Health Care Quality & Safety February 26, 2013

1. Health Care Quality & Safety February 26, 2013 Thomas E. Hamilton, Director Survey & Certification Group Centers for Medicare & Medicaid Services Essential Role of Territorial Leadership

2. Medicare & Medicaid Participation is … Conditional • Conditions of Participation (CoPs) • Hospitals … 42 CFR 482 • Nursing Homes … 42 CFR 483 • Dialysis Facilities … 42 CFR 494 • Ambulatory Surgical Centers … 42 CFR 416 • Clinical Laboratories … 42 CFR 493 • Essential Quality of Care & Safety Requirements • Governance • Staffing and Credentialing • Practice Standards – safe environment, informed patients, … • QAPI – Internal Quality Assessment + Performance Improvement

3. Why Survey &Certification?? • Quality Assurance - Medicare + Parts of Medicaid • 200,000 Providers, 100,000 Onsite Surveys + Investigations - 7,000 Surveyors

4. Clinical Laboratories Test TypeDesirable Range • Creatinine …. (0.5 - 1.6) • Uric Acid ……. (3.5 – 8.4) • Calcium …….. (8.6 – 10.6) • Albumin ……... (3.7 – 5.2) • Globulin …….. (1.4 – 4.5)

5. Health Care – What Could Possibly Go Wrong?

6. Up, Up, and Awry!! • Wrong Site Surgeries • Healthcare-Associated Infections • Medication Errors … Complications “If your remember, I did say there might be side effects…”

8. Today’s Health Care • Highly Complex and Sophisticated • More Dependent on … Teamwork • Performed by … Human Beings • “To Err is Human” – Institute of Medicine • Human Factors Engineering • Focus on the System

9. What Might Governors Do? • Hospital Governance • Leadership + Management • Finance • Funding • Local Funds • Medicaid Matching Funds • Medicaid Certified Public Expenditures • Medicaid Expansion • Billing Systems • Coding Systems (e.g., Medicare coding) • Private Insurance

13. Is Your Board Sending the Wrong Signals ?

14. Keeping Informed Systems – Require Regular Reporting on: • Hospital Finances, Billing, Liabilities • Quality (e.g., Check the CMS “Compare” websites) • Involvement in National Initiatives – Examples: • Value-Based Purchasing • http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based-purchasing/ • Partnership for Patients • http://innovation.cms.gov/initiatives/Partnership-for-Patients/ • http://hret-hen.org/ • Institute for Healthcare Improvement • http://www.ihi.org

15. Keeping Informed With 4. Governance + Leadership • http://www.governanceinstitute.com Welcome the Bad News Bearers • To Avoid becoming a Bad News Bear • QAPI 5. CMS and Accrediting Organization Surveys • Instruct Providers to Alert You on Every Survey • Immediate Jeopardy – 23 Days to Medicare Termination • “Condition” Level Deficiency – 90 Days + Onsite Revisit • Other “Standard” Level Deficiencies – Plan of Correction

16. Thank You • Attention to Health Care Quality • Attention to Access to Health Care • Efforts to Expand both Access + Quality