CCHS: Quality and Patient Safety

J Michael Henderson, MD

Guido Bergomi

Outline

• Integrated Quality & Safety structure

• Quality Goals and Performance

Improvement

• Quality data sources

• Quality Reporting

• The Future

Strategic Planning

Clinical Quality

The Enterprise Quality Goal is to move public

reported quality metrics to the top decile

nationally through:

• Integrated infrastructure

• Annual Quality Goals

• Continuous quality improvement

• Optimal use of data

Quality Structure

Board of Trustees

Executive Leadership

Quality Leadership Team

Content Experts

Functional Clinical Units

Frontline Caregivers

Oversight

Develop Plan

Implementation

Central Resources (Content Experts)

Local Implementation (Function)

LOCAL

Implementation

Quality and Patient Safety

Institute (QPSI)

Accreditation

Quality Regulation

Clinical Risk Management

Patient Safety

Infection Prevention

Performance Improvement

CENTRAL

Resources

Hospitals and

Clinical Institutes

Quality Director

Physician Lead

Nursing Director

Administrator

Execution of Quality Goals

• Set Goals

• Communication & Education

• Performance Improvement

• Data

• Review

CCHS 2013 Quality Goals

Domain Measure 2013 Targets

Safety

Patient Safety Indicators < 83 / month

HA Pressure Ulcers II-IV < 0.13%

Never Events: Wrong Site,

Retained FB, Falls with injury Zero

Hospital Acquired Infections

CLABSI < 1/1k

ICU CaUTI: 1.9/1k

SSI: NHSN SIR < 1

Communication and Education

Continuous Improvement Model

Create the Culture

Improve Quality and Performance

Set

Goals

Measure

Performance Improve

Reward and

Recognize

Define Plan Implement Transition

Quality Data Management Dashboard

Patients

In

Hospital

All

Patients

At

discharge

Data Review & Accountability

Board of Trustees and Executive Management

To the frontline Caregiver

Project Portfolio Management

Review date: 11/1/2012

Program NameQI

FTE

Number

Projects%

Earliest

Start

Latest

End

Lowest

Rating

QPSI Operations 4.8 18 48% 9/12/11 12/31/14 G

Core Measures 0.4 13 59% 12/13/11 12/31/12 G

Hospital Acquired Infections (HAI) 0.5 12 47% 9/2/11 3/1/13 Y

Never Events 0.6 5 66% 1/1/12 12/31/12 G

Patient Safety Indicators (PSI) 0.9 12 37% 7/11/11 7/1/13 Y

Readmissions 0.8 7 65% 3/17/11 3/31/13 G

Totals 8.0 67 54% 3/17/11 12/31/14 Y

FTEs include QI (7.0), and Safety (1.0). Two additional QI FTE started late-October and are onboarding; their hours are not reflected above.

Portfolio Summary: Active ProjectsQuality Project Portfolio Review

Examples

• Patient Safety Indicators –

documentation

• Central Line Associated Blood Stream

Infections – clinical processes

• Readmission rates – models of care

CCHS Patient Safety Indicators

0

50

100

150

200

250

J F M A M J J A S O N D J F M A M J J

#

2011 2012

CLABSI

1. Insertion Bundle

2. Line Maintenance

3. Line Removal

ICU CLABSI Rate

0

2

4

1 2 3 4 1 2 3 4 1 2

Per

1000

line

days

2010 2011 2012

Web Tool for Data Management

• Realtime: reports and patient level data

• Management tool

• Data for PI

30 day HF Readmissions

15%

20%

25%

30%

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3

2010 2011 2012

Quality Data Sources

For reporting and Improvement:

- Administrative (documentation/ coding)

- Abstracted (Core Measures)

- Quality Databases (STS, NSQIP, NDNQI)

- Clinical (eg Event reporting)

Type of Hospital, Location, Use of Registries

HCAHPS

Process Measures

30d Deaths & Readmissions AMI, HF, PN

PSIs, HACs, HAIs

Mammograms, CT scans, MRIs

Medicare Spend per Beneficiary

7 Medical, 29 Surgical conditions

10

38

20

10

1

79

Where is CMS Going?

1. $$$s tied to quality metrics:

- VBP, HACs, Readmissions ….

- Medicare Spend per Beneficiary

2. Physician Quality Reporting:

- Multiple programs

- Incentives, then penalties

Medicare Spend Per Beneficiary

• Required for inclusion in VBP

• Phases: 1. 3 days prior to admission

2. Index admission

3. 30 days post discharge

• Exclusions / Risk adjustment

• On HospitalCompare website

Physician

Quality

Data

Reporting

CMS Physician Quality Payment Reform

Initiatives

Physician Quality Reporting System (PQRS) Incentive 2%-0.5%

EHR Incentive Program (Meaningful Use)

ePrescribing Incentive 1%

Accountable Care Organization ??

Maintenance of Certification Incentive 0.5%

2008 2011 2010 2009 2015 2014 2013 2012 2016

ePrescribing Penalty 1-1.5%

MU Mandated

PQRS

Mandated

MD Value

Modifier

Physician Compare Website

Physician Feedback Reports No $$

Incentive

Penalty

Reporting

eRx Mandated

Physician Quality Reporting

• Emphasis moving to individual physicians

• Initial incentives for reporting data

• Moving to penalties for not reporting or poor performance

• Data flows through different routes

Physician Quality Reporting

Metrics

Tools

Communication

• Physician Quality Reporting System

• Physician Payment Value Modifier

• Ongoing Professional Performance Evaluation

• Meaningful Use

• Quality Alliance

• ACOs and Value Based Operations

• Commercial Payers

• Chronic Disease Management

• Maintenance of Certification

Physician Quality Reporting

Components:

Set priorities in these 3 areas

Metrics

Tools

Communication

CCHS Quality Programs

SUMMARY

• Integrated infrastructure

• Set goals / measure performance

• Optimal use of data sources

• Engagement at all levels

• New horizons