Transcript 7-26-05-Pay_for_perf.. - University of Washington

A Short History of Healthcare in
the 21st Century
The Regulatory Environment, Public
Reporting and Pay-for-Performance
(P4P)
Gene Peterson
Preston Simmons
Center for Clinical Excellence
University of Washington Medical Center
SIP #5
July 19, 2005
Goals for Today
 History
of the regulatory environment
 History of the quality movement
 What are we as a hospital reporting now?
 Where is this going in the future?
 Will there be individual physician profiling
on the same measures?
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One role of the Health Care Leader is to manage the
Environment of Care
Complex Undertaking
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“Regulatory Environment”, Spiegel and Kavaler, Risk management in Health
Care Institutions ,
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A flavor for regulations. Who regulates the industry ( just a few
examples)
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Federal, State and Local
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WAC
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RCW
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CMS
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Specific regulations on how health care organizations are built
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NFPA
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National Environmental Policy Act
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OSHA
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WISHA
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EPA
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Shoreline Act
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Department of Health
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L&I
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DSHS- Licensing Division
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JCAHO
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ADA
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Department of Construction and Land Use
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Etc. …………………………..
The good news is that we have proven structures to comply
ENVIRONMENT OF CARE
STRUCTURE AND COMMUNICATIONS
BOARD
Safety Hotline
E-Mail
Orientation
Training
LEADERSHIP
ENVIRONMENT OF CARE
Safety Fairs
Meetings
ICES
Newsletters
Safety Audits
PATIENTS, VISITORS
STAFF, PROPERTY AND
EQUIPMENT
KEY PROCESS SUBCOMMITTEES
Medical Equipment
Emergency Preparedness
Hazardous Materials and Waste
Security/ Public Safety
Fire Prevention
Safety
Utility Management
Education and Communication
Work Place Violence
F:/PUBLIC/SAFETY/SAFETYHEALTH/SMC-STRUCTURE&COMMUNCIATIONS
KEY SUPPORT ELEMENTS
Environmental Health and
Safety (EH&S)
Risk Management
Employee Health
Employee Safety Committee
Infection Control
Quality Improvement
Management
Safety Officer
Key Departments
1997- National Patient Safety
Foundation
1999- To Err is Human
The First Institute of Medicine Report Alerted
the Public and Congress of 45,000-98,000
Deaths due to “errors” in healthcare- first real
public attention to medical failures
2001- Crossing the Quality Chasm
The Second IOM Report
Safe
Effective
Patient Centered
Timely
Efficient
Equitable
2002-JCAHO Six National Patient
Safety Goals
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Patient identification
Communication among caregivers
High-alert medications
Eliminate wrong-site, wrong-patient,
wrong-procedure surgery
Infusion pumps
Clinical alarm systems
2002-Leapfrog Three Leaps
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Computerized Physician Order Entry
 ICU Care Standards
 Volume Measures
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CABG
PCI
AAA
Pancreatectomy
Esophagectomy
Neonatal Care
2003- National Voluntary Hospital
Reporting Initiative-CMS
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Hospitals are given the chance to voluntarily
report outcome data
 No take always but a reporting bonus
 Process measures
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Acute Myocardial Infarction
Heart Failure
Community Acquired Pneumonia
The Medicare Prescription Drug,
Improvement, and Modernization Act of
2003
Instructs the Center for Medicare Services to
contract with the Institute of Medicine of the
National Academy of Sciences to:
catalogue,
review, and evaluate the validity of
leading health care performance measures;
catalogue
and evaluate the success and utility of
alternative performance incentive programs in
public or private sector settings; and
The Medicare Prescription Drug,
Improvement, and Modernization Act of
2003
Identify and prioritize options to implement
policies that align performance with payment
under the Medicare program that indicate—
the performance measurement set to be used
the payment policy that will reward
performance
the key implementation issues (such as data
and information technology requirements)
that must be addressed
Who is supporting this idea…
An open letter in Health Affairs Co-authored by Berwick,
Eddy,…support this idea. They argue that the government
needs to become involved in pay-for-performance efforts:
The
human and financial costs of medical care and
substandard care have been exhaustively documented.
A robust inventory of measures and standards for quality
improvement has been developed and continues to grow.
The strategic concept of paying for performance-a
bedrock principle in most industries- has begun to emerge
in health care in a variety of experiments in both private
and public sectors.
Health Affairs, Vol 22(6) November/December 2003, pages 7-9.
2004- Leapfrog partners with the
National Quality Forum - Thirty
Leaps
Awareness
Accountability
Ability
Action
2004- Leapfrog adds process and
outcomes measures
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Society for Thoracic Surgery (STS) for CABG
 American College of Cardiologist National
Cardiac Data Registry (ACC-NCDR)
(Washington Data COAP)
 Vermont Oxford Data Base for Neonates
 Beta Blockade for AAA
2004- Institute for Healthcare Improvement
•Deploy Rapid Response Teams
•Deliver Reliable, Evidence-Based Care for
Acute Myocardial Infarction
•Prevent Adverse Drug Events
•Prevent Central Line Infections
•Prevent Surgical Site Infections
•Prevent Ventilator-Associated Pneumonia
2004- CMS Displays Quality Data from National
Hospital Voluntary Reporting Initiative
www.hospitalcompare.hhs.gov
Patients with pneumonia receiving antibiotics within 4 hours
AVERAGE FOR
ALL REPORTING
HOSPITALS IN
THE UNITED
STATES
AVERAGE FOR
ALL REPORTING
HOSPITALS IN
THE STATE OF
WASHINGTON
UNIVERSITY OF
WASHINGTON
MEDICAL CTR
72%
72%
39%
* Top Hospitals represents the
top 10% of hospitals
nationwide. Top hospitals
achieved a 89% rate or better.
HEALTH
GRADES
2005 Surgical Care Improvement
Project (SCIP)
Preventing Surgical Complications in four broad
areas where the incidence and cost of
complications are high:
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Surgical site infections
 Adverse cardiac events
 Venous thromboembolism
 Postoperative pneumonia
SCIP Steering Committee
Organizations
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Agency for Healthcare Research and Quality
American College of Surgeons
American Hospital Association
American Society of Anesthesiologists
Association of periOperative Registered Nurses
Centers for Disease Control and Prevention
Centers for Medicare & Medicaid Services
Department of Veterans Affairs
Institute for Healthcare Improvement
Joint Commission on Accreditation of Healthcare
Organizations
2006-Leapfrog-Hospital
Rewards Program
Coronary artery bypass graft (CABG)
Percutaneous coronary intervention (PCI)
Acute myocardial infarction (AMI)
Community acquired pneumonia (CAP)
Deliveries/newborns
These represent
33% of the
admissions and 20
% of the spending
by commercial
payers
Hospital Rewards Program Quality
Measures: CABG
Measure
Source
Weight
CABG mortality
LFG Survey
34.00%
CABG volume
LFG Survey
12.00%
Prophylactic antibiotic received within one
hour prior to surgical incisision
JCAHO Core Measure
3.50%
Prophylactic antibiotic selection for surgical
patients - CABG
JCAHO Core Measure
3.50%
Prophylactic antibiotics discontinued within 24
hours after surgery end time - CABG
JCAHO Core Measure
3.50%
Process of Care -- 80%+ adherence to at least
two:
•CABG using internal mammary artery
•Aspirin at discharge
•Beta-blocker within 24 hours after surgery
•Beta-blockers prescribed at discharge
•Lipid-lowering therapy prescribed at
discharge
•Extubation within 24 hours after surgery
LFG Survey
18.50%
Computerized physician order entry (CPOE)
system
LFG Survey
8.33%
ICU physician staffing (IPS)
LFG Survey
8.33%
Leapfrog Quality Index (NQF Safe Practices)
LFG Survey
8.33%
REWARDING SUPERIOR QUALITY CARE: THE PREMIER HOSPITAL QUALITY INCENTIVE DEMONSTRATION
CENTERS FOR MEDICARE & MEDICAID SERVICES
FACT SHEET
March 2005
Overview
CMS is pursuing a vision to improve the quality of health care by expanding the information available about quality of
care and through direct incentives to reward the delivery of superior quality care. Through the Premier Hospital Quality
Incentive Demonstration, CMS aims to see a significant improvement in the quality of inpatient care by awarding bonus
payments to hospitals for high quality in several clinical areas, and by reporting extensive quality data on the CMS web
site.
Quality of Care
Under the demonstration, top performing hospitals will receive bonuses based on their performance on evidence-based
quality measures for inpatients with: heart attack, heart failure, pneumonia, coronary artery bypass graft, and hip and
knee replacements.
Financial Awards
CMS will identify hospitals in the demonstration with the highest clinical quality performance for each of the five
clinical areas. Hospitals in the top 20% of quality for those clinical areas will be given a financial payment as a reward
for the quality of their care. Hospitals in the top decile of hospitals for a given diagnosis will be provided a 2% bonus of
their Medicare payments for the measured condition, while hospitals in the second decile will be paid a 1% bonus. The
cost of the bonuses to Medicare will be about $7 million a year, or $21 million over three years.
Improvement Over Baseline
In year three, hospitals that do not achieve performance improvements above demonstration baseline will have adjusted
payments. The demonstration baseline will be clinical thresholds set at the year one cut-off scores for the lower 9th and
10th decile hospitals. Hospitals will receive 1% lower DRG payment for clinical conditions that score below the 9th
decile baseline level and 2% less if they score below the 10th decile baseline level.
2005-Other Reports
 Washington
Clinical Outcomes
Assessment Project (COAP)
 SCOAP
 American College of Surgeons National
Surgical Quality Improvement Project
UWMC Operating Plan
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2001- Through CQI produce measurable
improvements in clinical care service and
operating performance. CORM
 2002-Lay the foundations for improving patient
safety. CORM
 2003- Make measurable progress toward
becoming the #1 AMC resource on patient safety
by building the culture of a high reliability
organization…(Increase reporting by 50% and
decrease harm events in 3 areas)
UWMC Operating Plan
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2004- Achieve measurable improvements in
patient safety and quality. (Six JCAHO National
Safety Patient Goals, Identify and adopt an
integrated quality model, Identify a balanced set
of key organizational and clinical quality
metrics.)
 2005-Provide the safest clinical care available.
Presented in a PASCO format (Increase
reporting by 30%, decreased falls by 50%,
reduce DVT by 50%)
2006 UWMC Operating Plan 13 of
25 Elements are Quality and safety
Elements
Critical Test Results
Medication Reconciliation
Hand Hygiene
Falls With Injury
AMI
Heart Failure
Community Acquired Pneumonia
Central Line Infections
Surgical Site Infections
Ventilator Associated Pneumonia
Venous Thromboembolism
Rapid Response Teams
These are organizational
performance measures. What
about physician performance
measures?
 When
will P4P role down to physicians on
the surgical side?
New York Times Friday April 15, 2005
Sample Outpatient Health
Outcomes/Safety Data
 Women’s
Health- Breast and Cervical
Cancer Screening
 Diabetes Care- Eye exams, HbA1c,
cholesterol screening, ACE inhibitors
 Use of Optimal Medications- Asthma,
Otitis Media, Acute Bronchitis
 Pharmacy Measures- Formulary
Compliance, Generic use
 Service Measures
P4P Options
 Financial
 Non
Financial
Financial Strategies
 Quality
Bonuses
 Compensation at Risk
 Performance Fee Schedules
 Quality grants
 Reimbursement for Care Planning
 Variable Cost Sharing for Patients
Non Financial Strategies
 Performance
Profiling
 Publicizing Performance
 Technical Assistance for Quality
Improvement
 Practice Sanctions
 Reducing Administrative Requirements
Discussion