The Family Tree
of Quality Improvement
Faye Nipps, MBA, BSN, CPHQ
Objectives
 Clarify knowledge of the Transition of Health and Care
in America
 Identify three strategies to improve cardiac health through
Best Practice Intervention Packages (BPIPS) and Home Health
Quality Improvement (HHQI)
 Communicate assistance provided for home health agencies
(HHAs) on improving influenza, pneumococcal and herpes
zoster immunization rates, reducing hospital readmissions and
improving medication safety
 Provide resources for data-driven performance improvement
from HHQI and the TMF Quality Innovation Network Quality
Improvement Organization (QIN-QIO)
2
The Centers for Medicare
and Medicaid Services
3
Family Tree of HHQI
Note: the Million Hearts® word and logo marks are owned by the U.S. Department of Health and Human Services (HHS). Use of these marks does not imply endorsement by HHS. Use of the Marks
also does not necessarily imply that the materials have been reviewed or approved by HHS.
4
2014 Success
The Triple Aim – CMS QIN-QIO
Approach to Clinical Quality
Goals
National Patient Safety
Foundational Principles




Enable innovation
Foster learning organizations
Eliminate disparities
Strengthen infrastructure and
data systems
 Make care safer
 Strengthen person and family
engagement
 Promote effective communication
and coordination of care
 Promote effective prevention and
treatment
 Promote best practices for healthy
living
 Make care affordable
6
7
Our Heritage
Source: CMS QIO Program Documentary, https://www.youtube.com/watch?v=jbqUlRRmQgs
8
TMF QIN-QIO
9
11th Statement of Work (SOW)
QIN-QIO Map
10
About the QIN-QIO Program
Leading rapid cycle, large-scale change in health
quality:
 Goals are bolder.
 The patient is at the center.
 All improvers are welcome.
 Everyone teaches and learns.
 Greater value is fostered.
11
Four Key Roles of the QIN-QIO
 Champion local-level, results-oriented change
› Data-driven
› Active engagement of patients and other partners
› Proactive, intentional innovation and spread of best practices
that stick
 Facilitate Learning and Action Networks (LANs)
› Create an all-teach, all-learn environment
› Place impetus for improvement at the bedside level (e.g., handwashing)
 Teach and advise as technical experts
› Consultation and education
› The management of knowledge so learning is never lost
 Communicate effectively
› Optimal learning, patient activation and sustained behavior change
12
TMF QIN-QIO Website
www.tmfqin.org
 Provides targeted technical assistance and engages
providers and stakeholders in improvement
initiatives through numerous LANs.
 The networks serve as information hubs to monitor
data, engage relevant organizations, facilitate
learning and sharing of best practices, reduce
disparities and elevate the voice of the patient.
13
LANs
Join any of the following TMFQIN.org networks and you can
sign up to receive email notifications to stay current on
announcements, emerging content, events and discussions
in the online forums.
 Cardiovascular Health
and Million Hearts
 Health for Life –
Everyone with Diabetes Counts
 Healthcare-Associated Infections
 Meaningful Use
 Medication Safety
 Nursing Home Quality
Improvement
 Patient and Family
 Quality Improvement Initiative
 Readmissions
 Value-Based Improvement
and Outcomes
14
All Are Welcome
 To join, create a free account at www.tmfqin.org.
Visit the Networks tab for more information.
 As you complete registration, follow the prompts
to choose the network(s) you would like to join.
 Choose the Readmission Network and set up a data
portal account to view your agencies’ readmission
reports if you are in a QIN-QIO-recruited coalition.
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Care
Coordination
 Readmission
Network
 Medication
Safety
Network
TMF QIN-QIOs
Provide technical assistance with:
 Community coalition formation
 Root cause analyses
 Intervention selection and implementation plan
 Measurement
 Readmission and medication safety metrics
 Educational webinars
 Open Forum calls
17
Communities
 ACT
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East ACT
Delta ACT
North Central ACT*
Northwest ACT*
 Oklahoma
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Lawton
Norman
Hugo
Durant
McAlester*
Clinton*
Oklahoma City*
 Missouri
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›
West Central
Kansas City*
St. Louis*
 Puerto Rico
›
›
LAZO
CUPRI*
 Texas
›
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›
›
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›
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Denton
El Paso
Lubbock
Rio Grande Valley, Upper
Rio Grande Valley, Lower
Lufkin/Nacogdoches
Temple/Waco
Sherman
Houston*
Dallas*
Ft Worth*
Laredo*
* Recruiting in 2015
TMF QIN-QIO Goals for Care Coordination
and Medication Safety Project
 Improve care transitions for Medicare Fee-for-Service (FFS)
beneficiaries by recruiting and working with community coalitions
 Improve medication safety and reduce adverse drug events (ADEs)
for Medicare FFS beneficiaries in the region
 Special emphasis on these sub-groups of Medicare FFS
beneficiaries:
›
›
›
›
›
Dual eligible
Multiple chronic conditions with multiple at-risk medications
Behavioral health issues
Alzheimer’s disease and dementia
Lower socioeconomic status and other social determinates
of health
19
Statement of Problem:
Readmissions
 Hospitalizations consume 31 percent
of $2 trillion in total health care
expenditures in the United States
› 1 in 4 hospitalizations (25 percent) are
avoidable
› 1 in 5 hospitalizations (20 percent) result
in 30-day readmissions
Source: Lynn J, Straube BM, Bell KM, Jencks SF, Kambic RT. Using population segmentation to provide better health care for all: The “Bridges to Health” model. Milbank Q. 2007;85:185-208.
20
Readmissions Network Goals
 Reduce hospital readmission rates in the Medicare program
by 20 percent
 Reduce hospital admission rates in the Medicare program
by 20 percent
 Increase community tenure by increasing the number
of days spent at home by Medicare FFS beneficiaries
by 10 percent
 Reduce the prevalence of adverse drug events, emergency
department visits and observation stays or readmissions
occurring as a result of the care transitions process
21
What is an unplanned readmission?
 A hospitalization within 30 days of discharge
that was not foreseen at discharge
 Almost always urgent or emergencies
 Often signal failure of the transition from hospital
to another source of care
22
Quick Facts
 In October 2013, Medicare reduced reimbursement by up
to 2 percent for 2,225 hospitals due to excess readmissions.
 The payment penalty for readmissions increased to 3 percent
in October 2014.
 MedPAC recommendation: adjust skilled nursing facility (SNF)
payments to reduce hospital readmissions.
> This proposal reduces payments by up to 3 percent for SNFs with high
rates of care-sensitive, preventable hospital readmissions, beginning
in 2017.
> This will accrue $2.2 billion in savings over 10 years.
> MedPAC estimates 14 percent of SNF readmissions are preventable.
23
Statement of Problem:
Medication Safety
 National estimates suggest that ADEs contribute an
additional $3.5 billion dollars to U.S. health care
costs.1
 Given the U.S. population’s large and ever-increasing
magnitude of medication exposure, the potential for
harm from ADEs is a critical patient safety and public
health challenge.
 ADEs are a direct result of drugs used during medical
care that produce harmful events. These harmful
events can include, but are not limited to, medication
errors, adverse drug reactions, allergic reactions and
overdoses.2,3
1Institute
of Medicine Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors: Quality Chasm Series.
Washington, DC: The National Academies Press, 2006.
2Agency for Healthcare Research and Quality. Adverse Drug Event (ADE), in Patient Safety Network: Glossary. Available at:
http://psnet.ahrq.gov/glossary.aspx.
3National Action Plan for Adverse Drug Event Prevention. U.S. Department of Health and Human Services, Office of Disease Prevention and
Health Promotion, 2013.
24
Research Shows
 80 percent of patients will forget what their providers say
 Almost 50 percent of what patients remember is recalled
incorrectly
 Health literacy costs health care systems as much as
$58 billion/year
 33 percent of patients are unable to read basic health care
material
 42 percent of patients do not understand directions for taking
medications on an empty stomach
Source: HHQI Best Practice Intervention Package: underserved populations
25
Medication Safety Network
 Reduce ADEs by 35 percent per 1,000 screened
Medicare FFS beneficiaries by the year 2019
 Monitor ADE rates by Medicare FFS beneficiaries
on anticoagulants, diabetic agents or opioids by
care setting, state, region and readmission rate
26
What causes ADEs in the elderly?
Research shows:


Among older adults (65 years of age
or older), 57-59 percent reported
taking five to nine medications,
while 17-19 percent reported taking
10 or more.1
ADEs can occur in any health care
setting, including inpatient (e.g.,
acute care hospitals), outpatient and
long-term care settings (e.g., nursing
homes).

The likelihood of ADEs occurring may
also increase during transitions of
care (transitions from one health care
setting to another) when information
may not be adequately transferred
among health care providers,2 or
patients may not completely
understand how to manage their
medications.3,4,5
1Slone
Epidemiology Center. Patterns of medication use in the United States: A report from the Slone Survey. Boston, MA: 2006.
S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker FW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for
patient safety and continuity of care. JAMA. 2007;297(8):831-41.
3Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166(5):565-71.
4Calkins DR, Davis RB, Reiley P, et al. Patient-physician communication at hospital discharge and patients’ understanding of the post-discharge treatment plan. Arch Intern Med. 1997;157(9):
1026-30.
5Lindquist LA, Go L, Fleisher J, Jain N, Friesema E, Baker DW. Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications. J Gen Intern Med.
2012;27(2):173-8.
2Kripalani
27
What causes ADEs in the elderly?
Research shows:

In inpatient settings, ADEs are the
single largest contributors to hospitalrelated complications.7 ADEs comprise
an estimated one-third of all hospital
adverse events,8 affect approximately
2 million hospital stays annually8,9
and prolong hospital length of stay
by approximately 1.7 to 4.6 days.9,10,11

ADEs have also been identified as
the most common causes of postdischarge complications (those
occurring within three weeks of
hospital discharge), accounting
for two-thirds of all post discharge
complications – more than half
of which are likely preventable.12
7Classen
DC, Resar R, Griffin F, et al. ‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood). 2011;30(4):581-9.
Department of Health and Human Services Office of Inspector General (OIG). Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. Washington, DC., 2010
November. Report No.: OEI-06-09-00090.
9Lucado, J. (Social & Scientific Systems, Inc.), Paez, K. (Social & Scientific Systems, Inc.), and Elixhauser A. (AHRQ). Medication-Related Adverse Outcomes in U.S. Hospitals and Emergency
Departments, 2008. HCUP Statistical Brief #109. April 2011. Agency for Healthcare Research and Quality, Rockville, MD. Available from: http://www.hcupus.ahrq.gov/reports/statbriefs/sb109.pdf.
10Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA. 1997;277(4):307-11.
11Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 1997;277(4):301-6.
12Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161-7.
8U.S.
28
Hospital VBP FY 2017 Domains
29
Improving Medicare Beneficiary
Influenza, Pneumococcal and
Herpes Zoster Immunization Rates
30
Immunization Project Objectives
Improve:
 Tracking
 Assessment and documentation
 Reporting
Special focus:
 Reducing immunization health care disparities
31
Discussion Question
Influenza and pneumonia are ranked what
number as the top 10 leading cause of death?
a. 7th leading cause
b. 5th leading cause
c. 8th leading cause
32
Influenza and Pneumonia:
Eighth-Leading Cause of Death
Source: CDC/NCHS, National Vital Statistics System, Mortality
33
Deaths from Pneumonia
53,282
Sources: http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf;
34
Deaths from Influenza
65 years and older
Less than 65 years
90%
35
Discussion Question
What percentage of Medicare beneficiaries
are vaccinated for influenza?
a. 60 percent
b. 54 percent
c. 49 percent
36
Percentage of Medicare Beneficiaries
Vaccinated
100
90
80
70
60
50
40
30
20
10
0
60%
54%
Pneumoccocal
Influenza
Pneumoccocal
Influenza
Source: Centers for Disease Control and Prevention. (2014). Interactive mapping tool: Live-tracking flu vaccinations of Medicare beneficiaries; Williams, W. W., Lu, P-J., O’Halloran, A.,
Bridges, C. B., Pilishvili, T., Hales, C. M., & Markowitz, L. E. (2014). Noninfluenza vaccination coverage among adults . United States, 2012. Morbidity and Mortality Weekly Report, 63(5), 95-102
37
Herpes Zoster
1 million
cases
Varicella /
Shingles
Source: http://www.cdc.gov/vaccines/vpd-vac/varicella/rationale-vacc.htm
100%
effective
Herpes
Zoster
Vaccine
20%
Vaccinated
38
39
Influenza Vaccination
100
90
80
70
60
50
40
30
20
10
0
59%
Received at Physician
Office
100
90
80
70
60
50
40
30
20
10
0
54%
Medicare Beneficiaries
Vaccinated
Source: Centers for Disease Control and Prevention. (2014). Interactive mapping tool: Live-tracking flu vaccinations of Medicare beneficiaries; Williams, W. W., Lu, PJ, O’Halloran, A., Bridges, CB,
Pilishvili, T., Hales, C. M., & Markowitz, L. E. (2014). Centers for Medicare and Medicaid Services. Overview Medicare Current Beneficiary Survey. 2011a Retrieved from http://www.cms.gov/mcbs/
40
Discussion Question
What racial/ethnic group has the lowest rates
for influenza vaccinations?
a. White
b. Asian
c. Black
d. Hispanic
41
Medicare Immunization Rates by Type,
Race and Ethnicity
64 %
41 %
Pneumococcal
46 .%
43 .%
71 %
56 %
Influenza
55 %
34 %
White
Asian
Black
Hispanic
23 %
Zoster
17 %
9%
9%
0 10 20 30 40 50 60 70 80 90 100
Source: Centers for Disease Control and Prevention. (2014). Interactive mapping tool: Live-tracking flu vaccinations of Medicare beneficiaries; Williams, W. W., Lu, P-J., O’Halloran, A., Bridges,
C. B., Pilishvili, T., Hales, C. M., & Markowitz, L. E. (2014). Noninfluenza vaccination coverage among adults – United States, 2012. Morbidity and Mortality Weekly Report, 63(5), 95-102
42
2019 Goals
 Align with the Healthy People 2020 Goals
› National Absolute Immunization Rates
• 70 percent influenza
• 90 percent pneumonia
• 30 percent zoster
 1 million previously unimmunized Medicare
beneficiaries will receive pneumonia immunization
 90 percent of adult immunizations will be reported
to the registry
43
Recruitment: Health Care Providers






Physician Offices
Hospitals
Critical Access Hospitals
HHAs
Pharmacies
Vaccination Centers
44
Recruitment: Community





Community Organizations
Physician Organizations
State/Territory Agencies
State/Territory Immunization Registries
Beneficiary Representatives
45
Technical Assistance
Collaborate with HHAs and provide technical
assistance on:
 Improving cardiac health through BPIPS
 Improving immunization rates for influenza,
pneumococcal and herpes zoster diseases
 Reducing hospital readmissions
 Improving medication safety
46
Technical Assistance, cont.
 Educating patients, staff, physicians
 Standing orders and protocols
 Electronic health record and paper chart:
reminder/recall systems
 Flu-Fit Program (American Cancer Society)
 Improving accessibility
 Immunization registry reporting
 Policy and procedure updates
47
Technical Assistance, cont.
 Providing evidence-based practices
 Sharing interventions and techniques
to increase community demand
 Promoting the “Immunization Passport” to
improve documentation and communication
 Identifying or developing educational tools
and resources
48
Proposed Annual Impact
61,000 Medicare beneficiaries:
 Pneumonia vaccination: 5,850
 Influenza vaccination: 52,950
 Herpes zoster vaccination: 2,200
49
IMMUNIZATION
REGISTRIES
FLU-FIT PROGRAM
ENHANCED
VACCINATION
ACCESS
Coordinated
Interventions
SHARED TOOLS AND
BEST PRACTICES
EDUCATIONAL
PROGRAMS
AFFINITY GROUP
SESSIONS
COMMUNITY VACCINATION CLINICS
50
www.HomeHealthQuality.org
51
Data
 Individualized reports:
› Acute Care Hospitalization
› Oral Medication
Management
› Immunizations
 Securely delivered online
 Updated monthly
 OASIS-based (raw and
risk-adjusted)
 Historical trends and
target setting
52
Cardiovascular Health Network
TMF QIN-QIO
56
Cardiovascular Health Network HHAs
Access to
resources and
literature
Assistance
focused on the
ABCS
Expert
Consulting
Services
Benefits
HHQI tools and
interventions
http://www.tmfqin.org
Access to live
online forums for
networking
57
Cardiovascular Health:
Let’s Get to the Heart of the Data
The Facts
 Heart disease and stroke
are the FIRST- and FOURTHleading causes of death
respectively for all races
in the United States
 Annually, heart disease
and stroke cost more than
$312.6 billion in health care
expenditures and lost
productivity
Put it into Perspective
1.5 million
people
800,000
people
2,200
people
The population
of San Antonio
Weekly
attendance at
Disney World®
Number of
passengers in
four loaded jets
Number of
Americans who
DIE from HEART
DISEASE EVERY
YEAR
People who die
EVERY DAY from
cardiovascular
disease
Number of
HEART ATTACKS
and STROKES
EACH YEAR in
the US
58
Cardiovascular Health Network
HHAs
We help HHAs sign up for the Cardiovascular Data Registry, developed through
the HHQI National Campaign. This registry allows HHAs to track progress related
to the ABCS (Aspirin therapy, Blood pressure management, Cholesterol control
and Smoking/tobacco cessation).
Utilize BPIPs
to provide
technical
assistance
Utilize health
literacy tools
to provide
education
Participate in cardiac
LAN Network
activities and share
success stories
59
Cardiovascular Health Network
Technical assistance:
 Focus on ABCS
 Improving health care delivery
 Regional open forums and LANs
 CMS incentive payment programs
 Patient/provider collaboration
 Tools and resources on www.tmfqin.org
60
Cardiovascular Health Network
Goals:
 Facilitate improvements and
best practices
 Assist Providers with reporting
cardiovascular PQRS reporting
 Assist HHAs to report
cardiovascular measures
through the Home Health
Cardiovascular Data Registry
(HHCDR)
 Improving performance on
the following clinical quality
measures:
>
>
>
>
Aspirin therapy;
Blood pressure control
Cholesterol control
Smoking/Tobacco Use
61
HHCDR







Available to CMS-certified HHAs
Helps target potential disparities in care
Provides evidence of impact made by improvement efforts
Most data auto-populates from OASIS-C transmissions
Requires approximately two to three hours per month
Option to select which measure/s to abstract: ABCS
Twelve patients per measure or total discharges (whichever
is smaller)
63
Do You Know Your ABCS?
The Million Hearts® word and logo marks are owned by the U.S. Department of Health and Human Services (HHS). Use of these marks does not imply endorsement by HHS. Use of the Marks also
does not necessarily imply that the materials have been reviewed or approved by HHS.
64
HHCDR
 Was the patient taking ASA?
 Final blood pressure?
› Was HTN addressed during this episode?
 Did the patient have a lipid panel in the record?
 Was the patient assessed for tobacco use?
› Was it addressed?
 Was the patient dually eligible?
65
Cardio Milestones






Sign up for the HHCDR
Download all cardiovascular BPIPs
Complete HHCDR security authentication
Close at least one month of required patient data in the HHCDR
Download at least one HHCDR report
Abstract and close a total of six months of required patient data
for HHCDR
 Validate data
 Achieve noted improvement in one or more cardiovascular
outcomes
66
http://homehealthquality.org
67
BPIPs
 Two primary cardiovascular health BPIPs
› Aspirin as appropriate and blood pressure control
› Cholesterol management and smoking cessation
 Fundamental BPIPS focus on:
› Blood pressure control
› Smoking cessation


Include patient tools and resources
Free nursing continuing education credits available
68
Sign Up Today
69
THE DNA
70
Questions?
Faye Nipps, MBA, BSN, CPHQ
TMF Quality Innovation Network
Phone: 501-920-4607
fnipps@afmc.org
Faye.Nipps@area-b.hcqis.org
This material was prepared by TMF Health Quality Institute, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the
Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy.
11SOW-QINQIO-C3-15-57
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