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QUALITY

Quality Defined

• Defined: Degree to which health care services for individuals and populations increase their likelihood of desired health outcomes and are consistent with current professional knowledge. – Institute of Medicine Definition

Benefits of Providing High Quality Care

• Increasing customer satisfaction. • Reducing costs associated with providing poor

quality. • Increased staff productivity.

High Focus and Attention on Quality • The IOM report estimates that medical errors cost the nation

approximately $37.6 billion each year; about $17 billion of those costs are associated with preventable errors. About half of the expenditures for preventable medical errors are for direct health care costs (IOM, 1999).

• Medication errors cost the U.S. $4 billion a year (Institute of Medicine, 2007).

• Annual cost of medical errors that harm patients estimated to be $17.1 billion in 2008 dollars (Milliman Inc study, 2011).

Can We Prevent Bad Outcomes? • 44 percent of the adverse events could have been prevented

with appropriate attention (Department of Health and Human Services report, 2008).

• One of the landmark studies on medical errors indicated 70 percent of adverse events found in a review of 1,133 medical records were preventable; 6 percent were potentially preventable; and 24 percent were not preventable.

• A study released last year, based on a chart review of 15,000 medical records in Colorado and Utah, found that 54 percent of surgical errors were preventable: http://www.ahrq.gov/qual/errback.htm

• 63.1 percent of the injuries were judged to be preventable (New York Times, 2010).

Safety of Health Care

Health care in the United States is not as safe as it should be--and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies. Even using the lower estimate, preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor- vehicle wrecks, breast cancer, and AIDS

http://www.iom.edu/Reports/1999/to-err-is-human-building-a-safer-health-system.aspx

Institute of Medicine

Quality Management • Defined: Planned systematic and organization-

wide approach to monitor, analyze, and improve organizational performance, thereby continually improving quality of care and services provided.

• Total Quality Management (TQM): Organization- wide strategy aiming at embedding awareness of quality among all staff and in every process of the organization in a cycle of continuous improvement to satisfying customer expectations and needs.

Principles of Quality Management • Active participation and commitment of senior management

team. • Establishment of new organizational structure that is solely

responsible for quality improvement initiatives. • Work is accomplished in processes. • Poor quality is costly. • Employee engagement through appropriate education and

training. • Recognition for providing high quality. • Corporate culture is based on providing high quality care.

PRINICIPLES OF TOTAL QUALITY MANAGEMENT (TQM)

Dr. W. Edwards Deming • Statistician who preached that by improving

quality, companies will decrease expenses and increase productivity and market share.

• Credited with starting the process of quality management with his 14-point management philosophy.

Deming’s 14 points 1. Create constant purpose toward improvement.

• Plan for quality in the long-term. • Predict and prepare for future challenges.

2. Adopt the new philosophy. • Put customer needs first rather than competitive pressure. • Be prepared for major changes.

3. Stop depending on inspections. • Inspections only find lack of quality. • Build quality from start to finish.

4. Use single supplier for any one item. • Less variation in the input leads to less variation for outputs.

5. Improve constantly and forever. • Plan-Do-Check-Act in process analysis and improvement.

Deming’s 14 points (cont’d) 6. Training on the job.

• Build foundation for common knowledge. • Encourage teamwork, and help employees understand role

towards “bigger picture.” 7. Implement leadership.

• Be a coach rather than police officer. • Focus on reaching full potential, not just meeting targets.

8. Eliminate fear. • Use honest and open communication. • Make workers feel valued.

9. Break down barriers. • Build shared vision through cross functional teamwork.

Deming’s 14 points (cont’d) 10. Get rid of unclear slogans.

• Don’t let words replace effective leadership. 11. Eliminate management by objectives.

• Look at how process is carried out rather than numerical targets. 12. Remove barriers to pride of workmanship.

• Allow everyone to take pride in their work without being rated or compared.

13. Implement education and self-improvement. • Improve current skills of workers. • Encourage people to learn new skills to prepare for future changes.

14. Make “transformation” everyone’s job. • Analyze each small step and understand how it fits in the bigger

picture.

A NEW ERA

A Better Health Care System • Six aims:

• Safe • Effective • Patient-centered • Timely • Efficient • Equitable

http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-QualityChasm/Quality%20Chasm%202001%20%20report%20brief.pdf

• Care based on continuous healing relationships. • Customization based on patient needs and

values. • The patient as the source of control. • Shared knowledge and the free flow of

information. • Evidence-based decision-making. • Safety as a system property. • Continuous decrease in waste. • Cooperation among clinicians.

IOM Recommendations for Providers

CONSIDER THIS….

How acceptable are practitioners to evidence based medicine?

QUALITY AND PUBLIC

History of Quality Reporting • Began in early 2000’s for hospitals. • Started with 10 simple voluntary metrics. • Today, tied to Medicare payments.

– 54 measures for inpatients. – 22 measures for outpatients. – 16 measures for EHR meaningful use.

Source: AHA

Quality Public Transparency Hospital Compare Hospital Compare is a consumer-oriented website that provides information on how well hospitals provide recommended care to their patients. Compare performance measures information related to heart attack, heart failure, pneumonia, surgery, and other conditions. • Patient survey results • Timely and effective care • Readmissions, complications, and deaths • Use of medical imaging • Linking quality to payment • Medicare volume

Access the Hospital Compare website at www.hospitalcompare.hhs.gov.

Improvement Success • A perfect score, or 100%, is when all things

were done at the right time for the right patient. Shown by the 2012 Joint Commission’s report. Measure 2002 2011 Points

Increased

Heart Attack 88.6% 98.5% 9.9

Surgical Care 82.1% 97.6% 15.5

Children’s Asthma 79.8% 94.7% 14.9

Improvement Success • Hospital Engagement Network (HEN) and Comprehensive

Unit-based Safety Program (CUSP), AHA’s partnership hospitals in collaboration with CMS, Dec ‘11 to Dec ’12.

Initiative Reduction Savings Benefit Readmissions 14%

Reduction $100M All payers

Early Elective Deliveries

42% Reduction

$10M Maternal & fetal outcomes

CLABSI 40% Reduction

$97M 290 lives

CLABSI,NICU 58% Reduction

$2.2M 131 infections prevented

Value Based Purchasing (VBP) Program • The Hospital Value Based Purchasing (HVBP) program is

designed to promote better clinical outcomes for hospital patients, as well as improve their experience of care during hospital stays. Specifically, Hospital VBP seeks to encourage hospitals to improve the quality and safety of care that Medicare beneficiaries and all patients receive during acute- care inpatient stays by: – Eliminating or reducing the occurrence of adverse events (health care

errors resulting in patient harm). – Adopting evidence-based care standards and protocols that result in

the best outcomes for the most patients. – Re-engineering hospital processes that improve patients’ experiences

of care.

Source: http://www.qualitynet.org/

What is VBP? • Initially required in the Affordable Care Act and further

defined in Section 1886(o) of the Social Security Act. • Quality incentive program built on the Hospital Inpatient

Quality Reporting (IQR) measure reporting infrastructure. • Next step in promoting higher quality care for Medicare

beneficiaries. • Pays for care that rewards better value, patient outcomes, and

innovations, instead of just volume of services. • Funded by a 1.50% reduction from participating hospitals’

Diagnosis-Related Group (DRG) payments in FY 2015. Hospitals have the potential to earn more than the 1.50% based on their total performance.

Program Measures – FY 2013 • 12 Clinical Process of

Care measures. • 8 Patient Experience of

Care dimensions of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

Source: http://www.qualitynet.org/

Domain Weight

Clinical Process of Care

70%

Patient Experience of

Care

30%

Domain Baseline Period Performance Period

Clinical Process of Care

July 1, 2009 – March 31, 2010

July 1, 2011 – March 31, 2012

Patient Experience of Care

July 1, 2009 – March 31, 2010

July 1, 2011 – March 31, 2012

Domain Baseline Period Performance Period

Clinical Process of Care

April 1, 2010 – Dec. 31, 2010

April 1, 2012 – Dec. 31, 2012

Patient Experience of Care

April 1, 2010 – Dec. 31, 2010

April 1, 2012 – Dec. 31, 2012

Outcome 30- Day Mortality (AMI, HF, PN)

July 1, 2009 – June 30, 2010

July 1, 2011 – June 30, 2012

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Performance Measures - FY 2014 • 13 Clinical Process of Care

measures. • 8 Patient Experience of

Care dimensions (HCAHPS). • 3 30-Day Outcome

Mortality measures: – Acute Myocardial Infarction

(AMI) – Heart Failure (HF) – Pneumonia (PN)

Domain Weight

Clinical Process of Care

45%

Patient Experience of

Care

30%

Outcome Mortality

25%

Fiscal Year 2015 Baseline and Performance Periods

Domain Baseline Period Performance Period

Clinical Process of Care Jan. 1, 2011 – Dec. 31, 2011 Jan. 1, 2013 – Dec. 31, 2013

Patient Experience of Care Jan. 1, 2011 – Dec. 31, 2011 Jan. 1, 2013 – Dec. 31, 2013

Outcome 30-Day Mortality (AMI, HF, PN)

Oct. 1, 2010 – June 30, 2011 Oct. 1, 2012 – June 30, 2013

Outcome Agency for Healthcare Research and Quality (PSI-90)

Oct. 15, 2010 – June 30, 2011 Oct. 15, 2012 – June 30, 2013

Outcome Healthcare- Associated Infections (CLABSI)

Jan. 1, 2011 – Dec. 31, 2011 Feb. 1, 2013 – Dec. 31, 2013

Efficiency (Medicare Spending Per Beneficiary)

May 1, 2011 – Dec. 31, 2011 May 1, 2013 – Dec. 31, 2013

Linking Federal Payment to Quality

• Penalties for: – High rate of hospital readmissions within 30 days.

• AMI, CHF, Pneumonia • Up to 1% of Medicare payment

– Hospital acquired conditions and infections. – Beyond CMS…

Source: http://www.aha.org/advocacy-issues/testimony/2013/130626-tes-quality.pdf

REID HOSPITAL AND HEALTH CARE SERVICES

Case Study

Organization

• Reid Hospital. • 223-bed facility. • Not-for-profit community hospital in

Richmond, Indiana.

Reid’s Goal • Concentration on improving hospital quality

measures in: – CHF – AMI – Pneumonia

• Increase quality through standardized procedures and utilizing best practices.

• QI Team included: physicians, nursing staff, and administrators.

Steps Taken to Improve Quality • Making use of collaborative learning: Obtained best

practices from workgroup consisting of 20 other organizations.

• Reviewing hospital policies: – Teams formed to review procedures and protocols and

make appropriate changes based on best practices. • Expansion of information technology:

– If AMI/CHF/PN diagnosis entered, case manager assigned to patient.

– Series of alerts, standing orders are generated. – All clinicians involved in care have access to electronic

record of the identified patient.

Results and Lessons Learned

• Prior to implementation, Reid performed below target and average levels.

• After implementation, Reid has achieved 100% compliance in 9 out of 10 Hospital Compare measures.