north carolina hospital association getting buff spread,transparency and reliability getting buff...

North Carolina Hospital Association

Getting BuffSpread,Transparency

and Reliability


and Reliability

Kansas State Network Council MeetingJeff Spade Vice President, NCHAAugust [email protected]

2North Carolina Hospital Association

Getting Buff Getting Buff

• Public Policy Imperatives• NC CAH Performance

Improvement Project• Performance Improvement

Primer• Performance Improvement

Concepts That Work


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Me.


Public Policy ImperativesPublic Policy Imperatives

Medicare Mandates in MMA• Voluntary submission of 10

inpatient measures.• Update is 0.4% higher for those

who submit.• No payment difference based on

submitted data.

10


CMS Value-Based Purchasing PlanCMS Value-Based Purchasing Plan

• Beginning FY 2007, hospitals report 21 measures or lose 2% in Medicare PPS reimbursement.

• Value-based payments beginning FY 2009.• No payment increase allowed for patients

with hospital-acquired infections.• Two VBP listening sessions:

• January 17, 2007• April 12, 2007

11


VBP Program DetailsVBP Program Details

• Budget neutral.• In-line with IOM and MedPAC.• Build on existing CMS measures.• Three domains:

1) Clinical quality

2) Patient centered care

3) Efficiency• Performance measures and payments

for outpatient care.

12


Goals of CMS Value-Based Purchasing ProgramGoals of CMS Value-Based Purchasing Program

• Improve clinical quality. • Reduce adverse events.• Encourage patient centered care.• Avoid unnecessary costs.• Stimulate investments in improving

quality and/or efficiency.• Make performance results transparent

and comprehensible, empowering consumers.

13


CMS and Premier Quality Demonstration Project

• Performance rates of >76% may prevent: 5,700 deaths and 8,100 complications 10,000 readmissions and 750,000 hospital days

• For 59,000 pneumonia cases: Patients receiving the least number of quality

measures cost the hospital $11,107. Patients receiving the highest number of quality

measures cost the hospital $8,351 -- a savings of $2,756 per case.

14


Key Lessons for HospitalsKey Lessons for Hospitals

From a CMS exec:

“We are moving toward value-based payments to hospitals.”

“More important for hospital and system managers may be the trend toward incentives for preventing admissions.”

15


CMSwww.hospitalcompare.hhs.govCMSwww.hospitalcompare.hhs.gov

16


nchospitalquality.orgnchospitalquality.orgHospital Name

LVF Assessment

Ace Inhibitor

Discharge Instructions

Smoking Counseling

Overall HF

Score1

Overall

Denominator 2

Top 10% of NC hospitals: 98% 95% 89% 100% 92%Average for NC hospitals: 85% 80% 57% 83% 75% NorthEast Medical Center 99% 92% 96% 100% 97% 1,619Rutherford Hospital 89% 80% 53% 81% 74% 422Sampson Regional Medical Ctr 81% 82% 71% 98% 79% 583Southeastern Regional 82% 79% 42% 87% 67% 870Spruce Pine Community Hospital 85% 79% 89% 80% 86% 164Stanly Memorial Hospital 96% 93% 75% 95% 88% 487Transylvania Community Hospital 85% 75% 7% 100% 62% 47University of NC Hospital 99% 95% NA 67% 93% 607Watauga Medical Center 99% 77% 61% 93% 82% 276Wayne Memorial Hospital 89% 93% NA NA 90% 525

then the overall score is an unreliable measure of performance and is, therefore, not shown.

Hospitals highlighted in green reported all 4 heart failure measures and are in the top 10% for the overall score.NA (not applicable) indicates that no data is available from the hospital for this measure.

1. The overall score is the sum of patients across the measures that received the appropriate treatment (i.e., sum of numerators) divided by the sum of patients eligible for treatment (i.e., sum of denominators). 2. The sum of denominators across measures. This is not a count of unique heart failure patients. If the sum of the demoninators < 25,

17


18


“If you’re going to be naked, you’d better be buff!”

Don Tapscott and David TicollThe Naked Corporation

“If you’re going to be naked, you’d better be buff!”

Don Tapscott and David TicollThe Naked Corporation

Performance Reporting and Transparency

19


• Based on CMS indicators for pneumonia and heart failure.

• In partnership with NC Office of Rural Health, NCHA and CCME.

• Commitment by 26 small, rural hospitals.• Utilizes an optimal care score to measure

performance.• Workshops and collaborative learning

along with performance reporting.• Considered a national model for CAHs.

CAH & Rural Hospital Improvement ProjectCAH & Rural Hospital Improvement Project

20


Improvements Achieved ByImprovements Achieved By

• Collaborative workgroups, coaching & mentoring, sharing resources.

• Initial focus on pneumonia and heart failure & development of reliable care processes.

• Performance measurement, benchmarks and transparency are key.

• Analyses and reports feature: Summary of inclusions and exclusions. Composite or “optimal care” scores. CAH mean and hospital performance vs. NC and

national benchmarks (top 10% performance) and reliability targets (10-2 performance).

Spider graphs to share with med staff and board.

Pneumonia Composite ScoreData Reported from January, 2006 to December, 2006

0%

10%

20%

30%

40%

50%

60%

70%

80%

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Mean of CAH/Rural Hosptials National Benchmark Reliable Care

95% Reliability

National Top 10%

22


“All-or-None” Measurement“All-or-None” Measurement

• Also Optimal Care or “perfect care”.• A more stringent outcome measure that reflects

ability to manage care processes.• Completion of a full set or bundle of tasks.• Emphasizes patient centered care and focuses

on system-wide improvement.• Appropriateness of care measures help to focus

improvement efforts.• JCAHO and CMS are moving toward optimal

care measures.

PneumoniaApril 2004 through March 2005

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

PNE Composite (n=109)

Init Abx 4 (n=93)

Abx Selct (n=80)

Blood CX24 (n=43)

Blood CXAbx (n=84)Inpt FLU (n=49)

Inpt PPV (n=76)

Smk Cess (n=26)

Oxy Assess (n=109)

Hospital Name Benchmark for NC Hospitals Mean of NC Critical Access Hospitals

Pneumonia Spider GraphPneumonia Spider Graph

Heart FailureApril 2004 through March 2005

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

HF Composite (n=51)

Disch Inst (n=47)

LVF Assess (n=51)ACEI (n=10)

Smk Cess (n=10)

Hospital Name Benchmark for NC Hospitals Mean of NC Critical Access Hospitals

Heart Failure Spider GraphHeart Failure Spider Graph

25


For each patient:

Received care for all measures for which they qualify?Qualified for any measure (1=yes, 0=no)

For hospital rate: Sum of numerators

Sum of denominators

Composite Score Calculation

Composite Score Calculation


0%

10%

20%

30%

40%

50%

60%

70%

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95% Reliability

National Top 10%

Pneumonia Trend Graph

26.4%29.6%

34.0%38.8%

47.10%

53.05% 52.00%50.0%

56.6%59.0%

63.9%

71.80%76.60%

79.80%

53.70%

83.70%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Q2 04 to Q105

Q3 04 to Q205

Q4 04 to Q305

Q1 05 to Q405

Q2 05 to Q106

Q3 05 to Q206

Q4 05 to Q306

Q1 06 to Q406

Mean of CAH/Rural Hospitals Benchmark for NC Hospitals

Top 10% NC Performance

103% Improvement

Heart Failure Composite ScoreData Reported from January 2006 to December 2006

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20%

40%

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95% Reliability

National Top 10%

Heart Failure Trend Graph

34.8% 34.2% 36.0%38.8%

42.40%45.58% 46.40%

89.0% 89.5% 88.9% 88.7% 90.90% 91.65% 92.80%

46.90%

93.40%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Q2 04 to Q105

Q3 04 to Q205

Q4 04 to Q305

Q1 05 to Q405

Q2 05 to Q106

Q3 05 to Q206

Q4 05 to Q306

Q1 06 to Q406



35% Improvement

CAH combined Indicator ScoresJanuary, 2006 through December, 2006

94.50%

89.70%

83.30%81.80% 81.10%

75.60%73.70%

71.10% 70.60%66.90%

55.10%53.00% 52.90%

0%

20%

40%

60%

80%

100%

BloodCXAB

Abx Selct Init AB 4 ACEI(HF)

SmkCess(PNE)

LVFAssess

BloodCX24

Inpt PPV SmkCess(HF)

Inpt FLU PNEACM

Dis Instr HF ACM

31


• Patient Centered Care• Design for Reliability (zero defect rates)• Evidence-based Practice• Clinical Process Improvement• Rapid Cycle Improvement • Collaborative Learning and Spreading

Innovations• Measurement and Segmentation (small tests

of change)• Commitment of Leadership• This is THE WORK of Healthcare

Organizations and Professionals

Performance Improvement PrimerPerformance Improvement Primer

32


The Concepts of Innovation, Diffusion and Spread

Spread is the Diffusion of Innovation

The Concepts of Innovation, Diffusion and Spread

Spread is the Diffusion of Innovation


33


The Nature of People (Everett Rogers) The Nature of People (Everett Rogers)

Late Majority

35%

Early Majority

35%

Early Adopters

13%

Traditionalists

15%2%

Innovators

34


Target Early AdoptersTarget Early Adopters

Early Adopters are the key to successful spread of changes …..

• Receptive to change.• More socially integrated than innovators, often

opinion leaders.• Trusted by peers to evaluate changes.

… Remember “Hey Mikey, he’ll try it”

35


• What are we trying to accomplish?• How will we know that a change is an improvement?• What changes can we make that will result in an

improvement?

Act Plan

Study Do

Model for ImprovementModel for Improvement

36


Transparency and Reliability

Transparency and Reliability


37


When hospitals’ quality data is reported publicly… Performance improves (for the measures being

reported). Market share doesn’t change appreciably. Reputation improves considerably.

Hibbard J, J Stockard, and M Tusler: Hospital performance reports: impact on quality, market share, and reputation.

Health Affairs 2005, 24, #4: 1150-116025

Transparency and ReliabilityTransparency and Reliability

38


39


40


A process achieves exactly the results it is designed to achieve.

Transparency and ReliabilityTransparency and Reliability

41


Reliability is failure free operation over time.David Garvin, Harvard

Choose the patient focus, who expects optimal care by all-or-none measures.IHI Innovation Team

Definitions of ReliabilityDefinitions of Reliability

Levels of Reliability in Health Care (Amalberti, Nolan)Levels of Reliability in Health Care (Amalberti, Nolan)

Chaos 10-1 10-2 10-3 10-5

Processes are largely custom-crafted each time

Standard process, checklists, training, trying hard

Standard process; redundancy, habits and patterns

Obsession with Failure: Prevent Mitigate

Redesign

Loss of identity

Each doctor writes individual orders, gives to RN

Standing orders, feedback on compliance

All MDs use same process, multi-disc. rounds

External approval necessary for certain orders

Equivalent

actor

Preventing, treating acute and chronic disease in US

Typical hospital working hard

Best hospitals Core Measures

ADEs per 1000 doses in best hospitals

Safety in anesthesia

Concentrate Your Work Here!Concentrate Your Work Here!

Chaos 10-1 10-2

Processes are largely custom-crafted each time

Standard process, checklists, training, trying hard

Standard process; redundancy, habits and patterns

Each doctor writes individual orders, gives to RN

Standing orders, feedback on compliance

All MDs use same process, multi-disc. rounds

Preventing, treating acute and chronic disease in US

Typical hospital working hard

Best hospitals in Core Measures

44


Starting Labels of ReliabilityStarting Labels of Reliability

• Chaotic process: Failure in greater than 20% of opportunities

• 10-1: 80 or 90 percent success. 1 or 2 failures out of 10 opportunities

• 10-2: 5 failures or less out of 100 opportunities

• These are IHI definitions and are not meant to be the true mathematical equivalent.


26.4%29.6%

34.0%38.8%

47.10%

53.05% 52.00%50.0%

56.6%59.0%

63.9%

71.80%76.60%

79.80%

53.70%

83.70%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Q2 04 to Q105

Q3 04 to Q205

Q4 04 to Q305

Q1 05 to Q405

Q2 05 to Q106

Q3 05 to Q206

Q4 05 to Q306

Q1 06 to Q406



103% Improvement

46


• Common equipment, standard order sheets, multiple choice protocols, procedures & policies

• Personal checklists• Feedback on compliance• Suggestions to work harder next time• Awareness and training• Intent, vigilance and hard work

Concepts for 10-1 PerformanceConcepts for 10-1 Performance

47


• Decision aids and built-in reminders.• Desired action is the default.• Redundant processes utilized.• Scheduling used in design development.• Habits and patterns known and included in design.• Standardization of processes based on clear specification and articulation of the norm.• Uses human factors and reliability science to design sophisticated failure prevention, identification and mitigation.

Concepts for 10-2 Performance Concepts for 10-2 Performance

48


1. Need an established, standardized improvement process, focused on rapid cycle improvement.

2. Use reliability concepts in process design.

3. 10-2 reliability requires outcomes of 95% or better. Set that as the target.

4. A commitment to measurement ..... 'rule of threes' as measurement guide. If you measure 30 cases and have three or more faults, then quit measuring and concentrate on redesign because the process is 10-1.

5. Use segmentation to develop and test the reliability of the design. Segmentation allows control of variables while the process is redesigned. Once the process is standardized to 10-2 reliability on the segmented group, then it can rollout to the broader population.

How To Accomplish10-2 Performance How To Accomplish10-2 Performance

49


The Pneumovax ExampleThe Pneumovax Example

• Commonly described in order sheets as “Give Pneumovax if indicated”

• Poorly defines a process.

• Default is too commonly not to give the Pneumovax

• No testing of competency or training of new employees can occur

The Three Step Design for ReliabilityThe Three Step Design for Reliability

Design Techniques Steps1-Identify the process to standardize

2-Segment the population to test the

design for anomalies

3-Use both 10-1 and 10-2 concepts

Prevent initial failure by standardizing the process to achieve 10-1 (step 1)

1-Utilize a robust 10-2 concept to make visible failures from step 1 after step 1 has achieved 10-1 reliability

2-Once the failure is identified, apply an action to mitigate the failure

Identify failures in step 1 and apply an action to achieve 10-1 for these failures (step 2)

1-Identify common failures

2-Develop a method to measure and study failures

3-Utilize knowledge of common failures to redesign either step 1 or step 2

In either step 1 and/or step 2 detect the failures, and use the knowledge from analysis of the failures to redesign (step 3)

51


Why SegmentationWhy Segmentation

• Allows for control of variables.• Defines the boundaries around which expectations

can be formed.• More likely to test the validity of the design rather

than confront barriers.• Fosters a deeper understanding of the design

complexity required.• Forces understanding of the differences between

segments as design strategies.• Permits design beyond the disease.• Allows the formation of more predictable timelines.

52


How to “Set-Up” ReliabilityHow to “Set-Up” Reliability

• Identify a process to make more reliable.• Determine a high volume segment for initial

design and testing.• Describe the current process (flow chart).• Identify where the defects occur in the

process.• Set a specific reliability goal for the

segment/process.

53


Reliability Design StrategyReliability Design Strategy

• Prevent initial failure using intent and standardization (10-1).• Identify defects, using redundancy,

then mitigate failures.• Measure, then communicate learning

from defects back into the process design.

Example of 3 Step Design in Implementing the Example of 3 Step Design in Implementing the Ventilator BundleVentilator Bundle

Integrate daily goals with MDR to identify defects as a 10-2 change concept (step 1)Education as

a 10-1 concept

Baseline

Feedback on compliance as a 10-1 concept

Redundancy in the form of a check by RT built into 1 hour scheduled vent checks as a 10-2 change concept (step 2)

55


• Level 1: Standardization, performance feedback, training, vigilance

• Level 2: Bundles, multidisciplinary rounds and other redundancy methods, scheduling discharges, habits and patterns

• Level 3: Failure mode analysis: prevent, detect, mitigate, and redesign

Hospital Leaders Must Understand Reliability Hospital Leaders Must Understand Reliability

56


What Improvement Teams Should Expect From LeadershipWhat Improvement Teams Should Expect From Leadership• Clearly describe the organizational outcome goals.• Understand the relationship between the processes

the teams are working on and the outcome goals of the organization.

• Set process expectations for the teams.• Demand data to show how reliable the process has

become.• Setting reasonable timelines. • If outcomes have not improved and process

reliability is high, provide resources to determine the “correctness of performance” of the processes.

57


What Leaders Should Expect of TeamsWhat Leaders Should Expect of Teams

• Expect the initial focus of work to be “getting the process right” with a known connection to an outcome.

• Expect the team to take a set of processes to an agreed upon level of reliability within a specified timeline.

• Expect the teams to use good design principles not just hard work and vigilance.

• Expect teams to develop good designs by using rapid cycle tests of change.

• Expect adequate process structure to sustain the work.

58


Key LessonKey Lesson

A single standardized process within the acceptable science is superior to allowing multiple processes while deciding which is the best because it allows testing for competency and training new employees.

59


Observation re: ReliabilityObservation re: Reliability

The reliability of known or required processes in healthcare commonly is 10-1

(80%) or worse (for non-catastrophic processes).

Given all the resources and talent that we have in healthcare, why does this happen?

The reliability of known or required processes in healthcare commonly is 10-1

(80%) or worse (for non-catastrophic processes).

Given all the resources and talent that we have in healthcare, why does this happen?


0%

10%

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95% Reliability

National Top 10%


26.4%29.6%

34.0%38.8%

47.10%

53.05% 52.00%50.0%

56.6%59.0%

63.9%

71.80%76.60%

79.80%

53.70%

83.70%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Q2 04 to Q105

Q3 04 to Q205

Q4 04 to Q305

Q1 05 to Q405

Q2 05 to Q106

Q3 05 to Q206

Q4 05 to Q306

Q1 06 to Q406



103% Improvement

62


Reasons Why?Reasons Why?

• Current improvement methods in healthcare are highly dependent on vigilance and hard work.

• There is an inordinate focus on outcomes rather than process.

• Failure to design standard work which can be used in testing and training.

• Poor understanding of how to design reliable processes.

63


Key Learning PointsKey Learning Points

• Hard work and vigilance are not good design principles.

• 10-2 change concepts should comprise at least 25% of the improvement effort for a given project.

• If you accept benchmark level performance in your organization you often compare yourself against mediocrity and foster 10-1 performance.

• Benchmark outcomes against the industry best. • Measure processes against a specific reliability

goal (10-2).

64


CMS/Premier Demonstration, 260 hospitals nationallyCMS/Premier Demonstration, 260 hospitals nationally

Financial incentives did focus hospital executive attention on measuring and improving quality.

Hospitals’ performance has improved continuously over time.

Financial Incentives and transparency improve hospital quality performance

Findings

Hypothesis

Norling, NCHA Winter Meeting, 2007

65


Potential National ImpactPotential National Impact

“MEDIUM” 50% - 99%

“HIGH” 100%

“LOW” 0% - 49%

71%

PPM*M7M6M5M4M3M2M1

100%

PPM*M7M6M5M4M3M2M1

43%

PPM*M7M6M5M4M3M2M1

M

H

L

Care Measures

Care Measures

Care Measures

* Patient Process Measure

66


Finding 1: Hospital CostsFinding 1: Hospital Costs

67


Finding 2: MortalityFinding 2: Mortality

68


Finding 3: ComplicationsFinding 3: Complications

69


Finding 4: ReadmissionsFinding 4: Readmissions

70


Finding 5: Length of StayFinding 5: Length of Stay

71


High Reliability PerformanceHigh Reliability Performance

For Pneumonia, Heart Bypass Surgery, Hip and Knee Surgery, and AMI

PatientsAnnual Potential

$1.4 Billion in Costs6,000 Avoidable Deaths

6,000 Complications10,000 Readmissions800,000 Hospital Days

72


Campaign ObjectivesCampaign Objectives

• Original 100K Campaign interventions• Prevent Methicillin-Resistant

Staphylococcus Aureus (MRSA)• Reduce harm from high-alert medications• Reduce surgical complications• Prevent pressure ulcers• Deliver reliable, evidence-based care for

congestive heart failure• Get Boards on Board

73


Take Home PointsTake Home Points

• Collaborative learning is paramount.• Move toward optimal care or ‘all-or-none’

care process measures.• Target reliability as THE Benchmark for

performance.• Performance measurement and

transparency are essential to improvement.

• CMS measures and the 5 Million Lives Campaign are great places to start.



and Reliability


and Reliability

Kansas State Network Council MeetingJeff Spade Vice President, NCHAAugust [email protected]

north carolina hospital association getting buff spread,transparency and reliability getting buff...

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