Improving Network Performance through Quality Management

1. “Quality and Network Performance” NCHN 2007 FALL CONFERENCE: Improving the Performance of Networks through Performance Management” Sherilyn Pruitt and Eileen Holloran Department of Health and Human Services Health Resources and Services Administration Office of Rural Health Policy

2. “Formal arrangement among rural health care providers (and possibly insurers, social service providers, and other entities) that uses the resources of more than one existing organization and specifies the objectives and methods by which various collaborative functions will be achieved.” (Academy for Health Services Research and Health Policy) Formal organizational arrangements of at least three separately owned entities (Federal Office of Rural Health Policy) Definitions: Rural Network

3. Networks strengthen health care delivery system by: Improving viability of individual providers Improving delivery of care to people served Can be vertical or horizontal May take any of several institutional forms An affiliation, an alliance, a consortium or a cooperative To keep your network grounded in the community you serve, include community organizations Value and Structure of Networks

4. Quality improvement is a “forward-looking process that allows heath care providers to use a collaborative approach to strive for excellence.” (Academy for Health Services Research and Health Policy) Quality assurance is “the process of looking at how well a medical service is provided” (www.hospitalcompare.hhs.gov), and is based on adherence to standards Quality of care is defined as “whether individuals can access the health structures and processes of care which they need and whether the care received is effective. (Campbell, Roland and Buetow, 2000) Definitions: Quality Improvement, Quality Assurance, and Quality of Care

5. Safe Care – avoiding injury to patients Effective care – providing services based on scientific knowledge Patient-centered care – providing care that is responsive to individual patient references Timely care – reducing waits and harmful delays Efficient care – avoiding waste Equitable care – permitting no variation in quality because of geographic location, etc (2001, Institute of Medicine, Crossing the Quality Chasm: A New Health Care System for the 21st Century) Six Dimensions of Quality

6. Developing a culture of quality improvement 1. Overcoming obstacles to implementation of quality improvement initiatives 2. Sharing information, expertise, and resources 3. Obtaining financial support for improvement initiatives 4. Collecting, analyzing, and reporting data 5. Developing rural quality indicators (Steps adapted from Academy for Health Services Research and Health Policy) How Networking Can Improve Quality

7. Educate network health care providers and patients about the necessity of quality improvement initiatives for ensuring quality care, and secure their “buy-in” Create a climate of trust and collaboration among network members. Encourage leadership development and learning (training, educational sessions, access to web information, etc.) Developing a Culture of Quality Improvement

8. Engage leaders of each network entity; secure their support of quality improvement activities Communicate regularly with network leaders and key staff Utilize outside facilitators or experts in quality and collaboration Adapt existing tools, resources, or examples to fit the network’s circumstances Overcoming Obstacles to Implementation of Quality Improvement Initiatives

9. Develop relationships with other networks that are implementing similar activities Share ideas, strategies, and models Make best use of networking opportunities within your state and region Attend national conferences to learn lessons from the successes and failures of others Sharing Information, Expertise, and Resources

10. Participate in a formal network that offers educational opportunities and technical assistance Partner with other organizations such as your state or regional health association Obtaining Education, Training and Technical Assistance

11. Apply for grants from federal, state and local organizations, including foundations Create revenue-producing services, and use the funds to offset costs of your network’s quality improvement activities Use savings generated through the network to support continued quality improvement activities Obtaining Financial Support for Quality Improvement Initiatives

12. Implement data collection and reporting mechanisms: Develop internal processes and procedures Use health information technology (HIT) tools: Take measures to ensure data security Collecting, Analyzing, and Reporting Data

13. Effects of multiple reporting requirements: May need to report quality measures to a variety of groups Data collected must be detailed enough to meet various reporting needs Data analysis capabilities must be robust enough to produce needed customized reports Collecting, Analyzing, and Reporting Data

14. Network advantages: Shared costs and shared resources across the network Gathering needed funds may be made easier Higher total patient volume from network participation Improved statistical validity of analyses Collecting, Analyzing, and Reporting Data

15. Select indicators that can be easily measured and that meet your reporting needs Learn what indicators other networks are using Be aware of confidentiality Developing Rural Quality Indicators

16. Quality can be measured by looking at Structure, Process, or Outcomes Developing Rural Quality Indicators (Donabedian 1966, Framework for Assessing Quality of Medical Care, as presented by Snyder, 2005 in Introduction to US HealthCare System, JHSPH )

17. (Moscovice et al, 2004, Measuring Rural Hospital Quality)

18. Most quality measures focus on process and outcomes (as opposed to structure). Effect of structure on quality is not as well studied or documented as the effects of process and outcomes on quality Provider’s level of quality is judged primarily based on just process and outcome measures that may not be appropriate for the rural setting because they do not take into account structural issues in the rural healthcare environment Developing Rural Quality Indicators

19. Most quality indicators are designed to measure quality in a high-volume, high-technology, inpatient setting Differences between rural and urban healthcare impact the rural system’s ability to produce quality care. Patient Volume: Lower patient volume in rural areas Care Setting: More ambulatory care and transfers in rural areas (vs. inpatient care) Rural Healthcare Environment: Effects on Quality

20. Differences between rural and urban healthcare impact the rural system’s ability to produce quality care.(continued) Case Mix: Older and sicker patients with higher risk factors in rural areas (yet risk-adjustment algorithms may be insufficient in quality reporting programs) Resources: Greater workforce and supply shortages in rural areas, and often less money to invest in HIT infrastructure Reimbursement: Tendency toward lower reimbursement in rural areas Rural Healthcare Environment: Effects on Quality

21. Reporting Pressure: Rural networks are under great pressure to meet quality-based standards of care and respond to various reporting requirements, pressures, and inducements Joint Commission accreditation serves as proxy for quality, but only 58% of the 2,200 rural US hospitals are currently accredited by the JCAHO (MedPAC report, 2000). Why? Policy Issues in Quality: P4P, Accreditation, and Public Reporting

22. Policy Issues in Quality: P4P, Accreditation, and Public Reporting (Pham et al, Health Affairs, 2006 , The Impact Of Quality-Reporting Programs On Hospital Operations)

23. (Pham et al, Health Affairs, 2006 , The Impact Of Quality-Reporting Programs On Hospital Operations)

24. (Kahn et al, 2006, Health Affairs, Snapshot Of Hospital Quality Reporting And Pay-For-Performance Under Medicare)

25. (Kahn et al, 2006, Health Affairs, Snapshot Of Hospital Quality Reporting And Pay-For-Performance Under Medicare)

26. Usual emphasis on the inpatient setting The IOM[1] reports “a large proportion of care, particularly in the management of chronic illness, is delivered from the offices of small group practices or individual clinicians Rural Areas – emphasis should include the ambulatory setting This allows the focus to include quality measures for common conditions ranging from diabetes to depression. New technologies incorporated into care impacts different levels of providers that network to increase quality care. [1] Committee on Quality of Health Care in America, Institute of Medicine, National Academy of Sciences. Crossing the Quality Chasm: A New Health Care System for the 21st Century. March 2001. Patient Care Impact of Quality Initiatives

27. Collect base line data and track your progress on an on-going basis Guideline Adherence: How well did your network adhere to guidelines/requirements set forth by various groups (CMS, Joint Commission, Institute for Healthcare Improvement, Hospital Quality Alliance, etc)? Evaluate your Progress

28. Compare your progress with other networks that are similar to you (for example, using Hospital Compare) Make adjustments as you go in order to continue your success Acknowledge your results Celebrate with staff when certain benchmarks are achieved Use results for marketing. Evaluate your Progress

29. Structure for Collaboration and Quality Improvement Convened a Clinical Integration Steering Committee (CISC) Composed of multidisciplinary group of clinicians from each MaineHealth community Role: To provide overall leadership for its clinical quality improvement efforts, and to identify priority clinical areas of focus, approve proposed methods, and evaluate results. Adopted the Chronic Care Model as its improvement framework (Wagner, 1996) Institutional Support and Program Funding: MaineHealth provided personnel and financial support for this effort. MaineHealth pursued extramural support, securing funding from the MacArthur Foundation, the Maine Health Access Foundation, and the Robert Wood Johnson Foundation. Case Study: MaineHealth

30. Quality Improvement Process Clinical Programs:Used nationally recognized, evidence-based guidelines to serve as the foundation for each program. Developed patient education/self-care materials, and provider tools for use in a variety of care settings Learning Collaboratives: Adopted the Institute for Healthcare Improvement’s (IHI) Breakthrough Series collaborative model (IHI, 2003; Kilo, 1998) to create system improvement in the outpatient setting. Case Study: MaineHealth

31. Quality Improvement Process Clinical Improvement Registry: Developed a Web-based clinical improvement registry (CIR) to meet growing need for population-based quality reporting Provided secure database, a free tool to track measures/evaluate performance Mapped data fields from the EHR most commonly used in the area to the CIR Case Study: MaineHealth

32. Quality Improvement Process Quality Measures, Data Collection, Analysis, and Reporting: Identified nationally recognized, evidence-based, quality measures to serve as the framework for each program’s annual evaluation Data on quality measures for each program were collected by clinicians and program staff Data analysis was provided by MMC’s Center for Outcomes Research and Evaluation. Case Study: MaineHealth

33. Activities to Spread of Improvement Practices Across MaineHealth System Partnership with Maine Physician Hospital Organizations (PHOs) (Maine PHOs consist of 1,186 physicians in 500 practice sites, 339 primary care physicians in 163 practice sites) Extension of Programs to New Care Settings: Extended several MaineHealth clinical integration programs to additional care settings, such as home care Case Study: MaineHealth

34. Activities to Spread of Improvement Practices Across MainHealth System Collaboration with State and Others Organizations:MaineHealth worked actively to integrate its activities with those of key organizations in the state, most notably the Maine Bureau of Health, other healthcare provider organizations, payers, and employers. Case Study: MaineHealth

35. Activities to Spread Improvement Practices Across MainHealth System Partnership with Maine Physician Hospital Organizations (PHOs) (Maine PHOs consist of 1,186 physicians in 500 practice sites, 339 primary care physicians in 163 practice sites) Extension of Programs to New Care Settings: Extended several MaineHealth clinical integration programs to additional care settings, such as home care Case Study: MaineHealth

36. (Letourneau et al, 2006)

39. Contact the Office of Rural Health Policy Sherilyn Z. Pruitt (301) 594-0819 spruitt@hrsa.gov Eileen Holloran (301) 443-7529 eholloran@hrsa.gov For More Information: