Physician Accountability: In the Public Eye

Jay Wish, MDMedical Director, Dialysis Program and Medical Director, Medical Quality

Karen Boyd, RN, BSN, MBADirector Quality InstituteUHCMC

Karen Saidel, RN BSNManager, Quality and RiskUHRMC

Corinne M. Hurley, RN, MSNDirector of Clinical ManagementUHPS

Sri K. Madan Mohan, MD, FACC, MRCPChief Quality Officer, Harrington Heart & Vascular InstituteProgram Director, Advanced Imaging FellowshipUHCMC

Anka Meges, RN, BSN, MBASenior Clinical Adoption AnalystElectronic Medical RecordsUniversity Hospitals

Raymond KrncevicAssociate General CounselUniversity Hospitals

Jennifer Carpenter, MSN, RN, CPHIMSManager, UHCare Clinical DocumentationUniversity Hospitals

October 27, 2012 University Hospitals 2

Objectives

• Understand anticipated future regulation• Understand how physician specific data are

being collected and how they are shared • Determine relevant physician specific metrics

– Determine what physicians would like to see on a UHCare physician scorecard

– Identify how physician accountability metrics can establish best practices

• Determine how to promote a win, win, win for patient, physicians, and the institution (aligning incentives)

October 27, 2012 University Hospitals 3

AHRQ Recommendations Regarding Provider Performance Measures

1.  Have a solid evidence basis2.  Measure clinical performance (not cost or

utilization)3.  Be actionable by a provider or professional4.  Cover the domains of interest5.  Specify methodologic considerations6.  Be biometrically tested for validity,

sensitivity, specificity, reliability and reproducibility

October 27, 2012 University Hospitals 4

AHRQ Recommendations Regarding Provider Performance Measures cont.

Furthermore, AHRQ recommended that public disclosure of provider profiles be postponed until

1.  methodology regarding case mix adjustment is validated (providers accepting higher-risk patients should not be penalized for adverse outcomes), and

2.  appropriate safeguards to avoid "cherry picking" (providers refusing to accept high-risk patients in order not to blemish their aggregate outcomes) must be specified.

October 27, 2012 University Hospitals 5

CMS Related Physician Measures

• ACO Quality Indicators• Physician Quality Reporting• Clinical Quality Measures for Meaningful Use• E-Prescribing eRx Metric

October 27, 2012 University Hospitals 6

Examples of Patient Accessible Physician Profile Websites

• Minnesota HealthScores - University of Minnesota Physicians

• Minnesota HealthScores - Ratings by Condition• Healthgrades• Vitals

October 27, 2012 University Hospitals 7

Examples of Patient Accessible Physician Profile Websites cont. – Physician Compare Provider Profile

• Minnesota HealthScores - University of Minnesota Physicians

• Minnesota HealthScores - Ratings by Condition• Healthgrades• Vitals• Physician Compare Provider Profile

October 27, 2012 University Hospitals 8

What are the Meaningful Use Requirements?

Providers

15 core objectivesMost require achievement of performance targets

5 objectives out of 10 from menu set

Most require achievement of performance targets

6 total Clinical Quality Measures

Do not have performance targets

- 3 core or alternate core - 3 out of 38 from menu set

Stage 1 Objectives and Measures Reporting

October 27, 2012 University Hospitals 9

Clinical Quality Measures

• Clinical Quality Measures align with other CMS Physicians Clinical Quality Reporting (for example: Medicare ACO; PQRS)

October 27, 2012 University Hospitals 10

Looking Ahead

• What has Giesinger done to align incentives?– Productivity

– Adherence to quality measures

– Citizenship

• UH ACO aligning incentives– UH leadership is working on how best to achieve this

– What would you us to share with leadership?

October 27, 2012 University Hospitals 11

Available reports

October 27, 2012 University Hospitals 1212

Physician Focus Report

Source:Premier

October 27, 2012 University Hospitals 1313

Physician Focus Report

Source:Premier

October 27, 2012 University Hospitals 1414

Physician Report

Source:Midas

Provider: (Sample Profile)Provider Service: DEPT-SURGERYFacil ity: UH CASE MEDICAL CENTER

Indicator Jul-Dec 2010 Jan-Jun 2011 Jul-Dec 2011 Jan-Jun 2012 Total SpecialtyDischarges - Inpatient 37 47 34 33 151 822Discharges - Observation 1 1 0 0 2 3

Total Inpatient Procedures (OR Cases) 38 75 55 44 212 912Total Ambulatory Procedures (OR Cases) 0 1 0 0 1 6

% Inpt/Obs Discharges Before 11am 0 4.167 14.706 6.061 5.882 3.636% Inpt/Obs Discharges Before 12noon 5.263 20.833 20.588 9.091 14.379 8.848% Inpt/Obs Discharges Before 1pm 13.158 33.333 29.412 15.151 23.529 16.242% Inpt/Obs Discharges Before 2pm 26.316 41.667 44.118 33.333 36.601 28.727

% Inpatient ICU Utilization 91.892 91.489 94.118 90.909 92.053 92.457ICU Average Length of Stay 5.565 9.453 7.334 6.677 7.415 5.189

Inpatient Mortality (% of discharges) 8.108 4.255 14.706 9.091 8.609 4.866CDB1034 - Attending Provider, Acute Care - % Readmit within 30 Days 8.823 13.333 17.241 27.586 16.058 13.811CDB920 - Acute Care - % Readmit within 14 Days 8.823 13.333 6.896 13.793 10.949 9.591CDB1076 - Acute Care - % Readmit within 7 Days 5.882 4.444 6.896 6.896 5.839 6.641

Patient Relations Complaints 0 0 0 0 0 0Patient Relations Compliments 0 0 0 0 0 3

Hospital Acquired ConditionsCatheter Associated UTI - Per 1000 Inpatients 0 0 0 0 0 3.708Catheter Associated UTI - Per 1000 Inpatients (numerator) 0 0 0 0 0 3Infection from Central Venous Catheter - Per 1000 Inpatients 0 0 29.412 0 6.803 2.472Infection from Central Venous Catheter - Per 1000 Inpatients (numerator) 0 0 1 0 1 2Hospital Acquired Injuries - Per 1000 Inpatients 0 0 0 0 0 0Hospital Acquired Injuries - Per 1000 Inpatients (numerator) 0 0 0 0 0 0Pressure Ulcers NPOA, Stage III and IV - Per 1000 Inpatients 0 21.276 0 0 6.803 3.708Pressure Ulcers NPOA, Stage III and IV - Per 1000 Inpatients (numerator) 0 1 0 0 1 3

October 27, 2012 University Hospitals 1515

Physician Report

Source:Midas

Patient Safety Measurses Jul-Dec 2010 Jan-Jun 2011 Jul-Dec 2011 Jan-Jun 2012 Total SpecialtyAdult Death in low-mortality DRGs /1000 0Adult Death in low-mortality DRGs /1000 (numerator) 0 0 0 0 0 0Death Among Surgical IP w/Serious Treatable Complications/1000 200 250 200 142.857 200 181.818Death Among Surgical IP w/Serious Treatable Complications/1000 (numerator) 1 2 1 1 5 12Adult Iatrogenic Pneumothorax /1000 0 0 0 0 0 0Adult Iatrogenic Pneumothorax /1000 (numerator) 0 0 0 0 0 0Adult Postoperative hemorrhage or hematoma /1000 0 0 0 0 0 3.793Adult Postoperative hemorrhage or hematoma /1000 (numerator) 0 0 0 0 0 3Adult Postoperative respiratory failure /1000 0 333.333 0 750 357.143 400Adult Postoperative respiratory failure /1000 (numerator) 0 2 0 3 5 8Adult Postoperative wound dehiscence /1000 0 0 0 0 0 0Adult Postoperative wound dehiscence /1000 (numerator) 0 0 0 0 0 0Adult Accidental puncture or laceration /1000 27.027 21.276 0 0 13.699 13.889Adult Accidental puncture or laceration /1000 (numerator) 1 1 0 0 2 11

Core MeasuresCore SCIP - cases selected in sample 11 20 13 12 56 324Core SCIP/SIP-Inf-1a - Antibiotic within 1 hr of incision-Overall 100 100 100 100 100 97.619Core SCIP/SIP-Inf-1a - numerator 7 17 9 5 38 246Core SCIP/SIP-Inf-1a - denominator 7 17 9 5 38 252Core SCIP/SIP-Inf-2a - Antibiotic selection-Overall 100 100 100 100 100 100Core SCIP/SIP-Inf-2a - numerator 7 18 9 5 39 258Core SCIP/SIP-Inf-2a - denominator 7 18 9 5 39 258Core SCIP/SIP-Inf-3a - Antibiotic disc. within 24 hrs-Overall 100 93.75 100 100 97.222 96.735Core SCIP/SIP-Inf-3a - numerator 7 15 8 5 35 237Core SCIP/SIP-Inf-3a - denominator 7 16 8 5 36 245Core SCIP-Inf-4 - Cardiac patients 6am postop serum glucose 75 100 100 57.143 88.372 92.754Core SCIP-Inf-4 - numerator 6 18 10 4 38 256Core SCIP-Inf-4 - denominator 8 18 10 7 43 276Core SCIP-Inf-6 - Appropriate hair removal 100 100 100 100 100 100Core SCIP-Inf-6 - numerator 11 20 13 11 55 320Core SCIP-Inf-6 - denominator 11 20 13 11 55 320Core SCIP-Inf-9 - Urinary catheter removed POD 1 or POD 2 100 91.667 100 100 95.454 90.322Core SCIP-Inf-9 - numerator 5 11 3 2 21 140

October 27, 2012 University Hospitals 16

UHCare reporting

Multiple reports for internal and external use look at physician performance & accountability

• Med Rec– Completion of admission & discharge Med

Rec, sorted by attending

• CPOE– Rate of CPOE vs. written, verbal– Unsigned orders

• Order set utilization– Rates– Relevance b diagnosis

• Notes– H&P utilization by attending– Attestation compliance by attending

• Meaningful Use– CPOE, coded diagnoses, cause of death

October 27, 2012 University Hospitals 17

Joint Commission Standards for Focused & Ongoing Professional Practice Evaluation

• FPPE: privilege-specific evaluation for doctors lacking documented competency– Newly-requested privileges

– Quality problems identified in doctor’s existing practice

– Triggers & remedial measures clearly identified

– Time-limited

• OPPE: process for identifying trends that impact quality of care and patient safety– Review period must be < 1 year (at UH, 8 months)

– Departments responsible for setting criteria

– Can give rise to FPPE

October 27, 2012 University Hospitals 18

Discussion

• How do you want to incentivize performance?• Carrots vs sticks?• Bonuses • What metrics would be helpful/relevant?• Barriers to consistent accountability • Process vs outcome measures• Aligning incentives

October 27, 2012 University Hospitals 19

Thank You.