hcq p medicare’s health care quality improvement program 1 quality measurement and improvement at...
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HCQ PMEDICARE’S HEALTH CARE QUALITY IMPROVEMENT PROGRAMMEDICARE’S HEALTH CARE QUALITY IMPROVEMENT PROGRAM
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Quality Measurement and Quality Measurement and Improvement at CMSImprovement at CMS
Stephen F. Jencks MD, MPH
Director, Quality Improvement Group
Centers for Medicare & Medicaid Services
August 23, 2004
VisionVisionfor the Healthcare Systemfor the Healthcare System
The right care for every person every time.
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MissionMissionCMS Quality Improvement ProgramsCMS Quality Improvement Programs
Accelerate the pace of healthcare quality improvement for CMS beneficiaries
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0
50
100
150
200
0% 20% 40% 60% 80% 100%LEVEL OF PERFORMANCE
NU
MBE
R O
F O
BSER
VATI
ON
S
1998-1999
2000-2001
2024-2025(Projection)
Pursuing Perfection in MedicarePursuing Perfection in MedicareHospital and Office Care (all states, 24 measures)Hospital and Office Care (all states, 24 measures)
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2 0 2 4
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Improvement StrategiesImprovement Strategies
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Seven Key StrategiesSeven Key Strategiesfor Culture Changefor Culture Change
• Raise expectations
• Foster transparency and defeat secrecy
• Support and create partnerships
• Promote better information systems
• Improve the workforce
• Shorten improvement cycles
• Spread successes
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Raise ExpectationsRaise Expectations• Healthcare has come to accept the current
failure and injury rates.
• There is widespread feeling that little real change has occurred in patient safety since the IOM report To Err is Human.
• We are not very good at celebrating successes and creating and expectation of greater success.
• This is, above all, a challenge to leadership.
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Defeat SecrecyDefeat Secrecy
The most important reason for public reporting is to undermine a culture of not knowing or of concealing what we know.
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Support and Create PartnershipsSupport and Create Partnerships
• Nobody, not even CMS, can do this alone.
• Partnerships are key to creating an environment for improvement
• Partners can overcome obstacles that individual organizations cannot.
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Promote Better Information SystemsPromote Better Information Systems
• Medicine has become so complex that people can only practice safely and effectively with strong information systems support.
• CMS is promoting information systems by standardizing methods (e.g.: SNOMED), free tools, promoting implementation, and rewarding results.
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Improve the WorkforceImprove the Workforce
• Workforce adequacy, skills, and stability are keys to better care.
• Workforce stability contributes to adequate staffing and to fiscal stability.
• Work environment strongly influences workforce stability.
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Shorten Improvement CyclesShorten Improvement Cycles
• Improvement is real but the pace is far too slow.
• The length of the improvement cycle is one of the key determinants of the pace of change.
• The long cycles in CMS and other payers and purchasers contribute to long cycles in providers.
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Spread SuccessesSpread Successes
• To transform the system we must spread successes from the few to the many.
• For example, today, – the most successful thousand nursing homes in
the country are virtually restraint-free, – the most successful half of nursing homes have
a collective restraint rate of about 2.5%.
• But the national rate remains above 8%.
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The
Toolkit
PATI-ENT
SUPPORTSTANDARDMETHODS
PROMOTE
OR CREATE
PARTNERSHIPS
PR
OV
IDE
TE
CH
NIC
AL
AS
SIS
TA
NC
E
STRENGTHEN
WORKFORCE
PROVIDEPUBLIC
INFORMATION
STRUCTURE
COVERAGE AND
PAYMENTS
RE
WA
RD
D
ES
IRE
D
PE
RF
OR
MA
NC
E
ESTABLISH &
ENFORCE
REQUIRE-
MENTS
1616THE TOOLKIT WITHIN THE CMS SYSTEM
IDENTIFY IMPROVEMENT OPPORTUNITIES AND SELECT APPROPRIATE IMPROVEMENT INTERVENTIONS
ADOPT OR DEVELOP MEASURES
COLLECT & ANALYZE DATA
SELECT PRIORITY AREAS
MANAGE PROCESS IN PARTNERSHIP WITH STAKEHOLDERS
ESTABLISH&
ENFORCE STANDARDS
STRUCTURE COVERAGE
AND PAYMENTS TO IMPROVE
CARE
SUPPORT STANDARD METHODS
GIVE CONSUMERS
INFOR-MATION
AND ASSISTANCE
TO MAKE CHOICES
PROMOTE OR CREATE
COLLABORA-TIONS ANDPARTNER-
SHIPS
GIVE PLANS,
DOCTORS&
PROVIDERS TECHNICAL
ASSISTANCE
REWARD DESIRED
PERFORM-ANCE
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StandardsStandards
• Health Information Technology
• Clinical Guidelines
• Performance Measures
• Coverage and Payment procedures
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PartnershipsPartnerships
e-Health Partnerships
• Surgical Care Improvement Partnership
• Corporate Nursing Home Improvement Collaborative
• Fistula First
• National Quality Forum
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Technical AssistanceTechnical Assistance
Quality Improvement Organizations
Nursing HomesNursing HomesPercent Decrease in Problem Rate
Non-participant
homes
Participant nursing homes
Participants selecting
topic
Chronic Pain -33.3% -46.1% -60.5%
Post-acute Pain
-9.3% -16.9% -26.1%
Physical Restraints
-17.6% -28.5% -68.3%
Pressure Ulcers
+3.3% -1.1% -7.8%
2020
Physician OfficePhysician Office
Percent decrease in failure rateWhole state Participants
HgbA1c 20.5 29.1
Lipid profile 29.8 36.4
Eye exam 0.6 4.9
Mammography -0.3 2.3
DIA
BE
TE
S2121
Home HealthHome HealthPercent Decrease in Failure Rate
National Participants
Participants selecting
topic
Pain 5.5 6.5 12.8
Dyspnea 6.8 7.6 17.1
Oral meds 7.5 6.1 14.1
Emergent Care -3.7 -5.3 -5.7
Acute hospitalization
1.1 1.7 1.5
InpatientInpatient Percent Decrease in Failure Rate1998-9 to 2000-1
Aspirin at admission 6.1
Aspirin at discharge 6.6
Beta blockers at admission 13.9
Beta blockers at discharge 25.0
ACEI for ventricular dysfunction 10.3
Left Ventricular Assessment 14.3
ACEI for ventricular dysfunction -3.3
Timely antibiotics 13.3
Appropriate antibiotics 28.6 P
NE
U
H
RT
FA
IL
HE
AR
T A
TT
AC
K
Customer SatisfactionCustomer Satisfaction(“Satisfied” or “Very Satisfied”)(“Satisfied” or “Very Satisfied”)
• Nursing homes (participating) 93%• Nursing homes (not participating) 80%• Home health (participating) 95%• Home health (nonparticipating) 90%• Hospitals (for quality improvement) 93%• Hospitals (for public reporting) 86%• Physicians (participating) 93%• M+C organizations 95%
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Restraints in Nursing HomesRestraints in Nursing Homes
0
2
4
6
8
10
12
14
16
18
2002Q2 2002Q3 2002Q4 2003Q1 2003Q2 2003Q3 2003Q4 2004Q1
Quarter
QM
sc
ore
Physical Restraints (Intensive Group forStates that chose Physical Restraints)
Physical Restraints (Non-Intensive Group forStates that chose Physical Restraints)
Physical Restraints (Select Intensive Groupfor States that chose Physical Restraints)
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Provide Performance InformationProvide Performance Information
• Nursing Home, Home Health, Dialysis Compare web sites.
• Hospital Voluntary Reporting Initiative and Reporting Hospital Quality Data for Annual Payment Update
• Public reporting under Premier demonstration
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CoverageCoverage
• Welcome to Medicare Assessment Visit
• Chronic care improvement pilots
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RewardsRewards
• Premier demo
• Chronic care improvement pilot
• Doctors Office Quality – Information Technology
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EnforcementEnforcement
• Survey and certification of providers
• Carried out by States under contract to CMS and using CMS regulations and interpretative guidelines
• Largest impact on nursing homes but applies to all provider groups.
• Quite uneven enforcement across states.
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Interstate VariationInterstate Variation
Eight Current DomainsEight Current Domains
Domain Population SampleAmbulatory clinical
FFS StateM+C Plan
Dialysis FFS ProviderHome health FFS ProviderInpatient FFS StateNursing home FFS & M+C ProviderConsumer perception
FFS StateM+C Plan
Overall: sum of standardized scores
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Quartile
First (13)Second (13)Third (13)Fourth (12)
Variation in Overall Quality Variation in Overall Quality
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Are Ranks A Documentation Artifact?Are Ranks A Documentation Artifact?Correlation of State Ranks
Amb FFS
AmbM+C Inpatient
Amb FFS 1.00 0.66 0.65
Amb M+C 0.66 1.00 0.45
Inpatient 0.65 0.45 1.00
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Predictors of Overall Predictors of Overall State-level QualityState-level Quality
• Single most powerful predictor of overall state quality is nursing supply, whether practicing (nursing census) or all (population census).
• Correlation of overall quality with nursing supply is 0.74 (R2=0.54). Correlation with primary care physician supply and poverty and weaker and add little to predictions based on nursing supply.
Leadership: Breakthrough PrioritiesLeadership: Breakthrough Priorities
Integrated CMS effort on• Vascular access in hemodialysis• Restraints and pressure ulcers in nursing homes• Prevention of surgical complicationsStudying similar efforts for• Increase adult immunizations in selected
settings• Stabilize workforce in hospitals and nursing
homes• Colon cancer screeing