Health Care Quality & Safety February 26, 2013

Thomas E. Hamilton, DirectorSurvey & Certification Group

Centers for Medicare & Medicaid Services

Essential Role of Territorial Leadership

Medicare & Medicaid Participation is … Conditional

• Conditions of Participation (CoPs)• Hospitals … 42 CFR 482

• Nursing Homes … 42 CFR 483

• Dialysis Facilities … 42 CFR 494

• Ambulatory Surgical Centers … 42 CFR 416

• Clinical Laboratories … 42 CFR 493

• Essential Quality of Care & Safety Requirements• Governance

• Staffing and Credentialing

• Practice Standards – safe environment, informed patients, …

• QAPI – Internal Quality Assessment + Performance Improvement

Why Survey & Certification??

• Quality Assurance - Medicare + Parts of Medicaid• 200,000 Providers, 100,000 Onsite Surveys +

Investigations - 7,000 Surveyors

•Hospitals (Acute, Psychiatric, Organ Transplant, Critical Access)

•Nursing Homes

•Clinical Laboratories

•Home Health

•Dialysis Facilities

•Hospice

•Outpatient Physical Therapy

•Comprehensive Outpatient Rehab.

•Rural Health Clinics

•Ambulatory Surgical Centers

•Organ Procurement (OPOs)

•ICFs-IID

•Accrediting Organizations

•Clinical Laboratories

Clinical Laboratories

Test Type Desirable Range

• Creatinine …. (0.5 - 1.6)

• Uric Acid ……. (3.5 – 8.4)

• Calcium …….. (8.6 – 10.6)

• Albumin ……... (3.7 – 5.2)

• Globulin …….. (1.4 – 4.5)

Health Care – What Could Possibly Go Wrong?

Up, Up, and Awry!!

• Wrong Site Surgeries

• Healthcare-Associated Infections

• Medication Errors … Complications

“If your remember,

I did say there might

be side effects…”

Today’s Health Care

• Highly Complex and Sophisticated

• More Dependent on … Teamwork

• Performed by … Human Beings

• “To Err is Human” – Institute of Medicine

• Human Factors Engineering

• Focus on the System

What Might Governors Do?

1. Hospital Governance2. Leadership + Management3. Finance

• Funding» Local Funds» Medicaid Matching Funds» Medicaid Certified Public Expenditures» Medicaid Expansion

• Billing Systems» Coding Systems (e.g., Medicare coding)» Private Insurance

Case: 1-Year Lung Graft SurvivalP A T U

82.3%80.9%79.9%79.6%77.4%

80.8%81.2%79.4%79.9%83.6%

65.3%68.1%

59.7%58.5%58.1%61.0%

67.3%

72.4%75.9%

73.3%

50%

60%

70%

80%

90%

100%

Jul-12

Jan-12

Jul-11

Jan-11

Jul-10

Jan-10

Jul-09

Jan-09

Jul-08

Jan-08

Expected Graft SurvivalActual Graft Survival

Is Your Board Sending the Wrong Signals ?Is Your Board Sending the Wrong Signals ?

Keeping Informed

Systems – Require Regular Reporting on:1. Hospital Finances, Billing, Liabilities2. Quality (e.g., Check the CMS “Compare” websites) 3. Involvement in National Initiatives – Examples:

• Value-Based Purchasing– http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-

purchasing/index.html?redirect=/hospital-value-based-purchasing/

• Partnership for Patients– http://innovation.cms.gov/initiatives/Partnership-for-

Patients/– http://hret-hen.org/

• Institute for Healthcare Improvement– http://www.ihi.org

Keeping Informed With

4. Governance + Leadership– http://www.governanceinstitute.com

Welcome the Bad News Bearers– To Avoid becoming a Bad News Bear– QAPI

5. CMS and Accrediting Organization Surveys• Instruct Providers to Alert You on Every Survey• Immediate Jeopardy – 23 Days to Medicare Termination• “Condition” Level Deficiency – 90 Days + Onsite Revisit• Other “Standard” Level Deficiencies – Plan of Correction

Thank You

• Attention to Health Care Quality

• Attention to Access to Health Care

• Efforts to Expand both Access + Quality