2011 Douglas T. Miller Symposium

Dennis Wagner, Acting Director, Office of Clinical Standards and QualityCenters for Medicare & Medicaid Services

April 29, 2011

Plan for This Segment

• “Gestalt” Overview of CMS, Health Reform and Quality Improvement

• Quality Improvement Lessons from the Organ Donation Breakthrough Collaborative

• Partnership for Patients• Discussion

Questions to Run On

• What is happening at CMS?• What is going on with the implementation of

healthcare reform – especially on quality?• What can we learn from the success of the national

organ donation quality improvement work?• What is the Partnership for Patients?• What is my advice for CMS?

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CMS is Changing

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CMS Vision

CMS is a major force and a trustworthy partner for the continual

improvement of health and health care for all Americans.

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Operating Values

How we shall work together and with others?• Boundarilessness• Speed and Agility• Unconditional Teamwork• Valuing Innovation• Customer Focus

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Better Health forthe Population

Better Carefor Individuals

Lower CostThrough

Improvement

The “Three-Part Aim”

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5 New Centers and Functions Added in 1 Year

1. Center for Strategic Planning, Tony Rodgers2. Center for Program Integrity, Peter Budetti3. Center for Medicare and Medicaid Innovation, Rick Gilfillan4. Center for Consumer Information and Insurance Oversight,

Steve Larsen5. Federal Coordinated Health Care Office, Melanie Bella

• Center for Medicare, Jon Blum• Center for Medicaid, CHIP, and S&C, Cindy Mann• Office of Clinical Standards and Quality, Dennis Wagner & Paul

McGann, MD

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Office of Clinical Standards and QualityLevers for Safety, Quality & Value

• Contemporary Quality Improvement• Transparency, Public Reporting & Data

Sharing• Incentives• Regulation• National & Local Coverage Decisions• Demonstrations, Pilots, Research, Grants,

Innovation9

Office of Clinical Standards and QualityLevers for Safety, Quality & Value

• Contemporary Quality Improvement: Quality Improvement Organizations

• Transparency, Public Reporting & Data Sharing: Hospital Inpatient Quality Reporting Program

• Incentives: Hospital Value Based Purchasing• Regulation: Conditions of Participation (OPOs, Hospitals,

14 other provider types)• National & Local Coverage Decisions: Coverage for

Preventative Services• Demonstrations, Pilots, Research, Grants, Innovation:

Diabetes Self Management in Mississippi10

Affordable Care ActSome Key CMS Accountabilities

• Major, Ongoing Demonstration & Testing Authority & Resources (CMMI)

• Accountable Care Organizations• Value Based Purchasing Programs• Health Insurance Exchanges• Expanded Medicaid Programs• Care Transitions to Reduce Readmissions• Expanded Quality Reporting Programs• Expanded Preventative Services• ….and Much More

Affordable Care Act Provision with Quality Focus

Value based purchasing• 3001 - Hospital value-based purchasing• 3006 - Value-based purchasing for SNF• 3014 - Quality and efficiency measurement• 10301 - Develop a plan to implement VBP for ambulatory surgical

centers• 10326 - Pilot testing for pay-for-performanceHospital readmissions• 3025 - Hospital readmissions reduction program• 3026 - Community-based care transitions programHealthcare acquired conditions• 2702 - Payment adjustment for health care-acquired conditions• 3008 - Payment adjustment for conditions acquired in hospitalsAccountable care organizations• 2706 - Pediatric accountable care organization demonstration

project• 3022 - Medicare Shared Savings ProgramDual eligibles• 2602 - Providing federal coverage and payment coordination for dual

eligible beneficiariesPreventative services• 4103 - Annual wellness visit providing a personalized plan• 4104 - Removing barriers to preventive services• 4105 - Evidence-based coverage of preventive services

Coordination of care• 2703 - State option to provide health homes for enrollees with chronic

conditions• 2704 - Demonstration project to evaluate integrated care around a

hospitalizationLong term care• 2401 - Community first choice option• 2402 - Removal of barriers to providing home and community based services• 2403 - Money follows the person rebalancing demo• 2404 - Protection for recipients of home and community-based services

against spousal• impoverishment• 10202 - Incentives for states to offer home community based servicedPublic reporting• 10303 - Development of outcome measures• 10327 - Improvements to the physician quality reporting system -- also see

Provision 3002• 10331 - Public reporting of performance informationQuality reporting initiative• 2701 - Adult health quality measures• 3002 - Improvements to the physician quality reporting system.• 3004 - Quality Reporting for Long Term Care Hospitals (LTCH), inpatient

rehabilitation• hospitals, and hospice programs• 3005 - Quality reporting for PPS-exempt cancer hospitals• 10322 - Quality reporting for psychiatric hospitals

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CMS Approach to Managing the Affordable Care Act

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Quadrant 1High impact, high complexity

program areas tomanage

Quadrant 2High impact priorities to

monitor and maintain

Quadrant 4Tertiary priorities tominimize resources

and conserve focus

Quadrant 3Secondary priorities to monitor

and manage

OCSQ Quadrant 1: High Impact, High Complexity Program

Areas to Manage

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1.Value Based Purchasing2.Public and Quality Reporting3.Reduced Readmissions4.Hospital Acquired Conditions5.ACOs6.Center for Medicare and Medicaid Innovation7- 8-9-10-11-12-13

Quadrant 2

Quadrant 3Quadrant 4

OCSQ Quadrant 2: High Impact Priorities to Monitor and Maintain

1.Preventative services

-- more in other CMS components --

Quadrant 2High impact priorities to monitor and maintain

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Quadrant 2

Quadrant 3Quadrant 4

Quadrant 1

What Will the Affordable Care ActLook Like on the Front Lines?

• Increasing measurement of quality, efficiency & value• Public reporting and sharing of data• Reimbursement linked to quality improvement, efficient

service delivery and cost reduction thru improvement• Increasing integration of delivery systems and coordination

of care across settings• Greater role in addressing public health issues• Greater use of health information technology• Creation of a learning environment in healthcare

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New Tools, New Incentives, New Penalties, New Organizations

What does it all mean?

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Value-Based Purchasing and Linking Payment to Quality

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New Tools, New Incentives, New Disincentives, New Organizations

What does it all mean?

Doing the right things for patients will become easier and doing the wrong things will become more difficult.

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Questions for Quick Reaction and Discussion

• What do you like about what you see in this high level gestalt?

• What does CMS need to do more of, better, differently?

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The Healthcare Quality/Value Challenge

• U.S. spends more per capita on healthcare than any other country in the world

• Quality is often inferior to that of other nations

• Significant variation in quality and cost by geographic location

• Serious disparities in the quality of health care by race, and socioeconomic status

How do we make quality better?

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How do we make quality better?

• Improvement as a Strategy• Customer-Mindedness• Process-Mindedness• Employee-Mindedness• Statistical Thinking• Supplier-Mindedness• Continual Improvement (PDSA)• Leadership

How do we make quality better?-- Stages of Facing Reality --

• Stage 1. “The data are wrong”• Stage 2. “The data are right, but it’s not a

problem”• Stage 3. “The data are right; it is a problem;

but it is not my problem.”• Stage 4. “I accept the burden of

improvement”

How do we make quality better?

• Clear Intent – Will• Proven Practices – Ideas• Focused, Constant Action -- Execution

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How do we make quality better?

• Clear Intent – Will• Proven Practices – Ideas• Focused, Constant Action – ExecutionOur work on organ donation is an

extraordinary national example of what is possible.

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50% of eligible donors are found in 206 hospitals

75% of eligible donors are found in 483 hospitals

90% of eligible donors are found in 846 hospitals

Concentration of Potential DonorsConcentration of Potential DonorsIn Nation’s Largest HospitalsIn Nation’s Largest Hospitals

Tremendous Variation in Donation Rates in 300 Largest Hospitals

Conversion Rate Distribution among the Largest 300 Hospitals 9/02-8/03

0

10

20

30

40

50

60

70

80

[0%,10%] [10%,20%] [20%,30%] [30%,40%] [40%,50%] [50%,60%] [60%,70%] [70%,80%] [80%,90%] Over 90%

Conversion Rate

Nu

mb

er o

f H

osp

ital

s

Collaborative Model An intensive, full-court-press to facilitate

breakthrough transformations in the performance of organizations, based on what already works.

Designed To: Designed To: Define, Document, and Disseminate Best Define, Document, and Disseminate Best

PracticesPractices Accelerate ImprovementAccelerate Improvement Achieve Results at a Rapid PaceAchieve Results at a Rapid Pace Build Clinical Leaders of ChangeBuild Clinical Leaders of Change

“All Teach, All Learn”

Collaborative Engine

Select Topic

Planning Group

Identify Change

Concepts

Enroll Participants

Prework

LS 1 LS3LS 2

Support System

ListServe Site Visits & Filming

Conference Calls Rapid Sharing

Data Reporting Website

S

A D

P

S

A D

P

Measures of Success

Organ Donation in USAOrgan Donation in USAJan 1999 – Apr 2007 (Monthly)Jan 1999 – Apr 2007 (Monthly)

400

450

500

550

600

650

700

750

1999 2000 2001 2002 2003 2004 2005 2006

Collaborative Start Date

Wisconsin Hospitals and OPO Led the NationWisconsin Hospitals and OPO Led the NationIn Generating Major National ResultsIn Generating Major National Results

Conversion Rate by Month: 2002-2010

40.0%

45.0%

50.0%

55.0%

60.0%

65.0%

70.0%

75.0%

80.0%

JAN02

AUG02

MAR03

OCT0

3

MAY04

DEC04

JUL0

5

FEB06

SEP06

APR07

NOV07

JUN08

JAN09

AUG09

MAR10

OCT1

0

Month/Year

Co

nv

ers

ion

Ra

te Collaborative starts here

data source: OPTN

UWHC OPO Performance Rates by Year

7369

66

7875

78 8184 84 84

8278

8386 88 88 88

52 5459 62

6771 72 75

70

0

10

20

30

40

50

60

70

80

90

100

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Conv

ersi

on R

ate

(%)

OPO Conversion Rate

OPO Adjusted Conversion Rate

National Conversion Rate (2010 Jan-Jun)

OPO Conversion Rate: (Eligible Donors/Eligible Deaths)OPO Adjusted Conversion Rate: (Eligible Donors + Other Donors/Eligible Deaths + Other Donors)

What made it work? Including the Customer: Donor Families and

Recipients Clear, Ambitious, Achievable Aims Transparent About Data and Practice Model for Improvement and Collaborative

Methodology Teaming Nationally to Work Smarter, Faster Creating Bolder, Thoughtful Agendas for Action Rapid Testing & Change Using Proven Practices Doing More Of What Works Relentless Pursuit of Improvement, Never Settling

for the Status Quo

Questions for Discussion and Action

• What are our key insights about the organ donation improvement work?

• How can we take this further?

• What can we learn and apply to our current challenges and opportunities with healthcare reform?

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Partnership for Patients: An Overview

April 2011

The Affordable Care Act Improves Health Care Quality

• The Affordable Care Act (ACA) is best known for fixing broken health insurance laws and helping to cover millions of previously uninsured Americans.

• What many people don’t know is all of the ways the new law is also reducing costs while improving the experience of being a patient, being a caregiver, and being a health care provider.

• The Partnership for Patients: Better Care, Lower Costs is one example of how Secretary Sebelius is using provisions of the ACA to make health care in America safer, more efficient, and less costly.

Meet Josie King

Unfortunately, Josie King’s story is not rare.

• On any given day, 1 out of every 20 patients in American hospitals is affected by a hospital-acquired infection.

• Among chronically ill adults, 22 percent report a “serious error” in their care.

• 1 out of 7 Medicare beneficiaries is harmed in the course of their care, costing the federal government over $4.4 billion each year.

• Despite pockets of success -- we still see massive variation in the quality of care, and no major change in the rates of harm and preventable readmissions over the past decade.

We can do much better – and we must.

Partnership for Patients Better Care, Lower Costs

1. Reduce harm caused to patients in hospitals. By the end of 2013,

preventable hospital-acquired conditions would decrease by 40% compared to 2010. 

– Achieving this goal would mean approximately 1.8 million fewer injuries to patients with more than 60,000 lives saved over the next three years.

2. Improve care transitions. By the end of 2013, preventable complications during a transition from one care setting to another would be decreased such that all hospital readmissions would be

reduced by 20% compared to 2010.

– Achieving this goal would mean more than 1.6 million patients would recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge.

Potential to save up to $35 billion dollars over three years.

How Will Change Actually Happen?

• There is no “silver bullet”• We must apply many incentives• We must show successful

alternatives• We must offer intensive supports

– Help providers with the painstaking work of improvement

We Know Major Improvement Is Possible

• 150 New Jersey health care facilities reduced pressure ulcers by 70%

• Rhode Island reported a 42% decrease in Central Line-Associated Bloodstream Infections (CLABSI) (2006-2007)

• More than 65 Institute for Healthcare Improvement Campaign hospitals reported going more than a year without a ventilator-associated pneumonia in at least one unit.

• Ascension Health sites participating in a 2007 peri-natal safety initiative achieved birth trauma rates that were at or near zero.

• And much more…

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Workin

g D

raft - La

st Mod

ified

04

/19

/23

05

:31

AM

Our Request to You• Join the Partnership for Patients

• Go to healthcare.gov/partnershipforpatients

Core Topics in Improvement

• Improvement as a Strategy• Customer-Mindedness• Process-Mindedness• Employee-Mindedness• Statistical Thinking• Supplier-Mindedness• Continual Improvement (PDSA)• Leadership

Defining “Quality”

“Meeting and Exceeding the Needs and Expectations of

Customers”

Learning about the Customer

• Observe• Survey• Use your own experience• Ask!

As a Customer…

• What is the #1 thing you would like CMS to improve?

• What is the #1 thing you want CMS to keep the same?

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“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.” –Margaret Mead

Contact Information

Dennis WagnerActing Director, Office of Clinical Standards and Quality

Centers for Medicare and Medicaid ServicesOffice of Clinical Standards and Quality

7500 Security Blvd., MSC: S3-02-01Baltimore, MD 21244-1850

Phone Number: 410-786-6841E-mail Address: dennis.wagner2@cms.hhs.gov

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Question for Reflection and Action

What is it about this work that makes my heart sing?

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