endorsement of national performance measures
  • To understand the origins and uses of major health care comparative data sets

Health Care Information Systems: A Practical Approach for Health Care Management, 4th editionK. WagerIF. LeeIJ. Glaser

Learning Objectives

Health Care Information Systems: A Practical Approach for Health Care Management, 4th editionK. WagerIF. LeeIJ. Glaser

  • Licensure, certification, and accreditation
  • The Joint Commission
  • National Committee for Quality Assurance (NCQA)
  • Data sources for quality measures
  • Comparative health care data sets
  • Quality improvement
  • –Federal initiatives
  • –CMS initiatives

Outline

Health Care Information Systems: A Practical Approach for Health Care Management, 4th editionK. WagerIF. LeeIJ. Glaser

  • Licensure
  • –The process that gives a facility legal approval to operate
  • –State governments oversee the licensure of health care facilities
  • Certification
  • –Gives a health care organization the authority to participate in the federalMedicare and Medicaid programs
  • –CMS developed minimum standards, conditions of participation (CoPs)
  • Accreditation
  • –Voluntary, external review process
  • –Financial and legal incentives for accredited organizations

Definitions

Health Care Information Systems: A Practical Approach for Health Care Management, 4th editionK. WagerIF. LeeIJ. Glaser

  • An independent, not-for-profit organization
  • Best-known health care accrediting agency in the US
  • Site-surveys every 3 years(2 years for laboratories)
  • Standards manuals are publishedannually
  • Categories of accreditation
  1. Preliminary accreditation
  2. Accreditation
  3. Accreditation with follow-up survey

The Joint Commission

  1. Contingent accreditation
  2. Preliminary denial of accreditation
  3. Denial of accreditation

Health Care Information Systems: A Practical Approach for Health Care Management, 4th editionK. WagerIF. LeeIJ. Glaser

  • Record of Care (RC), Treatment, and Services Standards
  • –Content needed for a complete health record, regardless of its format
  • Information Management (IM) Standards
  • –Apply to bothnoncomputerizedsystems and systems with the latesttechnologies

StandardsThe Joint Commission

Health Care Information Systems: A Practical Approach for Health Care Management, 4th editionK. WagerIF. LeeIJ. Glaser

  • National Committee for Quality Assurance (NCQA)
  • Leading accrediting body for health plans
  • –Quality management and improvement
  • –Utilization management
  • –Credentialing andrecredentialing
  • –Member’s rights and responsibilities
  • –Member connections
  • –Medicaid benefits and services
  • –Health effectiveness data and information set (HEDIS)

NCQA

Health Care Information Systems: A Practical Approach for Health Care Management, 4th editionK. WagerIF. LeeIJ. Glaser

  • Crossing the Quality Chasm
  • –Published in 2001 by Institute of Medicine (IOM)
  • –Outlined 6 aims for establishing quality health care
  • Safe
  • Effective
  • Patient-centered
  • Timely
  • Efficient
  • Equitable

Quality of Care

Health Care Information Systems: A Practical Approach for Health Care Management, 4th editionK. WagerIF. LeeIJ. Glaser

  • Administrative Data
  • –Claims databases
  • Disease registries
  • –Data on patients with specific conditions
  • Health records
  • –Detailed patient information
  • Qualitative data
  • –Patient surveys or interviews

Quality CareData Sources for Measures

Health Care Information Systems: A Practical Approach for Health Care Management, 4th editionK. WagerIF. LeeIJ. Glaser

  • HEDIS
  • –Set of health care performance measures
  • –90% of health plans in the US collect and report HEDIS data
  • Clinicalquality measures (CQMs)
  • –Identified and updated by CMS each year
  • –Developed by private organizations, health care societies,collaboratives,alliances, and government agencies
  • –Required for accreditation by the Joint Commission

Quality CareMeasurement Development

Health Care Information Systems: A Practical Approach for Health Care Management, 4th editionK. WagerIF. LeeIJ. Glaser

  • Comparative health data sets
  • –Benchmarking: comparing one or more performance measures against astandard
  • Patient satisfaction data sets
  • –Survey data
  • –Agency for Healthcare Research and Quality (AHRQ)
  • Consumer Assessment of Healthcare Providers and Systems (CAHPS) program
  • Practice patterns data set
  • –Dartmouth Atlas: interactive, online tool funded by the Dartmouth Institutefor Health Policy and Clinical Practice

Data Sets

Health Care Information Systems: A Practical Approach for Health Care Management, 4th editionK. WagerIF. LeeIJ. Glaser

  • Clinical data sets
  • –Quality Check: established by the Joint Commission
  • –Hospital Compare: sponsored by CMS
  • Comparative data for health plans

Data Sets

Health Care Information Systems: A Practical Approach for Health Care Management, 4th editionK. WagerIF. LeeIJ. Glaser

  • Patient Safety Act
  • –Patient safety organizations (PSOs): responsible for the collection andanalysis of health information that is referred to in the Final Rule as patientsafety work product (PSWP)
  • –PSWP: contains identifiable patient information covered by specificprivilege and confidentiality protections
  • Incidents
  • Near misses (or close calls)
  • Unsafe conditions
  • –Common formats: established by AHRQ to help providers uniformly reportpatient safety events

Quality ImprovementFederal Initiatives

Health Care Information Systems: A Practical Approach for Health Care Management, 4th editionK. WagerIF. LeeIJ. Glaser

  • National Quality Strategy (NQS)
  • –Established by the Affordable CareAct
  • –3 broad aims
  • Better care
  • Healthy people/healthycommunities
  • Affordable care
  • –“Levers” to ensure alignment withthe NQS
  • Measurement and feedback
  • Public reporting
  • Learning and technical assistance
  • Certification, accreditation, regulation
  • Consumer incentives & benefit designs
  • Payment
  • Health information technology
  • Innovation and diffusion
  • Workforce development

Quality ImprovementFederal Initiatives

Health Care Information Systems: A Practical Approach for Health Care Management, 4th editionK. WagerIF. LeeIJ. Glaser

  • Original value-based programs were an attempt to link performance onendorsed quality measures to reimbursement
  • –Hospital value-based purchasing (HVBP)
  • –Hospital readmissions reduction (HRR)
  • –Hospital-acquired conditions (HAC)
  • –Value modifier (VM) (or Physician value-based modifier [PVBM])
  • The Medicare Access and CHIP Reauthorization Act (MACRA)
  • –Enacted in 2015
  • –Streamlines quality programs under the Merit-based Incentive PaymentSystem (MIPS)

Quality ImprovementCMS Programs

Health Care Information Systems: A Practical Approach for Health Care Management, 4th editionK. WagerIF. LeeIJ. Glaser

  • Licensure, certification, andaccreditation
  • The Joint Commission
  • National Committee for QualityAssurance (NCQA)
  • Datasources for qualitymeasures
  • –Administrative data
  • –Disease registries
  • –Health records
  • –Qualitative data
  • Measurement development
  • –HEDIS
  • –CQMs
  • Comparativehealth care datasets
  • –Benchmarking
  • –Patient satisfaction
  • –Practice patterns
  • –Clinical data
  • –Comparative data for health plans

Summary

Health Care Information Systems: A Practical Approach for Health Care Management, 4th editionK. WagerIF. LeeIJ. Glaser

  • Qualityimprovement
  • –Federalinitiatives
  • Patient Safety Act
  • Patient safety workproduct (PSWP)
  • National Quality Strategy (NQS)
  • –CMSinitiatives
  • Value-based programs
  • MACRA
  • –MIPS

Summary