Healthcare Quality by DHHS

Healthcare Quality: DHHS
Don Wright, MD MPH
Deputy Assistant Secretary for Healthcare Quality
Office of Healthcare Quality
Office of the Assistant Secretary for Health
Office of the Secretary
U.S. Department of Health and Human Services
Washington, DC

Presentation OverviewPresentation Overview
1. Partnership for Patients1. Partnership for Patients
2. Initiative to Prevent Healthcare-Associated2. Initiative to Prevent Healthcare-Associated
InfectionsInfections
3. Changing Landscape3. Changing Landscape
3. Linking Payment to Quality3. Linking Payment to Quality
4. What’s Ahead for HAI Elimination4. What’s Ahead for HAI Elimination

Current State of Patient SafetyCurrent State of Patient Safety
••Massive variation in the quality of careMassive variation in the quality of care
••No appreciable change in rates of all-cause harmNo appreciable change in rates of all-cause harm
and preventable readmissionsand preventable readmissions
••A decade of hard work yielding pockets of successA decade of hard work yielding pockets of success
(targeted interventions, isolated settings)(targeted interventions, isolated settings)
••System-wide frustration and poorly coordinatedSystem-wide frustration and poorly coordinated
efforts in responseefforts in response
••Opportunity with the Affordable Care Act to moveOpportunity with the Affordable Care Act to move
from insurance reform to reform the deliveryfrom insurance reform to reform the delivery
systemsystem

Partnership for Patients:Partnership for Patients:
Better Care, Lower CostsBetter Care, Lower Costs
Objectives:Objectives:
 Keep patients from getting injured or sicker.Keep patients from getting injured or sicker.
By the end of 2013, preventable hospital-acquired conditions wouldBy the end of 2013, preventable hospital-acquired conditions would decrease bydecrease by
40%40% compared to 2010. Achieving this goal would mean approximately 1.8compared to 2010. Achieving this goal would mean approximately 1.8
million fewer injuries to patients with more thanmillion fewer injuries to patients with more than 60,000 lives saved60,000 lives saved overover
three years.three years.
 Help patients heal without complication.Help patients heal without complication.
By the end of 2013, preventable complications during a transition from one careBy the end of 2013, preventable complications during a transition from one care
setting to another would be decreased so that all hospital readmissions wouldsetting to another would be decreased so that all hospital readmissions would
bebe reduced by 20%reduced by 20% compared to 2010. Achieving this goal would meancompared to 2010. Achieving this goal would mean
more thanmore than 1.6 million patients would recover1.6 million patients would recover from illness without sufferingfrom illness without suffering
a preventable complication requiring re-hospitalization within 30 days ofa preventable complication requiring re-hospitalization within 30 days of
discharge.discharge.

Area of focus: Hospital-Acquired ConditionsArea of focus: Hospital-Acquired Conditions
1. Adverse Drug Events (ADE)1. Adverse Drug Events (ADE)
2. Catheter-Associated Urinary Tract Infections (CAUTI)2. Catheter-Associated Urinary Tract Infections (CAUTI)
3. Central Line-Associated Blood Stream Infections3. Central Line-Associated Blood Stream Infections
(CLABSI)(CLABSI)
4. Injuries from Falls and Immobility4. Injuries from Falls and Immobility
5. Obstetrical Adverse Events5. Obstetrical Adverse Events
6. Pressure Ulcers6. Pressure Ulcers
7. Surgical Site Infections7. Surgical Site Infections
8. Venous Thromboembolism (VTE)8. Venous Thromboembolism (VTE)
9. Ventilator-Associated Pneumonia (VAP)9. Ventilator-Associated Pneumonia (VAP)
10. All Other Hospital-Acquired Conditions10. All Other Hospital-Acquired Conditions

Next StepsNext Steps
 To learn more about the Partnership for Patients &To learn more about the Partnership for Patients &
related events, activities and materials:related events, activities and materials:
http://www.healthcare.gov/center/programs/partnershttp://www.healthcare.gov/center/programs/partners
hip/index.html.hip/index.html.
 To sign the pledge:To sign the pledge:
http://partnershippledge.healthcare.gov/http://partnershippledge.healthcare.gov/

Initiative to PreventInitiative to Prevent
Healthcare-Associated InfectionsHealthcare-Associated Infections

The BurdenThe Burden
 Each year, 1 in 20 U.S. hospital patients acquires an
HAI
 This is 1.7million infections, and 100,000 lives
lost every year
 Hospital-acquired HAIs alone are responsible for $28
to $33 billion dollars in preventable healthcare
expenditures every year.
 The vast majority of these infections can be
eliminated by implementing known prevention
practices.

10
2009 HHS Action Plan created in response to GAO2009 HHS Action Plan created in response to GAO

Incentives and Oversight
Lead: Centers for Medicare and
Medicaid Services (CMS)
Phase I (2008-Present)
Phase II (2009-Present)
Phase III Working Group (2011)
Federal
Steering Committee
for the Prevention of
Healthcare-Associated
Infections
Long-Term Care
Lead: CMS
Prevention & Implementation
Lead: Centers for Disease Control
and Prevention (CDC)
Research
Lead: Agency for Healthcare
Research and Quality
Information Systems & Technology
Co-Leads: Office of the National
Coordinator for Health IT & CDC
Evaluation
Lead: Office of
Healthcare Quality
Outreach & Messaging
Lead: Office of
Healthcare Quality
Ambulatory Surgical Centers
Co-Leads: Indian Health Service
& CDC
End-Stage Renal
Disease Facilities
Lead: CMS
Influenza Vaccination of
Healthcare Personnel
Co-Leads: CDC &
National Vaccine Program Office
Working Group Structure of the HAI Steering Committee

HHS Action Plan for the Prevention ofHHS Action Plan for the Prevention of
 Phase 1Phase 1
 Original focus on acute care hospitalsOriginal focus on acute care hospitals
 Targeted CAUTI, SSI, VAP, CLABSI, MRSA &Targeted CAUTI, SSI, VAP, CLABSI, MRSA & C.C.
difficiledifficile
 Phase 2 (under development):Phase 2 (under development):
 Ambulatory Surgical CentersAmbulatory Surgical Centers
 End-Stage Renal Disease Facilities (Hemodialysis Centers)End-Stage Renal Disease Facilities (Hemodialysis Centers)
 Flu Vaccination of Healthcare PersonnelFlu Vaccination of Healthcare Personnel
 Phase 3 (under development) – Long-Term CarePhase 3 (under development) – Long-Term Care
 Phase 4 (to be determined) – Ambulatory?Phase 4 (to be determined) – Ambulatory?

Measuring Progress Toward Action Plan Goals
Metric
Source
National 5-year Prevention Target
On Track to Meet 2013 Targets?
Bloodstream infections
NHSN
50% reduction
Adherence to central-line insertion practices
NHSN
100% adherence
Data not yet available*
Clostridium difficile (hospitalizations)
HCUP
30% reduction
Clostridium difficile infections
NHSN
30% reduction
Urinary tract infections
NHSN
25% reduction
MRSA invasive infections (population)
EIP
50% reduction
MRSA bacteremia (hospital)
NHSN
25% reduction
Surgical site infections
NHSN
25% reduction
Surgical Care Improvement Project Measures
SCIP
95% adherence
Metric Source
National 5-year
Prevention
Target
On Track to Meet
2013 Targets?
Bloodstream infections NHSN 50% reduction
Adherence to central-line insertion
practices
NHSN 100% adherence Data not yet available*
Clostridium difficile (hospitalizations) HCUP 30% reduction
Clostridium difficile infections NHSN 30% reduction Data not yet available*
Urinary tract infections NHSN 25% reduction Data not yet available*
MRSA invasive infections (population) EIP 50% reduction
MRSA bacteremia (hospital) NHSN 25% reduction Data not yet available*
Surgical site infections NHSN 25% reduction
Surgical Care Improvement Project
Measures
SCIP 95% adherence
*2009 or 2009 – 2010 is the baseline period.

Each state identified at least 2 priority prevention measures for surveillance in supportEach state identified at least 2 priority prevention measures for surveillance in support
of the HHS HAI Action Planof the HHS HAI Action Plan
State Prevention Plan PrioritiesState Prevention Plan Priorities
31
22
19
10
4
7
11
12
13
17
13
7
42
34
32
27
17
14
0
5
10
15
20
25
30
35
40
45
CLABSI SSI MRSA C. Diff CAUTI VAP
NumberofStates
Underway Planned Total

Changing LandscapeChanging Landscape
of HAI Preventionof HAI Prevention
1. State Reporting1. State Reporting
2. Research2. Research
3. Incentives3. Incentives

Disclosures of HAI
rates required
DC*
State-level Public Reporting HAI Legislation, 2004State-level Public Reporting HAI Legislation, 2004

Disclosures of
HAI rates
required
DC*
State-level Public Reporting HAI Legislation, 2011State-level Public Reporting HAI Legislation, 2011

Changing Landscape of HAI PreventionChanging Landscape of HAI Prevention
Over 4,500 healthcare facilities have enrolled inOver 4,500 healthcare facilities have enrolled in
CDC’s National Healthcare Safety NetworkCDC’s National Healthcare Safety Network
(NHSN) as of April 2011. NHSN is providing(NHSN) as of April 2011. NHSN is providing
CLABSI data for the CMS Hospital InpatientCLABSI data for the CMS Hospital Inpatient
Prospective Payment Systems for Acute CareProspective Payment Systems for Acute Care
Hospitals as a first step in implementing theHospitals as a first step in implementing the
Affordable Care Act.Affordable Care Act.

 $34 Million to Expand Fight$34 Million to Expand Fight
AgainstAgainst
 Goal:Goal: To help expand efforts to fightTo help expand efforts to fight
HAIs in hospitals, ambulatory careHAIs in hospitals, ambulatory care
settings, end-stage renal diseasesettings, end-stage renal disease
facilities, and long-term care facilities.facilities, and long-term care facilities.
 AHRQ has collaborated with CDC,AHRQ has collaborated with CDC,
CMS, and NIH to identify researchCMS, and NIH to identify research
gaps to improve HAI prevention.gaps to improve HAI prevention.
 Complete list of institutions andComplete list of institutions and
projects funded available at:projects funded available at:
www.ahrq.gov/qual/haify10.htmwww.ahrq.gov/qual/haify10.htm

Positive Incentives for ExcellencePositive Incentives for Excellence
National Awards ProgramNational Awards Program
 Cleveland Clinic Cardiovascular ICU recognized lastCleveland Clinic Cardiovascular ICU recognized last
week withweek with The Sustained Improvement Award (CLABSI)The Sustained Improvement Award (CLABSI)
 recognizes progress in implementing systems showing sustained andrecognizes progress in implementing systems showing sustained and
consistent reductions over a period of 18 to 24 monthsconsistent reductions over a period of 18 to 24 months

 AHRQ recently awarded $5.8M to Health ResearchAHRQ recently awarded $5.8M to Health Research
& Educational Trust& Educational Trust
 Funds will help States support staffing needs atFunds will help States support staffing needs at
hospitals participating inhospitals participating in On the CUSP: Stop BSIOn the CUSP: Stop BSI
 CUSP is aCUSP is a comprehensive unit-based safetycomprehensive unit-based safety
programprogram to reduce central line-associatedto reduce central line-associated
bloodstream infections and catheter-associated UTIsbloodstream infections and catheter-associated UTIs
 Builds on the foundation of the Michigan KeystoneBuilds on the foundation of the Michigan Keystone
ProjectProject

 American Recovery and Reinvestment Act of 2009American Recovery and Reinvestment Act of 2009
(ARRA)(ARRA)
 Created opportunities for building the state-levelCreated opportunities for building the state-level
infrastructure for HAI prevention.infrastructure for HAI prevention.
 Administered by CDC and CMSAdministered by CDC and CMS
 enhanced state capacity to reduce and prevent HAIs,enhanced state capacity to reduce and prevent HAIs,
 focusing on thefocusing on the Action PlanAction Plan goals,goals,
 enhanced state capacity to inspect ambulatory surgicalenhanced state capacity to inspect ambulatory surgical
centers.centers.

Linking PaymentLinking Payment
to Quality andto Quality and

CMS Programs Planning to LinkCMS Programs Planning to Link
Payment to QualityPayment to Quality
 Value Based Purchasing and Accountable Care Organizations are two
important steps to revamping payment for care and services are paid
 Rewarding better value, outcomes, and innovations instead of merely
volume
 Measures should rely on a mix of the following:
– Standards
– Process measures
– Outcomes
– Patient experience measures
 Care Transitions and Changes in Patient Functional Status
 Goal is to quickly move to using primarily outcome and patient
experience measures using risk adjustment as appropriate

CMS Programs Planning toCMS Programs Planning to
Link Payment to QualityLink Payment to Quality
–Hospital Value-Based Purchasing (HVBP)
–End Stage Renal Disease Quality Incentive
Program (ESRD QIP)
–Accountable Care Organizations (ACO)

Introduction: Proposed HospitalIntroduction: Proposed Hospital
Value-Based Purchasing (VBP) ProgramValue-Based Purchasing (VBP) Program
 Required by Congress under Section 1886(o) of the Social
Security Act
 Next step in promoting higher quality care for Medicare
beneficiaries
 CMS views value-based purchasing as an important driver in
revamping how care and services are paid for, moving
increasingly toward rewarding better value, outcomes, and
innovations instead of volume
 Note: Details presented here are proposals and are subject
to change in the Final Rule. Comment period ended on
March 8, 2011

Proposed HospitalProposed Hospital
Value-Based Purchasing (VBP)Value-Based Purchasing (VBP)
Measure TopicsMeasure Topics
 Acute Myocardial Infarction (AMI)
 Heart Failure (HF)
 Pneumonia (PN)
 Surgical Care Improvement Project (SCIP)
 Healthcare-Associated Infections, as defined by the
Secretary’s HAI Action Plan
 Hospital Consumer Assessment of Healthcare Providers
and Systems (HCAHPS) Survey

Proposed FY 2013 Domains andProposed FY 2013 Domains and
Measures/DimensionsMeasures/Dimensions

Measures Proposed for FY 2014Measures Proposed for FY 2014
Hospital VBP Program (1 of 3)Hospital VBP Program (1 of 3)
Proposed Hospital -Acquired Condition Measures:
1. Foreign Object Retained After Surgery
2. Air Embolism
3. Blood Incompatibility
4. Pressure Ulcer Stages III & IV
5. Falls and Trauma: includes Fracture, Dislocation,
Intracranial Injury, Crushing Injury, Burn, Electric Shock
6. Vascular Catheter-Associated Infections
7. Catheter-Associated Urinary Tract Infection (CAUTI)
8. Manifestations of Poor Glycemic Control
Proposed Hospital -Acquired Condition Measures:
1. Foreign Object Retained After Surgery
2. Air Embolism
3. Blood Incompatibility
4. Pressure Ulcer Stages III & IV
5. Falls and Trauma: includes Fracture, Dislocation,
Intracranial Injury, Crushing Injury, Burn, Electric Shock
6. Vascular Catheter-Associated Infections
7. Catheter-Associated Urinary Tract Infection (CAUTI)
8. Manifestations of Poor Glycemic Control

Proposed Hospital VBP MeasuresProposed Hospital VBP Measures
for FY 2014 (2 of 3)for FY 2014 (2 of 3)
Agency for Healthcare Research and Quality (AHRQ) Patient Safety
Indicators (PSI), Inpatient Quality Indicators (IQI), and Composite Measures:
1. PSI 06 – Iatrogenic Pneumothorax, adult
2. PSI 11 – Post-Operative Respiratory Failure
3. PSI 12 – Post-Operative Pulmonary Emboli (PE) or Deep Vein Thrombosis (DVT)
4. PSI 14 – Postoperative Wound Dehiscence
5. PSI 15 – Accidental Puncture or Laceration
6. IQI 11 – Abdominal Aortic Aneurysm (AAA) Repair Mortality Rate
(with or without volume)
7. IQI 19 – Hip Fracture Mortality Rate
8. Complication/Patient Safety for Selected Indicators (composite)
9. Mortality for Selected Medical Conditions (composite)
Agency for Healthcare Research and Quality (AHRQ) Patient Safety
Indicators (PSI), Inpatient Quality Indicators (IQI), and Composite Measures:
1. PSI 06 – Iatrogenic Pneumothorax, adult
2. PSI 11 – Post-Operative Respiratory Failure
3. PSI 12 – Post-Operative Pulmonary Emboli (PE) or Deep Vein
Thrombosis (DVT)
4. PSI 14 – Postoperative Wound Dehiscence
5. PSI 15 – Accidental Puncture or Laceration
6. IQI 11 – Abdominal Aortic Aneurysm (AAA) Repair Mortality Rate
(with or without volume)
7. IQI 19 – Hip Fracture Mortality Rate
8. Complication/Patient Safety for Selected Indicators (composite)
9. Mortality for Selected Medical Conditions (composite)

Measures Proposed for FY 2014Measures Proposed for FY 2014
Hospital VBP Program (3 of 3)Hospital VBP Program (3 of 3)
MORT-30-HF: Heart Failure (HF) 30-Day Mortality Rate
MORT-30-PN: Pneumonia (PN) 30-Day Mortality Rate
Proposed Mortality Measures
MORT-30-AMI: Acute Myocardial Infarction (AMI) 30-Day Mortality Rate
MORT-30-HF: Heart Failure (HF) 30-Day Mortality Rate
MORT-30-PN: Pneumonia (PN) 30-Day Mortality Rate

Anticipated HAI Expansion in FutureAnticipated HAI Expansion in Future
Years (subject to regulation proposal)Years (subject to regulation proposal)
–Central Line-Associated Blood Stream
Infection (CLABSI)
–Surgical Site Infection
–MRSA
–Clostridium Difficile
–Catheter -Associated Urinary Tract
Infection
–Central Line Insertion Protocol (CLIP)

ESRD QualityESRD Quality
Incentive Program is….Incentive Program is….
 A program designed to improve the quality of care for beneficiaries
by changing the way dialysis facilities in the ESRD Program are
reimbursed
 Designed to monitor and improve the quality of care furnished to
ESRD beneficiaries
 The first pay-for-performance program in a Medicare prospective
payment system
 A program that continues a long history of work by CMS to
improve the quality of care for beneficiaries with ESRD
 Efforts to improve beneficiary quality of care include:
– Dialysis Facility Compare
– Fistula First Breakthrough Initiative

ESRD QIP Future MeasuresESRD QIP Future Measures
Under ConsiderationUnder Consideration
 Committed to adding quality measures that will look at additional
aspects of an individual’s health in dialysis
 Some areas under consideration include:
– Bone and mineral metabolism
– Access infection rates (including healthcare acquired infections)
– Dialysis adequacy –(Kt/V instead of URR)
– Vascular access rates
 Committed to developing additional quality measures for future
years to better assess the quality of care provided by dialysis
facilities
– Kt/V = (dialyzer clearance of urea X dialysis time) / volume of
distribution of urea

Role of Accountable CareRole of Accountable Care
OrganizationsOrganizations
 Another key delivery system reform is the
encouragement of Accountable Care
Organizations (ACOs).
 ACOs facilitate coordination and cooperation
among providers to improve the quality of
care for Medicare beneficiaries and reduce
unnecessary costs.

What is an Accountable CareWhat is an Accountable Care
Organization?Organization?
 An organization of health care providers that agrees to be
accountable for the quality, cost, and overall care of Medicare
beneficiaries who are enrolled in the traditional fee-for-service
program who are assigned to it
 For ACO purposes, “assigned” means those beneficiaries for whom
the professionals in the ACO provide the bulk of primary care
services.
 Assignment will be invisible to the beneficiary, and will not affect
their guaranteed benefits or choice of doctor.
 A beneficiary may continue to seek services from the physicians
and other providers of their choice, whether or not the physician or
provider is a part of an ACO.

What forms of organizations mayWhat forms of organizations may
become an ACO?become an ACO?
The statute specifies the following:
 1) Physicians and other professionals in group practices
 2) Physicians and other professionals in networks of practices
 3) Partnerships or joint venture arrangements between hospitals and
physicians/professionals
 4) Hospitals employing physicians/professionals
 5) Other forms that the Secretary of Health and Human Services
may determine appropriate.
 An organization of health care providers that agrees to be
accountable for the quality, cost, and overall care of Medicare
beneficiaries who are enrolled in the traditional fee-for-service
program who are assigned to it.

What quality measures willWhat quality measures will
ACOs be assessed on?ACOs be assessed on?
Subject to the proposed program’s regulations,
they will include measures in such categories
as clinical processes and outcomes of care,
patient experience, and utilization (amounts
and rates) of services.

How would an ACO qualifyHow would an ACO qualify
for shared savings?for shared savings?
For each 12-month period, participating ACOs
that meet specified quality performance
standards will be eligible to receive a share of
any savings if the actual per capita
expenditures of their assigned Medicare
beneficiaries are a sufficient percentage below
their specified benchmark amount.

ACO Current StatusACO Current Status
– CMS plans to hold a listening session to hear stakeholder
ideas on ACOs this summer. Further details about this
listening session, to be held as a special open door forum,
will be posted by June 11.
– We plan to establish the program by January 1, 2012.
Agreements will begin for performance periods, to be at
least three years, on or after that date.
– Further details for the shared savings program will be
provided in a Notice of Proposed Rulemaking which CMS
expects to publish this fall.

Looking Ahead
 IPPS rule
 CMS to use NHSN data for Hospital Compare
 Affordable Care Act
 $500 million for care transitions
 Release of 2011 Action Plan
 Development of Phase III – Long-Term Care
 Partnering to Heal: Teaming Up Against
Healthcare Associated Infections
 Consumer Media Campaign

For more information
Office of Healthcare Quality
200 Independence Ave, SW
Room 716G
Washington, DC 20201
Telephone (202) 401-8006
ohq@hhs.gov
Subscribe to the HAI listserv
https://service.govdelivery.com/service/subscribe.html?code=USHHS_234

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Editor's Notes