Transcript Update on the College for Advanced Management of Health

Implementing Quality Improvement and
P4P in Ambulatory Academic Group
Practice
Neil Goldfarb
Associate Dean for Research, JSPH
Co-Director, College for Value-based Purchasing
of Health Benefits
Director of Ambulatory Care Performance
Improvement, Jefferson University Physicians
Disclosure: No identified conflicts of interest.
Jefferson University Physicians
– 500+ physicians
– Clinical Care Subcommittee
• History
• Staffing
• Approach to projects
– Departmental initiatives
– JUP-wide initiatives
– Value-based purchasing initiatives
Smoking Cessation Program
Department of Otolaryngology
• 85% of head & neck cancers are associated
with tobacco use and account for 3% of all
cancers in the U.S.
• In 2006, the Department of Otolaryngology
conducted a study of head & neck cancer
patients
– Baseline finding: 60% documentation of smoking hx
– Redesigned charting tool, educated providers
– Follow-up finding: 100% documentation
JUP-wide smoking cessation
initiative
• Charts reviewed
• Feedback provided
• Education and CME provided
– Includes information on billing for counseling
• Tools and resources provided
• Six-month follow-up charts reviewed
Physician Practice Patient Safety
Assessment (PPPSA)
• Developed and tested in 2006 by:
– Health Research Education Trust (HRET)
– Institute for Safe Medication Practices (ISMP)
– Medical Group Management Association (MGMA)
– National expert panel and advisory committee
• Self-assessment tool covers 79 safety-related ambulatory
processes and practices
• Self-administered by a multidisciplinary team of
administrators, physicians, pharmacists, nurses and
technicians
• Comparative national benchmarks established by MGMA
pilot test
Implementation
• Fall 2006
– Based on a review of patient safety assessment tools, the
PPPSA tool was selected for a pilot implementation
throughout JUP
• Spring 2007
– Pilot study performed in the Division of Internal Medicine
• 2007-2008: Survey expanded to other JUP practices
• January 2009, JUP Management Committee:
– Completion of the survey mandated across JUP practices
and tied to financial incentive for practice administrators
– Selection of one departmental/divisional priority areas for
improvement based on baseline measurement
– Development and implementation of an action plan
– Completion of a timeline for implementation of
performance improvement actions and re-measurement
PPPSA Scores for 18 practices
Total Percentage Score by Domain
100
80
74
60
73
77
71
63
46
40
MGMA
Baseline
20
0
Medications
HandSurgery/Invasive
off/Transitions
Procedures
Personnel
Competency
Management/
Culture
Pt. Education/
Communication
Recommendations
Department Level
• Identify one safety metric for improvement
• Develop and submit action plan for selected safety metric
JUP Level
• Interdisciplinary patient safety task force
• Medication safety educational initiatives
• Develop/improve patient education materials, including
literacy and language
• Develop staff education and competency programs and
standards
• Examine systems for patient notification of test results
• Develop a system for error and near-miss reporting
Physician Quality Reporting Initiative (PQRI)
2010 Measures Applicable to Cardiology
•Heart Failure: ACE or ARB for LVSD (5); Beta-blocker for LVSD (8);
LVF assessment (198); Patient Education (199); Warfarin for a-fib
(200)
•CAD: Oral antiplately therapy (6); Beta-blocker therapy for MI (7);
symptom and activity assessment (196); LDL Rx therapy (197)
•Ischemic Valve Disease: Complete lipid profile (202); LDL control
(203); Aspirin therapy (204); BP management (201)
•BMI screening and follow-up (128)
•Health information technology (124)
•Electronic prescribing (pay for performance)
Requirements for Successful
PQRI Implementation
• Leadership and faculty interest and
buy-in
• Infrastructure support
• Priority within the organization
JUP Approach to PQRI
Implementation
• Team of administrator and clinical quality nurse meet with
practices to provide education on PQRI measures
• Selection and specifications of measures
• Identification of process changes required for successful PQRI
reporting
• Development of tools and worksheets
• Testing of claims submission using CMS test code
• Follow-up with practices
• Members of the JUP quality team and JUP administration
function as a resource for all practices
• Larger PQRI team, consisting of compliance officer, statistician
and quality analysts meet to discuss PQRI progress across
JUP practices
Barriers and Lessons
Learned
• Difficult to get buy-in from providers and office staff
– Bonus size may be too small
– Increased cost of measure submission
– Belief that PQRI reporting will not improve patient care
• Measures are based on new billing codes and processes
• Complexity of measure specifications
• Constantly changing measurement set and specifications
• Multidisciplinary approach is crucial
• Essential to provide ongoing education to practices
• Staff must be available to practices as a resource for
clarification of measure specifications
Other Initiatives
• Support for EMR implementation and
achieving “meaningful use”
• P4P program support: chart reviews,
registry development, measurement
development, VBP task force
Summary: Challenges from the
provider perspective
• Need clarity and agreement on measurement
parameters (and recognition of issues such as
sample size, attribution)
• Need frequent, timely feedback
• Need recognition of sicker, under-served, nonadherent populations
• Need educational tools for providers and
patients
• Need resources to implement IT and QI
• Hospital and physician incentives need to be
aligned