ACMQ Annual Meeting 2010




Introduction to Quality Improvement
             Donald Fetterolf, MD, MBA, FACP
            ...
Abstract and Learning Objectives

Abstract:
          The American College of Medical Quality is committed to furthering a...
Outline

   Introduction

   Historical perspective

   Designing a Framework for Strategies for
    Quality Management...
Historical
Perspective
The Evolution -- Definitions of Medical Quality

   Many writers borrowed heavily from concurrent activities in
    busin...
Historical Perspective

   Quality has had an evolutionary course that has paralleled similar
    developments in the bus...
First Generation CQI

                 The Era of Inspection


   Physician Credentialing
   Institutional Credentialing...
"QA" Approach



                0.6000




                0.5000




                0.4000
    Frequency




          ...
Second Generation CQI

            The Era of Statistical Quality Control


   Diagnosis-Specific Admissions Variations
...
"QI" Approach


                0.6000




                0.5000




                0.4000
    Frequency




           ...
Third Generation CQI
              The Era of True Outcomes Measures
   Selected Claims-Based Outcomes
   Member Satisfa...
Fourth Generation CQI

                    The Era of Big Management

   Big Systems
      Integrated Care Management De...
Fifth Generation CQI
                The Era of Confusion and Cacophony
    Government Agency Participation
       CMS, ...
External Organizations Concerned about Health Care Quality
                   Governmental                                ...
Theories and Ideas Too!



   CQI
   Six Sigma
   Hoshin Planning
   ISO 9000
   Toyota Production System
   The Int...
Basic Tools in QI Management




                               16
Shewhart Cycle



                                  Plan
        Plan
        Do
        Check/
         Study       Do...
ACMQ Core Curriculum




                       18
Selection Grid




Reference: Morgenstern, p.3-3

19
Seven Helpful Charts

         Flow Chart
         Histograms
         Pareto Charts
         Run (Trend) Charts
     ...
Histograms




             21
Histograms


        “Bar Graphs”
        Show relative amounts of things in a group
        Can show trends over time
...
Histogram




Reference: Core Curriculum

23
Histogram




     Reference: Core Curriculum
24
25
Results of the Study



                    Results of the Study                            Results of the Study

        ...
Pareto Charts




                27
Pareto Charts


        Pareto charts are a type of histogram that
         arranges the bars on the chart from highest t...
Pareto Analysis




     Reference: Core Curriculum
29
Pareto Chart




     Reference: Morgenstern

30
31
Process Flowcharts




                     32
Flow Charts


        Clarify the process
        Identify observation points
        Address
             logical inc...
Process Flowchart




     Reference: Core Curriculum
34
35
Types of Flowcharts


           Process Flowchart
           Interrelationship Diagraphs
           CPM/PERT Charts
  ...
Interrelationship Diagraph




37   Reference: Brassard
Clean up the Mess!


        Look for redundant functions; create simpler models to
         do the task.
        Measur...
CPM/PERT Charts
     (Critical Path Method/Program Evaluation Review Technique)




39
Run Charts and Control Charts




                                40
Run Charts


        “Line charts”
        Used to measure relative changes in a value over time
        Specialized fo...
Run Chart




             80
             70
             60
             50
     Value




             40
             ...
43
Radar Chart



                        Radar Chart

                                 1
                            60
    ...
Shewhart:


        A phenomenon will be said to be controlled when,
        through the use of past experience, we can
  ...
Control Chart




             80
             70
             60
             50
     Value




             40
         ...
Dynamic Chart Terms



        Median position = average; horizontal line
         showing the average value
        Run...
Types of Control Charts


        X-R Average and Range
        XmR Average/Moving Range
            Control=x+/-2.66R
...
Control Chart Concerns


        Number of data points in a run
             Up to 8/5; 9 to 20/6; 21 to 100 /7

      ...
Time Series Analysis Techniques



        Run Chart (Shewart Model)
        Running Average (>6 mo)
        CUSUM Plot...
Cusum Plot




     A Cusum plot allows you to evaluate an important result before it reaches
51                          ...
CUSUM Plot



        Calculate the target mean
        Create running sum of differences of each variable
         from...
CUSUM Plot

                                 $1,500.00

                                 $1,250.00

                      ...
Scatter Diagrams




                   54
Scatter Plots


        Plot two or more variables simultaneously (up to six!)
        Two by two plots usually
       ...
Analysis of Variation
                                                  CV of Paid vs LOS for 90% Impact DRGs

           ...
Linear Regression


        Creates a line from a series of data in a scatter plot.
        The sum of the squared diffe...
Other Regression Things


        Correlation -- R2 or R value or Pearson Correlation
         Coefficient. R2 close to 1...
Cause and Effect Diagrams




                            59
Ishikawa (“Fishbone”) Cause and Effect
                Diagram: PT Referral Costs

               Environment             ...
Wishbone Diagram




                                  Reference:
                                        Core
           ...
CQI: Closing the Loop




                        62
Is That Really All There is to It?


   Formal programs for organizing the use of quality tools
    exist.

   “Continuo...
DMAIC Problem-Solving Model


     DMAIC equals Define, Measure, Analyze, Improve and
       Control.
      Step 1 - Defi...
Clinical Study Format


        Problem identification
        Determine the guidelines
        Establish the criteria
...
Six Sigma

   Six Sigma is a business management strategy, initially
    implemented by Motorola, that today enjoys wides...
LEAN

   Lean manufacturing or lean production, which is often known
    simply as "Lean", is a production practice that ...
MAKING THE BUSINESS CASE FOR HEALTHCARE
QUALITY IMPROVEMENT




                                          68
The Issue: Making the Business Case

Making the business case to someone or some entity that you
should be paid for your ...
Introduction: Case Study
The CEO of your company has made friends with the Vice President of
marketing of a national compa...
Wisdom from CMO’s:
    Stay Focused on the Important Stuff



   Lower/maintain PMPM costs for your clients
   Reduce ad...
The Business Case for Medical Quality
    Components of the Business Case for a QI Unit

   Government mandates
        ...
Conclusions and Summary


        The basic ingredients of a good quality program
         have not changed much over 20 ...
Questions?




             References on Next Slides
References
Basic References on Medical Quality
   American Journal of Medical Quality
   Carey, R. and Lloyd, R.. Measuring Quality...
Bibliography – Additional Reading
--Baker, Judith. Activity-Based Costing and Activity-Based Management for Health Care.
A...
Bibliography
--Fetterolf, D. and West, R. “The Business Case for Quality: Combining Medical Literature
Research with Healt...
Bibliography

--Luehrman, T. "What’s It Worth? A General Manager’s Guide to Valuation." Harvard
  Business Review. May-Jun...
Slide Set Information


    Author: Don Fetterolf, MD, MBA, FACP
             Fetterolf Healthcare Consulting
          ...
100217 ACMQ Intro to QI
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100217 ACMQ Intro to QI

  1. 1. ACMQ Annual Meeting 2010 Introduction to Quality Improvement Donald Fetterolf, MD, MBA, FACP President, American College of Medical Quality
  2. 2. Abstract and Learning Objectives Abstract: The American College of Medical Quality is committed to furthering a basic understanding of how to advance the quality of medicine using well established tools and techniques for continuous quality improvement. In this lecture, we will present an overview of basic tools used in the field, including an overview of the history of continuous quality improvement, basic techniques piloted by Deming, and some more advanced tools and their use in a medical management setting. The presentation would be a good introduction for students, medical directors new to QI analysis and similar individuals. Learning Objectives:  The listener will develop an appreciation for the unfolding history of the field of medical quality management.  The listener will become familiar with basic tools used in creating an approach to continuous quality improvement.  The group will collectively consider application of more advanced tools in the medical management setting.  The group will generally discuss common issues and experiences in the use of these tools and lessons learned. 1
  3. 3. Outline  Introduction  Historical perspective  Designing a Framework for Strategies for Quality Management  Making the business case for medical quality  References 2
  4. 4. Historical Perspective
  5. 5. The Evolution -- Definitions of Medical Quality  Many writers borrowed heavily from concurrent activities in business, engineering and statistical quality control programs in manufacturing.  Shewhart - Bell Labs 1920’s & 30’s  Deming/Juran - Industrial Quality Management Systems - CQI/TQM and the movement from QA to QI.  Crosby -- Conformance to requirements  Donabedian – Early basic thinking in medical QI  Couch – Quality = The attribute of a product, service, or outcome that is the extent to which achievable value is actually achieved. Value is usually defined in terms of consumer expectations, whether explicit (i.e. wants), or implicit (i.e. needs)  Eddy – Attributes of quality indicators and HEDIS  Berwick – Institute for Healthcare Improvement (IHI) Provider participation, continuous improvement. The IOM report.  Six Sigma, Toyota Production System, ISO9000 and others 4  ACMQ – Core Curriculum for Medical Quality Management
  6. 6. Historical Perspective  Quality has had an evolutionary course that has paralleled similar developments in the business world. The relationship to the business world and business thinking is important:  Stage 1: Quality Assurance, The Era of Inspection  CPCs, sentinel event monitoring, outlier review, inspection  Stage 2: Statistical Quality Control and CQI  Deming tools, control charts, multivariate normal distributions  Stage 3: Outcomes Focused Analysis  Prevention, functional status, patients perceptions,  Stage 4: Big Management  Rise of the QI bureaucracy: NCQA, JCAHO, URAC, CMS  Stage 5: Fluid Change, a Cacophony of Quality 5
  7. 7. First Generation CQI The Era of Inspection  Physician Credentialing  Institutional Credentialing  Procedure Specific Credentialing  UM/QI Process Adequacy  Technology Assessment Process Adequacy  Adverse Occurrence Monitoring  Sentinel Event Monitoring  External Accreditation Questions answered: Did the horse get out of the barn? Who left the barn door open? 6
  8. 8. "QA" Approach 0.6000 0.5000 0.4000 Frequency 0.3000 Focus 0.2000 0.1000 0.0000 3 0 3 9 3 7 4 1 8 5 2 9 6 3 3 6 9 2 5 8 1 4 7 3 3. 3. 2. 2. 2. 1. 1. 1. 0. 0. 0. 0. 0. 0. 1. 1. 1. 2. 2. 2. 3. STD “Good” Scores “Bad” Scores 7
  9. 9. Second Generation CQI The Era of Statistical Quality Control  Diagnosis-Specific Admissions Variations  Targeted Surgical Variations  Targeted Ambulatory Surgery Variations  Physician Statistical cost/mortality profiling  Pharmaceutical Profiling Questions Answered: How many horses get out per year? Can we make repeated door structural changes to reduce the number of escapes over time? 8
  10. 10. "QI" Approach 0.6000 0.5000 0.4000 Frequency 0.3000 0.2000 0.1000 0.0000 3 0 3 9 3 7 4 1 8 5 2 9 6 3 3 6 9 2 5 8 1 4 7 3 3. 3. 2. 2. 2. 1. 1. 1. 0. 0. 0. 0. 0. 0. 1. 1. 1. 2. 2. 2. 3. STD “Good” Scores “Bad” Scores 9
  11. 11. Third Generation CQI The Era of True Outcomes Measures  Selected Claims-Based Outcomes  Member Satisfaction/Perception of Health  Clinical Outcomes Measures  Disease Specific Patient Perceptions  Linkage to Disability/Absenteeism  Life Event Risk Intervention Analysis  Conventional Medical Outcomes  Social - small area analysis Dartmouth Study  Functional Status and Well Being  Health Risk Appraisal  Cost Effectiveness Analysis (CEA) Questions Answered: Can we reduce the reasons why the horse would want to leave the barn and instead want to stay and work for me? 10
  12. 12. Fourth Generation CQI The Era of Big Management  Big Systems  Integrated Care Management Delivery Systems  Multispecialty Group Practice  PHO, PHCO, IPA, CHIN, and Others  New Methods, Tools, and Concepts  “Data Driven” Information Systems  Statistical Quality Control - Shifting the Bell Curve  Comparing Across Plans, Hospitals, Companies and Individuals  Best Practice Analysis Questions Answered: If we hire consultants and build big farm coops, will fewer horses escape? Can data mining and predictive modeling reduce the number of horse escapes? 11
  13. 13. Fifth Generation CQI The Era of Confusion and Cacophony  Government Agency Participation  CMS, AHRQ, State DOH, State DOI  Pseudo-governmental Participation  NQF, IOM, PROs, QIOs  Accreditation Bureaucracies  JCAHO, URAC, NCQA, AAAHC  Integrated Care Management Delivery Systems  PHO, PHCO, IPA, CHIN, and Others  Health plans, HMOs, Group practice.  Other Players  Consultants  Accenturisms -- Buzzwords and Buzzwords for The Next Big Thing  P4P, Transparency, Accountable Networks, EMR, Medical Home Question: Our system of evaluation for accountable providers transparently creates acceptable deliverables to reduce equine elopement. 12
  14. 14. External Organizations Concerned about Health Care Quality Governmental Business  Centers for Medicare and Medicaid Services  Business Health Care and Purchasing Coalitions (CMS)  Washington Business Group on Health  Peer review organizations (“PROs”)  Pacific Business Group on Health  Quality Improvement Organizations (“QIOs”)  Leapfrog Group  State departments of health and insurance  Local business groups and councils  State health care cost control councils  Regional employer coalitions  Centers for Disease Control  Tech councils  National Business Coalition on Health Accreditation  Drug companies and their spin off organizations  National Committee for Quality Assurance (NCQA); includes use of Health Plan Employer Others Data Information Set (HEDIS) and Consumer Assessment of Health Plans Survey (CAHPS)  Americas Health Insurance Plans (AHIP) tools  Blue/Cross Blue Shield Association (BCBSA) and  Joint Commission for the Accreditation of the TEC Healthcare Organizations (JCAHO)  American Board of XYZ  American Accreditation Healthcare Commission  Council for Affordable Quality Healthcare (CAQH) (“URAC”)  Doctors Office Quality Project (DOQ)  Accreditation Association for Ambulatory  Institute of Medicine (IOM) Health Care (AAAHC)  National Quality Forum (NQF)  Organized medical associations (e.g. AMA)  Professional organizations (e.g., American Heart Association) and Specialty societies  The BIG UNIVERSITY “experts”  Benefit management consultant “experts” Question: How much money is being spent on the development and delivery of the medical quality initiatives that are present or being planned for the future? How much will you need to know about business in quality? 13
  15. 15. Theories and Ideas Too!  CQI  Six Sigma  Hoshin Planning  ISO 9000  Toyota Production System  The Intergalactic Business Group on Health’s RFP Analytic Quality Statistic Takeaway point: The language of business is pervasive in the language of medical quality. 14
  16. 16. Basic Tools in QI Management 16
  17. 17. Shewhart Cycle Plan  Plan  Do  Check/ Study Do Continuous Act Improvement  Act Study 17
  18. 18. ACMQ Core Curriculum 18
  19. 19. Selection Grid Reference: Morgenstern, p.3-3 19
  20. 20. Seven Helpful Charts  Flow Chart  Histograms  Pareto Charts  Run (Trend) Charts  Control Charts  Scatter Diagrams  Cause and Effect Diagrams Reference: Walton 20
  21. 21. Histograms 21
  22. 22. Histograms  “Bar Graphs”  Show relative amounts of things in a group  Can show trends over time  Special forms: Pareto charts 22
  23. 23. Histogram Reference: Core Curriculum 23
  24. 24. Histogram Reference: Core Curriculum 24
  25. 25. 25
  26. 26. Results of the Study Results of the Study Results of the Study 183 200 182 181 150 180 Result Result 179 Series1 Series1 100 178 Series2 Series2 177 50 176 175 174 0 Result Result Period Period 26
  27. 27. Pareto Charts 27
  28. 28. Pareto Charts  Pareto charts are a type of histogram that arranges the bars on the chart from highest to lowest value.  The focus then in QI processes is to concentrate on the highest sources of an issue first and eliminate them as problems.  A concurrent line often shows an accumulated total for each subsequent bar in the graph, reflecting total cumulative impact. 28
  29. 29. Pareto Analysis Reference: Core Curriculum 29
  30. 30. Pareto Chart Reference: Morgenstern 30
  31. 31. 31
  32. 32. Process Flowcharts 32
  33. 33. Flow Charts  Clarify the process  Identify observation points  Address  logical inconsistencies  redundancy  timing 33
  34. 34. Process Flowchart Reference: Core Curriculum 34
  35. 35. 35
  36. 36. Types of Flowcharts  Process Flowchart  Interrelationship Diagraphs  CPM/PERT Charts  Affinity Diagrams  Activity Network Diagram  Process Decision Program Chart  Others 36 Reference: Brassard, and others
  37. 37. Interrelationship Diagraph 37 Reference: Brassard
  38. 38. Clean up the Mess!  Look for redundant functions; create simpler models to do the task.  Measure each step for efficiency improvement and possible error reduction.  Redesign the program to reduce the number of nodes and handoffs 38
  39. 39. CPM/PERT Charts (Critical Path Method/Program Evaluation Review Technique) 39
  40. 40. Run Charts and Control Charts 40
  41. 41. Run Charts  “Line charts”  Used to measure relative changes in a value over time  Specialized forms for more sophisticated analyses 41
  42. 42. Run Chart 80 70 60 50 Value 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Month 42
  43. 43. 43
  44. 44. Radar Chart Radar Chart 1 60 12 2 40 11 3 20 10 0 4 9 5 8 6 7 44
  45. 45. Shewhart: A phenomenon will be said to be controlled when, through the use of past experience, we can predict, at least within limits, how the phenomenon may be expected to vary in the future. Here it is understood that prediction within limits means that we can state, at least approximately, the probability that the observed phenomenon will fall with the given limits…” Reference: Montgomery 45
  46. 46. Control Chart 80 70 60 50 Value 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Month 46
  47. 47. Dynamic Chart Terms  Median position = average; horizontal line showing the average value  Run = two or more consecutive data points on the same side of the median  Upper control limit, lower control limit = limiting horizontal lines drawn above and below the median, which show the limits of where the system is “in control” or “out of control” 47
  48. 48. Types of Control Charts  X-R Average and Range  XmR Average/Moving Range  Control=x+/-2.66R  p-Chart Control=p+/-3 √p(1-p)/n  p=defects/total occurrences  c-Chart Control=c+/-3 √c  c=number of defects/total observations  u-Chart Control=u+/-3 √u/n  u=defects for all subgroups/total observations in all subgroups 48 Reference: Carey and Lloyd
  49. 49. Control Chart Concerns  Number of data points in a run  Up to 8/5; 9 to 20/6; 21 to 100 /7  Too few or too many runs?  Run = 2+ data points on one side of median  Trends  Zig Zag or “sawtooth” patterns  Normal vs special cause variations  Bell curve on the side  Divide control chart into zones of concern - action limits vs warning limits Reference: Carey and Lloyd. 49
  50. 50. Time Series Analysis Techniques  Run Chart (Shewart Model)  Running Average (>6 mo)  CUSUM Plot (sensitive to small changes in σ  Exponentially Weighted Moving Average (EWMA) Current items weighted more.  Autoregressive integrated moving average model (ARIMA), when series are autocorrelated. 50
  51. 51. Cusum Plot A Cusum plot allows you to evaluate an important result before it reaches 51 statistical significance!
  52. 52. CUSUM Plot  Calculate the target mean  Create running sum of differences of each variable from the mean  Note upper and lower control limit formulas exist C = Σ(xi-avg) 52
  53. 53. CUSUM Plot $1,500.00 $1,250.00 $1,000.00 $750.00 $500.00 $250.00 CUSUM cf 12 Month Average $0.00 -12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 ($250.00) ($500.00) ($750.00) ($1,000.00) ($1,250.00) ($1,500.00) ($1,750.00) ($2,000.00) ($2,250.00) ($2,500.00) ($2,750.00) ($3,000.00) Month 53
  54. 54. Scatter Diagrams 54
  55. 55. Scatter Plots  Plot two or more variables simultaneously (up to six!)  Two by two plots usually  Association testing  Correlation coefficient calculations 55
  56. 56. Analysis of Variation CV of Paid vs LOS for 90% Impact DRGs 2.50 I 2.00 1.50 III C.V. LOS Series1 1.00 0.50 IV II 0.00 0.00 0.50 1.00 1.50 2.00 2.50 C.V. Paid 56 Reference: ACPM Presentation 2/2003
  57. 57. Linear Regression  Creates a line from a series of data in a scatter plot.  The sum of the squared differences of each data point from the line is minimized.  It is possible to have more than two variables (multiple regression)  It is also possible not to be linear (nonlinear regression) 57
  58. 58. Other Regression Things  Correlation -- R2 or R value or Pearson Correlation Coefficient. R2 close to 1 shows high correlation.  Autocorrelation -- Durbin Watson Statistic -- 0 - 2 - 4 scale  Forecasting by extrapolation  lagged variables, cycles, etc.  exponential smoothing  software Forecast Pro for Windows 58
  59. 59. Cause and Effect Diagrams 59
  60. 60. Ishikawa (“Fishbone”) Cause and Effect Diagram: PT Referral Costs Environment Equipment High Profit Equipment costs Low prior control In house expenses Benefit design Medical policy Elevated Referral Costs Staff do referrals Specialists Open ended referrals Physical therapists No guidelines PCPs No feedback Greed, personal gain Procedures People 60 Reference: Carey and Lloyd
  61. 61. Wishbone Diagram Reference: Core Curriculum 61 Reference: Core Curriculum
  62. 62. CQI: Closing the Loop 62
  63. 63. Is That Really All There is to It?  Formal programs for organizing the use of quality tools exist.  “Continuout Quality Improvement”  Six Sigma  Lean Six Sigma  Toyota Production System  ISO 9000; ISO 9001 63
  64. 64. DMAIC Problem-Solving Model DMAIC equals Define, Measure, Analyze, Improve and Control.  Step 1 - Define the problem.  Step 2 - Measure.  Step 3 - Analyze.  Step 4 - Improve.  Step 5 - Control. 64
  65. 65. Clinical Study Format  Problem identification  Determine the guidelines  Establish the criteria  Design the study  (population, sample, data collection techniques)  Data analysis  Identify deficiencies  Develop recommendations for problem resolution  Feedback to appropriate providers, depts, committees, individuals  Reevaluate problem to determine if corrective actions have been implemented/problem resolution occurred Thanks to: NCQA 65
  66. 66. Six Sigma  Six Sigma is a business management strategy, initially implemented by Motorola, that today enjoys widespread application in many sectors of industry.  Six Sigma seeks to improve the quality of process outputs by identifying and removing the causes of defects (errors) and variation in manufacturing and business processes.[1] It uses a set of quality management methods, including statistical methods, and creates a special infrastructure of people within the organization ("Black Belts","Green Belts", etc.) who are experts in these methods.[1] Each Six Sigma project carried out within an organization follows a defined sequence of steps and has quantified financial targets (cost reduction or profit increase).[1] Reference: Wikipedia, accessed July, 2009 66
  67. 67. LEAN  Lean manufacturing or lean production, which is often known simply as "Lean", is a production practice that considers the expenditure of resources for any goal other than the creation of value for the end customer to be wasteful, and thus a target for elimination. Working from the perspective of the customer who consumes a product or service, "value" is defined as any action or process that a customer would be willing to pay for. Basically, lean is centered around creating more value with less work. Lean manufacturing is a generic process management philosophy derived mostly from the Toyota Production System (TPS) (hence the term Toyotism is also prevalent) and identified as "Lean" only in the 1990s.[ Reference: Wikipedia, accessed July, 2009 67
  68. 68. MAKING THE BUSINESS CASE FOR HEALTHCARE QUALITY IMPROVEMENT 68
  69. 69. The Issue: Making the Business Case Making the business case to someone or some entity that you should be paid for your valuable services is difficult for anyone. Money is tight everywhere. You were trained as a clinician, not a business person. So, how do you put a price on quality or clinical improvement? What is the strategy to convince a potential nonclinical payer of diabetic education services that they are worth it? Do your services create a “value proposition” for your services? How do you construct the approach and the arguments for the government, health plans and clinics that create a compelling case in your favor in the mind of a business person? 69
  70. 70. Introduction: Case Study The CEO of your company has made friends with the Vice President of marketing of a national company that claims that it can provide [what your area does] effectively using a cool web based tool his company has designed. The two have gone golfing, have had dinner together, and have had several “high-level” discussions about having the vendor replace your program staff with the vendor's web site. Two of your organization’s senior vice presidents, in totally unrelated areas and who have no knowledge of clinical issues, think the proposal might be a viable option. The vendor claims that he can give your company an “8 to1 return on investment,” and will ”guarantee” it. You are now approached by the CEO, who admits that he might dissolve your area, but offers to give you 20 minutes to talk him out of it. He is interested in the value/return that you get now. What do you tell him? Your answer should address both an analytic approach and recognition of the various political factors that may influence your choices. 70 Paraphrased and restated from Fetterolf, AJMQ Jan/Feb 2003.
  71. 71. Wisdom from CMO’s: Stay Focused on the Important Stuff  Lower/maintain PMPM costs for your clients  Reduce administrative overhead  Generate more revenue  Measurably improve patient care quality  Improve relationships with business contacts – “co- opetition”  Have real impact, not inconsequential activities 71
  72. 72. The Business Case for Medical Quality Components of the Business Case for a QI Unit  Government mandates  Basically, you have to…  Demands by the payer/business/consultant community  Financial effect  Lower quality is more expensive  Logical requirements for quality oversight  Demands of business partners  Trade off between value of accreditation and lower costs  Estimated economic impact from econometric attempts  NCQA Quality dividend calculator  Social goals 72
  73. 73. Conclusions and Summary  The basic ingredients of a good quality program have not changed much over 20 years.  People still need to use them however.  From simple charts to complex analyses, QI will continue to make things better wherever it is applied. 73
  74. 74. Questions? References on Next Slides
  75. 75. References
  76. 76. Basic References on Medical Quality  American Journal of Medical Quality  Carey, R. and Lloyd, R.. Measuring Quality Improvement in Healthcare. New York. Quality Resources. 1995. An old but great reference. Lots of terms and a standardized approach.  Couch, JB. Health Care Quality Management for the 21st Century. Tampa, FL. Hillsboro Printing Co for the American College of Physician Executives. 1991. The last really good book on the subject before the ACMQ one.  Dlugacz, Yosef. Measuring Health Care. Jossey Bass.2006  Langley, G. et. al.. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Josey-Bass Publishers. 1996.  McLaughlin, C. and Kaluzny, A. "Continuous Quality Improvement in Healthcare." 1999. This is a college type textbook.  Nash, D and Goldfarb, N (Ed) "The Quality Solution: The Stakeholder's Guide to Improving Health Care." 2006. A solid reference also.  Varkey, P. Ed.. Medical Quality Management: Theory and Practice. Boston, MA. Jones and Bartlett Publishers. 2009. ACMQ just published. 76
  77. 77. Bibliography – Additional Reading --Baker, Judith. Activity-Based Costing and Activity-Based Management for Health Care. Aspen Publishers. 1998. --Berwick, D. Curing Health Care. New Strategies for Quality Improvement. San Francisco. Jossey-Bass. 1990. --Blissenbach, H. "Use of Cost-Consequence Models in Managed Care." Pharmacotherapy. (15)5. 1995. pp. 59s-61s. --Carey, R. and Lloyd, R. Measuring Quality Improvement in Healthcare. New York. Quality Resources. 1995. --Corrigan, J.; Greiner, A.; and Erickson, S. "Fostering Rapid Advances in Health Care: Learning from System Demonstrations." 2002. --Coddington, D. Making Integrated Health Care Work. Center for Research in Ambulatory Health Care Administration. Englewood, CO. 1996. --Couch, JB. Health Care Quality Management for the 21st Century. Tampa, FL. Hillsboro Printing Co for the American College of Physician Executives. 1991. --Crosby, P. Quality is Free. New York. New American Library. 1979. --Crosby, P. Quality Without Tears. New York. McGraw Hill Book Company. 1984. --Donabedian, A. Explorations in Quality Assessment and Monitoring. Volume II. The Criteria and Standards of Quality. Health Administration Press. Ann Arbor. 1982. --Drummond, M. and McGuire, A. Economic Evaluation in Health Care. Merging Theory with Practice. Oxford University Press. 2001. --Drummond, M., O'Brien, B., Stoddart, G. and Torrance, G. Methods for the Evaluation of Health Care Programmes, 2nd Ed.. New York. Oxford Medical Publications. 1998. --Fetterolf, D. "Commentary: Presenting the Value of Medical Quality to Nonclinical Senior Management and Boards of Directors." American Journal of Medical Quality. (18)1. Jan/Feb 2003. pp. 10-14. 77
  78. 78. Bibliography --Fetterolf, D. and West, R. “The Business Case for Quality: Combining Medical Literature Research with Health Plan Data to Establish Value for Non-Clinical Managers.” American Journal of Medical Quality. (19)2. March/April 2004. pp. 48-55. --Gafni, A. "Willingness to Pay in the Context of an Economic Evaluation of Healthcare Programs: Theory and Practice." Am. J. Man. Care. (3(suppl))S21-S32. 1997. --Galvin, R. "The Business Case for Quality. Developing a business case for quality will require a deliberate approach, with all economic parties at the table.." Health Affairs. Nov/Dec 2001. pp. 57- 58. --Gladowski,P., Fetterolf, D, Beals, S., Holleran, MK, and Reich, S. “Analysis of a Large Cohort of HMO Patients with Congestive Heart Failure.” American Journal of Medical Quality. (18)2 April 2003. --Gold, M. et. al. Cost Effectiveness in Health and Medicine. (Report of the U.S. Public Health Service Panel on Cost Effectiveness in Health and Medicine.). Oxford University Press. 1996. --Haddix, A., Teutsch, S., Shaffer, P. et al. Prevention Effectiveness: A Guide to Decision Analysis and Economic Evaluation. New York/Oxford. Oxford University Press. 1996. --Hubbell, W. "Combining Economic Value Added and Activity Based Management." Journal of Cost Management. Spring 1996. pp. 18-29. --Kohn, L., Corrigan, J., and Donaldson, M.. To Err Is Human - Building a Safer Health System. Washington, DC. National Academy Press. 1999. pp. 1-13. 78
  79. 79. Bibliography --Luehrman, T. "What’s It Worth? A General Manager’s Guide to Valuation." Harvard Business Review. May-June 1997. pp. 132-142. --Millenson, M. America's Health Care Challenge: Rising Costs. A report commissioned by the American Association of Health Plans. Washington, DC. AAHP. 1/22/2002. --National Academy of Sciences "Priority Areas for National Action: Transforming Health Care Quality 2003." 2003. --NCQA. The Business Case for Health Care Quality. 2002. -- Santerre, R. and Neun, S. Health Economics: Theories, Insights, and Industry Studies. Irwin. Chicago. 1996. --Stephens, K. et al. "What is Economic Value Added? A practitioner's view. (corporate performance measure)." Business Credit. (99)4. pp. 39(4). --Torrance, G. "Preferences for Health Outcomes and Cost-Utility Analysis." The American Journal of Managed Care. (3(Suppl)). 1997. pp. S8-S20. --Walton, M. The Deming Management Method. New York, NY. Perigee Books. 1986. --Weinstein, M., Siegel, J., et al. "Recommendations of the Panel on Cost-Effectiveness in Health and Medicine." JAMA. (276)15. October 16, 1996. pp. 1253-1258.Wessels, WJ. Economics. Second Edition 1993. --Wessels, WJ. Economics. Barron’s Business Review Series. New York. 1993. 79
  80. 80. Slide Set Information  Author: Don Fetterolf, MD, MBA, FACP  Fetterolf Healthcare Consulting  Phone: 412-638-2891  Email: donfetterolf@gmail.com  filename: 100217 ACMQ QI v1.ppt  date: February, 2010.  date of this printout: February 21, 2010 80
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