CMS Hospital Quality Leadership Summit

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CMS Hospital Quality Leadership Summit

• Transforming Leadership
• Transforming Culture

Dale W. Bratzler, DO, MPH QIOSC Medical
Director Oklahoma Foundation for Medical Quality
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The Problem
Five years after the IOMs Crossing the Quality
Chasm, hospitals have not shown adequate
improvement in the most basic measures of
quality. Furthermore, governing board, executive
and physician engagement in the quality arena
needs significant attention.
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• Four key themes
• Improvement pace is modest
• Improvement is variable
• Quality has improved but much remains to be done
• Sustained improvement is possible

http//www.ahrq.gov/qual/nhqr05/nhqr05.pdf
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Medicare QIO Program

• Created by statute in 1982 to improve quality and
  efficiency of services delivered to Medicare
  beneficiaries
• Specific roles to address quality of care in
• Hospitals
• Nursing homes
• Home health agencies
• Physician offices

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Medicare QIO Program

• contracted to CMS to .assist providers in
  measuring and reporting quality, producing and
  using electronic clinical information,
  redesigning care processes, and transforming
  organizational cultures so as to accelerate the
  rate of quality improvement..

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Medicare QIO Program

• Two key requirements in the contract
• to assist providers in developing the capacity
  for and achieving excellence in care
• To protect beneficiaries and the Medicare Program

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Quality Improvement Landscape

• Recognition of the need to fundamentally change
  health care processes and systems to deliver
  consistent high-quality care
• The need to incorporate the IOMs six aims for
  health care

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We cannot save lives or fix the problems in
todays healthcare without making a commitment to
rapid transformational change. CMS
Administrator Mark B. McClellan, M.D., PhD
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Need for New Metrics for Quality

• Leadership and culture
• Patient outcomes
• Care coordination and transitions
• Costs and efficiency
• Adverse events
• Patient experience and satisfaction

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Why Focus on Hospital Leadership?

• Research suggests that more engagement of of
  hospital leadership (C-suite, boards, and
  physicians), in cooperation with other health
  care professionals in QI, is associated with
  higher performance in clinical care.
• The active involvement and collaborative
  participation of top level leaders is essential
• Hospital leaders must be given the knowledge and
  tools to address the issue

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The Developing Evidence Base

• Studies that have looked at high performing
  hospitals in relation to governance and
  leadership
• Solucients /Governance100 Top Hospitals
• Yale/AHRQ
• Commonwealth Fund
• Vanderbilt
• Mathematica/Delmarva
• HSAG- Health Services Advisory Group
• Iowa Field Study
• CMS/Iowa/CareScience
• Estes Park/NPSG

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Current CMS Activities addressing
Transformational Change

• CMS Current Scope of Work SIOC
• Hospital Interventions QIOSC/OFMQ is tasked with
  providing QIOs and hospitals with information
  and tools to facilitate work on the CMS quality
  improvement projects
• QIOs are contracted to help hospitals implement
  system changes and organizational culture change.
  

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What are the barriers to transformation?
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Barriers to Transformation

• Challenges
• Culture of quality not promoted
• Inadequate tools to drive quality improvement
  efforts
• Lack of perceived leadership and prioritization
  of quality

Quality cannot be delegated to a department.
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Barriers to Transformation

• Feeling of being overwhelmed by the process
• Challenges
• Stretched resources, limited personnel, competing
  priorities
• Perception that medical staff priorities are not
  aligned with hospital measurement and reporting
  requirements
• Physician autonomy
• Inadequate training for members of Boards about
  hospital quality and performance measurement and
  improvement

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Barriers to Transformation

• Must be able to focus on more than the short-term
  including financial instability
• Need for Board members to understand their
  responsibility for hospital quality just as well
  as they understand their fiduciary responsibility
• Overcome the lack of personnel, skills, and
  experience
• Challenges
• Lack of training in performance improvement
• Need to better describe the business case for
  quality

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• There are still plenty of opportunities to
  improve even for the limited measures that we
  currently focus on.

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The Pace of Improvement is ModestMeasure Trends
Surgical Infection Prevention
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Quality from the Patients PerspectiveNational
ACM Rate, Qtr. 4, 2005
The Appropriate Care Measure reflects the
percentage of hospital patients that receive all
indicated care (all-or-none).
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How do we achieve transformation?
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What do the QIOs need?

• New metrics
• Reliable and valid measurement tools to assess
  organizational culture
• Focus on governance and leadership structure and
  processes
• New interventions
• How do we use the information obtained to assist
  a low-performing institution to transform culture
  and leadership?

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Shannon ArcherHospital Interventions QIOSC
Educator
Hospital Leadership Activities of the
Collaborative Workgroup
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Leadership CollaborativeWork Group

• CMS
• Strategic direction and project coordination
• Oklahoma Foundation for Medical Quality/HI QIOSC
• --Collaboration in development and deployment
  process for assessment instrument and possibly
  other tools
• University of Iowa / CareScience
• Development of assessment instrument and
  sampling strategies. Analysis of feedback and
  data following testing. Refinement of tool.

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Broad Objectives of the Workgroup

• To identify specific structures and
  administrative processes related to leadership
  engagement in QI that are most closely correlated
  to high performance in clinical quality .
• Compile leadership and organizational attributes,
  functions, and processes shown to be associated
  with high-reliability organizations into an
  organizational self-assessment tool.
• Share findings and tool with CMS, the QIO
  community and the hospital industry at large in
  order to facilitate transformational improvements
  in quality.

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Workgroup Project Plan

• Development of a standardized hospital assessment
  tool based on a systematic investigation of the
  relationship between key organizational
  attributes and performance in clinical quality.
• Field testing of the tool with voluntary hospital
  participants to get input for maximum value to
  user.
• Deployment of a CMS-endorsed assessment to QIOs,
  hospitals and other stakeholders.

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Proposed Approach Summary View
CMS/CareScience/HI QIOSC
Aggregate Knowledge
Assess Current State
Relate Practice to Performance
Prepare for Action
March-August 2006
Feb - May 2007
May April 2007
October Feb. 2007
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Develop Framework, sampling strategy, and Draft
Assessment Tool
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Performance on clinical indicators
Based on participant feedback and
comparative findings, Refine Self Assessment Tool
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Synthesize Research
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Validate Findings with external SMEs
Stratify Recruit hospital participants for
field testing
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Administer revised tool to same cohort.
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Administer Draft Assessment Tool to test hospitals
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Strategize deployment of Self Assessment Tool for
9th SOW
.
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Twelve common findings
A. Leadership

• CEO dedication to quality as job 1
• Direct board involvement
• Leadership both understands and articulates the
  business case for quality
• Support for a culture of quality
• Support for EBM beyond mere lip service

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Twelve common findings (contd)
B. Structure Process

• Medical and nursing leadership engagement at all
  levels
• Attraction and retention of the right people
• Development of effective in-house processes
• Monitoring and use of benchmarks
• Exploitation of the power of IT

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Twelve common findings (contd)
C. External Resources

• Engagement with consumers
• Access to external support and assistance from
  peers

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DimensionCEO Dedication to Quality as Job 1

• Action CEO demonstrates commitment to quality.
• 1. CEO doesnt participate in PI activities,
  adequate funds are not allocated for necessary PI
  activities.
• 2. CEO addresses PI and patient safety in staff
  meetings, but doesnt allocate sufficient
  resources to support quality initiatives,
  improvement efforts, and necessary FTEs to
  achieve PI goals.
• 3. CEO speaks enthusiastically to board,
  management and staff about PI activities, but
  doesnt allocate adequate resources. Not
  perceived as main driver within organization.
• 4. CEO ensures adequate resources for PI are made
  available, but doesnt personally champion
  activities.
• 5. CEO demonstrates knowledge of, passion for,
  and financial commitment to securing adequate
  resources for PI. Is perceived by all levels of
  organization as the main driver for quality
  improvement and patient safety.

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CEO Dedication to Quality is Job 1
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Benchmarks are used to set quality Improvement
goals for organization
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Central Plan for Leadership Collaborative
Activities

• Development of organizational self-assessment
  tool
• Testing the tool
• Refining the assessment
• Deploying the assessment
• Future activities
• Extending the research
• Creation of additional tools and resources

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They always say time changes things, but you
actually have to change them yourself.
ANDY WARHOL

• The future ain't what it used to be. YOGI
  BERRA