Perspectives from CMS: Towards Continuous Improvement in the Future

1. Perspectives from CMS: Towards Continuous Improvement in the Future Barry M. Straube, M.D. Centers for Medicare & Medicaid Services (CMS) 2008 American Health Quality Association Annual Meeting February 26, 2008

2. 2 Discussion Roadmap for Today 8th SOW: Accomplishments & Lessons Learned BQI Pilots & Chartered Value Exchanges QIO Program Brand/Image

3. 3 Scoring of 8th SOW TASK Performance Excellent Pass (EP) Full Pass (FP) Conditional Pass (CP) Non-Pass (NP) Note: Achieving a NP on any sub-task resulted in an overall �failure� and the QIO was invited to panel

4. 4 8th SOW-Final Results Summary

5. 5 Overall 8th SOW Results Excellent or full passes received 94% of the time out of 456 �opportunities� across the 9 tasks and 53 QIOs (some QIOS were exempt on certain tasks) 312 (68%) excellent passes 118 (26%) full passes Only 11 not passes received for overall failure rate across tasks of 2%

6. 6 Overall 8th SOW Results 8 QIOs have their contracts subjected to competitive renewal because of performance deficiencies (achieving at least one NP) 6 of these QIOs failed 1d1 (physician office) 3 QIOs failed 1b (Home Health) 1 QIO failed 1c2 (critical access hospitals) �Failure� is task specific and doesn�t reflect overall QIO performance Deficiency in metrics, process orientation v.s. outcomes, evaluation process addressed in 9th SOW

7. 7 8th SOW Highlights Home Health STAR Home Health Quality Improvement (HHQI) National Campaign & Summit Nursing Home Campaign � Advancing Excellence STAR Reducing Avoidable Hospitalization � Nursing Home Residents RHQDAPU Case Review

8. 8 Home Health STAR Website  Setting Targets-Achieving Results (STAR) website allows: Home Health agencies to set targets for the 11 publicly reported home health quality measures Tracking of progress towards the target rates (with an emphasis on setting a target and tracking progress related to ACH) Comparison between the individual agency rates and the state and national rates associated with the selected measure on a quarterly basis

9. 9 Home Health STAR Website  Total # of IPs that set targets: 1,302 (82.9%) Total # non-IPs that set targets: 2,447 (47.0%) ACH Performance of Target Setters vs. Non-Target Setters:

10. 10 Goal: Reduce unnecessary hospitalizations of home health patients and improve the publicly reported measure of acute care Hospitalization (ACH) Summit: Held at CMS on January 11, 2007 Over 250 attendees including: National stakeholders QIOs (100% participation) State home care associations Home health agencies Home Health Quality Improvement (HHQI) National Campaign & Summit

11. 11 Home Health Quality Improvement (HHQI) National Campaign & Summit Campaign: 5,590 HHAs participated. This represents approx. 64% of the HHAs nationally Participants provided with monthly data reports, best practice packages, and E-Bulletin Website developed for communication and resource sharing QIOs and State Home Care Associations formed LANEs (local area networks of excellence) to assist with communications, resource sharing and local provider assistance

12. 12 Home Health Quality Improvement (HHQI) National Campaign & Summit Campaign: Improvement in the ACH rate was demonstrated by the participating agencies Based on data through 10/2007: Participating HHAs improved their ACH rate on average by 0.09% Non-participating HHAs� ACH rate worsened on average by 1.10%

13. Nursing Homes that Select Pressure Ulcers Goal Show Greater Improvement Participants = registered providers Non-participants = 11078 Participants = Participants = registered providers Non-participants = 11078 Participants =

14. Nursing Homes that Select Physical Restraint Goal Show Greater Improvement Participants = registered providersParticipants = registered providers

15. 15 Improved Quality of Life for Nursing Home Residents From Q3 2006 to Q3 2007 3238 fewer pressure ulcers occurred 4419 fewer daily restraints were applied 3797 fewer long-stay residents experienced pain Nursing homes registered for the campaign had 644 fewer pressure ulcers over and above the rate of homes not registered Participants = registered providers The reduced numerator for pressure sores from 2006 Q3 to 2007 Q3: For the nation: 87868 reduced to 84630 (3238 difference, 1876 of those in high risk residents, 1362 in low risk) For Non-participants: 51398 reduced to 49805 (1593 difference, 791 in high risk residents, 802 in low risk) For Participants: 26440 reduced to 24977 (1463 difference, 966 in high risk residents, 497 low risk) Although participants account for only 30% of the country�s nursing home residents with pressure sores, they account for 45% of the improvement Participants experienced 644 fewer pressure ulcers than predicted, had they improved at the rate of non-participants; the Participants = registered providers The reduced numerator for pressure sores from 2006 Q3 to 2007 Q3: For the nation: 87868 reduced to 84630 (3238 difference, 1876 of those in high risk residents, 1362 in low risk) For Non-participants: 51398 reduced to 49805 (1593 difference, 791 in high risk residents, 802 in low risk) For Participants: 26440 reduced to 24977 (1463 difference, 966 in high risk residents, 497 low risk) Although participants account for only 30% of the country�s nursing home residents with pressure sores, they account for 45% of the improvement Participants experienced 644 fewer pressure ulcers than predicted, had they improved at the rate of non-participants; the

16. 16 Nursing Homes Registered for the Campaign Select Organizational Improvement Goals Year 1 Goal 5 31.0% Setting targets Goal 6 21.4% Assessing satisfaction Goal 7 11.8% Increasing staff retention Goal 8* 36.5% Improving consistent assignment  * For Goal 8, % represents implementation of consistent assignment Participants = registered providersParticipants = registered providers

17. 17 Survey Shows that Nursing Homes Registered for the Campaign Increase Focus on Quality Goals (N=1,082) 75% or more participants indicated NEW QI efforts on four goals due to campaign pain (Goals 3 and 4) setting targets (Goal 5) improving consistent assignment (Goal 8) (n= 948 to 977)(n= 948 to 977)

18. 18 Survey Shows that Nursing Homes Not Registered for the Campaign Are an Untapped Opportunity (N=584) Nearly half of non-participants (45%) of survey respondents are unaware of the campaign Opportunity still to reach many more Similar to the IHI hospital campaign, participant�s association with success and quality may improve recruitment traction over the next years Registered Providers = participantsRegistered Providers = participants

19. 19 Advancing Excellence:Progress and Opportunities Early success apparent on all clinical goals Thousands of lives impacted Substantial cost-avoidance Progress on all organizational goals Participants give attribution to campaign for focus There is opportunity to recruit additional participants, especially if the campaign is extended

20. 20 Setting Targets Achieving Results (STAR) Developed to provide a quality improvement tool for all Medicare and/or Medicaid nursing homes in the country to take a critical first step in making improvements in their quality measures: setting an improvement goal

21. 21 Nearly 10,000 (9,981 of 15,855 as of 2/4/08) nursing home have established a STAR account since STAR was implemented in June 2005. For a six-month period, ending January 31, 2008, STAR web statistics showed: Total Hits: 1,816,904 Total Page Views: 684,985 Average Daily Hits: 8,451 Average Daily Page Views: 3,186 Average Page Views Per Session: 20 Setting Targets Achieving Results (STAR)

22. 22 Nursing homes participating in the Advancing Excellence campaign use STAR for the clinical goals Current data shows that all of the participants that selected a clinical goal and set a target improved more than those that just selected the clinical goal and did not set targets Setting Targets Achieving Results (STAR)

23. 23 RHQDAPU 2008 FY 2008 Results FY 2008 - Over 94% of PPS hospitals received the full update � Additional measures in FY 2008 � HCAHPS AMI and Heart Failure mortality 3 SCIP measures � FY 2008 RHQDAPU Reconsideration Process FY 2008 � Notifications of results were mailed on January 29, 2008 (90 days after deadline) 49 reconsideration requests out of 147 were overturned.

24. 24 RHQDAPU 2008 RHQDAPU Validation Over 99% of hospitals passed FY 2008 annual RHQDAPU validation requirement RHQDAPU Communications Focus on clear and consistent communications to all affected parties More communications targeted directly to hospitals through email blasts and QualityNet website Increased outreach to associations and state hospital associations

25. 25 The RHQDAPU Program The RHQDAPU Program developed from a small 10-measure voluntary reporting initiative in 2002 into the current 30-measure pay-for-reporting program. CMS has adapted to substantially increased demands and recognizes the continuing need for resources. Our goal is an efficient and effective program. We appreciate the input we have received from stakeholders and will continue our outreach efforts to ensure we continue to get hospital input

26. 26 Reducing Avoidable Hospitalizations of Nursing Home Residents Goals: Identify nursing homes with high and low rates of hospitalizations and compare characteristics Develop a set of potentially feasible and effective strategies to reduce avoidable hospitalizations

27. 27 Reducing Avoidable Hospitalizations of Nursing Home Residents Pilot phase of the Study 5/1/07 � 10/31/07 in three Georgia NHs Three nursing homes selected for implementation of intervention tools Each participating NH appointed a team responsible implementation, including the Director or Assistant Director of Nursing, a Social Worker or Social Services designee, and a licensed nurse

28. 28 Characteristics of Nursing Homes with High Hospitalization Rates More certified beds Higher proportion of residents on Medicaid Fewer residents who were Caucasian More residents with pressure ulcers (stage 2 or higher) Substantial differences in availability of the medical director, primary care physicians, and nurse practitioners or physician assistants

29. 29 Common Diagnoses for Acute Hospitalization 95% of the hospital admitting diagnoses: Congestive heart failure and chest pain Pneumonia and bronchitis Acute mental status changes Sepsis and fever Dehydration Cellulitis Diarrhea

30. 30 INTERACT Tool-Kit Developed INTERACT tool-kits: Care paths and Communication Tools developed for: congestive heart failure symptoms of lower respiratory infections fever altered mental status urinary tract infection dehydration

31. 31 Factors to Prevent Avoidable Hospitalizations Availability of on-site evaluation by a physician, nurse practitioner or physician�s assistant Quality of care by a Registered Nurse Availability of laboratory results within 3 hours Ability of the NH to initiate and maintain intravenous hydration

32. 32 Interventions Rated Highly Feasible and Very Important Pneumonia care path Protocol and tools to communicate changes in status by telephone from LPN or RN to primary care provider using SBAR format (Situation, Background, Assessment, Recommendations) Fall risk assessment and management protocol and tools

33. 33 Interventions Rated Highly Feasible and Very Important CHF care path Availability of critical medications (e.g. parenteral antibiotics/analgesics, cardiac meds) within 2-4 hours UTI care path Dehydration care path

34. 34 Outcome of Study Better implementation of the framework and the INTERACT toolkit could result in: Improvements in quality of care, Reduction in avoidable hospitalizations, Substantial cost-avoidance for the Medicare program

35. 35 Task 3a: Beneficiary Protection Goals Perform statutorily mandated reviews Beneficiary satisfaction with the complaint process Mandated quality improvement activities Implement alternative dispute resolution methods (ADR) to resolve beneficiary complaints when appropriate

36. 36 Task 3a: Beneficiary Protection8th SoW Performance Timeliness of Review National Average 95% Beneficiary Satisfaction with the complaint process National Average 86% Quality Improvement Activities National Average 62% **All of the QIOs successfully met performance standards

37. 37 Task 3a: Beneficiary ProtectionLessons Learned Lessons learned are driving transformation of the program Linking case review to quality improvement Increased collaboration to maximize opportunities for improvement Broader impact on quality of care Independent evaluation of the of the program is leading to standardization and increased efficiencies

38. 38 Case Review Costs

39. 39 Volume Data Comparison

40. 40 Impact of New Process for Hospital to Notify Beneficiaries of Appeals Rights Hospital Appeals Volume: 1/1/07 � 6/30/07 3,157 Hospital Appeals Volume: 7/1/07 � 12/31/07 5,595 77% Increase in Volume CMS is Monitoring Volume and Cost Impact Closely

41. 41 BQI Pilots: A Brief History Spring, 2006: Six original sites selected by AQA Wisconsin Minnesota Massachusetts California Indiana Arizona Delmarva Foundation: QIO Program leadership CMS: Pilot site primary functions of data aggregation and reporting across multiple payers AHRQ: Program support and evaluation

42. 42 BQI Pilots: Lessons Learned Data aggregation across multiple payers is not easy Identifying providers Linking patients to accountable provider(s) Demonstrating attribution Cooperation among stakeholders not always streamlined Medicare data as provided by CMS doesn�t always agree with Medicare data collected by private & local entities Aggregated data across payers may reveal startling differences between commercial-only results, Medicare-only results, and aggregated results

43. 43 Chartered Value Exchanges (CVEs) CVE Program administered by AHRQ Responds to President�s Executive Order Part of Secretary�s Value-driven Health Care Initiative (VDHC) Builds on the Four Cornerstones

44. 44 Criteria to Become a CVE Recognized as a Community Leader for VDHC Submit application to AHRQ describing capacity for using & reporting quality measures, sharing information, promoting use of interoperable HIT, and conducting ongoing improvement efforts

45. 45 CVE Selection Process May 2007 � AHRQ�s intent to post a public call for interested parties to become CVEs was published Oct 19 � Dec 19, 2007 � first CVE application period Dec 19 - 39 applications received Feb 1, 2008 � Secretary announced the selection of 14 applicants February 28, 2008: Kick-off meeting of CVEs

46. 46 Selections Announced February 2008 Greater Detroit Area Health Council, Detroit, Mich. Niagara Health Quality Coalition, Williamsville, N.Y. Oregon Health Care Quality Corporation, Portland, Ore. Pittsburgh Regional Health Initiative, Pittsburgh, Pa. Puget Sound Health Alliance, Seattle, Wash. Utah Partnership for Value-driven Health Care, Salt Lake City, Utah Louisiana Health Care Quality Forum, Baton Rouge, La.  Maine Chartered Value Exchange Alliance, Scarborough, Maine Minnesota Healthcare Value Exchange, St. Paul, Minn. Massachusetts Chartered Value Exchange, Watertown, Mass. Alliance for Health, Grand Rapids, Mich. New York Quality Alliance, Albany, N.Y. Healthy Memphis Common Table, Germantown, Tenn. Wisconsin Healthcare Value Exchange, Madison, Wisc.

47. 47 CMS� Role to Support CVEs July 2008 - Provide physician group practice-level results on 12 measures using 2006 Medicare FFS administrative data Measures cover the topics of diabetes care, cardiovascular care, cancer screening, and medication management Provide numerator, denominator and rate for each measure Provide national, state and zip code level rates at the population level

48. 48 Vision for How CVEs Can Use Medicare Data

49. 49 QIO Program Image/Branding The QIO Program, regardless of past achievements, is perceived by many as: Not having achieved its potential Inefficient and not competitive Inadequately administered Burdened by governance inadequacies and potential conflicts of interest Lacking evidence-based metrics and interventions focused on improving outcomes Without accountability and process to demonstrate attribution of interventions to improvement

50. 50 QIO Program Image/Branding Goals Develop a simple, easily understood QIO Program description to answer the question of �what do the QIOs do?� Significantly improve the perceptions of individual QIOs, the QIO Program and CMS oversight and leadership, as perceived by multiple audiences Promote a uniform set of key messages that resonate with our audiences, and which are based in data that demonstrate the value of individual QIOs and the QIO Program Ensure that QIOs are seen as the �go to� experts for any significant healthcare quality and efficiency efforts

51. 51 Increasing QIO Recognition Recruitment, implementation and promotion of national CMS and stakeholder quality campaigns Hospital Quality Initiative Advancing Excellence in America�s Nursing Homes Home Health Quality Campaign IHI 100K Lives PQRI BQI Pilots Chartered Value Exchanges (CVEs) DOQIT and HIT promotion

52. 52 Increasing QIO Recognition Publicity of QIO involvement in national CMS priorities Technical assistance to hospitals during RHQDAPU data collection process Technical assistance to hospitals after publication of mortality quality measures Survey & Certification and State Survey Agency alignment SNF Focused Facility List Hospital and SNF �facilities targeted for improvement�

53. 53 Increasing QIO Recognition CMS Annual QIO Report to Congress History Recently reactive/defensive, must now switch to more proactive mode Periodic general updates during 8th SOW Unique local accomplishments Sporadically promoted Local v.s. national promotion Better if QIOs and CMS together Represents a large, untapped opportunity Must be focused on measurable outcomes that can demonstrate attribution, less on �feel good� events, to be most effective �Bundling� may prove effective nationally

54. 54 Promoting the Program QIO Program News Quarterly publication Highlights positive QIO impact at national and local levels Received well in the partner community Working on strategies for increasing readership by expanding the universe of partners even further Other Public Venues? QIO Program Open Door Forum? National, Regional, & Local conferences and meetings

55. 55 Communicating Program Impact National Program Impact Statement Communications QIOSC developing strategies for promoting Program�s success through data-driven messaging Will be supplemented with a strategy for CMS to promote the �wins� of the 8th SOW at the national level Some QIOs have been working on state-level impact statements that tell the �story� of the QIO Program and its impact on local health care delivery systems See examples from the Illinois Foundation for Medical Care and Qualis Health

56. 56 Support from the Communications QIOSC Communications Clearinghouse on QIONet Contains over 80 tools, all adaptable for local use Key messages Fact sheets Advertisement templates How-to guides/best practices Communications Handbook Tools for developing your own impact statement �Lives impacted� formulae for different care settings State-level impact statement support Guidelines/templates for development Training support and on-going assistance

57. 57 Training Support from Communications QIOSC Communications policy at the staff level How can you leverage the resources available from the QIOSC and from CMS to supplement your communications projects? Social marketing techniques How can the skills of your communications staffer(s) align with what your clinical QI staff are doing for your recruitment and educational efforts? Methods of using data to drive messaging Is there a story within your Westat survey data that can communicate the impact you have on your communities?

58. 58 Target Audiences CMS and individual QIOs Department of Health & Human Services (DHHS) & other federal agencies Office of Management & Budget (OMB) Government Accountability Office (GAO) Office of the Inspector General (OIG) Institute of Medicine (IOM) and relevant healthcare non-profit organizations IHI NQF National Quality Alliances NCQA, Leapfrog, Bridges to Excellence, etc.

59. 59 Target Audiences Press & Media Capitol Hill Senate Finance Committee Senate Health Education, Labor & Pensions Committee House Ways & Means Committee Various caucuses and other Congressional alliances State & Local governments Regional and local healthcare collaboratives Employers Health plans

60. 60 Target Audiences Ultimately, two of our most important audiences are: Providers (and their advocates) Beneficiaries (and their advocates) These two focused audiences can: Help promote the QIO Program with positive stories Hurt us more than help us with negative stories or bad �customer service�

61. 61 Moving Forward Utilize and evaluate existing Communications QIOSC support Lessons learned to apply to 9th SOW from Day #1 Develop a communications/branding strategy for 9th SOW (in process), but implement some of it immediately Local focus National focus

62. 62 Moving Forward Utilize key Program events, starting immediately, for promoting the QIOs and QIO Program CMS/HHS Quality Initiatives announcements & roll-outs Award of 9th SOW contracts Start of the 9th SOW QualNet Conference Quarterly monitoring updates CMS Annual Report to Congress Beginning of planning for 10th SOW

63. 63 Moving Forward Align with CMS Office of External Affairs (OEA) to: Disseminate important QIO Program accomplishments as they occur, but also on a regular schedule Examine opportunities to identify QIO contributions, prior or future, to any CMS initiative or press release Similarly align with Departmental Assistant Secretary for Public Affairs (ASPA) and other Departmental components Tailored outreach to target audiences

64. 64 Moving Forward Special need to do a good job, conduct outreach and manage perceptions of providers and beneficiaries Identify opportunities for publication of SOW tasks, special studies, etc., and promote publicly when published as appropriate Identify �alignment opportunities� outside the QIO Program SOW funding to which QIOs might Survey and Certification ESRD Networks CVEs and similar endeavors focused on Value-Driven Health Care Medicaid, SCHIP, other Consider strategy to �brand� the QIOs at major healthcare quality conferences

65. 65 Contact Information Barry M. Straube, M.D. CMS Chief Medical Officer & Director, Office of Clinical Standards & Quality Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD 21244 Email: Barry.Straube@cms.hhs.gov Phone: (410) 786-6841