Quality and Performance Improvement

1. Quality and Performance Improvement HLNDV Study Group Summary May 1, 2013

2. Quality and Performance Improvement (19 of 200 questions) • Quality Benchmarking • Medical staff peer review and disciplinary processes • Risk management principles and programs (e.g., insurance, education, safety, injury management, patient complaint) • Performance and process improvement (e.g., CQI, TQM, QA/QI) • Customer satisfaction principles and tools • Clinical pathways and disease management • Utilization review and management regulations • Source: Reference Manual Page 72 to 82 (http://www.ache.org/mbership/credentialing/EXAM/BOG_exam_reference_manual.pdf)

3. Part 1: Benchmarking • Performance refers to output results obtained from processes and services that permit evaluation and comparison relative to goals, standards, past results, and other organizations • Benchmarking- comparative process used by organizations to collect and measure internal or external data that may be used for the purpose of developing, implementing, and sustaining quality improvements

4. Benchmarking Techniques • Hospitals are under increasing pressure to reduce costs • Hospital leaders have been intensifying efforts to identify the steps the organization needs to take to make a difference • Can use publicly reported (Medicare) data for benchmarking • The benchmarking analysis should seek to identify any unexpected differences related to similar or “like” hospitals • It is important to select a peer group carefully i.e. teaching hospital to teaching hospital

5. Sources of Comparative Measures • Patient Satisfaction –CMS HCAHPS • Practice Patterns – Dartmouth Health Atlas • Health Plans – NCQA (HEDIS) • Clinical Indicators – CMS Quality Indicators • Population Measures- State Health Departments, AHRQ (National Healthcare Quality Report)

6. Common sources for Benchmarking • U.S. Agency for Healthcare Research and Quality (AHRQ) State Snapshots • A government tool created to help States improve healthcare quality • Can see how the State performed overall on more than 100 quality measures • Helps organizations develop programs, etc… • http://statesnapshots.ahrq.gov/snaps10/ • Hospital Compare • http://www.hospitalcompare.hhs.gov/ • The Joint Commission Oryx data • http://www.jointcommission.org/core_measure_sets.aspx

11. What are the Core Measures ? • Core measures are disease specific best practice measures. • The measures are part of the performance measurement system developed by the JCAHO. • The measures are publicly reported on the internet and are also utilized by Medicare to judge clinical quality.

12. Where do the Core Measures come from ? • The measures are developed based on best practice literature, medical association clinical recommendations, as well as the National Quality Forum, who is the recognized final pathway for the review and approval of performance measures. • The measures are developed in a collaborative manner, tested and then subsequently approved for performance measurement.

13. What Measures are utilized for Performance Measurement ? • Congestive Heart Failure • Pneumonia • Acute Myocardial Infarction • Pregnancy and Related Conditions • Surgical Care Improvement Project

14. Congestive Heat FailureCore Measure • Discharge instructions specially prepared for CHF patients • Including: activity, diet, weight monitoring, mediations, follow-up appointments, what do do if symptoms worsen • Left Ventricular Assessment • Ace Inhibitor / ARB at discharge for patients with LVEF <40% • Smoking cessation counseling

16. A balanced scorecard is a set of performance measurements used to: a. Assess patient satisfaction b. Ensure the organization does not exceed one performance metric at the expense of another c. Provide a scorecard for annual performance monitoring d. Gather and monitor financial data

20. One method for evaluating relative value of different jobs is: a. Broad banding b. Gant charting c. Scalability d. Benchmarking

21. Which of the following are parts of the dimensions of the strategic balanced scorecard? a. Financial performance b. New technology c. Competitor activity d. Board/management team

22. Part 2: Medical Staff Peer Review and Disciplinary Processes • TJC Standards: The Role of the Medical Staff “The organized medical staff has a critical role in the process of providing oversight of quality of care, treatment, and services. The organized medical staff is a self-governing body that is charged with overseeing the quality of care, treatment, and services delivered by practitioners who are credentialed and privileged through the medical staff process”

23. TJC Standards: Medical Staff and Hospital Governing Board Must create and maintain a set of bylaws that defines its role “The hospital’s governing board has the ultimate authority and responsibility for the oversight and delivery of health care rendered by its LIPs and other practitioners credentialed and privileged through the medical staff process or any equivalent process.”

24. Standards: Disciplinary Processes • Medical Staff Bylaws must include: • Corrective Action • Description of the indications and procedures for automatic and summary suspension • Description of mechanism to recommend medical staff membership and/or termination, suspensions, or reduction in privileges • Fair Hearing • A mechanism for a fair hearing and appeal procedure

25. TJC Standards: Role of Medical Staff Peers “Peer recommendations from peers in the same professional discipline as the applicant are used as part of the basis for the initial granting of privileges.” “There is a process that defines circumstances requiring a focused review of a practitioner’s performance and evaluation of a practitioner by peers.”

26. TJC Standards: Focused Performance Review Define circumstances Method for selecting review panels Timeframes Define circumstances requiring external review Medical staff Involved in evaluation of individuals Communicate findings to appropriate parties Implement changes to improve performance

27. Part 3: Risk ManagementPrinciples and Programs • TJC Standards: Principles of Risk Management • Involve both clinical and administrative activities • Most effective when pro-active, rather than reactive • Include collecting data on potentially high risk processes

28. Risk Management Program • The internal risk management program is the responsibility of the governing board of the health care facility. Each licensed facility shall hire a risk manager, licensed under s. 395.10974, who is responsible for implementation and oversight of such facility’s internal risk management program as required by this section. A risk manager must not be made responsible for more than four internal risk management programs in separate licensed facilities, unless the facilities are under one corporate ownership or the risk management programs are in rural hospitals

29. Risk Management Principles • Which programs, departments, and activities in the organization are subject to risk management policies and procedures? • Serve as a principle operational guide to prevent incidents • Leadership emphasis on the importance of strict compliance, training and retraining for new employees • Incident reports, insurance, universal precautions, exposure, workplace violence, fire alarms and prevention, weapons, hazardous substances, communication interruptions, and emergency evacuation

30. Risk Management Components • Define objectives • Put into place structure and organization • Employ information and reports • Establish IT infrastructure • Clarify and recognize roles and responsibilities • Monitor- identify risks early. Mitigate, intervene, and control effectiveness

31. Contemporary Risk Management: Enterprise-wide Enterprise Risk Management (ERM): • A structured analytical process • Focuses on identifying and eliminating the financial impact and • Volatility of a portfolio of risks rather than on risk avoidance alone

32. TJC Standards: Concepts Related to Risk Management • Safety • Patient • Environment of Care • Sentinel Event • Near Miss • Root Cause Analysis

33. Complaint Management Systems • Prompt and effective resolution of complaints • Recovery of patient/customer confidence • Best resolved at the point of service to assure customer loyalty • Must have a mechanism for learning from complaints and ensuring that staff receives the information needed to eliminate the underlying cause of the complaints • Aggregation, analysis, and root cause determination leads to effective elimination of the cause if possible

34. Patient Safety • Freedom from accidental injury • Adverse event- when a patient experiences harm or injury from a medical intervention • Harm can be preventable. Often errors occur without harm reaching the patient (near miss) • James Reason- Swiss cheese model of harm. When holes align harm can get thru layers of defensive barriers • Error traditionally was blamed on the individual but really is considered a system problem. We need to fix the system/process, but also to hold individuals accountable to expectations- a just culture

35. Patient Safety Tools • Root Cause Analysis (RCA)- retrospective, investigative tool to identify and understand the root causes of an adverse event with a focus on processes and systems • Failure Mode and Effects Analysis (FMEA)- proactive, preventative tool which provides a systematic way to ask: what has failed? What could fail and how? What are the consequences? Improvements are applied to prevent adverse events

36. The Joint CommissionNational Patient Safety Goals • Use at least two patient identifiers when providing care • Eliminate transfusion errors related to patient misidentificaiton • Report critical test results timely • Reduce the likelihood of harm from use of anticoagulation therapy • Comply with hand hygiene guidelines

37. The Joint CommissionNational Patient Safety Goals • Implement best practices to prevent central line associated blood stream infections • Implement best practices to prevent surgical site infections • Reduce the risk of falls • Identify patients at risk for suicide • A time out is performed before a procedure

38. The Joint CommissionSentinel Event • A “sentinel event” is an unexpected occurrence involving death or a serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or risk thereof” includes any process variation for which recurrence would carry a significant chance of a serious adverse outcome

39. The principles of quality improvement require that healthcare executives change their management philosophy from: a. Finding fault with employees to finding problems in processes b. Finding fault with employees to involving them in the improvement of processes c. Focusing on enhanced inspection techniques to focusing on variance d. Focusing on employees’ roles to focusing on process outcomes

40. Which of the following would represent the most common cause of adverse drug events (ADEs)? a. Lack of standardization b. Lack of knowledge of drug c. Preparation errors d. Transcription errors

42. The single most important way patients can help prevent medical errors from affecting them is to: a. Interact with their caregivers b. Research medical error rates among organizations c. Read and understand consent forms d. Choose large, reputable healthcare providers

43. Incident reports should be initiated by: a. A member of the medical/professional staff or by any employee b. Any person with direct patient-care responsibilities c. The department director or supervisor d. The risk manager/quality assurance coordinator

45. Part 4: Performance Excellence • An integrated approach to organizational performance management that results in: • Delivery of ever-improving value to patients and other customers, contributing to improvement healthcare quality • Improvement of overall organizational effectiveness and capabilities as healthcare providers • Organizational and personal learning Source: www.baldrige.gov

46. Quality Improvement • 1924 Walter Shewhart designed a tool to help guide the appropriate action to take in response to variation. The “Control Chart” can differentiate random (common cause) variation from assignable (special) causes • W. Edwards Deming in the 1970s created his 14 Points. He also described the Plan-Do-Study(Check)- Act cycle

47. Quality Improvement • Joseph M. Juran- described three interrelated processes: quality planning, quality control, and quality improvement. The Juran Trilogy • Taiichi Ohno- developed the Toyota Production System (Lean). He described 7 categories of MUDA or waste. These don’t add value to the process. These include: overproduction, inventory, repairs/rejects, motion, processing, waiting, and transport

48. Quality Improvement • Crosby introduced the idea of “zero defects” in 1961 • Feigenbaum originated the concept of TQC- Total Quality Control- excellence driven rather than defect driven. Three steps to Quality- Leadership, Technology, and Organizational Commitment • Ishikawa- developed the Cause and Effect Diagram

49. Definitions • Quality is always judged in comparison to economic limitations • Quality of Care- degree to which health services increase the likelihood of desired health outcomes and are consistent with current professional knowledge • Appropriate care- care for which expected health benefits exceed negative consequences

50. Terminology Quality Assurance - focuses on output Quality Improvement - emphasizes prevention of error (also known as CQI – Continuous Quality Improvement) Quality Control - focuses on proper function of equipment