Transcript Document

Getting Buff
Spread,Transparency
and Reliability
Kansas State Network Council Meeting
Jeff Spade
Vice President, NCHA
August 2007
[email protected]
North Carolina Hospital Association
Getting Buff
• Public Policy Imperatives
• NC CAH Performance
Improvement Project
• Performance Improvement
Primer
• Performance Improvement
Concepts That Work
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Public 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.
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CMS 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
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VBP 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.
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Goals 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.
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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.
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Key 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.”
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CMS
www.hospitalcompare.hhs.gov
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nchospitalquality.org
Hospital Nam e
Top 10% of NC hospitals:
Average for NC hospitals:
NorthEas t Medical Center
Rutherford Hospital
Sampson Regional Medical Ctr
Southeastern Regional
Spruce Pine Community Hospital
Stanly Memorial Hospital
Transylvania Community Hospital
University of NC Hospital
Watauga Medical Center
Wayne Memorial Hospital
Overall
LVF
Ace
Discharge Sm oking Overall HF
Assessm ent Inhibitor InstructionsCounseling Score1
Denom inator2
98%
85%
99%
89%
81%
82%
85%
96%
85%
99%
99%
89%
95%
80%
92%
80%
82%
79%
79%
93%
75%
95%
77%
93%
89%
57%
96%
53%
71%
42%
89%
75%
7%
NA
61%
NA
100%
83%
100%
81%
98%
87%
80%
95%
100%
67%
93%
NA
92%
75%
97%
74%
79%
67%
86%
88%
62%
93%
82%
90%
1,619
422
583
870
164
487
47
607
276
525
1. The ov erall score is the sum of patients across the measures that receiv ed the appropriate treatment (i.e., sum of numerators)
div ided by the sum of patients eligible f or treatment (i.e., sum of denominators).
2. The sum of denominators across measures. This is not a count of unique heart f ailure patients. If the sum of the demoninators < 25,
then the ov erall score is an unreliable measure of perf ormance and is, theref ore, not shown.
NA (not applicable) indicates that no data is available from the hospital for this measure.
Hospitalshighlighted in greenreported all 4 heart failure measures and are
in the top 10% for the ov erall score
.
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Performance Reporting and
Transparency
“If you’re going to be naked,
you’d better be buff!”
Don Tapscott and David Ticoll
The Naked Corporation
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CAH & Rural Hospital
Improvement Project
• 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.
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Improvements 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.
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Mean of CAH/Rural Hosptials
National Benchmark
Reliable Care
Outer Banks (n=32)
St. Lukes (n=72)
Blowing Rock (n=17)
Alleghany(n=74)
Transylvania (n=64)
Chowan (n=56)
Stokes-Reynold (n=31)
Highlands Cashier (20)
Bladen (n=66)
Washington (n=49)
Davie (n=36)
Chatham (n=24)
Pungo (n=22)
Hoots (n=18)
70%
Pender (n=64)
Swain (n=58)
Bertie (n=19)
Firsthealth Mont. (n=62)
Murphy (n=182)
Person(n=127)
Martin General (n=121)
Dosher (n=55)
80%
Duplin (n=131)
Anson (n=155)
Kings Mountain (n=116)
Pne um onia Com pos ite Scor e
Data Re por te d fr om Januar y, 2006 to De ce m be r , 2006
100%
90%
95% Reliability
National Top 10%
60%
50%
40%
30%
20%
10%
0%
“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.
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Pneumonia Spider Graph
Pneumonia
April 2004 through March 2005
PNE Composite (n=109)
100.0%
Oxy Assess (n=109)
80.0%
Init Abx 4 (n=93)
60.0%
40.0%
Smk Cess (n=26)
20.0%
Abx Selct (n=80)
0.0%
Inpt PPV (n=76)
Inpt FLU (n=49)
Hospital Name
Blood CX24 (n=43)
Blood CXAbx (n=84)
Benchmark for NC Hospitals
Mean of NC Critical Access
Heart Failure Spider Graph
Heart Failure
April 2004 through March 2005
HF Composite (n=51)
100.0%
80.0%
60.0%
Smk Cess (n=10)
40.0%
Disch Inst (n=47)
20.0%
0.0%
ACEI (n=10)
Hospital Name
LVF Assess (n=51)
Benchmark for NC Hospitals
Mean of NC Critical Access H
Composite Score Calculation
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
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Mean of CAH/Rural Hosptials
National Benchmark
Reliable Care
Outer Banks (n=32)
St. Lukes (n=72)
Blowing Rock (n=17)
Alleghany(n=74)
Transylvania (n=64)
Chowan (n=56)
Stokes-Reynold (n=31)
Highlands Cashier (20)
Bladen (n=66)
Washington (n=49)
Davie (n=36)
Chatham (n=24)
Pungo (n=22)
Hoots (n=18)
70%
Pender (n=64)
Swain (n=58)
Bertie (n=19)
Firsthealth Mont. (n=62)
Murphy (n=182)
Person(n=127)
Martin General (n=121)
Dosher (n=55)
80%
Duplin (n=131)
Anson (n=155)
Kings Mountain (n=116)
Pne um onia Com pos ite Scor e
Data Re por te d fr om Januar y, 2006 to De ce m be r , 2006
100%
90%
95% Reliability
National Top 10%
60%
50%
40%
30%
20%
10%
0%
Pneumonia Trend Graph
100.0%
Top 10% NC
Performance
90.0%
80.0%
76.60%
83.70%
79.80%
71.80%
70.0%
63.9%
60.0%
50.0%
56.6%
59.0%
53.70%
53.05%
50.0%
47.10%
40.0%
38.8%
34.0%
30.0%
26.4%
52.00%
29.6%
103%
Improvement
20.0%
10.0%
0.0%
Q 2 04 to Q 1 Q 3 04 to Q 2 Q 4 04 to Q 3 Q 1 05 to Q 4 Q 2 05 to Q 1 Q 3 05 to Q 2 Q 4 05 to Q 3 Q 1 06 to Q 4
05
05
05
05
06
06
06
06
Mean of CAH/Rural Hospitals
Benchmark for NC Hospitals
Mean of CAH/Rural Hosptials
National Benchmark
Reliable Care
Outer Banks (n=15)
St. Lukes (n=33)
Blowing Rock (n=3)
Alleghany (n=42)
Transylvania (n=26)
Chowan (n=69)
Stokes-Reynold (n=30)
Highlands Cashier (n=10)
Bladen (n=49)
Washington (n=60)
Davie (n=23)
Chatham (n=16)
Pungo (n=34)
80%
Hoots (n=3)
Pender(n=37)
Swain(n=14)
Bertie (n=34)
First Health Mont. (n=37)
Murphy (n=73)
Person (n=59)
Martin General (n=148)
Dosher (n=43)
Duplin (n=99)
Anson (n=126)
Kings Mountain (n=87)
He art Failure Com pos ite Scor e
Data Re por te d fr om Januar y 2006 to De ce m ber 2006
120%
95% Reliability
100%
National Top 10%
60%
40%
20%
0%
Heart Failure Trend Graph
100.0%
90.0%
89.0%
89.5%
88.9%
88.7%
80.0%
90.90%
91.65%
92.80%
93.40%
Top 10% NC
Performance
70.0%
60.0%
50.0%
40.0%
34.8%
34.2%
36.0%
38.8%
30.0%
42.40%
45.58%
46.40%
46.90%
35%
Improvement
20.0%
10.0%
0.0%
Q 2 04 to Q 1 Q 3 04 to Q 2 Q 4 04 to Q 3 Q 1 05 to Q 4 Q 2 05 to Q 1 Q 3 05 to Q 2 Q 4 05 to Q 3 Q 1 06 to Q 4
05
05
05
05
06
06
06
06
Mean of CAH/Rural Hospitals
Benchmark for NC Hospitals
CAH com bined Indicator Score s
January, 2006 through Decem ber, 2006
100%
94.50%
89.70%
83.30%
81.80%
81.10%
80%
75.60%
73.70%
71.10%
70.60%
66.90%
60%
55.10%
53.00%
52.90%
Dis Instr
HF ACM
40%
20%
0%
Blood
CXAB
Abx Selct Init AB 4
ACEI
(HF)
Smk
Cess
(PNE)
LVF
Assess
Blood
CX24
Inpt PPV
Smk
Cess
(HF)
Inpt FLU
PNE
ACM
Performance Improvement
Primer
• 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
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Performance Improvement
Primer
The Concepts of Innovation,
Diffusion and Spread
Spread is the Diffusion of
Innovation
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The Nature of People
(Everett Rogers)
2%
Early
Adopters
Early
Majority
Late
Majority
Traditionalists
13%
35%
35%
15%
Innovators
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Target 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”
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Model for Improvement
• 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
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Performance Improvement
Primer
Transparency and
Reliability
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Transparency and Reliability
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
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Transparency and Reliability
A process achieves exactly
the results it is designed to
achieve.
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Definitions of Reliability
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
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Levels of Reliability in Health Care
(Amalberti, Nolan)
Chaos
10-1
10-2
10-3
10-5
Processes are
largely
customcrafted 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!
Chaos
10-1
10-2
Processes are
largely
customcrafted 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
Starting 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.
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Pneumonia Trend Graph
100.0%
Top 10% NC
Performance
90.0%
80.0%
76.60%
83.70%
79.80%
71.80%
70.0%
63.9%
60.0%
50.0%
56.6%
59.0%
53.70%
53.05%
50.0%
47.10%
40.0%
38.8%
34.0%
30.0%
26.4%
52.00%
29.6%
103%
Improvement
20.0%
10.0%
0.0%
Q 2 04 to Q 1 Q 3 04 to Q 2 Q 4 04 to Q 3 Q 1 05 to Q 4 Q 2 05 to Q 1 Q 3 05 to Q 2 Q 4 05 to Q 3 Q 1 06 to Q 4
05
05
05
05
06
06
06
06
Mean of CAH/Rural Hospitals
Benchmark for NC Hospitals
Concepts for
-1
10
Performance
• 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
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Concepts for
-2
10
Performance
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.
•
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How To Accomplish
10-2 Performance
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.
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The 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
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The Three Step Design for
Reliability
Design Techniques
Steps
1-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)
Why 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.
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How 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.
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Reliability 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.
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Example of 3 Step Design in Implementing the
Ventilator Bundle
Baseline
Feedback on
compliance as
a 10-1 concept
Education as
a 10-1
concept
Integrate daily
goals with MDR
to identify
defects as a
10-2 change
concept (step 1)
Redundancy in
the form of a
check by RT built
into 1 hour
scheduled vent
checks as a 10-2
change concept
(step 2)
Hospital Leaders Must
Understand Reliability
• 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
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What 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.
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What 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.
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Key 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.
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Observation 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?
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Mean of CAH/Rural Hosptials
National Benchmark
Reliable Care
Outer Banks (n=32)
St. Lukes (n=72)
Blowing Rock (n=17)
Alleghany(n=74)
Transylvania (n=64)
Chowan (n=56)
Stokes-Reynold (n=31)
Highlands Cashier (20)
Bladen (n=66)
Washington (n=49)
Davie (n=36)
Chatham (n=24)
Pungo (n=22)
Hoots (n=18)
70%
Pender (n=64)
Swain (n=58)
Bertie (n=19)
Firsthealth Mont. (n=62)
Murphy (n=182)
Person(n=127)
Martin General (n=121)
Dosher (n=55)
80%
Duplin (n=131)
Anson (n=155)
Kings Mountain (n=116)
Pne um onia Com pos ite Scor e
Data Re por te d fr om Januar y, 2006 to De ce m be r , 2006
100%
90%
95% Reliability
National Top 10%
60%
50%
40%
30%
20%
10%
0%
Pneumonia Trend Graph
100.0%
Top 10% NC
Performance
90.0%
80.0%
76.60%
83.70%
79.80%
71.80%
70.0%
63.9%
60.0%
50.0%
56.6%
59.0%
53.70%
53.05%
50.0%
47.10%
40.0%
38.8%
34.0%
30.0%
26.4%
52.00%
29.6%
103%
Improvement
20.0%
10.0%
0.0%
Q 2 04 to Q 1 Q 3 04 to Q 2 Q 4 04 to Q 3 Q 1 05 to Q 4 Q 2 05 to Q 1 Q 3 05 to Q 2 Q 4 05 to Q 3 Q 1 06 to Q 4
05
05
05
05
06
06
06
06
Mean of CAH/Rural Hospitals
Benchmark for NC Hospitals
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.
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Key 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).
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CMS/Premier Demonstration,
260 hospitals nationally
Hypothesis
Financial Incentives and transparency improve
hospital quality performance
Findings
Financial incentives did focus hospital executive attention
on measuring and improving quality.
Hospitals’ performance has improved continuously over
time.
Norling, NCHA Winter Meeting, 2007
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Potential National Impact
Care Measures
H
M1
M2
M3
M4
M5
M6
M7
PPM*
100%
“HIGH”
100%
Care Measures
M
M1
M2
M3
M4
M5
M6
M7
PPM*
71%
“MEDIUM”
50% - 99%
Care Measures
L
M1
M2
M3
M4
M5
M6
M7
PPM*
43%
“LOW”
0% - 49%
* Patient Process Measure
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Finding 1: Hospital Costs
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Finding 2: Mortality
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Finding 3: Complications
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Finding 4: Readmissions
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Finding 5: Length of Stay
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High Reliability Performance
For Pneumonia, Heart Bypass Surgery,
Hip and Knee Surgery, and AMI
Patients
Annual Potential
$1.4 Billion in Costs
6,000 Avoidable Deaths
6,000 Complications
10,000 Readmissions
800,000 Hospital Days
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Campaign 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
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Take 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.
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Getting Buff
Spread,Transparency
and Reliability
Kansas State Network Council Meeting
Jeff Spade
Vice President, NCHA
August 2007
[email protected]
North Carolina Hospital Association