Download Value Based Purchasing Puts Pressure on AMC’s to Perform

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Value Based Purchasing Puts Pressure
on AMC’s to Perform
The IQ Program Provides Solutions
Julie Cerese, RN, MSN
Vice President, Performance Improvement
April 4, 2011
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 1
Value Based Purchasing is Here
Proposed Clinical Measures
AMI-2 Aspirin prescribed at discharge
SCIP-Inf-1 Prophylactic antibiotic received within 1
hour prior to surgical incision
AMI-7a Fibrinolytic therapy received within 30
minutes of hospital arrival
SCIP-Inf-2 Prophylactic antibiotic selection for
surgical patients
AMI-8a Primary percutaneous coronary
intervention (PCI) received within 90 minutes of
hospital arrival
SCIP-Inf-3 Prophylactic antibiotics discontinued
within 24 hours after surgery end time
HF-1 Discharge instructions
HF-2 Left ventricular function assessment
HF-3 ACE-I or ARBs for left ventricular systolic
dysfunction
SCIP-Inf-4 Cardiac Surgery patients with controlled
6AM postoperative serum glucose
SCIP-Card- 2 Surgery pts on a beta blocker prior to
arrival that receive beta blocker during the periop
period
PN-2 Pneumococcal vaccination status
SCIP-VTE-1 VTE prophylaxis ordered for surgery
patients
PN-3b Blood culture performed before first
antibiotic received in hospital
SCIP-VTE-2 VTE prophylaxis within 24 hours
pre/post surgery
PN-6 Appropriate antibiotic selection
PN-7 Influenza vaccination status
Scoring will be based on
achievement or improvement
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 2
Clinical Care Scores Vary
Widely Among AMCs
% of clinical process of care domain score earned (Achievement Scores Only)
100%
80%
75th Percentile
Nationally
60%
40%
25th Percentile
Nationally
20%
345
56
78
54
395
29
218
38
336
96
58
74
163
4
72
6
97
52
79
32
14
46
80
17
214
8
92
179
67
236
42
3
15
26
5
1
234
346
11
61
47
12
240
60
40
43
10
37
274
9
45
69
28
167
57
70
82
34
291
84
53
13
48
55
486
35
23
7
810
91
83
299
89
87
39
27
180
33
71
2
388
526
49
21
88
76
77
368
222
525
66
22
16
290
73
19
90
298
0%
NOTE: Includes UHC Full Members
Source: CMS Hospital Compare Q2 2009 – Q1 2010 (Apr 09 – Mar 10)
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 3
Proposed HCAHPS Measures
• Nurse Communication
• Doctor Communication
• Pain Management
• Communication about Medications
• Cleanliness and Quietness of Hospital Environment (average of
the 2 rees)
• Responsiveness of Hospital Staff
• Discharge Information
• Overall Rating of Hospital (excludes recommend hospital item)
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 4
Similar Findings Across
HCAHPS Scores
% of satisfaction domain score earned (Achievement Scores Only)
100%
75th Percentile
Nationally
80%
60%
25th Percentile
Nationally
40%
20%
97
96
9
78
39
163
21
180
8
37
19
218
395
33
91
6
47
84
13
66
79
53
240
336
22
48
290
525
32
11
72
43
54
38
61
73
16
34
26
92
60
10
810
179
71
67
29
222
526
274
52
12
2
346
42
15
7
3
56
55
368
291
23
35
5
90
17
14
486
46
1
45
76
214
57
82
236
4
70
234
27
298
388
167
80
77
89
40
58
83
87
49
88
69
299
28
74
345
0%
NOTE: Includes UHC Full Members
Source: CMS Hospital Compare Q2 2009 – Q1 2010 (Apr 09 – Mar 10)
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 5
Total VBP Performance
Scores
% of total VBP performance score earned (Achievement Scores Only)
100%
80%
75th Percentile
Nationally
60%
25th Percentile
Nationally
40%
20%
78
54
395
218
56
96
336
163
38
29
97
6
72
79
32
52
8
14
46
4
17
92
179
67
214
58
47
240
9
37
11
26
43
61
42
80
3
60
10
15
346
12
345
274
5
236
34
84
53
1
13
48
291
45
234
91
74
39
57
810
55
180
33
82
7
70
23
35
486
71
40
167
21
2
526
27
525
89
66
222
388
83
69
368
22
28
87
76
290
19
16
73
49
299
77
88
90
298
0%
Notes: 1) VBP Performance Score determined based on weighted average of clinical process of care score
(70%) and HCAHPS score (30%)
2) Includes UHC Full Members
Source: CMS Hospital Compare Q2 2009 – Q1 2010 (Apr 09 – Mar 10)
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 6
VBP Financial Impact
• Initially, all hospitals will lose 1% of their Medicare
payments (in 2013).
• A hospital’s VBP score determines how much of that 1%
they can earn back.
• Top performers (nationally) have the potential to earn
back their initial 1% and more.
• CMS intends to use a “linear exchange function” to
determine how much each hospital earns back₁
1 CMS has not yet defined the linear exchange function they will employ to determine VBP payments. UHC has modeled
the VBP financial impact under two possible linear exchange scenarios to estimate the financial impact of a
given member’s VBP score (for more details, see ‘Linear Exchange Functions’).
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 7
VBP Financial Impact
1% Medicare Reimbursement at Risk
Scenario 1
High
UHC
Medicare Volume
Medium
25th
Median
75th
Low
Scenario 2
High
Medium
1% Recovered + upside
Low
($3,000,000)
Unrecovered VBP $
($2,000,000)
($1,000,000)
$0
Break-even
$1,000,000
$2,000,000
$3,000,000
Scenario 1: continuous linearity from 0th to 100th percentile
*n = 98
Scenario 2: linearity, 25th - 75th percentiles; max penalty 0-25th percentile; max incentive 75-100th percentile
Medicare Volume Discharge Thresholds: Low < 6,700; Medium 6,700 – 12,000; High < 12,000
*In this analysis, 30 UHC members fully recover their 1% incentive payment and get an additional payment (green = upside payment)
© 2010 University HealthSystem Consortium
$0 on the graphs above indicates that a hospital fully recovers 1% of Medicare payment (break even)
VBP Scores IQ 9-10
8
More Stick Than Carrot
• Performance must be at exceptional levels or demonstrate
remarkable improvement in order to obtain the highest scores
• One failure in a measure with a small sample size can cost
significant points
• AMCs less likely to fall into bottom quartile in core
measures…also less likely to be among top quartile
• Two-thirds of AMCs below median for patient satisfaction . One
in three AMCs in bottom quartile– fewer than 10% make top
quartile
However there are top performers among AMC’s
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 9
9
AMC Focus Identified: UHC’s
Imperatives for Quality
Capacity
Management
Mortality
HospitalAcquired
Conditions
Core Measures /
CAHPS
Cost
Reduction
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 10
10
AMC Opportunities for Improvement
Identified in IQ Program
Core
Measure
UHC
Best Quartile
UHC
Best Decile
National Best
Decile
AMI
98.2%
100.0%
100%%
HF
93.3%
97.1%
99.8%
PN
85.4%*
90.0%
99.3%
SCIP
90.0%
92.6%
99.4%
AMC Opportunities
D2B, Smoking
D/C Instructions
Vaccines, Abx timing
Beta blocker. ABX
dcd, normothermia
“ensure
that members are nationally recognized for
their leadership in safety, quality, and costeffectiveness”
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 11
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IQ Offers Practical Improvement Resources
AMI: Door-to-Balloon
Best Practice
Staff arrival requirement is < 30 minutes
after the initial page (both in-house and
on-call staff)
Best Practice
EKG performed by emergency medical
services triggers emergency department
action
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 12
Traditional Elements of D2B: Parallel Process
Chest Pain
EMS
Transport
Registration
ECG
MD Eval
Int. Cardiol.
STEMI Team
Call for
Pt
PCI
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 13
ST Segment Elevation Myocardial Infarction (STEMI)
UMMHC Process Improvement: 2005-YTD
160
Cardiac Alert Team Initiative Began
Critical Success Factors
- Communication Overhaul
- ED Activation of cath lab
- Real time review of STEMI cases
- Reserved parking for on-call
staff
140
100
(minutes)
Door to Balloon Time
120
80
60
40
20
0
Jan'05
Jun'05
Nov'05
Apr'06
Sep'06
Feb'07
Jul'07
Median
Number of Cases
CY2005: 55
CY2009: 117
CY2006: 62
Mean
CY2007: 89
CY2010: 92
Dec'07
M ay'08
Oct'08
M ar"09
Aug'09
Jan'10
Jun'10
Goal
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 14
CY2008 : 82
Nov"10
Heart Failure Discharge Instructions
Doesn’t Require Sophistication, Just Determination
Measures Required
• Diet
• Activity
• Medications
• What to do if symptoms worsen
• Follow up
• Weight Monitoring
Critical Success Factors
• Redesign discharge form; keep it SIMPLE
• EHR hard stop
• Share unit-based rates
• Share performance with Board of Directors
• Concurrent Review – individual feedback
• Focus on non-compliant areas
• When all else failed – disciplinary action
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 15
Pneumonia: Improving Vaccination Rates
Pneumococcal Vaccine Compliance
Why it works
• Automated admit and transfer out
of ICU order sets were
developed,
• Nurse responsible to screen and
administer the vaccine if the
patient met criteria
• Staff were well-educated on the
new process
• Process is built into the nurses
daily routine
• Performance was an expectation
and became part of the culture
• Screening tool is user-friendly
100%
90%
80%
Vaccine Process
Implemented 4Q 07
70%
60%
50%
1Q06 3Q06 1Q07 4Q07 1Q08 2Q08 3Q08 4Q08 1Q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10
Influenza Vaccine Compliance
100%
90%
80%
Vaccine Process
Implemented 4Q 07
70%
60%
50%
1Q06
4Q06
1Q07
4Q07
1Q08
4Q08
1Q09
4Q09
1Q10
*Compliance rates only collected during flu season (4Q - 1Q)
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 16
SCIP: Multiple Measures Call for
Multidisciplinary Effort
SCIP Process Measures
• SCIP-Inf-1: Prophylactic antibiotic
timing
• SCIP-Inf-2: Prophylactic antibiotic
administration
• SCIP-Inf-3: Prophylactic antibiotic
discontinuation
• SCIP-Inf-4: Post-op Serum Glucose
(Cardiac)
• SCIP-Inf-6: Hair Removal
• SCIP-Inf-7: Post-op Normothermia
(Colorectal)
• SCIP-Card-2: Beta-blocker
administration
• SCIP-VTE-1: VTE Prophylaxis ordered
• SCIP-VTE-2: VTE Prophylaxis
administered
Focused Perioperative Interventions to
Improve Performance
•
Team effort to identify gaps in process
•
Developed tools to improve antibiotic
ordering and dosing (standardized
order sets, signage)
•
Included antibiotic selection in “Time
Out Process,”
•
Improve availability of antibiotics
•
Educated Surgeons, Anesthesia Care
Providers and Nursing: What are the
SCIP measures and why are they
important?
•
Communicated and reinforced desired
behaviors
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 17
Data Distribution and Communication
Helps to Maintain the Gains
•
Viewable on Quality & Patient
Safety Web site
•
Shared at leadership meetings
•
Shared at OR committee,
Anesthesia committee, Quality
and Staff meetings
•
Emailed to Division
Chairs/Chiefs and Residents
•
Displayed in Staff areas
•
Letters and education mailed to
failed case physicians (infection
measures)
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 18
Study of Top HCAHPS Performers
Reveals Critical Success Factors
• Leaders communicate to inform, inspire, and promote healthy
competition
UC San Diego Health System
• Combine commitment to quality and service
Massachusetts General Hospital
• Set goals and work together to achieve success
University of South Alabama Health System
• Customer service is ingrained in the mission and values
Mayo Clinic in Rochester
• Data-driven decisions are critical to the change effort
University of Mississippi Health Care
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 19
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HCAHPS: Combine Commitment to Quality & Service
Massachusetts General Hospital
•
Used QDM data to focus improvement areas:
cleanliness, communications, and responsiveness
•
Incentive program for employed physicians
•
Managerial goals tied to patient experience
•
Wide dissemination of performance data
•
RNs round on each patient hourly
•
Light-duty staff interview patients about satisfaction
“It’s a journey, it takes a village, and it requires taking ownership,
remaining focused on the goals, celebrating what’s working, fixing what’s
broken, communicating and remaining committed to delivering the
highest quality, safest care as defined by patients and their families.”
Richard Corder, Senior Director of Service
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 20
IQ Offers Solutions for
Proposed Measures for FY2014
• Three 30-day Mortality Rates (AMI, HF, Pneumonia)
• 8 Hospital Acquired Conditions (foreign object retained after
surgery, air embolism, blood incompatibility, pressure ulcers III&IV,
falls and trauma, vascular catheter-associated infections, catheterassociated UTIs, manifestations of poor glycemic control)
• 9 AHRQ Patient Safety Indicators (PSIs) and Inpatient Quality
Indicators (IQIs)
•
•
•
•
•
•
•
•
•
Iatrogenic pneumothorax, adult
Post operative respiratory failure
Post operative PE or DVT
Post operative wound dehiscence
Accidental puncture or laceration
Abdominal aortic aneurysm (AAA) repair mortality rate (with or without volume)
Hip fracture mortality rate
Complication/patient safety for selected indicators (composite)
Mortaility for selected medical conditions
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 21
Summary
The demand for quality and safety performance and
transparency is increasing
Pay for performance is here
Great clinical outcomes require reliable data and a culture
of accountability
Be prepared and anticipate the future
© 2010 University HealthSystem Consortium
VBP Scores IQ 9-10 22
22