IU Medical Group's quality improvement goals are to decrease mortality and morbidity, increase patient satisfaction, improve patient safety, and link these goals to management accountability. Metrics such as UHC reports and patient satisfaction surveys are used to measure progress. Clinical department chairs must annually report progress on these goals to the board. The organization utilizes numerous quality reports and surveys to measure and improve patient care. Each clinical department is responsible for quality and safety programs within their department.

1. Lisa Hancock
Quality Presentation For
Boston Children’s Hospital
July 2008

2. What are the goals of IU Medical Group’s quality improvement
program? What metrics and benchmarks are used to measure
progress towards each of these performance goals? How is each
goal specifically linked to management accountability?
IU Medical Group’s goals for our patients are to:
• Decrease Mortality
• Decrease Morbidity
• Increase Patient Satisfaction
• Improve Patient Safety
• IU Medical Group utilizes the University Healthcare
Consortium for benchmarks in mortality, morbidity and
safety. Our patient satisfaction information utilizes the
Regenstrief organization, and the Pickar survey.
• Each Clinical Chair will be asked to report their
departments progress on these goals to the Board at
least annually.

3. Where we were…

4. Where we are now…
UHC Results for IU Hospital
2007 Rank 2008 Goal
Mortality (35%) 17 12-15
Effectiveness (35%) 62 25-30
Safety (20%) 6 3-5
• In 2007 Methodist ranked #1 in the UHC database out of all Academic
Medical Centers
• IU Hospital moved up to #29 with the addition of the latest quarter.
• IU Hospital was among the most improved of all the 82 hospitals evaluated.

6. How does IU measure and improve the quality of
patient care? Who are the key management and clinical
leaders responsible for these quality and safety
programs?
IU Medical Group measures and improves the quality of patient care
with the following metrics:
• UHC Reports:
– Quality and Safety Management Report (QSMR)
– Hospital Quality Measures Report (HQMR)
– Clinical Outcomes Report
– Key Indicator Report
– Quality and Accountability Report
• Patient and Referring Physician Satisfaction Surveys
• Clarian Quality Matrix
• Wishard Hospital Incentive Program
• Each of the 19 clinical departments are responsible for ensuring the
quality and safety of their departments.

7. University Hospital Category Summary
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50
AHRQ
(20)
Anthem
(10)
Cancer(9)
Core
M
easure
(46)
Glycem
icControl(13)
Home
Health
(0)
Infection
Control(11)
JCAHO
(21)
Leapfrog
(17)
LOS-Riley(0)
M
ortality(19)
NDNQI(29)
NSQIP
(8)
Other(9)
PatientSatisfaction
(10)
Transplant(13)
VDC
(10)
Category (# Measures)
Progress
Jun-08

8. Quality Matrix Items--Improvements
• Success stories
– Surgical Quality Committee
• Reducing complications, mortality & readmissions
• Improving patient throughput
• Beginning to use NSQIP risk adjusted data
– Central line blood stream infection teams in progress
– UHC Palliative Care Benchmarking Study
– Clinical Documentation Improvement Program
– Engagement of Department of Medicine

9. Case example
Surgical - Complications of anesthesia - Adults (Rate per 1000)
AHRQ
• Definition: Cases of anesthetic overdose, reaction, or endotrachial
tube misplacement per 1,000 surgery discharges.
• Denominator: All surgical discharges 18 years and older or MDC 14
defined by specific DRGs. Exclude patients with codes for poisoning
due to anesthetics (E8551, 9681-4, 9687) and any diagnosis code
for active drug dependence,
• active non-dependent abuse of drugs, or self-inflicted injury.
• Numerator: Discharges with ICD-9-CM diagnosis codes for
anesthesia complications in any secondary diagnosis field per 1,000
discharges.
• Target: AHRQ expected rate (O/E ratio of 1.0). Rank and Top-10
based on O/E ratios.

10. Performance was substantially worse
than target

11. How are IU’s quality assessment and improvement processes integrated
into overall corporate policies and operations? Are clinical quality
standards supported by operational policies? How does management
implement and enforce these policies? What internal controls exist to
monitor and report on quality metrics?
• Our faculty adheres to the policy and procedures of the
health care entities in which they practice. These
include, but are not limited to Clarian’s downtown
hospitals, Wishard Health System, the Roudebush VA
Medical Center, Clarian West, and Clarian North.
• The Compliance Committee of the IU School of Medicine
enforces the compliance of the practices of the school.
• The IUMG Credentialing Committee credentials all IUMG
providers.
• The Medical Management Committee of IUMG SC has
been charged by the IUMG – SC Board to develop,
implement, and review all the quality and safety activities
of the organization.

12. IU Medical Group – Specialty Care
Medical Management Committee
July 17, 2008
NEXT MEETING: Thursday, August 21st, 2008, Medical Sciences Building, Daly Center 122C-D
Herbert Cushing MD MS 164 Bill Wooden MD EH 232 Jeffrey M. Rothenberg
MD
UH 2440 David Kovach MD FH 204
David Crabb M.D EH 317 Michael A. Kraus MD UH 1115 Daniel A. Rushing MD RT 473 Deanna Willis MD LO
200
Lisa Hancock RN LO 401 Richard T. Miyamoto M.D RI 0860 Mike Ober MD UH 2100 Keith Lillemoe MD EH
203
John Fitzgerald LO 401 Darrell WuDunn MD RO 301 David Posey MD ROC
4300
Henry Pitt MD RT
130d
Val Jackson MD UH0663 Michael Lykens MD EH 312 Steve Hugenberg MD LO 545
Agenda Item
PQRI results for IUMG
-Jan through May 2008
Policy Review
-Identification and Monitoring of Quality Issues
-Ongoing Monitoring of Complaints and Quality Issues
Regenstrief Survey Results
Jul ’06-Jan ‘08
Credentials Committee 2nd Quarter 2008 Results
Health Care Notification Network Overview

13. Does the IUMG board have a formal orientation and
continuing education process that helps members
appreciate external quality and patient safety
requirements? Does the board include members with
expertise in patient safety and quality improvement
issues?
• The IUMG – SC Medical Director meets with each of the
Department Chairs, or their designee to share and
review the departments quality and safety data and
develop improvement plans when necessary.
• The IUMG – SC Board includes members with expertise
in patient quality and safety.

14. Physician Education and Training
 Partnership between Medical Education, IUSOM, & Quality
 Residents, Faculty, New medical staff, & Medical students.
Orientations for all new interns, 3rd
year med students, new
faculty on staff.
 Ongoing training with quality and safety lunches,
intersessions for med students, orientation for new faculty
mid-year.
 Core curriculum
 Quality, Safety, Medical Equipment, Cerner, Regulatory
Compliance, Infection Control, Medication Safety, etc.
 Designed for orientation & on-going information sharing

15. What information is essential to the board’s ability to understand and
evaluate the organization’s quality assessment and performance
improvement programs? Once these performance metrics and
benchmarks are established, how frequently does the board receive
reports about the quality improvement efforts?
• The IUMG – SC Board requires each of the Clinical
Departments to report at least annually to report on the
following:
• Mortality
• Morbidity
• Satisfaction
• Safety
• CMS Physician Voluntary Reporting Program (PQRI)
• EMR implementation
• Communication with referring physicians and patients

16. Physician Quality Reporting Initiative (PQRI)
• PQRI establishes a financial incentive for eligible professionals to
participate in a voluntary quality reporting program. Eligible
professionals who successfully reported PQRI quality measures
may earn an incentive, of 1.5% of total allowed charges for covered
Medicare physician fee schedule services.
• If no more than three 2007 PQRI quality measures were applicable,
each measure must have been reported in at least 80% of the cases
in which the measure was reportable.
• 27,811 PQRI measures were reported on from July – December
2007
• 84% of those reported measures were for Medicare patients
• Anesthesia, Dermatology, Emergency Medicine, Primary Care,
Medicine, Ophthalmology, Orthopaedic Surgery, and Surgery
reported measures. These groups met the 30 minimum
patient/encounter episode to qualify for participation.
• 5% of the reported PQRI measures did not meet the performance
requirement.

17. PQRI Results Example
Anesthesia
• 19 providers reported:
• 819 Total patients were reported on that antibiotics
were given w/in 1 hour prior to surgery
– 717 Medicare patients (88% of the patients reported on)
– 453 Medicare patients had documentation that antibiotics
were given w/in 1 hour prior to surgery
• 63% of Medicare patients were given antibiotics w/in 1 hour prior
to surgery
• 36% of Medicare patients did not have the documentation that
antibiotics were given, but were successfully reported on.

18. Case example
Otolaryngology wanted to report on the following
CMS measures:
• Acute Otitis Externa-Topical Therapy (ages 2
and older)
• Acute Otitis Externa-Pain Assessment (ages 2
and older)
• Acute Otitis Externa-Systemic Antimicrobial
Therapy, Avoidance of Inappropriate Use (ages
2 and older)

19. Case example
• How many Medicare patients, age 2 or
greater have a diagnosis of Acute Otitis
Externa?
• How many Medicare patients, age 2
months to 12 years, have Otitis Media with
Effusion?

20. Case Example
Data query
• Otolaryngology PQRI Data Date: 5/9/08 Detail Filter: Group Department
Name - Txn = 'OTOLARYNGOLOGY' and Invoice DOS - Txn between
2007-04-12 and 2008-04-12 and Orig Pmt FSC Report Category 1 - Txn =
'MEDICARE' and ( DX1 ICD9-CM Code - Txn in ( '380.10' , '380.11' ,
'380.12' , '380.13' , '380.22' , '381.10' , '381.19' , '381.20' , '381.29' , '381.3' ,
'381.4' ) or DX2 ICD9-CM Code - Txn in ( '380.10' , '380.11' , '380.12' ,
'380.13' , '380.22' , '381.10' , '381.19' , '381.20' , '381.29' , '381.3' , '381.4' )
or DX3 ICD9-CM Code - Txn in ( '380.10' , '380.11' , '380.12' , '380.13' ,
'380.22' , '381.10' , '381.19' , '381.20' , '381.29' , '381.3' , '381.4' ) or DX4
ICD9-CM Code - Txn in ( '380.10' , '380.11' , '380.12' , '380.13' , '380.22' ,
'381.10' , '381.19' , '381.20' , '381.29' , '381.3' , '381.4' ) or DX5 ICD9-CM
Code - Txn in ( '380.10' , '380.11' , '380.12' , '380.13' , '380.22' , '381.10' ,
'381.19' , '381.20' , '381.29' , '381.3' , '381.4' ) or DX6 ICD9-CM Code - Txn
in ( '380.10' , '380.11' , '380.12' , '380.13' , '380.22' , '381.10' , '381.19' ,
'381.20' , '381.29' , '381.3' , '381.4' ) )

21. How does IU’s quality assessment and improvement
processes coordinated with its corporate compliance
program? How are quality of care and patient safety
issues addressed in the organization’s risk assessment
and corrective action plans?
• The IUMG faculty are integral to promoting corporate
compliance, as well as to risk management and
organizational reputation. All employees and faculty are
encouraged to use the confidential hotline numbers to
report compliance issues anonymously. The use of the
hotline is not limited to compliance, and can be used for
quality and safety concerns as well.
• IUMG collaborates with each of our hospital partners in
their risk assessment and corrective action programs

22. What processes are in place to promote the reporting
of quality concerns and medical errors and to protect
those who ask questions and report problems? What
guidelines exist for reporting quality and patient safety
concerns to the board?
• IUMG encourages all employees and faculty to utilize the
confidential compliance hotlines to report any issue.
This includes the University, Clarian, Wishard, and the
VA. All quality and safety issues are investigated by the
Medical Director, and are reviewed by the Medical
Management Committee, which reports to the IUMG –
SC Board. All such reports are handled in a confidential
manner.

23. Are human and other resources adequate to support
patient safety and clinical quality? How are proposed
changes in resource allocation evaluated from the
perspective of clinical quality and patient care? Are
systems in place to provide adequate resources to
account for differences in patient acuity and care
needs?
• Resources are assessed at least on an annual
basis. Our Board has recently allocated
additional resources for quality and safety.
• IUMG – SC utilizes the UHC case mix index to
benchmark the acuity of our patients.

24. Does IU’s competency assessment and training,
credentialing, and peer review processes adequately
recognize the necessary focus on clinical quality and
patient safety issues?
• IUMG – SC reviews malpractice complaints, the
National Practitioner Databank, patient
satisfaction, credentialing and physician specific
complaints. The Credentialing Committee and
the Medical Management Committee review and
act on this information and report to the Board.

25. How are “adverse patient events” and other medical
errors identified, analyzed, reported, and incorporated
into IU’s performance improvement activities? How do
management and the board address quality
deficiencies without unnecessarily increasing the
organization’s liability exposure?
• IUMG – SC is linked to the Risk Management
departments of each of our affiliated hospitals. We also
assist with the following:
• Indiana State Department of Health Reportable Events
• JCAHO Sentinal Events
• Internal investigations and Reviews of adverse events

26. Questions?
Lisa Hancock, RN, MHA
Director of Quality Care
IU Medical Group - Specialty Care
ph. 317-278-9907
fax 317-278-9926
lcox@iupui.edu