Quality Improvement Across the Continuum – Responding to Imperatives

1. Susan K. Pingleton, MD Chief Learning Officer University Healthsystem Consortium Quality Improvement Across the Continuum – Responding to Imperatives

2. Quality Improvement Across the Continuum • Setting the Stage: External Imperatives for: • Quality and Patient Safety • Learning • Learning Initiatives to meet Imperatives • Quality and Safety Education for Clinicians • Resident learning in teaching hospitals • What is the future?

3. Quality Improvement Across the Continuum • Imperatives for Quality and Safety • Teaching hospitals demonstrate quality and safety performance • Public reporting, P4P - $$$ • Physician performance • Physician Quality Report Initiatives PQRI)- $$$ • Imperatives for Learning • Medical School Initiatives • Medical School Objective Project (MSOP) • Graduate Medical Education • ACGME • CME • ACCME • Physician performance improvement • Joint Commission • OPPE (ongoing physician performance improvement) • Certification • Licensure, re-licensure, Certification, MOC

4. External Imperatives Hospital Proprietary Voluntary , Quasi Government Local Policy / Government Hospital Associations The Joint Commission Institute forHealthcare Improvement MeasureSets / Initiatives HAI Hospitals, Health Systems National Quality Forum Adverse Events CMS NPSGs SCIP Emerging Physician / Ambulatory Value Based Purchasing ( $$$ ) Hospital Acquired Conditions P 4 P / P 4 R ( $$$ ) Hospital ( $$$ ) Hospital Compare P 4 R , . Physician ( $$$ ) PQRI Adapted from J. Pfeffer, Quality Periscope 4 Page 1

7. Hospital death rates unveiled for first-time comparisonBy Steve Sternberg and Anthony DeBarros, USA TODAY By Steve Sternberg and Anthony DeBarros, USA TODAY Motorists heading through the Lehigh Valley from Allentown, Pa., earlier this year passed two giant billboards proclaiming: "Fast Heart Attack Care Saved My Husband's Life." What the billboards didn't say was just how fast. It took 24 minutes for Richard Silverman's doctors at Lehigh Valley Hospital to clear a 100% blockage from his heart's most vital artery. That's a third of the 90-minute goal that hospitals strive for. "Maybe five minutes more and I'd be gone," Silverman, 63, co-owner of Pro-dent, a dental laboratory in Allentown, says his doctor told him. Doctors at Lehigh Valley are proud of their speed. It's one reason the hospital boasts the lowest heart attack death rate in the country, 11.6%, in a new government analysis obtained by USA TODAY. Among those at the other end of the spectrum is Virginia's Danville Regional Medical Center with death rates for heart attack of 19.6% and for heart failure of 15.5%. August 20, 2008 Source: http://www.usatoday.com/news/health/2008-08-20-hospital-death-rates_N.htm?loc=interstitialskip&POE=click-refer

9. Variance in Health care delivery

10. Marked Increase in Evidence

11. But…Adherence to Evidence-Based Guidelines Varies Widely Percent of Patients in Compliance With Guidelines • Cataracts 79% • Low Back Pain 68% • Depression 58% • Osteoarthritis 57% • Colon cancer 54% • Headaches 45% • Diabetes 45% • Ulcers 33% • Alcoholism 11% • Overall adherence to guidelines 55% • Visits 73% • Counseling 18% & education • Variance involving • Underuse 46% • Overuse 11% Rand survey of 13,000 adults in 12 metro areas. McGlynn, New England Journal of Medicine 6/26/03

12. US Health Care Payments Second to None… Yearly Health Care Expenditures, 2003 GF Anderson, Health Affairs 2006

13. …But What Do We Get For Our Money ? WHO World Health Report, 2006

14. Sooooo…..

16. Crossing the Quality Chasm: Recommendations: STEEEP IOM, 2001

17. What did these IOM reports begin? • Changed the conversation • Bad systems, not bad people • Enlisted a broad group of stakeholders • Federal government • Codify AHRQ as lead federal agency for pt safety • VAH • Nongovernmental • Joint Commission • National Quality Forum • Institute for Health Care Improvement • Regional Coalitions • Purchasers and Payors • Physicians, nurses, therapists, pharmacists • Accelerated changes in practice needed to make health care safe Leape L, Berwick, D JAMA, 293:2005

18. IOM, 2003

19. IOM, 2007

20. Education Training Skills Knowledge Learning

21. Education Training Skills Knowledge Learning Results “Performance through Learning”

22. Shift from activity to results Shift from a Traditional Activity Approach: Follow up & reinforce 5% Education/Training Event 90% Planning 5% To a Learning Results Approach: Planning, pre-work 25% Learning Event 25% Post-work, Apply, Sustain, Measure 50%

23. National Learning Initiatives Across the Continuum • AAMC • Educating Doctors to Provide High Quality Medical Care • MSOP – Quality of Care • ACGME • Resident Involvement in Quality projects • Alliance for Independent Academic Medical Centers • National Initiative – Improving Patient Care through GME • Hand-offs, Infection control, Medication safety • University Healthsystem Consortium (UHC) • Medical Leadership Development, Performance Improvement • American College of Physicians • Transitions of Care • American Board of Internal Medicine • Step Up to the Plate Initiative • Robert Wood Johnson • Pursuing Perfection

25. Quality Improvement Learning Across the Continuum JAMA, September 5, 2007

26. Effectiveness of Teaching QI to Clinicians • Thirty-nine studies evaluated from Jan 1, 1980 to April 30, 2007 • Eligibility Criteria • Curriculum • Formal supervised program using system-based approach • Clinicians • Any practitioner who provides direct medical care to patients • Trainees (medical students, nursing students, residents) • Nontrainees (faculty, medical staff physicians, nurses) • Study inclusion: • Curriculum that taught QI to clinicians • Comparative evaluation - ie, pre/post evaluation, time series • Benefit definition • Baseline difference < 0.05 • 10 studies (32%) evaluated trainees, 7 involved residents • Only 4 studies (of 39) evaluated both educational and clinical processes • Limited evidence that educational outcomes influence clinical outcomes Boonyasai, JAMA, 2007

27. Classification of Studies • Curricula for Trainees • Medical students, nursing student – 3 • Residents – 7 • All ambulatory • Combined didactic instruction with OI activities • 4week ambulatory module – 5 • Weekly or biweekly meetings for year – 2 • Curricula for Nontrainees with Educational Focus (5 of 29) • Hospital faculty, Medical staff • Curricula for Nontrainees included in Multifaceted QI Intervention (24) • QI Training Session Supplementing Noneducational QI Interventions • GI Curricula in IMPROVE and IDEAL Collaboratives • QI Curricula in Breakthrough Series Collaboratives • QI Curricula in Interventions using other collaborative models Boonyasai, JAMA, 2007

28. Results: • Very small number of studies • Limited data showing effectiveness Boonyasai, JAMA, 2007

29. Quality Education for Residents in Major Teaching Hospitals • Purpose: • Determine what residents know about quality and patient safety and how they learned, (curriculum?) • Methods: • Qualitative study of 6 academic medical centers • High vs lower quality clinical performance • Individual interviews at each site (52 total) • IM and Surgery residents (4 total) • IM and Surgery residency program directors • GME Dean and CMO Pingleton, AAMC Petersdorf Project

30. Resident knowledge and curriculum • Resident Knowledge: • General Themes of quality & patient safety • Evidence based medicine • Improvement • Avoiding harm • Extensive knowledge of patient safety • >90 % correct answers Joint Patient Safety goals • Articulated clear understanding of Systems based practice • Curriculum • Positive informal curriculum • Hospitals initiatives and resources (all programs) • Infrequent formal curriculum • Ambulatory only (2 programs) Pingleton, AAMC Petersdorf Project

31. Continuing External Imperatives:The Future….is here

32. CMS hit list 1 CMS Proposed IPPS rule for FY09 (http://www.cms.hhs.gov/AcuteInpatientPPS/IPPS) 32

33. National Quality Forum, 2008

34. Value Based PurchasingWhat Does Value Mean to Healthcare Purchasers? • CMS (Medicare and Medicaid)- Transforming Medicare from a passive payer to an active purchaser of high quality, efficient health care • Private Payers-Adopting tools for promoting better quality, while avoiding unnecessary costs • Explicit payment incentives to achieve identified quality and efficiency goals • Pay for reporting, pay for performance, gainsharing, and competitive bidding are all VBP tools

35. No Increased Payment for Hospital Acquired Conditions (HAC) 1-3. Serious Preventable Events (“Never Events”) • Object left in during surgery • Air embolism • Blood incompatibility • Complications of Care • Cather Associated Urinary Tract Infection • Pressure Ulcers • Vascular Catheter Associated Infections • Falls and Trauma

36. Mandatory public reporting of HAIs 36

37. The Unwanted Visitor • Reality

38. Summary • Many external quality and safety imperatives on Hospitals and Health Systems (more to come) • Need to demonstrate clinical performance improvement, $$ • Financial relationship of teaching hospital to SOM • Importance of learning initiatives • For students, trainees and faculty/medical staff • Need to align learning with the result of improved performance • Need quality education data with improved outcomes • Suggestion of importance of hospitals in providing informal curriculum to residents • Mechanisms to maximize informal curriculum • Learning strategies developed should utilize clinical data to demonstrate clinical performance improvement