Gene Peterson
Preston Simmons
Center for Clinical Excellence
University of Washington Medical Center
SIP #5
July 19, 2005

 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?

 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 ,

 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
RCW
CMS
Specific regulations on how health care organizations are built
NFPA
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National Environmental Policy Act
OSHA
WISHA
EPA
Shoreline Act
Department of Health
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L&I
DSHS- Licensing Division
JCAHO
ADA
Department of Construction and Land Use
Etc. …………………………..

The good news is that we have proven structures to comply
B
OARD
Safety Hotline
E-Mail
Orientation
Training
E NVIRONMENT OF C ARE
S TRUCTURE AND C OMMUNICATIONS
E NVIRONMENT OF C ARE
P
ATIENTS
, V
ISITORS
S
TAFF
, P
ROPERTY AND
E
QUIPMENT
L
EADERSHIP
Safety Fairs
Meetings
ICES
Newsletters
Safety Audits
K
EY
P
ROCESS
S
UBCOMMITTEES
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
K EY S UPPORT E LEMENTS
Environmental Health and
Safety (EH&S)
Risk Management
Employee Health
Employee Safety Committee
Infection Control
Quality Improvement
Management
Safety Officer
Key Departments

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

The Second IOM Report

 Patient identification
 Communication among caregivers
 High-alert medications
 Eliminate wrong-site, wrong-patient, wrong-procedure surgery
 Infusion pumps
 Clinical alarm systems

 Computerized Physician Order Entry
 ICU Care Standards
 Volume Measures
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CABG
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PCI
AAA
Pancreatectomy
Esophagectomy
Neonatal Care

 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
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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

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.

 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
39%
72%
72%
* Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved a 89% rate or better.

Preventing Surgical Complications in four broad areas where the incidence and cost of complications are high:
 Surgical site infections
 Adverse cardiac events
 Venous thromboembolism
 Postoperative pneumonia

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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

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
CABG mortality
CABG volume
Prophylactic antibiotic received within one hour prior to surgical incisision
Prophylactic antibiotic selection for surgical patients - CABG
Prophylactic antibiotics discontinued within 24 hours after surgery end time - CABG
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
Computerized physician order entry (CPOE) system
ICU physician staffing (IPS)
Leapfrog Quality Index (NQF Safe Practices)
LFG Survey
LFG Survey
JCAHO Core Measure
JCAHO Core Measure
JCAHO Core Measure
LFG Survey
LFG Survey
LFG Survey
LFG Survey
Weight
34.00%
12.00%
3.50%
3.50%
3.50%
18.50%
8.33%
8.33%
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.

 Washington Clinical Outcomes
Assessment Project (COAP)
 SCOAP
 American College of Surgeons National
Surgical Quality Improvement Project

 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)

 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%)

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

 When will P4P role down to physicians on the surgical side?

New York Times Friday April 15, 2005

 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

 Financial
 Non Financial

 Quality Bonuses
 Compensation at Risk
 Performance Fee Schedules
 Quality grants
 Reimbursement for Care Planning
 Variable Cost Sharing for Patients

 Performance Profiling
 Publicizing Performance
 Technical Assistance for Quality
Improvement
 Practice Sanctions
 Reducing Administrative Requirements