Improving Quality through Better Information Len Fishman
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Improving Quality through Better Information Len Fishman President and CEO June 5, 2004 1 About HRCA g g 7 site system of senior housing & health care: affordable and market-rate housing, CCRC, adult day programs, LTC, sub-acute care, LTAC and outpatient. Serving more than 3,000 seniors in the Greater Boston area. 2 g g g g g Internationally known leader in medical and social gerontological research. Largest provider-based geriatric research facility in U.S. With a research portfolio of $41M, ranks in top 12% of all U.S. research institutions in NIH funding. HQ for Harvard Medical School Geriatric Fellowship Program. Outstanding geriatrician staff – faculty at Harvard Medical School. 3 Our Common Goal Using information to improve the Q of care and Q of life of NH residents. More specifically, improving Q by stimulating each resident’s health, well-being and spiritual vigor in an environment that provides dignity, privacy and freedom of choice. 4 Questions g g g g g g Does disseminating information about quality lead to improvement in quality of care/life? Who should be using the information and how? How do we stimulate providers to pursue quality initiatives? Are we measuring what matters most to key stakeholders? Do the things we measure actually reflect quality of care/life? How do we determine which providers are “best overall?” 5 Public reporting of outcomes: What difference does it make? Case study of CABG outcomes in NJ, NY and PA. 6 7 8 9 10 The NY experience In 1989, NYSDH (with Cardiac Advisory Committee, CAC) begins effort to reduce mortality after CABG. Hospital data collected and kept confidentially. NYSDH & CAC develop methodology to risk-adjust mortality (RAM) rates. Newsday sues NYSDH under FOI Law to get data and wins. Unanticipated, precipitate release of information leads to sensational reporting and ranking of hospitals in media. 11 Over time, media understands concept of “statistically significant” differences, begins to emphasize how hospitals and surgeons use data to improve outcomes. Selected results/issues: Reports of RAM rates did not affect referral patterns. Concern about accuracy of data on risk factors. Concern that some hospitals and surgeons might avoid high-risk patients. Between 1989 and 1992, RAM rates in NY declined 41% (vs. national decline of 18%). Low volume surgeons had higher RAM rates. 12 St. Peter’s Hospital in Albany 1 of 3 hospitals with RAM rate significantly higher than state average. Instinctive reaction: data is wrong, RA methodology is flawed, “Our patients are sicker.” With nowhere left to hide, hospital drilled down internally, with help from NYSDH, and discovered that main problem was with patients who required CABG on emergency basis (mortality rate of 26% at St. Peter’s vs. 7% statewide) Solution: spend more time stabilizing patients before CABG. Following year, mortality rate among high-risk patients drops to 0. 13 The PA experience Researchers polled 50% of PA cardiologists and cardiac surgeons. Among cardiologists— - 10% found RAM rates were “very important” in assessing surgeon’s performance. - Less than 10% discussed them with their patients who were candidates for a CABG. - 87% reported that the guide had a minimal or no influence on their referral recommendations. For cardiologists and surgeons, most important limitations— - Mortality an incomplete measure of quality of care. - “Risk adjustment will never be perfect.” - Unreliable data. 59% of cardiologists reported increased difficulty in finding surgeons willing to perform CABG surgery on severely ill patients. 63% of cardiac surgeons less willing to operate on such patients. 14 What can we learn from these case studies? State partnered with providers (CHAP, CAC) to develop methodologies. Public release of outcomes focused media’s and providers’ attention. Initial reporting was misleading, improved over time. Despite hullabaloo, outcomes had little or no impact on referral patterns. Finding that low volume correlates with higher RAM rates led to reduction in low-volume surgeons. Increased accountability: with nowhere to hide, poor performers were forced to look inward and some materially improved their RAM rates. Handed evidence to “change agents.” May have perverse effect of decreasing access to care of most severely ill patients. 15 Sharing of outcomes among providers: What difference does it make? Case study of Wellspring Model. 16 Wellspring Model Alliance of 11 independent nonprofit NHs in Wisconsin Six key elements of Wellspring program: 1. Top management committed to making Q of care a top priority. 2. Shared services of GNP to train staff in Q of care and best practices. 3. Interdisciplinary “care resource teams” in specific areas of care who then teach other staff. 4. Involvement of all departments w/in facility to share what works. 5. Empowerment of all staff, including front line caregivers, by giving them Q data and authority to make decisions. 6. Quarterly reviews by 11 CEOs to share unblinded data on outcomes. 17 Evaluation by IFAS (funded by Commonwealth Fund) in 2002 revealed: 1. 2. 3. 4. 5. Successful meshing of clinical and culture change. Staff turnover reduced. Fewer deficiencies. No additional net resources expended. Staff appeared more vigilant in assessing problems and more proactive in resident care. 6. Observational evidence indicated better Q of life for residents, improved interaction between residents and staff. 18 Conclusion: Accurate data + sound risk-adjustment methodology + provider input + public spotlight = potential for improvement in quality outcomes. By whom? - Not necessarily by the referring “intermediaries” (cardiologists). - Probably not by patients/consumers. - By hospitals and surgeons, especially with state agency assistance. Caution: Perverse consequences may occur. 19 Framework for thinking about information and quality; creating the climate for change 20 “The common initial reaction when an error occurs is to find and blame someone.” Institute of Medicine To Err is Human 21 “Building safety into processes of care is a more effective way to reduce errors….The focus must shift from blaming individuals for past errors to focus on preventing future errors….” Institute of Medicine To Err is Human 22 “The committee believes that a major force for improving patient safety is the intrinsic motivation of health care providers, shaped by professional ethics, norms and expectations.” Institute of Medicine To Err is Human 23 Contrast regulatory regime for NHs: A system skewed toward mediocrity OBRA and MDS revolutionized resident care: standardized assessments and triggered interventions (forced caregivers to “connect the dots”); required “interdisciplinary team” to be interdisciplinary (“every problem is a team problem”); laid down the law on resident rights; heightened awareness among staff of how these rights were to be respected. But focus has not been on both ends of the quality continuum. Goal has been to pull up bottom performers. No effort to highlight top performers. Inadvertently (or perhaps intentionally), the OBRA Survey and QI’s reinforce a culture of mediocrity. 24 Top half of the scale is missing. Best you can be is deficiency free. Imagine a report card where the best mark is “satisfactory,” where a student could get a “C,” a “D” or an “F”—but not an “A” or a “B.” In NH setting, “The Survey” and QIs suck up all the oxygen for quality improvement. Failure to praise, to recognize above average achievement or excellence demoralizes and demeans caregivers. 25 Consider other evaluation systems: •Movies: “Two Thumps Up” (Ebert and Roeper) •Colleges: Ranking #1 to #100 (US News & World Report) •Cars: “Best and Worst,” P, F, G. VG, E (Consumer Reports) •Report Cards: A, B, C, D, E •Hotels: “Luxury,” Top Class,” “Quite Comfortable,” etc., Others (Michelin) •Hospitals: Ranking #1 to #___, “Honor Roll” (US News & World Report) 26 The unique challenges of measuring quality of care/life in a NH How do you capture quality of life in a LTCF? How dependent is it on the— g Proximity of family members. g Friendliness of staff. g Bond with particular caregiver. g Programming and activities. g Ambiance of room (and whether private or double). g Ability to get outside (outdoors). g Food. g Pastoral counseling. g Spiritual life. g Palliative care and care at the end of life. Quality is not based upon a single episode but a composite of hundreds of kinds of encounters delivered hundreds and thousands of times. 27 Missing voices: Let’s hear from the major stakeholders: residents and families RESIDENT SATISFACTION SURVEY Item Question A B Do you think this place, The Center is a wonderful place? If a nursing home were needed for another family member or friend, would you recommend this facility? C Scale: LIVING C1 C2 C3 C4 C5 C6 C7 C8 C9 Is this a comfortable place to live? Do you have enough privacy? Are your personal belongings safe here? Is the residence clean and tidy? Is your room how you would like it to be? Is it possible that you could hurt yourself and a staff member would not know? Does the noise around here bother you? Does this place need fixing up? Does the smell in the residence bother you? D Scale: FOOD D1 D2 D3 D4 D5 D6 D7 D8 Are there enough different kinds of food to choose from? Can you get the type of foods you like to eat? Is the taste of the food okay? Is the temperature of the food okay? Are you given the right amount of food? When you are hungry, is food available? Do you get help to eat when you want it? Are you given enough time to eat? No Sometimes Yes No Sometimes Yes No Sometimes Yes 28 E Scale: ACTIVITY E1 Is there enough opportunity for you to do personal activities such as reading, watching TV, writing letters, visiting with family, etc.? Are there enough trips and outings? Is there enough entertainment? Are there enough games offered? (such as trivia, bingo, bowling) Are there enough activities (such as arts & crafts, cooking, music) for you on the unit? Are you told about what activities are available? Do you participate in the activities here? Are activities offered at the right time for you? Do you get the help you need with activities? Are there enough activities for you that use your mind? E2 E3 E4 E5 E6 E7 E8 E9 E10 F Scale: STAFF F1 F2 F3 F4 F5 F6 F7 F8 F9 Do the staff show you that they care about you? Do the staff respect your wishes? Do the staff try to understand what you're feeling? Do the staff help you when you need it? Is help freely given? When the staff comes to your room, do they tell you what they have come for? Are the staff skilled and knowledgeable? Do the staff answer promptly when you call? Do the staff involve you in decisions about your care? G Scale: DIGNITY G1 G2 G3 G4 G5 G6 G7 G8 G9 Do the staff call you by name? Do the staff help you to look nice? Is you personal and physical privacy respected? Do you have opportunities to help or support others? Do the day-to-day things you do make you feel worthwhile? Do the staff ever make you feel like you are a burden? Do the staff ever take advantage of you? Do you ever feel ignored by staff? Are you treated the way you want to be treated? No Sometimes Yes No Sometimes Yes No Sometimes Yes 29 H Scale: RELATIONS H1 H2 Is it easy to make friends at this nursing home? Do you consider that any other resident here is your close friend? In the last month, have people who worked here stopped just to have a friendly conversation with you? Do you consider any staff member to be your friend? Do you think that HRCA tries to make this an easy and pleasant place for families and friends of residents to visit? H3 H4 H5 I Scale: SPIRITUALITY I1 I2 Do you participate in religious activities here? Do the religious activities here have personal meaning for you? Do you feel your life as a whole has meaning? Do you feel at peace? I3 I4 J Scale: SUMMARY J1 J2 J3 Can you find a place to be alone when you wish? Can you make a private phone call? When you have a visitor, can you find a place to visit in private? Can you be together in private with another resident (other than your roommate)? Do you enjoy the organized activities here at the nursing home? Outside of the religious activities, do you have enjoyable things to do at HRCA during the weekends? Do you like the food here? Do you enjoy mealtimes here? Can you get your favorite foods here? Do you feel your possessions are safe at this nursing home? Do your clothes get lost or damaged in the laundry? Do you feel safe? J4 J5 J6 J7 J8 J9 J10 J11 J12 No Sometimes Yes No Sometimes Yes No Sometimes Yes 30 K Scale: AUTONOMY No Sometimes Yes K1 Are you encouraged to participate in decisions about your care? K2 Do you decide what you are going to do each day? K3 Do you feel you can express your feelings and opinions around here? K4 Is equipment available that allows you to be more independent? (For example, wheelchair, walker, bars in bathrooms) K5 Are you free to come and go as you please? K6 Are you ever forced to do things that you don't want to do? K7 Will staff get back at you if you say/do something they don't like? K8 If you could, would you choose to have a different roommate(s)? K9 Can you choose when to have your bath or shower? K10 Do you feel you have enough freedom to make your own choices? 31 Sounding off: Some miscellaneous thoughts about information and quality Facility quality in some ways is an artificial construct. Quality varies between units, individual care teams, and individual caregivers. CEO and chairman of the board or owner should be required to sign off on survey reports (a la SarbanesOxley). For profits vs. not-for-profits are markedly different in deficiencies, direct and indirect resident care expenditures and staffing hours. 32 Money matters: The Federal and State governments “insure” nearly ¾ of residents. They know that Medicaid funding is inadequate to meet even minimum staffing needs. (They will grandstand, but they won’t spend the money.) 33 DASH BOARD An attempt to distill a handful of key indicators. OPERATIONS INDICATORS Staff turnover Facility census Staffing levels (hours per patient day*) Agency use and overtime use CLINICAL INDICATORS Facility acquired pressure sores Weight loss Falls SURVEY RESULTS Code Red Code Green Code Blue * Should be replaced by the development of a consistent, reliable acuity measurement tool that can translate into a range of minimum staffing patterns. Show performance against regional benchmarks. Use 3-year rolling average. 34 Conclusion So, how do we use information to improve quality of care/life? ANSWER: Not available as outline went to print. (Speaker will wing it.) 35
