A More Perfect Union: Better Health; Better Care; Lower Costs through Improvement

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A More Perfect Union Better Health Better Care
Lower Costs through Improvement

• Jean D. Moody-Williams, RN, MPP
• Director, Quality Improvement Group

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2012 Quote

• Collaboration is Hard Work!

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Characteristics of a Learning Organization

• It should review data and respond to it - with
  tests of new solutions and ideas - every week.
• It should bring all participating sites together
  by phone, in person or webinar frequently
• It should set one or two quantifiable,
  project-level goals, with a deadline, preferably
  defined in terms of outcomes, related to the
  projects area of work.
• It should invest more in learning than in
  teaching.

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Characteristics of a Learning Organization

• It should employ regional innovator agents
• It should celebrate success
• It should use metrics to measure its success such
  as
• Rate of testing
• Rate of spread
• Time from idea to full implementation
• Commitment rate (rate at which 50 of
  organizations take action for any specific
  request)
• Number of questions asked per day
• Network affinity/reported affection for the
  network
•  

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Operating Values for Change

• Rapid Cycle Improvement in Quality Improvement
  Activities and Outputs
• Customer Focus and Value of the Quality
  Improvement Activities
• Ability to Prepare the Field to Sustain the
  Improvements
• Valuing Innovation
• Commitment to Boundarilessness
• Unconditional Teamwork
• Commitments Secured/Participants Engaged/Results
  toward Achieving Targets

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Measuring Progress Towards Goals

• Track national progress towards the program
  goals
• Support local quality improvement measurement
• Obtain feedback on progress, in close to real
  time, so the project can be effectively managed
  and
• Evaluate the programs impact on achieving stated
  goals.
• J Patient Saf - Volume 8, 2012 Hackbarth
  etAndrew D. Hackbarth1, MPhil, William B.
  Munier2, MD, MBA, Noel Eldridge2, MS, Jack
  Jordan1, MS, Chesley Richards3, MD, MPH, Niall J.
  Brennan1, PhD , Dennis Wagner1, MPA, Paul
  McGann1, MD

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National and CMS Quality Strategy
Aims
Goals
Make care safer
Strengthen person and family engagement
Promote effective communication and coordination
of care

• Foundational Principles
• Enable innovation
• Foster learning organizations
• Eliminate disparities
• Strengthen infrastructure and data systems

Promote effective prevention and treatment
Promote best practices for healthy living
Make care affordable
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Implementation Levers at CMS
Fraud Abuse Enforcement
Target surveys Quality Assessment Performance
Improvement
ACOs Community Based Transitions Care
Program Dual Eligibles
Coverage of services Physician Feedback report
Quality Resource Utilization Report Physician
Value Modifier Readmissions
Demonstration Projects Pilots
Partnership for Patients Million Hearts
National Quality Strategy Data.gov
ESRD QIP Hospital VBP Plans for Skilled Nursing
Facility and Home Health Agencies, Ambulatory
Surgical Centers
HITECH Hospital Inpatient Quality Reporting
Programs
QIOs QIO Innovation Projects ESRD
Networks Learning Communities
Hospitals, Home Health Agencies, Hospices, ESRD
facilities
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Improving Individual Patient Care

• January 31, 2013

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C.7.1Hospital Acquired Infections (HAIs)

• Early Outreach
• CAUTI 672 hospitals
• ICU/Non-ICUs 1,269 units
• CLABSI 151 hospitals
• ICU/Non-ICUs 245 units

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CLABSI Progress Rates
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CAUTI Progress Incidence RateRates
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Reason for Increased CAUTI rates

• The reason behind the increase in national CAUTI
  SIR figures appears to be multifactorial
• New Reporters into NHSN
• The CMS IPPS rule in January 2012, which
  coincided with the first two quarters of this
  goal, added 2,000 new CAUTI reporters into NHSN.
  
• Many of these hospitals had higher CAUTI SIRs
  increasing the aggregate SIR figure.
• Better Reporters
• Widespread outreach and education efforts of CDC
  throughout 2012 to improve accuracy in reporting
  would reduce underreporting errors and contribute
  to increase in CAUTI figures.
• Reducing Catheter Use
• Reducing urinary catheter use decreases the
  denominator in the SIR calculation making it more
  difficult to show reductions in the SIR.
• The need for more aggressive implementation of
  infection prevention strategies
• Increased implementation of infection control and
  prevention methods consistently applied within a
  system that is dedicated to a culture of safety
  is needed to further impact CAUTI reductions on a
  wide scale.

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CAUTI Progress Utilization RateEarly National
Rates
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CLABSI and CAUTI SIR
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Collaboration Example

• COLLABORATION provides the opportunity to share
  both evidence-based infection prevention strategy
  and data-driven results on a broader scale.
• CMS continues to lead regular interagency
  meetings to ensure continued knowledge and
  coordination between the 10th SOW QIO and PfPs
  HEN contractor efforts at the state, local and
  facility-level.
• In working to promote CUSP principles nationwide,
  AHRQs contractor for the CUSP for CAUTI project,
  and QIOs are contractually obligated to work
  together to educate recruited facilities on
  principles of CUSP.
• CDC continues to work closely with state HAI
  coordinators to accelerate prevention efforts at
  the state level.  CDCs most recent funding
  opportunity announcement sets forth that one of
  the primary responsibilities of an HAI
  coordinator is to ensure coordination of
  state-based prevention initiatives (e.g. CUSP,
  QIO, Partnership for Patients) and facilitate
  connections with leads of the various
  federally-supported prevention efforts.

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Pressure Ulcer ProgressEarly National Rates
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CLABSI Rate in CUSPNational Project
CLABSIs per 1,000 central line days
Quarters of participation by hospital cohorts,
20092012
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C.7.2 - Healthcare Acquired Conditions (HACs)
Phase I
QIO outreach as of 01/31/2013 Pressure Ulcers
788 Nursing Homes and Physical Restraints 981
Nursing Homes
Early and Preliminary Physical Restraints Results
Baseline Q4Y10Q1Y11 Baseline Q4Y10Q1Y11 Baseline Q4Y10Q1Y11 Baseline Q4Y10Q1Y11 Current Period Q2Y12Q3Y12 Current Period Q2Y12Q3Y12 Current Period Q2Y12Q3Y12 Current Period Q2Y12Q3Y12 Current Period Q2Y12Q3Y12
Recruited Num. Denom. Rate Recruited Num. Denom. Rate RIR
Total 1,006 15,334 164,857 9.30 1,004 8,024 169,106 4.74 48.99
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National Nursing Home Quality of Care
Collaborative (NNHQCC) Phase II
High Performing Nursing Home site visits (10)
completed by November 2012 Recruitment by January
31, 2013 Over 4,208 nursing homes NNHQCC LAN
Event activities start February 26, 2013 Change
Package finalized and shared with QIOs and homes
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Best Practice Nursing Homes Using prescribed
criteria as of 1/1/13
QIO Nursing Homes Recruited that desire to Become
Best Practice Facilities since the 1/31/13 Launch
4500
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Reducing Adverse Drug Events
QIO/PSPC Teams on 01/31/2013over 215
teams Anti-coagulant focus only 36
teams Diabetic focus only 43 teams Anti-psychotic
focus 42 teams Multi-focus 62 teams
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ADE Rates per Month
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Quality Reporting and Incentives Highlights

• 97 of hospitals successfully report data to the
  Hospital Inpatient Quality Reporting (IQR)
  Program
• Intensive support to providers experiencing
  difficulty reporting new measures such as NHSN
  measures
• Successful first year for the Hospital Value
  Based Purchasing (VBP) Program, with over 900
  million redistributed based on quality based on
  IQR data

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National Medicare 30 Day Readmissions
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Innovation Center Initiatives

• Innovation Center Initiatives Support Care
  Transformation
• ACO Initiatives Shared Savings Program, Pioneer,
  Advance Payment, Learning Sessions
• Bundled Payments for Care Improvement
• Innovation Advisors Program
• Multi-Payer Advanced Primary Care Practice
  Demonstration
• Comprehensive Primary Care Initiative
• Partnership for Patients
• Federally Qualified Health Center (FQHC) Advanced
  Primary Care Practice Demonstration
• Medicaid Health Home State Plan Option
• State Demonstrations to Integrate Care for Dual
  Eligible Individuals
• Demonstration to Improve Quality of Care for
  Nursing Facility Residents
• Financial Models to Support State Efforts to
  Coordinate Care for Medicare-Medicaid Enrollees

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Hospital Readmissions from Post Acute Care (PAC)
Settings

• CMS work in Progress for PAC settings, over Next
  Year
• Developing 30-day Readmission Quality Measures
  for
• NHs, LTCHs, IRFs.
• Key Considerations from Technical Expert Panels
• Risk Adjustment may need to vary by provider
  setting, population.
• Various models to consider.
• Planned Readmissions exclusions?
  Reasons/diagnoses
• may vary by provider setting.
• 30-day Readmission Measurement Period Could
  cover the 30 days after hospital discharge. Could
  have separate measure to cover the 30 days after
  PAC discharge.

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PAC Readmission Other CMS Targeting Strategies

• CMS is currently updating the surveyor
  interpretive guidance for transfer and discharge
  planning regulations
• New regulations are being developed to establish
  Quality Assurance and Performance Improvement
  (QAPI) programs in all CMS-certified nursing
  homes.

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It Worked!!
http//jama.jamanetwork.com/article.aspx?articleid
1558278
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Rehospitalization Trends, Intervention and
Comparison Communities
-5.7 (plt.001) -2.1 (p.08) P.03 (difference)
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Hospitalization Trends, Intervention and
Comparison Communities
-5.7 (plt.001) -3.1 (plt.001) P.01 (difference)
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QIO Accomplishments as of March 31, 2013
of Engaged Communities 375
of Beneficiaries Living there 12,455,368
Formally Recruited Communities 227
Communities with Signed Coalition Charter 221
Applications Submitted 125
Communities Receiving Formal Funding 81
Recruited Hospitals 859
Recruited Nursing Homes 1533
Recruited Home Health Agencies 901
Recruited Hospice Facilities 342
Recruited Dialysis Facilities 91
Recruited Outpatient Physicians gt 1300
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National Coalition of QIO-engaged Communities
Early Progress
4.4
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National Coalition of QIO-engaged Communities
Early Progress
6.0
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State by State Admissions/1000
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State by State Readmissions/1000
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State by State ED Visits/1000
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State by State Observation Stays/1000
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ESRD Networks Continue to Make Progress

• Fistula First
• Catheter Last
• Graphs when necessary
• National AV Fistula Rate Reaches
• 60.6 in April 2012

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ESRD

• Dialyisis Adequacy via URR 96.75
• Moving to Kt//V measuring hemodialysis,
  peritoneal dialysis and pediatric hemodialyis.
• Working to develop better anemia management, bone
  and mineral metabolism, HAI measures and patient
  experience of care measures
• Active involvement in care coordination to reduce
  hospital admissions
• Exploring issues of volume, nutrition and quality
  of life
• Beginning the second year of the ESRD QIP

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Moving in the Right Direction