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All Hands Meeting September 25, 2008

All Hands Meeting September 25, 2008. Theme: “Quality Improvement” The Big Picture: Brian Goldstein (15 min) Quality Programs: Darren DeWalt (10 min) Application to our practice: Annie Whitney (10 min) Clinic staff and provider roles: Kelly Andress and Cristin Colford (10 min)

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All Hands Meeting September 25, 2008

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  1. All Hands MeetingSeptember 25, 2008 • Theme: “Quality Improvement” • The Big Picture: Brian Goldstein (15 min) • Quality Programs: Darren DeWalt (10 min) • Application to our practice: Annie Whitney (10 min) • Clinic staff and provider roles: Kelly Andress and Cristin Colford (10 min) • Miscellaneous: (10 min) • Home health/equipment/etc.: Judy Martin • Flu vaccines: Judy Martin • Rabies vaccine limitations: Judy Martin

  2. Performance Improvement and Patient Safety Activities Dr. Brian Goldstein

  3. Collaborators • William Furman, MD • David Weber, MD • Larry Mandelkehr, MBA • Celeste Mayer, PhD, RN • Many Department Chairs • Many of you • PIPS Staff • House Staff • Medical Staff Committees • Hospital Epidemiology • Nursing • UNC P&A • Many others . . . .

  4. UNC Health Care Strategic Framework

  5. Performance Improvement and Patient Safety Division-- Values • Our focus is to promote and support System-level improvements in patient care • If you want to say you improved it, you have to measure it • A great culture is a key to outstanding care

  6. Performance Improvement • Acute care • Prevention • Care of chronic conditions/populations • Deliver appropriate care more often • Steer more care to experienced practitioners • Deliver Less “inappropriate” care, less care of unproved benefit • Improve “efficiency”; i.e. eliminate non-value-added “waste” in care delivery • Help make “improving performance” the objective of every person in the organization

  7. Select Core Measures

  8. Anticoagulation Clinic

  9. Reducing Infections

  10. Reducing Infections

  11. Reducing Infections

  12. Reducing Infections

  13. Fisher, ES, et.al. Health Affairs, Web Exclusives, 7 Oct. 2004, pp19-32

  14. Patient Safety • Definition: Eliminating and mitigating potential harms in the course of doing good • “Be more careful” goals • Standardized processes • Ensure competencies • More timely interventions • Involve patients and families • Design tools with human nature in mind • Promote a culture of safety • Teamwork • “Reporting” culture • “Just” culture • Learning culture • Executive involvement

  15. Leapfrog Survey

  16. Pay for Performance • UNC (and Rex) seeing first significant programs • Medicare – “Value based purchasing” using Core Measures • Private insurers -- generally planning to use existing public programs • BCBSNC “customized” partnership with UNC and Rex

  17. Pay for Performance – current reality in our market • Performance-related reimbursement for the entire System will be driven by the performance of a relatively small subset of people – at UNC: faculty, residents, and some Hospitals staff • The measured “performance” represents only a sliver of what we do • The measures are flawed

  18. Pay for Performance - Medicare • Plans October 2008 shift to tie 2-5% of DRG payments to performance • Separately – several “complications” will no longer be paid for if they are deemed to occur during hospitalization

  19. Pay for Performance -- BCBS • Core Measures • Additional measures proposed by UNC and Rex • For UNC P&A – certification in meeting care goals for Diabetes and Cardiovascular diseases, and in using data effectively to improve care • Likely >$10 Million annually (including Rex) potential marginal reimbursement

  20. Core Measures 27

  21. Core Measures

  22. Centers for Medicare and Medicaid ServicesSurgical Care Improvement Measures • Administer prophylactic antibiotics (when indicated) within one hour of surgical incision (two hours for Vancomycin; for cases involving tourniquet, administer abx before tourniquet applied) • Choose a prophylactic antibiotic consistent with current recommendations (these will be reflected on the paper version of the Pre-Procedure Orders Form; we are still working on a CPOE order set)

  23. Surgical Care Improvement Measures • Administer prophylactic antibiotics for no more than 24 hours after surgery end time (48 hours for CABG and other cardiac surgery) • When hair removal is indicated, CLIP hair and do not SHAVE hair (no razors), AND DOCUMENT THIS CORRECTLY (don’t dictate “shaved”)

  24. Surgical Care Improvement Measures • Prevent Venous Thromboembolism: Order and ensure prophylaxis before, and/or immediately after, surgery (e.g. enoxaparin, SCD or TEDs) • For patients on a beta-blocker prior to admission, make sure patient continues to receive beta-blocker perioperatively (from 24 hours pre-op, to discharge from PACU; or within six hours post-op if patient skips PACU); IF BETA-BLOCKER CONTRAINDICATED, DOCUMENT WHY

  25. Surgical Care Improvement Measures • For cardiac surgery patients ONLY -- Ensure that the 6am post-op serum glucose (on POD #1 and POD #2) is less than or equal to 200 mg/dl • For colorectal surgery patients ONLY– Maintain “immediate” postoperative normothermia within 15 min after leaving OR (defined as > 96.8 °F)

  26. CollaborativeMeasures 33

  27. Patient Satisfaction • Results of two (2) questions from UNC’s Press- Ganey survey results will be used to determine UNC’s score: • Overall rating of care received during your visit? • Likelihood of your recommending this hospital to others? • Survey results for the twelve-month period ending May 31 will be provided to BCBSNC no later than July 1 of the year in which the increase is to be implemented 34

  28. Ventilator Associated Pneumonias and Catheter Associated Bloodstream Infections • Data will be a weighted, pooled rate per 1,000 ventilator days (or central line days, respectively) for these intensive care units: Coronary Care, Cardiothoracic, Medicine, Pediatric, Neurosurgery, and Surgery. • Evaluation period: • July 2008 – June 2009 for the 2009 increase • July 2009 – June 2010 for the 2010 increase 35

  29. Prophylactic antibiotics within one hour of surgery • Data will be evaluated according to the individual measure score of the Surgical Infection Prevention Core Measure, calculated as described in Section A above • Evaluation period will be as follows: • October 2008 – March 2009 for the 2009 increase • October 2009 – March 2010 for the 2010 increase 36

  30. NCQA Physician Recognition 37

  31. NCQA Physician Recognition 38

  32. NCQA Physician Recognition 39

  33. Questions?

  34. Health Care Quality and Recognition Programs Dr. Darren DeWalt

  35. Why Worry about Quality? • Americans receive about half of recommended care. Care that meets quality standards McGlynn et al. NEJM 2003

  36. Current Payment for Medical Care • Fee-for-Service • If we document talking about a problem with a patient, we can get paid. • Assume that the meeting with the doctor accomplished all the recommended care….doctors are highly trained and will do the right thing • This was designed when medical care was mostly acute care (patient comes in with infection, we diagnose, treat with antibiotics, episode over) • Current care is more complex, mostly chronic illnesses like diabetes, asthma, heart disease, high blood pressure

  37. Emphasis on Quality • Patients/payers/policy makers want more emphasis on the quality of their medical care and less on “quantity” • How do we demonstrate that we provide quality medical care? • Measure what we do and improve upon it • Our patients deserve this!!!

  38. Role of Recognition Programs • National Committee on Quality Assurance (NCQA) provides recognition to doctors and practices • They create standards to judge whether care is good • Public reporting of recognition status is coming • Payers are now providing enhanced payment for practices that are NCQA recognized (so-called Pay for Performance)

  39. Certification Programs • Specialty Boards (American Board of Internal Medicine) are requiring that all physicians demonstrate measurable quality in order to maintain certification • State Medical Boards are moving in this direction

  40. Future of Performance Assessment • We will be expected to produce evidence that our care quality is excellent • No more reliance upon reputation • Requires ongoing assessment and improvement • This will drive us to provide better care for our patients

  41. New Ways of Doing Things • Performance measures help us identify what we can do better • We design better ways to do our jobs • Our patients receive better care • We like our jobs better and patients have better health

  42. How do we accomplish this? Everyone is needed!

  43. PPC-PCMH Content and Scoring **Must Pass Elements

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