Quality Improvement
Committee
Patient Experience and Clinical
Excellence: FY14 YTD, Jan. 14
Presenter:
Dr. George Block, CMO
Ashraf Gulzar, Director Quality Management
Mike Thornton, Supervisor Quality Management
Date:
May 28, 2014
Framework for Clinical Excellence
Measures that align national initiatives to the front line
Measure Domains
VBP
Evidence-based Care
Heart Failure, AMI, Pneumonia,
SCIP, VTE, Immunization, Stroke, IP
ED Throughput, Pregnancy Care
Patient and Family Engagement
HCAHPS Overall Rating 9-10
Likelihood to Recommend
VBP
Mortality
Sepsis/Documentation(Medicare - AMI,
PN, CHF, COPD, Stroke, Hip/Knee)
VBP
Safety
PSI-90 + HAI + AHRQ PSI +
Composite Harm Index
(30 measures/6 LHM priorities)
VBP
Risk Adjusted Mortality Ratio
PFP
2
2
PFP
$
Appropriate Hospital Use
30-day all cause readmissions
(Medicare - AMI, PN, CHF,
COPD, Stroke, Hip/Knee)
VBP
$
Cost and Efficiency
Length of Stay
Inlier Opportunity Index (IOI)
Community Health
Measures to be developed.
PFP=Partnership for Patients
VBP = Value Based Purchasing
$ = standalone payment penalty
Evidence-Base Care
Patient Experience
Evidence-based Care
Mortality
Harm
Desired Trend
Readmissions
Cost of Care
Quest - Appropriate Care Score
100%
90%
94%
94%
96%
96%
95%
99%
97%
80%
Notes:
70%
1.
2.
60%
50%
QE-Mar.12
QE-Jun.12
QE-Sep.12
QE-Dec.12
QE-Mar.13
FY2013
ACS All or None
QE-Jun.13
QE-Sep13
FY2014
Quest Top Performance
Source: Premier - Quest
3.
4.
5.
6.
7.
3
Staff education
Nursing
Competency
Daily core
measure list
PCI task force
Immunization
rounds
Meeting with
Nursing Directors/
Managers for
individual
performance
issues.
PN – Blood C/S
ED issue (need to
work with ED)
Evidence-Base Care
Patient Experience
Evidence-based Care
Mortality
Harm
Desired Trend
Readmissions
Cost of Care
Notes:
1.
2.
3.
4.
5.
6.
4
Staff education
Nursing
Competency
Daily core
measure list
Foley rounds
Meeting with
Nursing
Directors/
Managers for
individual
performance
issues.
ARCIS DVT
assessment
documentation
changed for
patient
transferring to
higher level of
care.
Evidence-Base Care
Patient Experience
HCAHPS
Patient Experience
Mortality
Desired Trend
Harm
Readmissions
Overall Rating 9's and 10's
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
79%
74%
67%
65%
65%
60%
Cost of Care
Notes:
73%
73%
71%
74%
64%
60%
70%
68%
1.
2.
Feb.13
Mar.13
Apr.13
May.13
Jun.13
Jul.13
Aug.13
Overall Rating 9's and 10's
Sep.13
Oct.13
Nov.13
Dec.13
Jan.14
Feb.14
14-Mar
CMS Benchmark 75th %tile (75%)
3.
4.
Likelihood to Recommend
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
5.
6.
73%
71%
76%
80%
69%
72%
77%
80%
75%
82%
76%
80%
70%
7.
Feb.13
Mar.13
Apr.13
May.13
Jun.13
Jul.13
Likelihood to Recommend
5
78%
Aug.13
Sep.13
Oct.13
Nov.13
Dec.13
Jan.14
CMS Benchmark 75th %tile (77%)
*Stoplight report to be presented monthly
Feb.14
14-Mar
Studer training
(Apr – May 2011)
Leader rounding on
Associates
(Sept. – Oct. 2011)
AIDET training
(Jan. – Mar. 2012)
Charge Nurse
Rounding
(Apr. - May 2012)
AIDET Validation
(Jan. – Mar. 2013)
Difficult Conversation
Training
(Feb. 2013)
Leader Patient
Rounding
(Apr. 2013)
Evidence-Base Care
Patient Satisfaction
Emergency Department
Patient Experience
Mortality
Desired Trend
Harm
Readmissions
Cost of Care
Patient Satisfaction
Emergency Department - Overall Mean
Notes:
1.
Studer training
(September 2013)
2.
Initiated Leader
Rounding in ED
100%
90%
80%
70%
81%
83%
81%
82%
83%
84%
Apr.13
May.13
Jun.13
Jul.13
87%
85%
86%
87%
83%
79%
80%
81%
Feb.14
14-Mar
60%
50%
40%
30%
20%
10%
0%
Feb.13
Mar.13
ED - Overall Mean
6
Aug.13
Sep.13
Oct.13
Nov.13
Dec.13
Press Ganey 75th %tile (88.5%)
Jan.14
Evidence-Base Care
Emergency Department
Throughput
Patient Experience
Mortality
Desired Trend
Readmissions
Inpatient ED Arrival to Discharge
Median Minutes/Patient
Median Minutes/Patient
400
350
300
250
200
150
100
50
0
Cost of Care
373
318
Feb.13
342
339
336
324
327
324
Mar.13
Apr.13
May.13
Jun.13
Jul.13
Aug.13
322
301
296
Median Time ED Arrival to DC
Sep.13
316
278
Oct.13
Nov.13
Dec.13
Jan.14
Feb.14
NQF - Benchmark (274.0 Min)
Outpatient ED Arrival to Discharge
Median Minutes/Patient
Median Minutes/Patient
400
350
300
250
200
150
100
50
0
171
149
139
110
101
128
107
Feb.13 Mar.13 Apr.13 May.13 Jun.13
7
Harm
Median Time ED Arrival to DC
Jul.13
Aug.13
156
Sep.13
172
142
134
Oct.13
Nov.13 Dec.13
NQF - Benchmark (139.0 Min)
152
Jan.14
Notes:
1. I.O.T.
Committee
oversee ED
throughput
process.
Evidence-Base Care
Mortality:
Risk Adjusted Ratio
Patient Experience
Mortality
Desired Trend
Harm
Readmissions
Mortality Risk Adjusted Ratio
Acute Inpatients
Cost of Care
1.40
1.20
1.05
0.99
0.97
0.89
1.00
1.06
0.99
0.82
0.76
0.91
Notes:
1.
0.80
2.
3.
0.60
0.40
0.20
0.00
QE-Mar.12
QE-Jun.12
QE-Sep.12
QE-Dec.12
O/E
QE-Mar.13
FY2013
QE-Jun.13
DCHS Goal
QE-Sep13
QE-Dec13
QE-Mar14
(Jan-Feb)
4.
FY2014
5.
6.
8
Mortality Drill down
(Jan – March 2013)
IHI trigger tool
Coding issues such as
comfort care or
palliative care
Change in peer review
form.
Reassess criteria for
mortality screening.
Review of peer
process at Medical
Staff Retreat
Evidence-Base Care
Mortality: Observed Rate
(Condition Specific)
Desired Trend
Patient Experience
Mortality
Harm
Readmissions
AMI Observed Mortality Rate
Acute Inpatients
CARE Project
Sepsis Mortality Rate
25%
20%
15%
10%
12.0%
17.9%
16.3%
14.6%
14.0%
13.1%
14.2%
10.5%
5%
0%
QE-Jun.12
QE-Sep.12 QE-Dec.12 QE-Mar.13 QE-Jun.13
Mortality Rate
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
FY2013
Mortality Rate Baseline
QE-Dec13
0.0%
2.6%
6.7%
2.7%
6.8%
QEQE-Jun.13 QE-Sep13 QE-Dec13 QE-Mar14
Mar.13
(Jan-Feb)
FY2013
CHF - Observed
3.5%
FY2014
CHF - Expected
11.1%
7.1%
7.8% 11.7%
2.1%
FY2014
AMI - Observed
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
12.1%
QEQE-Jun.13 QE-Sep13 QE-Dec13 QE-Mar14
Mar.13
(Jan-Feb)
FY2013
FY2014
Mortality Rate Goal (11.8%)
8.8%
6.8%
11.9%
5.3%
QE-Jun.12 QE-Sep.12QE-Dec.12
QE-Mar14
(Jan-Feb)
Heart Failure Observed Mortality Rate
Acute Inpatients
QE-Jun.12 QE-Sep.12QE-Dec.12
9
QE-Sep13
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Cost of Care
AMI - Expected
Pneumonia Observed Mortality Rate
Acute Inpatients
8.8%
7.9%
2.9%
3.6%
1.4%
QE-Jun.12 QE-Sep.12QE-Dec.12
1.4%
7.9%
5.2%
QEQE-Jun.13 QE-Sep13 QE-Dec13 QE-Mar14
Mar.13
(Jan-Feb)
FY2013
PNU - Observed
FY2014
PNU - Expected
Evidence-Base Care
Mortality: Observed Rate
(Condition Specific)
Desired Trend
Patient and Family
Engagement
Mortality
Safety
Appropriate Hospital
Use
Cost and Efficiency
Community Engagement
Notes:
Total Hip and Knee,
Stroke, and COPD
mortality rates are
new focus areas for
CMS as of January
2014.
10
Harm – Overall Composite and
Focus Areas
Desired Trend
Evidence-Base Care
Patient Experience
Mortality
Harm
Readmissions
Quest - Harm Composite Score
1.00
0.80
0.60
0.40
0.20
0.00
-0.20
-0.40
Cost of Care
0.278
0.040
QE-Mar.12
0.116
-0.072
QE-Jun.12
-0.270
QE-Dec.12
QE-Sep.12
0.243
-0.147
QE-Sep13
QE-Dec13
-0.165
QE-Mar.13
QE-Jun.13
FY2013
1000/Discharges
Quest Top Performance
1.40
1.20
1.00
0.80
0.60
0.40
0.20
0.00
11
Quest Harm Composite
Source: Premier - Quest
PSI - 90 Harm Composite
1.319
0.977
Mar.13
FY2014
Apr.13
1.013
May.13
0.994
Jun.13
1.061
1.047
1.167
Jul.13
Aug.13
Sep.13
1.035
0.992
0.904
Oct.13
Nov.13
0.826
0.782
Dec.13
Jan.14
PSI-90 Composite Inpatients
PSI-90 Composite Medicare
CMS VBP Achievement (50th %tile)
CMS VBP Benchmark (Top Decile)
Feb.14
Notes:
1. Outlier cases referred to
Medical Staff for peer
review in June 2013.
2. Outlier cases reviewed
and reported to Nursing
Quality Committee.
3. For all inpatients, our PSI90 HARM composite
score is at 1.073 and this
score is higher than
Medicare patients. As
this measure has just
become available, we will
need to investigate but it
is probably the number of
accidental puncture/
laceration patients in the
All Payor population.
Evidence-Base Care
Harm Focus Areas
Patient Experience
Mortality
Desired Trend
Harm
Readmissions
Cost of Care
Notes:
1.
2.
3.
4.
12
SUP Therapy
discontinued
when patient
leaves ICU in
Nov. 2012.
Antibiotic
Stewardship
Program
implemented
4/2009.
Daily CAUTI
Catheter
Utilization
Surveillance in
March 2012.
TRUDI U.V.
Robot for C.Diff
decontamination
in Oct. 2013
Evidence-Base Care
Readmissions:
Overall and Condition Specific
Desired Trend
Readmission Risk Adjusted Ratio
Acute Inpatient - All Cause
1.40
1.20
1.00
0.80
0.60
0.40
0.20
0.00
0.87
QEJun.12
QESep.12
0.89
QEDec.12
0.89
0.88
QEQEMar.13 Jun.13
FY 2012
FY2013
Readmission Risk Adjusted Ratio
0.87
0.80
QEQESep.13 Dec.13
QEMar.14
(JanFeb)
18.8%
22.7%
20.8%
13.6%
FY 2012
QEDec.12
QE- QE-Jun.13 QEMar.13
Sep.13
FY2013
Observed Readmission Rate
13
22.5%
12.2%
QESep.12
QEDec.13
Harm
Readmissions
Cost of Care
28.6%
18.2%
14.3%
12.5%
Notes:
14.3%
7.7%
4.4%
0.0%
QEJun.12
QESep.12
FY 2012
QEDec.12
QEMar.13
QEJun.13
QESep.13
FY2013
Observed Readmission Rate
QEDec.13
QEMar.14
(Jan-Feb)
FY2014
Expected Readmission Rate
Pneumonia Observed Readmission Rate
Medicare All Cause
6.5%
QE-Jun.12
35%
30%
25%
20%
15%
10%
5%
0%
FY2014
DCHS FY14 Goal (.88)
Heart Failure Observed Readmission Rate
Medicare
- All Cause
33.3%
35%
30%
25%
20%
15%
10%
5%
0%
Mortality
AMI Observed Readmission Rate
Medicare - All Cause
1.06
0.95
Patient Experience
QEMar.14
(Jan-Feb)
FY2014
Expected Readmission Rate
35%
30%
25%
20%
15%
10%
5%
0%
16.0%
14.8%
11.1%
QE-Jun.12
FY 2012
QESep.12
13.2%
12.5%
13.0%
13.3%
QEDec.13
QEMar.14
(Jan-Feb)
8.0%
QEDec.12
QE- QE-Jun.13 QEMar.13
Sep.13
FY2013
Observed Readmission Rate
FY2014
Expected Readmission Rate
1. LACE tool
completed by Case
Managers in 3M
03/2013.
2. RAAD tool being
refined.
3. CHF Clinic
10/14/2013.
4. HCNC SNF
Collaborative
12/2013.
5. EMMI pt. education
started 10/2013.
6. Improved mgmt.
review of discharge
planning process.
Appropriate Hospital Use:
Condition Specific
Desired Trend
Evidence-Base Care
Patient and Family
Engagement
Mortality
Safety
Appropriate Hospital
Use
Cost and Efficiency
Community Engagement
Notes:
1. Total Hip and Knee,
Stroke, and COPD
readmissions are
new focus areas for
CMS as of January
2014.
O'Connor Hospital
COPD Observed Readmission Rate
Medicare - All Cause
30.43%
35%
30%
26.32%
25.81%
25%
19.51%
20%
15.15%
11.11%
15%
10%
13.64%
3.57%
5%
0.00%
0%
QE-Dec.11
QE-Mar.12
QE-Jun.12
QE-Sep.12
FY2012
Expected Readmission Rate
14
QE-Dec.12
QE-Mar.13
FY2013
QE-Jun.13
QE-Sep.13
QE-Dec.13
FY2014
Observed Readmission Rate
Evidence-Base Care
Patient Experience
Cost Effectiveness
Mortality
Desired Trend
Harm
Readmissions
Medicare LOS
Cost of Care
7.00
6.00
5.00
4.00
3.00
2.00
1.00
0.00
5.55
5.26
5.20
5.16
5.00
4.98
5.51
5.39
4.49
4.92
4.72
5.25
5.37
Notes:
Feb.13 Mar.13 Apr.13 May.13 Jun.13
Jul.13
Medicare PPS LOS
Aug.13 Sep.13 Oct.13 Nov.13 Dec.13
Jan.14
Feb.14
Medicare Geometrc LOS
Medicare
Inlier Opportunity Index
1.00
0.80
0.60
0.40
0.20
0.00
-0.20
-0.40
0.49
0.38
0.33
0.35
0.30
0.09
0.06
-0.06
Feb.13
Mar.13
Apr.13
May.13
Jun.13
Jul.13
Aug.13
Medicare Inlier Opp Index
15
0.16
0.15
Sep.13
0.11
0.03
-0.14
Oct.13
Nov.13
DCHS Goal
Dec.13
Jan.14
Feb.14
1. Utilization Mgmt.
Committee oversees
this process.
2. Medical Staff Advisors
available for expert
opinion during case
review and may consult
with medical staff as
needed.
3. Excellent application of
discharge planning
process has aided in
decreasing I.O.I.
16
Financial risks on quality and cost
OCT
2011
OCT
2012
OCT
2013
OCT
2014
OCT
2015
Value-Based
Purchasing (VBP)
1.0%
1.25%
1.5%
1.75%
30-day
readmissions
1.0%
1%
2.0%
2%
3.0%
Hospital-acquired
conditions
OCT
2016
OCT
2019
OCT
2020
0.65%
0.9%
0.7%
8.9%
8.7%
1.0%
0.1%
0.1%
0.3%
0.2%
Multifactor Productivity
Adjustment*
1.0%
0.7%
0.5%
0.5%
0.4%
0.5%
4.9%
1.9%
2.1%
2.1%
2.1%
2.1%
10.6%
10.5%
11.4%
TOTAL IMPACT
OCT
2018
2.0%
Market basket
reductions
Documentation and
Coding Adjustment
(DCA)**
Across the board cuts
to finance the debt ***
OCT
2017
0.75%
2.0%
6.0%
6.7%
8.1%
9.3%
10% 9.4%
% = % OF MEDICARE INPATIENT OPERATING PAYMENTS
*The Multifactor Productivity Adjustment is an estimate generated by the CMS Office of the Actuary
**DCA, also known as the behavioral offset, shown here does not show the future affects of these cuts on baseline spending. Estimates FY 2014-FY 2017 impact
of the American Taxpayer Relief Act of 2012
*** If Congress has not adopted the Joint Committee’s report to reduce the deficit by at least $1.2 trillion, the 2% cut will be implemented January 2013
17
New HAC policy 10/1/14 and
overlapping HACs
Hospital-acquired conditions
(HACs)
Not eligible
higher payment
IP VBP
(FY 13 ongoing)
(FY 08 ongoing)
HAC Reduction
Program
(Starting FY 2015)
Catheter associated UTI
X
Proposed FY 16
Proposed FY 15
Surgical Site Infections
X*
Proposed FY 16
Proposed FY 16
Vascular cath-assoc. infections
X**
PSI-90 FY 2015
Alt. Proposed FY 15
Foreign object retained after surgery
X
Proposed FY 15
Air embolism
X
TBD
Blood incompatibility
X
TBD
Pressure ulcer stages III or IV
X
Falls and trauma
X
DVT/PE after hip/knee replacement
X
Manifestations of poor glycemic control
X
Iatrogenic pneumothorax
X
PSI-90 FY 2015
Proposed FY 15
Partial?
PSI-90 FY 2015
Proposed FY 15
Proposed FY 15
PSI-90 FY 2015
Proposed FY 15
TBD
TBD
Methicillin resistant Staph. aureus (MRSA)
Proposed FY 17
Proposed FY 17
Clostridium difficile (CDAD)
Proposed FY 17
Proposed FY 17
Ventilator associated pneumonia
18
*SSI includes different conditions. ** Vascular Catheter is broader than the CLABSI measure.
Measure evolution toward outcomes
and efficiency
Hospitals’ VBP payment will increasingly be based
on their performance on outcomes/efficiency
FY 2013
FY 2014
FY 2015
Active Performance Period
Clinical process
19
Patient experience
Outcomes
Efficiency