Transcript Slide 1

Quality / Performance Improvement
Mike Holland
Vice President, Lean Healthcare
NEXT LEVEL Partners, LLC
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Highlights
 Quality / Performance Improvement
• 20 questions for 10% of exam
• 8 knowledge areas
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American
Reinvestment &
Recovery Act (ARRA)
Provide incentive payments for Meaningful Use of
Certified EHR technology
Stage 1 Components:
 Electronically capture health information in a coded
format
 Use that information to track key clinical conditions
 Communicate that information for care coordination
purposes
 Initiate the reporting of clinical quality measures and
public health information
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American
Reinvestment &
Recovery Act (ARRA)
Meaningful Use Priorities
 Improve quality, safety, efficiency, and reducing
health disparities
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Engage patients and families in their health care
Improve care coordination
Improve population and public health outcomes
Ensure adequate privacy and security protections
for personal health information
 Engage decision support for national high-priority
conditions
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Stage I - Functional Measures (Final Rule)
Stage I - Clinical Quality Measures (Final Rule)
Hospital
Eligible Professional
Hospital
Eligible Professional
23 Meaningful Use Functional
Measures
24 Meaningful Use Functional
Measures
15 Meaningful Use Clinical
Quality Measures
6 Meaningful Use Clinical
Quality Measures per EP
Measures with a
denominator of unique
patients regardless of
whether the patients records
are maintained using
certified EHR technology
5 measures
Example: Maintain active
medication list
Measures with a
denominator of unique
patients regardless of
whether the patients records
are maintained using
certified EHR technology
6 measures
Example: Maintain active
medication list
Stage I Hospital
Meaningful Use Clinical
Quality Measures
Stage I Eligible
Professional Meaningful
Use Clinical Quality
Measures
or
Chronic Condition
Management
Measures with a
denominator based on
counting actions for patients
whose records are
maintained using certified
EHR technology
9 measures
Example: Record and chart
changes in vital signs
Measures with a
denominator based on
counting actions for patients
whose records are
maintained using certified
EHR technology
10 measures
Example: Record and chart
changes in vital signs
Functional Capability
Yes/No Attestation Only
9 measures
Functional Capability
Yes/No Attestation Only
8 measures
Example: Implement drugdrug and drug-allergy
interaction checks
Example: Implement drugdrug and drug-allergy
interaction checks
Functional reports will be developed by Cerner as part of each solution’s departmental
reports. Clients who have implemented the corresponding solution will receive the reports
as part of that solution.
Core Measures: Stroke
7 measures
Core Measures: VTE
6 measures
Core Measures: ED
Throughput
2 measures – Reports
Only
Cerner Millennium® Core Measure
solutions requires a subscription and
services for implementation.
Please note – this does not cover the
2012 future e-submission
capabilities based on pending
definition and requirements.
Core Measures
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Alternate Core Measures
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Additional Measures for
Selection by Specialty
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Cerner Millennium® Stage I Eligible
Professional Meaningful Use solution
and Cerner Millennium® Chronic
Condition Management solution
require a subscription and services
for implementation.
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Cerner Corp. All rights reserved
Quality and PI
Knowledge Areas
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Benchmarking techniques
Medical staff peer review and discipline process
Risk management principles and programs
Performance and process improvement (e.g. CQI,
TQM, QA/QI, PI)
 Customer satisfaction principles and tools
 Clinical methodologies, evidence-based medicine,
population health, pay for performance
 Utilization review and management regulations
 National quality initiatives (e.g. patient safety)
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Quality & PI
Why the focus on Quality & Performance
Improvement?
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Accreditation guidelines
Growing consumerism
Efficiencies and cost savings
Improved patient outcomes
Transparency
National reporting, e.g. HHS Hospital Compare
http://www.hospitalcompare.hhs.gov
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Quality & PI
Organizations that support quality initiatives:
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The Joint Commission (TJC)
CMS Core Measures (NHQM, HOP)
Institute of Medicine (IOM)
Leapfrog Group
NQF ( National Quality Forum)
AHRQ (Agency for Healthcare Research and
Quality)
 IHI (Institute for Healthcare Improvement)
 Baldrige National Quality Program
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Quality & PI
The Joint Commission (TJC):
 Requires organizations to systematically monitor, analyze,
and improve patient outcomes
 TJC National Patient Safety Goals
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Improve the accuracy of patient ID
Improve the effectiveness of communication among caregivers
Improve the safety of using high-alert medications
Eliminate wrong-site, wrong patient and wrong procedures
surgery
• Improve the safety of using infusion pumps
• Improve the effectiveness of clinical alarm systems
• Reduce the risk of healthcare acquired infections
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Quality & PI
The Joint Commission & Medical Records
 The record must contain sufficient information to
identify the patient and to support the diagnosis
and treatment, and it must furnish adequate
documentation of results.
 Requires that the medical history, diagnostic and
therapeutic orders, all reports, consultations,
tests, progress notes, and clinical resume are
entered and signed by the attending physician.
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Core Measures
 The Joint Commission Measures
 CMS/Premier Core Measures
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AMI
CHF
Pneumonia
SCIP (hip and knee replacement, vascular surgery, CABG,
other cardiac surgery, hysterectomy, colon surgery)
Stroke
VTE
Readmission and Mortality (HF, AMI, Pneumonia)
Children’s Asthma Care
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HHS Website – Hospital Compare
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HCAHPS
Hospital Consumer Assessment Health Plans Survey
 Looks at satisfaction with:
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Communication
Pain management
Environment
Education of patient
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IOM Reports
Emphasis on Patient Safety
1999 – To Err Is Human
2001 – Crossing the Quality Chasm
 Between 44K and 98K people die as the result of medical errors that
could have been prevented
 Medical errors
• Failure of planned action as intended
• Use of wrong plan to achieve outcome
 Common problems
• Drug and blood reactions
• Restraint deaths
• Falls, burns and pressure ulcers
• Mistaken identity
 Most high risk areas
• ICUs, ORs and EDs
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Institute for Healthcare
Improvement (IHI)
 100,000 Lives Campaign inspired by IOM reports
• Saved 124,000 lives in 18 months
 Dec ‘06 – Dec ’08 5 Million Lives Campaign
 IHI Improvement Map
 IHI.org
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Leapfrog
 Leapfrog Group’s inception 2000 – built on fact that
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provider performance transparency is critical to optimal
functioning in marketplace
Save lives by reducing preventable medical mistakes
NQF endorsed practices
CPOE
Evidence-based Hospital Referrals (EHR)
ICU Physician Staffing
Never Events (Pressure Ulcers, wrong surgical site, etc.)
Mortality by Surgeon
Surgeon Volumes
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HEDIS
Healthcare Effectiveness Data and Information Set
 Report card primarily from the consumers’
perspective on health plan performance
 Assists employers with health plan selections, etc.
 Measures were developed by the National
Committee for Quality Assurance (NCQA
 Rate health plans on quality of care, access to care,
and member satisfaction with the plan
 Used by more than 90 percent of America’s health
plans
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Pay for Performance
P4P
 Model built on defined measures, data collection,
and public reporting
 Payment incentives aimed at quality, efficiency, and
patient satisfaction
 Focus on value while taken into account the
relationship between quality and cost
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Baldrige Criteria
 Enhance the competitiveness, quality and productivity of
US organizations for benefit to all residents
 Categories (7)
• Leadership, Strategic Planning, Focus on Patients,
Measurement & Analysis, Staff Focus, Process Management
and Performance Results
 Measurement of processes that have
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Approach
Deployment
Learning
Integration (horizontal vs. vertical alignment)
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Quality & PI Themes
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Processes and Progress are measurable
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Empowerment and fear are mutually exclusive
Quality tools improve the reliability of collecting data
Better decisions can be made with proper analysis
Individual success improves when allowed to participate
in decision making
Serving the customer is paramount to survival
Customers provide feedback (expectations)
Acting on feedback improves customer satisfaction
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Risk Management
 Aids in identifying, evaluating, and reducing risks that
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could be encountered by staff, patients, and visitors
Reduces the legal and financial exposure of the
organization, while TQM/CQI improves processes that
may have been poorly designed, and as a result increase
risk to the patient
Common risk management concepts: near miss, root
cause analysis, sentinel events, safety, etc.
In some organizations, the risk management function
overlaps or is included with the corporate compliance
function
QI/PI perspective – is there a trend or disequality?
RM perspective – is an accident waiting to happen?
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Risk Management and
Medical Records
 Ownership of the medical record rests with the hospital
or with the physician who keeps patient records
 The owner of the record thus has the right of physical
possession and control
 Neither the patient nor an authorized representative has
the right to physical possession of original medical
records
 The physician or hospital can transfer a copy
 The hospital or physician has a legal obligation to make
available to the receiving physician or hospital all
information that is necessary for the care of the patient
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Quality & PI
Leadership Role
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Establish a mission and culture that are committed to excellence
Nurture commitment to quality principles and lead by example
Ensure the safety systems are in place
Hold people accountable to be technically competent to meet the
needs of patients
Identify gaps between actual and desired performance
Provide a framework to identify, debate, and resolve issues
limiting clinical capability
Provide training in in use of tools and statistical concepts for
accurate data collection
Select problems to address
Understand fluctuation with a goal to reduce variation
As variation is reduced, the quality becomes more consistent and
patient outcomes and satisfaction improve
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Quality and PI
Medical Staff Roles
 Create and maintain the bylaws that help govern the
health care organization’s setting
 Provide the medical oversight for quality care,
services offered, types of treatment
 Establish medical privileging and credentialing of
staff
 Provide ongoing evaluation of the competencies
related to the medical community
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Quality & PI
Common Process Improvement Methods
 Total Quality Management (TQM) and Continuous
Quality Improvement (CQI) – often used interchangeably
 Six Sigma – reduce variations
 LEAN thinking – remove waste
 Plan-Do-Check-Act Cycle – study the process, put plans
into action, observe key learnings, and repeat the cycle
with needed modifications
 Rapid Cycle Improvement (Kaizen) – improve
performance by incremental process changes
 Review the teachings of Deming, Phillip Crosby, Juran,
Ishikawa
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Quality & PI
 TQM/CQI focus is on the system and processes,
rather than the individual
 PDCA cycles encourage analysis of data to
assess interrelated parts of the system and how
they function
 As one part of a system is improved, the
relationship or functioning between parts of the
system can be improved
 Focus on interdependencies and hand-offs
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Quality & PI
Tools
 Pareto charts – arrange data by relative
importance
 Scatter diagrams – relationship between two
qualitative variables
 Check sheets – collection of data that help
summarize information
 Control charts – determine upper and lower
limits of expected common cause variation
 Cause and Effect diagrams – AKA Fishbone
diagrams
 Histograms – graphical display of a set of
numbers and their variation
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Quality and PI
Examples of quality data use:
 Reporting on data related to adverse effects,
outcomes, incidents, complaints and malpractice
 Patient and family satisfaction survey
 Total costs per patient or per episode
 Compliance/Variation with clinical practice
guidelines
 Number of rules/alerts acted upon or ignored
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Quality and PI
Examples of quality in clinical performance
 Using patient management protocols to guide
clinical care
 Using functional protocols to ensure safe, reliable,
patient centered care elements
 Continuously improving clinical care
 Strengthening illness prevention and health
promotion
 Supporting a culture of clinical improvement
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“…total score-able offsets put forward by the
[U.S. Presidential] Administration to nearly
$950 billion over 10 years…”
- June 13, 2009 White House
release in response to how the
government plans to cover the
cost of health care reform
Additional CMS Savings
(billions of dollars)
$110 billion in
Productivity
Improvements
over 10 years
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The impact of $110B in Productivity Improvements
on every hospital assuming…
 50% of the productivity improvements are imposed upon
all acute care hospitals in the US (will likely be more)
 The improvement expectations will be imposed
proportionate with hospital size (# registered beds)
Currently ~575,000
registered beds in US
Rough estimate of this impact on your
hospital(s) over 10 years:
100 Bed Hospital = $1M / year
250 Bed Hospital = $2.5M / year
500 Bed Hospital = $5M / year
1,000 Bed Hospital = $10M / year
Prepared for this?
From NATIONAL AND LOCAL IMPACT OF LONG-TERM DEMOGRAPHIC
CHANGE ON INPATIENT ACUTE CARE, Solucient, 2005
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This will require disruptive
change to the way we lead our
healthcare organizations!
 Quality and  Costs
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Quality & PI
Need more in-depth resources?
Applying Quality Management in Healthcare: A Process for
Improvement, Diane L. Kelly, Dr.P.H.
Continuous Quality Improvement in Health Care, Curtis P.
McLaughlin and Arnold D. Kaluzny
Crossing the Quality Chasm: A New Health System for the
21st Century, Committee on Quality of Health Care in
America, Institute of Medicine
Error Reduction in Health Care, Patrice L. Spath
To Err is Human: Building a Safer Health System, Linda T.
Kohn, Janet M. Corrigan, Molla S. Donaldson,
Committee on Quality of Health Care In America,
Institute of Medicine.
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Quality & PI
Test Questions
The primary purpose of the quality assurance/risk
management program is to:
A. Comply with licensure and accreditation standards
as required by state and federal legislation
B. Monitor medical staff practices in order to control
the increases in malpractice rates
C. Identify potential problems that will keep the
hospital from becoming a party to litigation
D. Monitor, control, and direct the institution’s efforts
towards achieving delivery of the optimal level of
care
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Quality & PI
Test Questions
In consultation with the board, the administrator has decided
that an effort must be made to increase the level of
involvement among management personnel in quality
assessment and assurance. Which one of the following
options is most likely to achieve the desired results?
A.
Send all key management personnel to quality
assessment workshops over the next year
B.
Delegate quality assessment function in question to the
medical records committee
C.
Delegate quality assessment education functions to the
utilization review coordinator
D.
Develop an in-house program using trained key
personnel for presenting and discussing quality
assurance and its implication for the organization.
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Quality & PI
Test Questions
The governing body of a healthcare institution meets its
responsibility for the quality of patient care by:
A. Delegating accountability for patient care to the committee
appointed by the governing body, which provides a formal
administrative liaison between the governing body, the
administration, and the medical/professional staff.
B. Delegating to the chief executive officer the responsibility
for developing criteria for making certain that an effective
medical/professional audit is carried out.
C. Establishing, maintaining, and supporting through
medical/professional staff and management staff an
ongoing program of review and evaluation of patient/client
care and action on findings
D. Establishing an effective system for utilization review,
medical/professional audit activities, and credentialing of
the medical/professional staff.
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Quality and PI
Test Questions
Which of the following statements most accurately describe how
the Baldrige Quality Program criteria relates to the health care
sector?
A. Addresses key areas of running a successful health care
organization and is compatible with other performance
improvement initiatives, i.e. Magnet status, Joint Commission
and Institute For Healthcare Improvement initiatives
B. Valuable framework for measuring performance and planning
in an uncertain environment
C. Criteria helps health care organizations achieve and sustain
the highest national levels of patient safety and patient loyalty,
health outcomes, physician/staff satisfaction, revenue and
market share, and community services
D. All of the above
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Quality and PI
Test Questions
All of the following are commonly recognized to be a
right of each patient except:
A. Right to considerate and respectful care
B. Right to receive a reasonable response to his/her
requests
C. Right to communicate with a caregiver in the
language of the patient’s choosing
D. For dying patients, the right to receive effective pain
management
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Quality and PI
Test Questions
The governing authority assures itself about the
quality of care by:
A. Holding the CEO of the health facility accountable.
B. Making the president of the medical/professional
staff an ex officio member of the governing authority
C. Approving the process and then following up
regularly and continuously to see that it is being
used
D. Reviewing tabulated results of incidence reports
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Quality & PI
Test Questions
Which PI tool would best show process problems,
in ranking order of the most frequent, down to
the least frequent, in descending order from
left to right?
A. Histogram
B. Pareto Chart
C. Scatter diagrams
D. None of the above
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Quality & PI
Test Questions
Which of the following statements most accurately
describes the HEDIS, Health Plan Employer
Data and Information Set?
A. HEDIS indicators can easily be adopted for use by
acute care hospitals
B. HEDIS quality indicators evaluate preventive
services, prenatal care, acute and chronic illness,
and mental health and substance abuse programs
C. HEDIS was developed primarily to meet the needs
of patients and their families
D. Financial performance has no bearing on HEDIS
indicators
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More Question Areas
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Benchmarking techniques and their use
Performance improvement tools and their use
Board role for Quality of Care – Medical Staff
Ultimate responsibility for Credentialing
Functions of a Quality Council or Performance
Improvement Council
 Understanding Patient Rights and Responsibilities
 Utilization review concepts
 Overview of the Joint Commission Standards on Medical
Documentation
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