Turbo Charging Quality

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Turbo Charging Quality

  1. 1. Data Transparency<br />Evidence-Based<br /> Medicine<br />Pay for Performance<br />TurboCharging Quality 2011<br />Steven M. Berkowitz, MD<br />Chief Medical Officer<br />St. David’s HealthCare<br />Austin, Texas<br />512-415-6095<br />Steve.berkowitz@stdavids.com<br />
  2. 2. Data Transparency<br />Evidence-Based<br /> Medicine<br />Pay for Performance<br />TurboCharging Quality 2011<br />Despite whatever happens, or does NOT happen in Washington<br />Steven M. Berkowitz, MD<br />Chief Medical Officer<br />St. David’s HealthCare<br />Austin, Texas<br />512-415-6095<br />Steve.berkowitz@stdavids.com<br />
  3. 3. What can we Learn from the Airline Industry ?<br />Today’s Pilots <br /> A nice, boring flight !!<br /> MUCH safer !!<br />HIGH reliance on systems and multidisciplinary<br />support<br />
  4. 4. The Health Care Team<br />Medicine is a Team effort….<br /> …..Why do we insist on playing Solo!<br />
  5. 5. What is Quality in Health Care?<br />In health care, quality is assumed*<br />* Furthermore, it is assumed to be perfect and uniform<br />There is no consistent definition of quality*<br />* Quality means different things to different customers<br />
  6. 6. Quality in Health Care is Questioned:<br />Our Friends in the Media !<br />
  7. 7. Quality in Health Care is Questioned:<br />The Medical Literature- 1999<br />
  8. 8. Quality in Health Care is Questioned:<br />The Medical Literature- 2006 We are Still Not There<br />Asch, et al, NEJM , 2006<br />Everyone gets equally mediocre healthcare- only 54.9% get recommended care<br />“Problems with the quality of care are indeed <br />widespread and require a system-wide approach.”<br />
  9. 9. The Quality Wave 2008- 2009 What Have We Seen:<br />Quality is improving faster than ever <br /><ul><li>Consumer scrutiny of data- the rise of DataTransparency</li></ul>Many effective quality initiatives have been determined<br /><ul><li>Implement known Evidence-BasedPractices</li></ul>Payors are willing to PayforPerformance<br /><ul><li>Medicare, Managed Care Organizations</li></li></ul><li>Data Transparency<br />Evidence-Based<br /> Medicine<br />Turbo-Charging Quality !!<br />Pay for Performance<br />Or… The New Quality Improvement EngineFor Health Care<br />
  10. 10. Data Transparency<br />Evidence-Based<br /> Medicine<br />Turbo-Charging Quality !!<br />Pay for Performance<br />Or… The New Quality Improvement EngineFor Health Care<br />
  11. 11. Read all about it !!<br />April 2005<br />Data Transparency<br />
  12. 12. Pennsylvania<br /> Coronary Artery Bypass Surgery<br />2006 - 2007<br /> Released: August 2009<br />Data Transparency<br />
  13. 13.
  14. 14. Use of Public Performance ReportsA Survey of Patients Undergoing Cardiac SurgerySchneider, JAMA May 27, 1998<br />58% of patients probably or definitely would change surgeons if their doctor had a higher than expected mortality rate the previous year<br />1% knew the rating of their surgeon<br />Data Transparency<br />
  15. 15. CABG Mortality in Pennsylvania Results !<br />Data Transparency<br />
  16. 16. The New York State CABG ExperienceChassin, Health Affairs, 2002<br />41% reduction in mortality in first four years<br />Mortality higher in facilities with low volumes<br />Reduction in hospitals doing CABG<br />Reduction in physicians performing procedures<br />27 surgeons ceased operations in NY<br /> Their combined mortality was 11.9% <br /> ( NY stateaverage 3.1% )<br />
  17. 17. Wisconsin<br />QualityCounts<br />Report on the Safety<br />of Hospital Care<br />Released January 2003<br />Data Transparency<br />
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  19. 19. The Wisconsin Experience:<br />That which is measured, tends to improve.<br />That which is measured publicly, tends to improvefaster.<br />“What we concluded was that even when hospitals know their performance is not good, that's not sufficient motivation for them to do something. Making it public made a big difference in motivating them to improve.” <br />Julie Hibbard, Health Affairs 2003<br />Data Transparency<br />
  20. 20. Core Measures:<br /> Heart Attack<br /> Heart Failure<br />Pneumonia<br /> Surgical Care Improvement<br /> HCAHPS<br />Data Transparency<br />
  21. 21. All CMS Core Measures- 90th Percentile<br />
  22. 22. Goal:<br /> 100% Compliance !!<br />Core Measures:<br /> Heart Attack<br /> Heart Failure<br />Pneumonia<br /> Surgical Care Improvement<br /> HCAHPS<br />Data Transparency<br />
  23. 23. Core Measures:<br /> Heart Attack<br /> Heart Failure<br />Pneumonia<br /> Surgical Care Improvement<br /> HCAHPS<br />Standard of Care ? !!<br />Data Transparency<br />
  24. 24. The Challenge of HCAHPS Scores and Facility Size<br />
  25. 25. The Challenge of HCAHPS Scores and Facility Size<br />
  26. 26. Knowledge of the Existence of the CMS Hospital Compare Website<br />Kaiser Family Foundation, October 2008<br />
  27. 27. How Consumers Define Quality2007<br />Thomson Healthcare, 2006 HealthView Plus<br />
  28. 28. How Consumers Obtain Information1999 -2006<br />Solucient/ Thompson HealthCare<br />
  29. 29. Exposure to and Use of Quality InformationPercent Who Saw and Acted Upon the InformationChoice of Hospitals<br />Kaiser Family Foundation, October 2008<br />
  30. 30. If the other guy’s getting better, then you’d better be getting better faster than that other guy’s getting better…<br /> …Or you’re getting worse. <br /> Tom Peters<br />Data Transparency<br />
  31. 31. Data Transparency<br />Evidence-Based<br /> Medicine<br />Turbo-Charging Quality !!<br />Pay for Performance<br />Or… The New Quality Improvement EngineFor Health Care<br />
  32. 32. What Can we Learn from the Airline Industry?GuidelinesandChecklists<br />
  33. 33. Our Greatest Challenge in Clinical Medicine<br />Eliminate the “DEADLY” Delay !!<br />
  34. 34. The Deadly Delay…From Clinical Trials to Clinical Practice…<br />
  35. 35. Core Measures:<br /> Acute Myocardial Infarction <br /> Heart Failure<br /> Pneumonia<br />Surgical Care Improvement<br /> HCAHPS <br />
  36. 36. Core Measures:<br /> Acute Myocardial Infarction <br /> Heart Failure<br /> Pneumonia<br />Surgical Care Improvement<br /> HCAHPS <br />
  37. 37. Beta-Blocker for Acute MI<br />The Evidence is Published<br />29 Years Ago !!<br />
  38. 38. Find the Happy Medium:Previously “accepted” practices currently Not Recommended<br />Aggressive surgery for early breast cancer<br />Hormone replacement for post-menopausal women<br />Vioxx for pain and inflammation<br />Drug eluting stents in off-label indications<br />Not too fast....<br />
  39. 39. Where Do We Find the Best Practices ?Examine Your Own Specialty Literature<br />
  40. 40. Guidelines for Guidelines<br />There will be MORE guidelines in clinical medicine<br />Guidelines wereNEVERintended to apply to all patients and do NOT take the place of individual physician judgment<br />Expect physicians to occasionally deviate from guidelines in the daily practice of prudent medical care<br /> When so… <br /> … DOCUMENTIn the medical recordthat:<br /> The patient was seen and evaluated <br /> The options were thoughtfully considered<br /> The best clinical judgment was used <br /> Discussed with the patient<br />
  41. 41. What Can we Learn from the Airline Industry ?<br />Guidelines<br />“In airline literature regarding protocol development, <br />the eliminationofambiguity is consistently cited <br />as a key factor in protocol success and safety”<br />Degani and Weiner 1993<br />In contrast, most medical guidelines are based upon ambiguity as a guiding principle of protocol development<br />
  42. 42. Example:Oxytocin Treatment GuidelinesACOG 2006 Compendium<br />“Any of the low or high dose regimens <br /> outlined in table 2 are appropriate” <br />(0.5 – 6 mU/min every 15-40 min)<br />“Each hospital’s OB/Gyn department should develop guidelines for preparation and administration of oxytocin”<br />“The uterine contractions and fetal heart rate should be monitored closely”<br />Evidence-Based <br />Medicine<br />
  43. 43. Example:Postdates GuidelinesACOG 2006 Compendium<br />“ Women with post-term gestations who<br /> have unfavorable cervices can either <br /> undergo labor induction or be managed expectantly”<br />“Delivery should be effected if there is evidence of fetal compromise….”<br />Evidence-Based <br />Medicine<br />
  44. 44. How to Land a 747 in a Strong Cross Wind**(Had It Been Written by ACOG)<br /><ul><li>Use any settings of the plane’s </li></ul> instruments you feel like<br /><ul><li> Every airline and pilot can do it </li></ul>differently<br /><ul><li> Be really careful as you get close to</li></ul> the ground Steve Clark, MD<br />
  45. 45. Do Guidelines Help or Hurt?<br />“Yeah, but Pilots do not have to worry about Malpractice Suits”<br />Obstetrician, Texas<br />
  46. 46. Adverse <br />Outcomes<br />Adverse <br />Outcomes<br />protocols<br />Do Guidelines Help or Hurt?<br />We keep missing the point…..<br /> Simply put…<br />Evidence-based Guidelines reduce adverse outcomes!<br />Evidence-based Guidelines improve patient care !<br />Evidence-Based <br />Medicine<br />
  47. 47. Data Transparency<br />Evidence-Based<br /> Medicine<br />Turbo-Charging Quality !!<br />Pay for Performance<br />Or… The New Quality Improvement EngineFor Health Care<br />
  48. 48. Number of Pay for Performance ProgramsSteady Increase Despite Questions <br />Med-Vantage, December 2007<br />
  49. 49. From Pay to Participate to Pay for PerformanceHospital Example: CMS Medicare<br />Top deciles of hospitals rewarded on core measures<br />Hospital acquired conditions- October 2008<br />Hospital- Physician bundling in pilot demonstration projects<br />Pay for Performance<br />
  50. 50. Hospital Acquired ConditionsCMS Approved Effective October 1, 2008<br />Pay for Performance<br />
  51. 51. Reasonably PreventableAn Example from the Auto Repair Shop<br />You take your car in to get the brakes fixed.<br />While fixing the brakes, the repairman accidentally punctures the tire with the tire iron.<br /> You now receive the following bill:<br />Bill for Services:<br />Fixing Brakes: $ 300<br /> Repairing Tire: $ 200<br />Total Due: $ 500<br />Pay for Performance<br />
  52. 52. .… What Medicare does, <br />so follow the other Payors<br />Pay for Performance<br />
  53. 53. Hospital Acquired Conditions<br />Going from knowncomplication…..<br /> ….. to known complication.<br />NO <br />Pay for Performance<br />
  54. 54. Surgical Consent Form….<br />Death<br />Stroke<br />Heart Attack<br />Emergency Surgery<br />Infection<br />Bleeding<br />Allergic Reaction<br />Nerve Damage<br />Renal Failure ….<br />
  55. 55. ICU<br />Days Without Bloodstream Infection<br />142<br />Looking Good !!<br />
  56. 56. Zero<br /> Defects !!<br />Mapping<br /> Hardwiring<br />Process<br />Step<br />Process Step versus Clinical Outcome<br />The Journey to Zero Defects<br />
  57. 57. Incomplete<br />Medical Knowledge<br />Zero<br /> Defects !!<br />Mapping<br /> Hardwiring<br />Clinical<br />Outcome <br />X<br />Poor Protoplasm<br />Process Step versus Clinical Outcome<br />The Journey to Zero Defects<br />
  58. 58. Ventilator-Associated Pneumonia<br />Urinary Catheter- Associated UTI<br />Central Line-Associated BSI<br />Edwards, AJIC, December 2009<br />Infection Rates of Zero !Pipe Dream or Reality?National Healthcare Safety Network (NHSN) Report<br />
  59. 59. Change<br />Perfection is unattainable. But if we chase it, <br />we can catch excellence. <br />Vince Lombardi<br />Change<br />
  60. 60. Who Benefits?<br />The Patient !!<br />
  61. 61. Data Transparency<br />Evidence-Based<br /> Medicine<br />Turbo-Charging Quality into the Future !!<br />Pay for Performance<br />Put it all Together:The New Quality Improvement EngineFor Health Care<br />Are You Ready for the Ride !!<br />
  62. 62. What’s New with Health Care Reform?Same Old Wine in a Brand New Bottle ?<br />
  63. 63. Change<br />You can always count on Americans to do the right thing…<br /> …after they’ve exhausted all the other possibilities !!” <br />Winston Churchill<br />Change<br />
  64. 64. Change<br />Change<br />People do not change until the pain of staying the same…<br /> … exceeds the pain of changing.<br />Anonymous<br />Change<br />
  65. 65. What’s New with Health Care Reform?Same Old Wine in a Brand New Bottle ?<br />
  66. 66. “Deal Killers” in Integration Strategies<br />What is the best model for your organization?<br /> Any hand’s a winner…. Any hand’s a loser !!<br />
  67. 67. “Deal Killers” in Integration Strategies<br />What is the best model for your organization?<br /> Any hand’s a winner…. Any hand’s a loser !!<br />1. Define and Excel in<br />your core business !!<br />
  68. 68. “Deal Killers” in Integration Strategies<br />What is the best model for your organization?<br /> Any hand’s a winner…. Any hand’s a loser !!<br />2. Maintain Flexibility !!<br />
  69. 69. “Deal Killers” in Integration Strategies<br />What is the best model for your organization?<br /> Any hand’s a winner…. Any hand’s a loser !!<br />3. Understand the differences<br />between Market and Mandate<br />
  70. 70. What’s New with Health Care Reform?Can your organization tell the difference?<br />Market<br />Mandate<br />Quality<br />Patient Satisfaction<br />Technology<br />Cost Effectiveness<br />Operational Efficiency<br />Universal Access<br />Non Funded Pts<br />Covered Benefits<br />
  71. 71. The Evolution of Health Care Reform<br />1990’s-- Market Correction<br /> 2011-- Market Revolution<br />
  72. 72. Data Transparency<br />Evidence-Based<br /> Medicine<br />Turbo-Charging Quality into the Future !!<br />Pay for Performance<br />Put it all Together:The New Quality Improvement EngineFor Health Care Reform<br />Are You Ready for the Ride !!<br />
  73. 73. Are you Ready for the Ride ??10 Challenges a Healthcare Organization Must Face<br />1. Adopt the philosophy of “Perception is Reality”<br />Starts at the Board, and progresses to administration, staff and physicians<br />The data is significant whether it is significant or not.<br />2. Put a process in place for physicians and staff to quickly analyze data and implement improvement measures<br />3.A lower rating usually points to a real problem<br />When there is a “one star” rating, assume there is a reason for it.<br />Saying “low volumes” or “sicker patients” does not cut it anymore<br />
  74. 74. Are you Ready for the Ride ??10 Challenges a Healthcare Organization Must Face<br />4. Anticipate upcoming clinical measures and develop care improvement processes early<br />A “ramp up” period will no longer be acceptable<br />5. Clinical data is driven by physician documentation.<br />Accurate and complete documentation is more important than ever before<br />A “good” doctor that does not document well is not a “good” doctor<br />6. Compliance with core measures is so universally high, it has become a StandardofCare<br />100% compliance is to be expected<br />Variances are issues for peer review<br />
  75. 75. Are you Ready for the Ride ??10 Challenges a Healthcare Organization Must Face<br />7. Anticipate the continued growth of pay for performance reimbursement<br />Most managed care payors will use CMS as a benchmark<br />Don’t forget the importance of steerage volume as well as higher unit cost reimbursement<br />8. Complications considered preventable will be increasingly not reimbursed<br />Not paying for avoidable complications is gaining public support<br />What is starting at 10 conditions for CMS will undoubtedly grow<br />
  76. 76. Are you Ready for the Ride ??10 Challenges a Healthcare Organization Must Face<br />Lose the “I don’t do cookbook medicine” mentality<br />Learn from the success of other industries<br />Evidence-based clinical guidelines improve care <br />Guidelines were never intended to apply to all patients<br />They never take the place of individual physician judgment<br />When the physician opts out, document: <br />Evaluation<br />Consideration of the options<br />Exercising best judgment<br />Discussion of such with the patient<br />
  77. 77. Are you Ready for the Ride ??10 Challenges a Healthcare Organization Must Face<br />Going from Known Complication to NO Complication<br />View a hospital complication as industry views an industrial accident<br />Set a goal/ benchmark of ZERO<br />Never be “too old a DOG to learn a new trick!!”<br />
  78. 78. Change<br />Change<br />To the world you may be just one person,<br />But to one person you may just be the world.Unknown <br />Change<br />

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