Economic Outlook: Quality Edition | Summer 2013 by Premier, Inc.

outlook OUALITY

>>> PROVIDING STRATEGIC LEADERSHIP TO FINANCIAL AND CLINICAL HEALTHCARE EXECUTIVES

SUMMER • 2 0 1 3 • SPECIAL EDITION

THE QUEST FOR QUALITY

THE HIGH COST OF LOW RELIABILITY HEALTHCARE

SYRINGE REUSE ENDANGERS PATIENTS

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About the cover This edition of the Outlook is focused on “finding strength in numbers,” both through transparent collaboration with other health systems, like in Premier’s QUEST Collaborative, as well as by developing robust metrics to identify and target areas for quality improvement initiatives. The content in this edition is intended to provide insights to our readership on what health systems are doing to improve quality and enhance the value of healthcare services.

About the publication The Economic Outlook team is excited to bring you the first edition of the Quality Outlook. The Quality Outlook highlights emerging industry trends, specific to quality and performance improvement, impacting our membership and shaping the healthcare landscape. Through publication of the Quality Outlook, we seek to expand the breadth of information and thought leadership we provide to alliance members and other industry stakeholders. A key aspect of the long-term strategy for the Outlook is to collaborate with internal and external subject matter experts to build consensus from diverse points of view. The publication harnesses the expertise of our network of healthcare leaders to illuminate best practices and strategies needed to drive performance improvement. We strive to provide our members and healthcare organizations with valuable, timely information and business intelligence derived from the industry’s most progressive participants. We welcome your comments and questions. For additional information, please email economicoutlook@premierinc.com. premierinc.com/economicoutlook

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letter 04 EXECUTIVE LETTER HEALTHCARE’S DROUGHT CONDITIONS

Mike Alkire, chief operating officer, Premier healthcare alliance

features 06 FINDING STRENGTH IN NUMBERS

THE HIGH COST OF LOW RELIABILITY HEALTHCARE

IMPROVING CHRONIC CARE: IT TAKES A TEAM Creating a national campaign to improve hypertension control

SYRINGE REUSE ENDANGERS PATIENTS

IMPROVING QUALITY THROUGH ENHANCED PUBLIC REPORTING

14 THE QUEST FOR QUALITY

perspectives CHALLENGES OF CLINICAL INTEGRATION: The impact of the Affordable Care Act on supply chain decision-making...............................................................……30

trends in quality improvement THE COST CRISIS: An update on identifying waste............................................................................................................…..38 PACER: Piloting a unified approach to improve quality and reduce costs...............................................................…..44 Cost and case mix transparency in shoulder arthroplasty.................................…..............................................................46 Ventilator-associated pneumonia event reporting demands process and product evaluation.........................50 OUTLOOK LEADERSHIP

EDITORIAL STAFF

Managing director Kayla Sutton

Design and production Christopher Cardelli, director, creative services Sung Ginader, senior graphics designer, creative services Bryan Verrone, project manager, creative services Arkon Stewart, designer, StewartMarr Creative

Executive sponsors Mike Alkire, chief operating officer Durral Gilbert, president, supply chain services Amy Denny, vice president, strategy, supply chain services A special thanks to Tina Harlan, Donna Jansen, Becky Leavitt, Tim Lowe, John Martin, Doug Miller, Carolyn Scott, and Laura Yandell for their contributions to this edition of the Quality Outlook.

Editorial support Amanda Forster, senior director, public relations Alven Weil, director, public relations Bryan Alsop, senior manager, corporate communications Andrea Blom, publishing intern, Economic Outlook OUTLO O K • QTR 3 .1 3 |

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Executive letter Healthcare’s drought conditions

Department launched the “Use Only What You Need” program to reduce water waste. It collaborated with area schools on educational programs and partnered with appliance manufacturers to incent use of water-saving equipment. Penalties for improper water use were also implemented. Advertisements on billboards, sidewalk benches and bus placards featured phrases, such as “CNSRV” and “B STNGY,” that omitted unneeded letters. And it worked. Water usage dropped 30 percent in just one year, and citizens consume 20 percent less water to this day, despite a 10 percent population increase.

Members of the Premier healthcare alliance, Like much of the Southwest, the Denver metro area is facing one of the worst droughts in its history, with experts suggesting that at least 16 billion gallons of water need to be saved in the next year. The good news is they’re prepared. About a decade ago, the Denver Water

Healthcare is facing its own drought. Provider margins are depleted at a time significant investments in technology, labor and other resources are necessary to transition to new care delivery models. And our industry is enduring a shortage of physicians and other clinicians while the aging population and number of people with multiple chronic conditions continues to grow. But like the Denver Water Department and its community, the Premier alliance and our members are prepared.

Building a pathway to change Over the last decade, alliance member hospitals and health systems have pioneered a pathway to change that continues to prove successful. It started with the Hospital Quality Incentive Demonstration (HQID). The purpose of HQID was to see whether economic incentives would spur improvement in the quality of inpatient care. And they did. QUEST built off of HQID’s success, and has become one of the most successful performance improvement collaboratives in history. Members’ mortality rates have dropped 10 percent lower than national averages due to reductions in harms such as sepsis, pressure ulcers and falls. In addition, QUEST hospital costs are 14 percent lower than national averages, and have remained flat for the last three quarters. Now through the PACT Population Health Collaborative, members are developing accountable care organizations (ACOs) to meet the challenge of improving their populations’ health and care experience. And they’re seeing the effect they’re having on the industry as a whole.

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Provider margins are depleted at a time significant investments in technology, labor and other resources are necessary to transition to new care delivery models. And our industry is enduring a shortage of physicians and other clinicians while the aging population and number of people with multiple chronic conditions continues to grow.

Last year in Chicago’s inner city, Mount Sinai Hospital’s Sinai Urban Health Institute (SUHI) launched a program to educate citizens about preventing and managing diabetes. Community health educators go door-todoor in communities hit particularly hard by the disease, some having a diabetes rate three times the national average. Among the major reasons for the high rate of diabetes is a lack of access to healthy foods – the area is known as a “food desert” with only one grocery store serving it. So SUHI partnered with that store to offer healthy shopping and food preparation classes, as well as free health and dental screenings. And opportunities now exist for parents to enroll their children in wellness programs at local schools, day camps and other youth programs.

Over the last three years healthcare spending has flattened out at 3.9 percent, a significant drop compared to the 6.2 percent norm and 9.7 percent in the 2000s. Clearly the recession and other economic factors played a role in this decline. But a recent Health Affairs article argues the slowdown “preceded the recession,” and that spending “slowed more than the drop in income in the most recent recession would predict.” Further Health Affairs analysis directly associates a portion of the slowdown with the implementation of value-based purchasing, as well as shared savings and bundled payment. I couldn’t agree more. Location, location, location The alliance has learned that to reduce healthcare waste, patients must get the right care, at the right time, in the right place. But a traditional care setting isn’t always necessary.

University Hospitals (UH) Rainbow Babies & Children’s Hospital created the UH Rainbow Care Connection — one of the country’s first pediatric ACOs — to improve care and overall health for children while lowering costs. The program targets children with chronic and behavioral health problems. Focusing on patients who under- and over-utilize the care system, the ACO offers alternatives to high cost EDs, since about 70 percent of visits don’t require emergency care. Nurses and doctors are available via phone 24/7 to prescribe medications and provide care advice. Children and their families also have direct access to medical teams with their personal health information as well as state-of-the-art telemedicine stations monitored by a physician who consults on minor issues such as colds and earaches. Though in its early stages, UH Rainbow Care Connection will impact 200,000 children in northeast Ohio, one-third of them Medicaid enrollees.

Through 2012, health educators had canvassed well over 1,000 homes, working with 300 diabetics. They’ve increased their outreach in 2013, and plan to partner with Wal-Mart to expand their wellness program. Prepare for tomorrow today There’s no quick or easy fix to solve healthcare’s drought. Members of the Premier alliance have been taking and continue to take incredibly meaningful steps forward that are setting standards for the nation. It’s clear that collaboration centered on education and innovation is key to replenishing our resources and promoting future success. It’s why alliance members are ready for today’s issues and tomorrow’s challenges. Sincerely,

Mike Alkire Chief operating officer Premier healthcare alliance

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FINDING STRENGTH IN NUMBERS QUALITY OUTLOOK

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n his role as Premier’s chief medical officer, Richard Bankowitz works at an enterprise level to engage physicians, provide thought leadership and ensure that Premier continues to deliver value to its clinician constituency. A boardcertified internist and a medical informaticist, Dr. Bankowitz has devoted his career to improving healthcare quality at the national level by engaging senior clinicians and healthcare leaders in the promotion of rigorous, data-driven approaches to quality improvement. Dr. Bankowitz was named by Modern Healthcare as one of the top 25 clinical informaticists in the U.S. in 2010, 2011 and 2012. In 2013, he was named by the same publication as one of the 50 most Richard Bankowitz, MD, MBA Chief medical officer influential physician executives in the United States. Premier healthcare alliance

Prior to joining Premier, Dr. Bankowitz was medical director at CareScience. He also previously served as the corporate information architect of the University HealthSystem Consortium (UHC), where he was responsible for the strategic direction of the organization's executive reporting tools and comparative data. He earned both his MD and his MBA at the University of Chicago.

Though we tend to associate waste exclusively with inefficiency, healthcare waste comes in many varieties. While optimizing labor and supply costs per case mix adjusted discharge is important in reducing waste, we must not overlook another significant contributor – failure to provide reliable care. In his six-part classification of waste in healthcare, Don Berwick, Institute for Healthcare Improvement (IHI) founder and former CMS administrator, defines failures of reliability as waste caused by poorly executing what we know how to do, resulting in safety hazards and worse outcomes.

FAILURES OF RELIABILITY IN HEALTHCARE TAKE MANY FORMS, INCLUDING: Avoidable hospital-acquired infections Adverse drug events Hospital-acquired conditions that represent avoidable consequences of the therapy itself

In analyzing variations in care delivery, it is helpful to separate common and special causes. Common-cause variation results from inefficiencies inherent in our delivery systems. This is the waste we would find if we could optimize delivery in a mainstream group of patients – those who are not outliers and who have not experienced complications. Special-cause variation, which includes all hospital-associated conditions, is due to intermittent and possibly unpredictable factors. The distinction is important. Too often we assume variations are common cause and begin applying solutions that are ineffective for special cause variations.

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For example, we modeled a population of approximately 2,200 patients undergoing hip and knee surgery in a single large health system. All of these patients were having elective procedures, meaning that they presumably entered the hospital in an otherwise healthy state. We then defined a set of acquired conditions that would clearly be the result of care, including post-operative respiratory failure, pneumonia and other infections. By these standards, we identified 220 patients, or 10 percent of the total, who acquired complications from the hospital. Without analyzing the cases individually, there is a visible average variance of $572 per case, yielding an overall savings opportunity of $1.2 million. Of course, the source of this waste could be attributed to a common cause, such as high device cost. However, if we use the risk-adjusted value of the expected cost per case in the mainstream group as a benchmark, the 220 cases

with hospital-acquired conditions cost, on average, $5,750 more per case. Instead of going after the sources of the waste, which in this case were respiratory conditions (post-operative pneumonia and other infections), we could spend considerable time and effort looking for a common-cause source of inefficiency. To better quantify the true cost of some of the most common hospital-acquired conditions, we analyzed 500,000 cases from the Premier analytic database. We defined a set of potential inpatient complications (PICs) by examining secondary diagnoses together with the present-on-admission (POA) indicator that became a mandatory component of the discharge abstract. We grouped all the observed secondary conditions not present on admission (i.e., acquired in hospital) into related clinical clusters and found 138 individual PICs. We then performed a statistical analysis to determine how much each of these 138 conditions contributed to excess mortality, length of stay and cost.

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WE FOUND THAT IN THE POPULATION

had one or more potential inpatient complications

2,500 excess deaths were associated with these conditions (five excess deaths per 1,000)

44 $20,000

conditions had associated excess costs of more than

per patient. An episode of ventilatorassociated pneumonia, for example, resulted in more than

$64,000 $24,000 $24,000

of excess costs; an episode of simple pneumonia, almost The length of stay associated with these conditions averaged 0.4 days, representing

The additional cost associated with these conditions was almost

200,000

$1,000

excess patient days

per patient

Many argue, sometimes correctly, that although hospital-acquired infections and other conditions add significantly to the cost of care, they nonetheless result in higher reimbursement because of the mechanics of the MS-DRG payment model, which assigns a higher payment for complicated cases. Unlike any other industry, inefficiency within the healthcare system is not just tolerated, itâ&#x20AC;&#x2122;s rewarded. As we move to more accountable healthcare and pay-for-performance models, relying on additional reimbursement to offset the added cost of preventable acquired conditions is clearly an unsustainable strategy. Several hospital-acquired conditions are already denied increased reimbursement by CMS, and beginning next year, reducing hospital-acquired conditions will be a component of value-based payment rewards. It will also form the basis of significant financial penalties. Increasingly, CMS and other payors are refusing to pay more for conditions caused by the delivery system itself.

and a case of acute renal failure, more than

THE LESSON IS CLEAR. FAILURE TO PROVIDE RELIABLE, ERROR-FREE CARE IS A SIGNIFICANT SOURCE OF WASTE IN HEALTHCARE. While we might argue that a higher-cost device or unit of skilled labor might be justified because it results in a better outcome, it is impossible to say that the additional costs of conditions such as ventilator-associated pneumonias are anything other than waste. No one can claim these represent higher-quality care. So here is a case in which the CFO and CMO can each agree: reducing hospital-acquired conditions provides better patient care and decreases excess costs due to waste. The healthcare industry is no exception to the rule that high-quality, waste-free delivery is in fact low-cost delivery.

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500,000 DISCHARGES:

QUALITY OUTLOOK

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SYRINGE

REUSE ENDANGERS PATIENTS

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t has been more than 20 years since I first learned about the problem of reusing syringes on multiple patients. Soon thereafter, I saw a flurry of guidelines cautioning about the practice and recommending the use of a single syringe for each patient. Even so, continued outbreaks of hepatitis C and other diseases among patients indicate that some providers are failing to follow these guidelines.

Safe injection practices, which include the use of a syringe or single-dose vial (SDV) only once and only for a single patient, are imperative. Patients have a right to be protected from infection after receiving an injectable medication. Healthcare providers and organizational leaders have a responsibility to ensure the safety of patients receiving injections.

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Gina Pugliese, RN, MS, is the vice president of the Premier Safety InstituteÂŽ. She has more than 25 years of healthcare safety experience, eight of those as director of safety at the American Hospital Association (AHA). Pugliese is the author of more than 140 publications and is a frequent national and international speaker on healthcare safety-related Gina Pugliese, RN, MS Vice president topics. She holds faculty appointments at Premier Safety Institute Rush University College of Nursing and the University of Illinois School of Public Health, as well as numerous editorial positions with medical journals. She is currently a member of the HHS Healthcare Infection Control Practices Advisory Committee (HICPAC) and the National Quality Forum Steering Committee for Patient Safety Measures: Complications.

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Use of injectable medications Injection is commonly used in healthcare settings to administer a number of drugs and therapeutic agents, including antibiotics, vaccinations, medications used for sedation and anesthesia, and chemotherapeutic agents. Injections are also administered in conjunction with a variety of procedures, such as endoscopy, imaging studies and pain control interventions. To ensure the safety of injectable agents, both the medication and the administration must be governed by safe manufacturing and pharmacy practices that ensure the availability of sterile medication. Sterile medication must be safely prepared (e.g., drawn up in a sterile syringe) and administered in a manner that maintains sterility and minimizes the risk of contamination. To prevent contamination at the time of administration, healthcare providers should adhere to the practices outlined in the Centers for Disease Control and Prevention (CDC) evidence-based Standard Precautions guidelines (see Figure 1).

Figure 1

have been at least 49 outbreaks of injection-related infections from unsafe administration practices, with hundreds of patients infected.1 Twenty-one of these outbreaks involved transmission of hepatitis B virus (HBV) or hepatitis C virus (HCV); the other 28 were of bacterial origin and were primarily invasive bloodstream infections. Approximately 90 percent of the outbreaks occurred in outpatient settings. Pain management clinics, where injections are often administered into the spine and other sterile spaces using preservative-free medications, and cancer clinics, which typically provide chemotherapy or other infusion services to patients who are immunocompromised, were represented disproportionately relative to the overall volume of services provided. In one of the largest outbreaks reported to the CDC, 106 patients were infected with HCV in a Nevada ambulatory surgery center. The infections were linked to the reuse of both syringes and single-use

Three things every provider needs to know about injection safety

Needles and syringes are single-use devices. They should not be used for more than one patient or reused to draw up additional medication. Medications should not be administered from a single-dose vial or intravenous bag to multiple patients. The use of multi-dose vials should be limited and dedicated to a single patient whenever possible. Source: "Frequently asked questions regarding safe practices for medical injections," CDC, last modified February 9, 2011, http://www.cdc.gov/injectionsafety/providers/provider_faqs.html.

Evidence of unsafe practices Though not widespread, evidence suggests that some providers to this day fail to consistently follow safe injection practices. According to the CDC, since 2001 there

propofol medication vials on multiple patients during endoscopy. According to the CDC report, the long-standing practice at the center was to reuse a syringe after changing needles

to obtain additional doses of propofol from SDVs for patients who required additional sedation. Although the syringe was discarded at the end of the procedure, medication remaining in the single-dose propofol vial, which may have been contaminated, was used for subsequent patients. The outbreak cost the health department nearly $21 million for outbreak investigation, response, and notification and testing of 63,000 potentially exposed patients.2 In addition to the hundreds of patients who became infected during these outbreaks over the past decade, an additional 150,000 patients required notification advising them to undergo bloodborne pathogen testing after possible exposure to unsafe injections.3 In response, the CDC has released a new patient notification toolkit to help with patient notification for any infection control lapse or potential disease transmission during medical care.4 Root causes of unsafe injection practices Healthcare providers do not come to work intending to harm patients. Yet lack of awareness and mistaken beliefs about safe injection practices can lead some providers to unwittingly put their patients at risk. For example, it is not true that contamination only affects the needle, leaving the syringe sterile; simply changing the needle and reusing the syringe is unsafe. Likewise, it is unsafe to reuse an SDV for multiple patients or reuse a syringe, even if it was only used to inject medication into intravenous tubing. Although the vast majority of the 5,500 U.S. healthcare professionals surveyed by the Premier healthcare allianceâ&#x20AC;&#x2122;s Safety Institute reported that they follow recommended safe injection practices, a minority reported reusing syringes (1 percent) and single-dose vials (6 percent), unsafe practices linked to outbreaks and necessary patient notifications.5

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CMS added that it shares the concern of providers and suppliers about patient access to critical medications that are in short supply. But since the practice of SDV reuse is not in compliance with infection control requirements, the agency would not change its policy. CMS cited several examples of inappropriate SDV reuse, including: •Preparation of multiple doses for multiple patients from one SDV; •A syringe with a single dose from an SDV prepared on a patient/resident care unit that will be administered more than one hour after preparation; •Use of an SDV to administer injections to more than one patient/resident; and •Use of an SDV to administer anesthesia, moderate sedation or other medication to more than one patient.8 Premier collaboration To support improved patient safety practices regarding injection medication, the Premier healthcare alliance is collaborating with the CDC and its Safe Injection Practices Coalition (SIPC) on their “One and Only Campaign.” The goal of the SIPC is increasing awareness among the general public and providers about safe injection practices.9 At a 2011 meeting convened by Premier

Meeting participants agreed that although significant strides have been made, much work still remains to eliminate unsafe injection practices. The group speculated that cost pressures would continue to be a challenge and require greater clinician involvement in purchasing decisions across all healthcare delivery settings. Role of organizational leaders A culture of safety includes empowering patients to speak up and healthcare professionals to follow and promote safe injection practices. Because it takes just one individual to put hundreds of patients at risk, healthcare leaders must develop and enforce policies and procedures regarding safe injection practices for all relevant staff, including agency and contract personnel, in all care settings. These policies should encompass mandatory education, competency training and ongoing observation of practices. Some organizations have taken additional steps to address unsafe injection practices by eliminating devices and products that pose a significant danger. To reduce the risk of reuse, some hospitals are no longer using large-volume, single-dose vials of medications and instead have stocked medication vials in sizes most appropriate for specific procedures. Ultimately, prevention of injection-related infections will require a comprehensive approach that includes greater attention by all healthcare personnel to basic

infection control coupled with adoption of technological advances. The solution will also require continued partnerships among professional, governmental and non-governmental organizations, with a focus on education and redesigning devices, products and processes. Unsafe injections increase the financial and emotional burden borne by patients, healthcare providers, and our public health and medical care systems. The harm related to unsafe injection practices is entirely preventable. Additional information and recommendations are available on the Premier Safety Institute website: www.premierinc.com/safety. References 1. “CDC Grand Rounds: Preventing Unsafe Injection Practices in the U.S. Health-Care System,” CDC, MMWR 62, no. 21 (2013): 423-25, http://www.cdc.gov/mmwr/preview/mmwrhtml/ mm6221a3.htm. 2. “Outbreak of Hepatitis C at Outpatient Surgical Centers,” Southern Nevada Health District Outbreak Investigation Team, December 2009, http://www.southernnevadahealthdistrict.org/do wnload/outbreaks/final-hepc-investigation-report.pdf. 3. A.Y. Guh, N.D. Thompson, M.K. Schaefer, P.R. Patel, J.F. Perz, “Patient notification for bloodborne pathogen testing due to unsafe injection practices in the US healthcare settings,” Med Care 50 (2012): 785–91. 4. “Patient Notification Toolkit,” CDC, June 2013, http://www.cdc.gov/injectionsafety/pntoolkit/inde x.html. 5. G. Pugliese, C. Gosnell, J. Bartley, S. Robinson, “Injection practices of clinicians in U.S. healthcare settings,” Am J Infect Control 38 (2010): 789-98, http://www.ajicjournal.org/article/S01966553(10)00853-9/abstract. 6. “Memorandum: Safe Use of Single Dose/Single Use Medications to Prevent Healthcare-associated Infections,” CMS, June 15, 2012, https://www.premierinc.com/quality-safety/toolsservices/safety/topics/guidelines/downloads/CMSPolicy-Single-Dose-Vials-June-2012.pdf. 7. “Injection Safety,” CDC, last modified June 6, 2013, www.cdc.gov/injectionsafety. 8. “Memorandum: Safe Use of Single Dose/Single Use Medications,” CMS, June 15, 2012. 9. Safe Injection Practices Coalition (SIPC) One and Only Campaign, CDC, www.oneandonlycampaign.org. 10. ”Safer designs for safer injections: Innovations in process, products and practices,” Premier healthcare alliance, April 11, 2011, https://www.premierinc.com/quality-safety/tools-services/safety/topics /safe_injection_practices/meeting.jsp.

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Concerned about the continuing safety risk associated with SDV reuse, the Centers for Medicare & Medicaid Services (CMS) issued a memorandum in June 2012 reiterating its existing policy about SDVs, noting that a citation would be issued if SDVs are re-entered and used for multiple patients.6 In clarifying its policy, CMS said that the risk of infection associated with using SDVs for multiple patients is well documented with evidence from the investigation of multiple outbreaks. CMS also emphasized that the practice of reuse conflicts with nationally recognized standards, such as those issued by the CDC.7

and SIPC, stakeholders including clinicians, patients, manufacturers and representatives from government, public health, and professional and accreditation organizations identified vital needs in the effort.10 These included increased use of existing innovations, additional product innovations, improvements in related regulatory standards, and increased education and empowerment of both patients and clinicians regarding safe practices.

QUALITY OUTLOOK

CMS prohibits reuse of single-dose vials

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in improving the quality of care they provide. With declining reimbursements and other financial cuts implemented by the Affordable Care Act, healthcare providers must optimize their performance to avoid penalties and meet the demands of value-based purchasing.

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THE QUEST FOR QUALITY. Hospitals today face overwhelming challenges

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To help our members succeed in the new era of healthcare reform, Premier has launched the Quality, Efficiency, Safety

QUEST works with member health systems through various engagement activities, including:

and Transparency (QUEST®) initiative. Through QUEST, member hospitals work with program directors to identify areas of weakness. After reviewing data from member institutions and collaborating with other executives, hospitals and health systems are able to implement successful strategies that raise the quality and efficiency of their care. QUEST helps hospitals find success in a value-based purchasing model, both today and in the future.

• PremierConnect™, a comprehensive, online best-practices forum where hospital executives can easily review successful techniques implemented at peer institutions that may be of use in their own; • Semiannual national meetings that provide health system executives with an opportunity to meet in person and discuss crucial issues and solutions; and • Individual health system assessments using Premier’s benchmarking and analytics that result in collaborative-specific, customized comparative reports. These activities are followed by “sprints,” a 90-day rapid cycle improvement series in which health systems work to improve specific indicators. Members are given additional help through small issue-based collaboratives. Furthermore, members work one-on-one with program directors, who help hospitals develop facility-specific action plans on a quarterly basis. These plans are designed to close performance gaps in QUEST’s six domains of focus (see Figure 1).

The QUEST collaborative began in 2008, defining its role in the healthcare community by its four foundational goals: • Driving rapid improvement in both cost and quality; • Shaping policy and payment guidelines; • Developing and refining data collection, analytical tools, and collaborative methods in support of value-based purchasing and public reporting; and • Helping members achieve top performance in the six QUEST focus areas as measured by “Top Performance Thresholds” (TPTs).

The collaborative, which has grown from an initial 157 members to 333 as of mid-2013, has members in nearly every state and is expanding every quarter. In less than five years, QUEST has experienced tremendous success in driving member hospital improvements. As of Q3 2012, the program has cumulatively prevented 91,480 inpatient deaths, reduced healthcare spending by $9.13 billion, and provided 80,128 patients with quality, evidence-based care.1

The QUEST collaborative has experienced several evolutions since its inception. The sixth goal of readmissions reduction was added in 2011, following the inclusion of readmission penalties as part of the Affordable Care Act. QUEST continues to evaluate new measures as it strives to improve hospital performance. QUEST has also changed the way in which it evaluates the six areas of focus. For instance, a waste report was added to the cost reduction analysis in 2011. This report identifies the greatest opportunities to eliminate wasteful spending within individual institutions.

Figure 1

QUEST’s six domains of focus

Prevented 90,480 inpatient deaths

Cost of of care care Cost

Reduced spending by $9.13

Evidence Evidence- based based care care

billion

Mortality Mortality

Provided 80,128 patients with quality, evidence-based evidence-based care.care

QUEST Patient Patient experience experience

Harm Harm

Readmissions Readmissions

REDUCING HARM The cohort members and quality improvement advisors faced specific challenges in creating a harm index that would assess performance across the collaborative by a single value. Initially, the cohort reviewed existing and proposed measures that could be included in value-based purchasing or other types of reporting. From there, the cohort selected 24 measures for inclusion in the index, dropping factors of low predictive value. The group’s efforts have paid off, as QUEST members’ average harm index score has decreased from 0.22 to 0.12. This reduction was accompanied by a significant decrease in range-of-harm scores. In addition to the harm measures tracked through the index, other safety-related metrics are also tracked and reported, allowing organizations to broaden their efforts and focus on “all-cause harm.”

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One issue QUEST faced early on was creating reliable metrics for subjective qualities. While an area such as cost can be assessed objectively, more abstract concepts such as patient experience and harm are more difficult to analyze. QUEST established its own metrics for these areas, enabling hospitals to assess new aspects of quality.

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Additionally, four measures within evidence-based care (EBC) analysis topped out, signifying adherence rates nearing 100 percent. The collaborative decided to eliminate those measures, as significant improvement was no longer possible.

Trends in inpatient mortality, comparing QUEST and non-QUEST hospitals

Figure 2

■ Non-QUEST

■ QUEST

1.20 1.00

Overall inpatient mortality has decreased for both QUEST and matched facilities since 2006, though QUEST members have seen accelerated improvement, evidenced

12 20

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Trends in adherence to evidence-based care, comparing QUEST and non-QUEST hospitals

Figure 3

■ Non-QUEST

■ QUEST

100% 90% 80% 70%

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by the gap between QUEST and non-QUEST trends in mortality (see Figure 2).

Q3 2012, the QUEST EBC adherence rate was 96 percent (see Figure 3).

Evidence-based care

Notably, the gap between QUEST members and non-members has closed over the years due to mandated hospital reporting of EBC adherence. Required reporting has increased adherence across the nation and has closed the gap to top performance. This trend is evidenced in Figure 4, showing less variation among QUEST hospitals and higher adherence to strictly evidencebased care.

Inpatient mortality rates Inpatient mortality rates, measured by a ratio of observed-to-expected inpatient deaths, decreased 39 percent from 1.02 at the baseline to 0.62 in 2011.

0.40

Overall, QUEST members have improved in each of the six focus areas and have demonstrated better performance than non-QUEST hospitals. The most dramatic advances have come in inpatient mortality, evidence-based care, and cost.

0.60

In the first few years of the program, members have shown improvement across the board, causing QUEST to raise its TPTs from 95 to 98 percent. Adjustments were also made in the cost domain: the bar for TPTs was originally set at the top quartile of performance for all areas except cost, which was set at the performance median. Since then, member hospitals have shown dramatic improvements in cost reduction, and the TPT is now set at the top tercile.

0.80

QUEST raised some of its original thresholds for top performance to match the improvements achieved by members. Since the program’s ultimate goal is for all members to make significant improvement in each focus area, QUEST evaluates performance and re-calibrates its thresholds every three years.

Numerous measures of EBC maxed out their potential, and the remaining measures have experienced tremendous improvement as well. QUEST members began with a baseline of providing EBC 82 percent of the time. (In order for a case to qualify as maintaining EBC, the patient must receive all of the evidence-based care he or she is entitled to. Neglecting even one aspect or option is considered a failure.) As of

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Improvement of QUEST hospitals in adherence to evidence-based care from 2006 to Q4 2011-Q3 2012

REAPING THE BENEFITS OF THE COLLABORATIVE

100%

96% 90%

82%

80% 70%

In reviewing inpatient mortality,

60%

QUEST participants noticed three conditions that resulted in death

50%

more often than expected: 40%

sepsis, respiratory conditions Baseline

Q4 2011 - Q3 2012

and cardiac conditions. Participants decided to target sepsis in hopes of reducing the

Trends in cost adjusted for inflation, comparing QUEST and non-QUEST hospitals

Figure 5

■ Non-QUEST

excessive number of deaths. The collaborative studied QUEST’s

■ QUEST

top performers and extended

$10,000

their best practices to other members. These best practices

$8,000

included early detection of $6,000

sepsis in the emergency department, early measurement

$4,000

of serum lactate levels, prompt initiation of antibiotics after 20

12 20

12 3 Q

11 1 Q

11 3 Q

10 1 Q

0 01

09 3 Q

08 1 Q

08 3 Q

07 1 Q

07 3 Q

06 1 Q

20 3 Q

$2,000

blood cultures, and aggressive fluid necessitation. As a result, the collaborative experienced a

Cost While hospitals nationwide have seen an increase in average cost per discharge, QUEST member increases have been lower than average. The national average shows a 26 percent increase from 2006 to 2011, compared to 11 percent for QUEST members. When inflation is taken into account, all facilities actually show a decrease in average cost per discharge. However, QUEST members show a steadier decline than the

national average and maintain a difference of $1,000 or more between themselves and non-member hospitals (see Figure 5). Furthermore, the aforementioned waste report has identified labor expense, excess readmissions, length of stay, and overutilization of lab work and imaging as the largest sources of waste. The collaborative has worked specifically to reduce these measures as a result.

dramatic drop in sepsis-related inpatient deaths, and as of 2012, sepsis is no longer in the top 10 causes of inpatient deaths for QUEST members.

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QUALITY OUTLOOK

Figure 4

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Evidence E vidence Evidence based babased sed care ccare are Cost Coand st and and Cost efficiency efficiency efficiency

Community Community Comm unity health healthhealth

Mortality

Mortality Mortality

QUEST QUEST QU EST 3.0 3.0 3.0 Patients healthy P atients and he althy communities co mmunities Appropriate hospital use

Patient and family Patient and Patient a nd engagement

family family engagement engagement

Safety

Appropriate Appropriate h ospital hospital use use

LOOKING TOWARD THE FUTURE QUEST 3.0, launching in January 2014, will offer seven modified areas of focus (see Figure 6). The QUEST domains have been expanded to take a broader approach to quality

CMS efficiency measure, and provide specific efforts to eliminate waste using information derived from the waste reports.

improvement, evaluating even more aspects of care.

With the Affordable Care Act well underway, new measures must be taken to ensure the future success of hospitals. With that in mind, QUEST 3.0 will introduce the “Community Health” component which arose from new IRS requirements tied to the Affordable Care Act that require hospitals to conduct community health assessments at least once every three years. The cohort

will use this data to identify a common need across the QUEST collaborative, which could include diabetes, hypertension, or childhood and adult obesity. The Affordable Care Act will also be accounted for in the modified “Cost and Efficiency” domain, which will target an overall cost of care metric, focus on the

With quality improvements necessary for survival in the new era of healthcare, QUEST 3.0 will enable members to achieve maximum performance by considering all current and potential aspects of healthcare reform. Whatever lies ahead, this cohort is ready. References 1. Premier Inc. (March 19, 2013). Major reductions in mortality and costs by U.S. hospitals sharing data, expertise [press release]. 2. Ibid.

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CREATING A NATIONAL CAMPAIGN TO IMPROVE HYPERTENSION CONTROL Jerry Penso, MD, MBA, chief medical and quality officer American Medical Group Association

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Improving chronic care: It takes a team

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Jerry Penso, MD, MBA Chief medical and quality officer American Medical Group Association

here is a growing imperative for medical groups and healthcare delivery systems to improve clinical quality. Many payors include ambulatory quality measures in performance-based contracts, such as value-based purchasing or accountable care, with financial incentives linked to clinical outcomes. Public reporting of quality performance is also increasingly common, compounding the pressure to create a sustainable quality infrastructure. In addition, many payment models now reward the successful management of designated populations. Since a large percentage of healthcare costs are associated with patients who have one or more chronic conditions, many organizations have developed programs to address preventive and chronic disease needs to reduce the total cost of care. Groups beginning their quality journey face a strategic challenge. They must find a target area that will result in improved outcomes and lower costs, while simultaneously engaging and motivating their physicians, employees and patients. For our purposes, an appropriate chronic condition to target is one that is common,

As chief medical and quality officer for AMGA, Dr. Penso leads bestpractices learning collaboratives for the 400-plus member groups, research and benchmarking programs, and AMGA’s national hypertension campaign. Prior to joining AMGA, Dr. Penso served as medical director, continuum of care for Sharp Rees-Stealy Medical Group (SRSMG) in San Diego. When Dr. Penso coordinated pay-for-performance initiatives and chronic disease management at SRSMG, it was recognized as a top performer in California’s pay-for performance program every year, beginning in 2005. Dr. Penso has served on the Integrated Healthcare Association’s board of directors, the California Cooperative Healthcare Reporting Initiative Executive Committee, and the board of directors of the Behavioral Diabetes Institute, as well as chairing the Technical Quality Committee for California’s pay-for-performance initiative.

costly, can be improved and has proven evidence-based care processes. To help groups determine the appropriate chronic condition to target for their respective populations and develop treatment programs, the American Medical Group Foundation (AMGF), the philanthropic arm of the American Medical Group Association (AMGA), created a series of learning collaboratives that targeted specific diseases, such as chronic obstructive pulmonary disease (COPD), diabetes and hypertension. In these collaboratives, teams of physicians, nurses, administrators and quality improvement staff work together and with other teams around the country over the course of a year. The two collaboratives focused on managing hypertension were remarkably successful. In many teams, more than 80 percent of patients were able to control their high blood pressure. These groups learned that the key to improvement was engaging the entire care team and creating standardized processes that were implemented throughout the organization. They had to move away from the more typical practice of medicine that resulted in unwanted variation in outcomes and

toward a more systematic, team-based approach. Borrowing from Lean manufacturing methodologies, the groups learned how to efficiently and consistently produce better results. Impressed by the results, the AMGF board decided to take the program to another level by creating a national campaign centered on the knowledge gained from the 30 groups that participated in the two hypertension collaboratives. Measure Up/Pressure Down is a three-year national campaign to improve care and reduce high blood pressure. It currently includes nearly 150 medical groups and health systems caring for approximately 45 million patients, as well as national partners such as the U.S. Department of Health and Human Services’ (HHS) Million Hearts™ initiative. The goal of the campaign is to have 80 percent of high blood pressure patients in control of their condition by 2016. Improving hypertension control Even though patients have their blood pressure checked at a physician’s office, pharmacy or community screenings, national data indicate that only onehalf of American adults have their blood

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Measure Up/Pressure Down was developed to improve high blood pressure prevention

Figure 1

Creating the campaign The committee identified three elements necessary to make a national campaign for blood pressure control a reality, including the need for: • A concrete, time-limited goal; • Defined, easily understood and adopted care processes; and • An evaluation process to track progress throughout the campaign and confirm the goal had been reached.

Step 1: Pick an ambitious but achievable goal. It was critical to select a goal that would motivate all participants and create excitement around the campaign. The goal needed to be specific; vague, undefined goals would not sustain efforts. The steering committee reviewed medical literature, national quality results in hypertension and results of the previous AMGF

collaboratives. The goal of 80 percent control within three years was identified as a stretch goal, yet one that was reachable. Many of the provider groups in the earlier collaboratives had achieved this result, and national Healthcare Effectiveness Data and Information Set (HEDIS) quality data indicated that 80 percent was doable.3

Step 2: Determine the care processes that would lead to proposed outcomes. Eight critical care processes were chosen as the framework for blood pressure improvement (see Figure 1). The care processes were selected by practical considerations including likelihood of success, ease of adoption, involvement of entire care team, cost concerns, and patient engagement. The committee also decided that medical groups joining the campaign could choose the processes or “campaign planks” that made sense for their local environments. It was not an all-or-none package, which could have kept many groups from joining.

Critical care processes for blood pressure improvement

CHRONIC CARE CHALLENGE - Measure Up/Pressure Down

PRIMARY PROCESS

Hypertension campaign goal: 80% of patients at goal

>>>>>>>>>>>>>>>

Direct care staff trained in accurate BP measurement

Hypertension guideline used and adherence monitored

BP addressed for every hypertension patient, every PC visit

All patients not at goal and with new Rx seen within 30 days

Prevention, engagement and self-management program in place

VALUE-ADDED PROCESS >>>>>>>>>>>>>>>

Registry to identify and track hypertension patients

All team members trained in importance of BP goals

All specialties intervene with patients not in control

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According to the Centers for Disease Control and Prevention, an astonishing 68 million American adults have high blood pressure.1 Approximately 30 million, or 45 percent, are not maintaining good control of their high blood pressure and are currently being treated in the healthcare system, indicating that something is lacking in the healthcare delivery or education process. High blood pressure was listed as a primary or contributing cause of death for about 348,000 Americans in 2008, or nearly 1,000 deaths per day. And the annual cost of high blood pressure is estimated at $131 billion in healthcare services, medications and missed days of work.2

and control to reduce the burden of this chronic condition and lift the standard of care for patients nationwide.

QUALITY OUTLOOK

pressure under control. Why has blood pressure, with good medications and treatment available for more than 50 years, been so hard to manage? And, more importantly, what can we do as healthcare providers to produce better quality outcomes for our patients?

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Standardized measurement is key to quality improvement. If each group measured blood pressure control rates differently, we would never know if the campaign’s goal was reached. So standard measurements were determined, and groups joining the campaign agreed to provide aggregate data to AMGF for evaluation by external researchers. In addition, information was compared to AMGA’s data warehouse, which compiled data from 25 medical groups. Detailed information about participants’ performance – including prescribing patterns, physician performance, visit frequency and demographic factors affecting blood pressure control – provided additional insights for the campaign. Launching the campaign After almost a year of planning, Measure Up/Pressure Down officially launched in November 2012, and additional functions were developed in the first half of 2013. These included monthly webinars focused on individual campaign planks and presented by leading medical experts in implementing hypertension improvement strategies; a website (www.measureuppressuredown.com) that provides resources for both health professionals and patients; and a provider toolkit that serves as a “how to” handbook for participating teams. While improving patient care is not easy, it is essential if we are going to enhance the experience of care, improve the health of populations and reduce per capita costs. As the American population ages, more and more patients will be living with at least one chronic condition such as high blood pressure, increasing the total cost of healthcare. To meet these challenges, we must learn to do things differently, work collaboratively and apply best practices from other organizations.

E STUD Y

Step 3: Create an evaluation plan.

Improving hypertension control at ThedaCare Located in northeastern Wisconsin, ThedaCare Physicians is part of a community health system that encompasses four hospitals, home health, senior services, behavioral health and employee wellness. ThedaCare noted that hypertension was the number one diagnosis in its system, with more than 14,000 patients affected. In 2007, ThedaCare Physicians initiated an improvement program that used a multifaceted approach to help providers in caring for patients with uncomplicated hypertension. Some key innovations adopted by ThedaCare included: • Templates in the EHR that allowed providers to document high blood pressure care in a consistent format and avoid omissions; • Standardized workflows that required patients with elevated blood pressures to speak to a physician before leaving the clinic; • Adjusted refill protocols to prompt office visits for patients with poor control; • Monthly automated emails sent to all physicians showing high blood pressure results by clinic site and individual provider in an unblinded, transparent report; • Competency training and testing for staff to reduce variation in blood pressure measurement techniques across clinics; and • Other patient incentives, including an educational DVD and a free home blood pressure monitor. Within three years, 81 percent of ThedaCare’s patients had their blood pressure under control, according to statewide publicly reported data. References 1. “High Blood Pressure,” CDC, last modified May 2, 2013, http://www.cdc.gov/bloodpressure/. 2. U.S. Department of Health and Human Services (May 2, 2012). HHS Secretary Sebelius statement on National High Blood Pressure Education Month [press release], http://www.hhs.gov/news/press/2012pres/05/20120502a.html. 3. “Continuous Improvement and the Expansion of Quality Measurement: The State of Health Care Quality 2011,” The National Committee for Quality Assurance 2011, http://www.ncqa.org/Portals/0/SOHC-web1.pdf.

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E STUD Y

Improving primary care management of high blood pressure at Riverside Medical Group

Using nurse health coaches to improve high blood pressure control at Mercy Clinics

Based in Newport News, VA, Riverside Medical Group (RMG) is one of the largest multispecialty group practices in the state, with 150 physician practices staffed by 450 providers in 28 specialties. In 2009, RMG’s quality committee decided to make high blood pressure a priority for the practice and assembled a team that focused first on patients with uncomplicated high blood pressure. Some of the interventions included:

Established in 1983, Mercy Clinics Inc. covers the greater metropolitan area of Des Moines, IA. There were 878,000 patient visits to Mercy Clinics in 2010, and the medical staff includes 150 physicians in 10 specialties.

• Educational sessions on hypertension guidelines; • Automated telephone reminders to patients for appointment scheduling; • A nurse leader who traveled to the practice locations to evaluate hypertension management; • Monthly scorecards that provided blood pressure control rates by practice, provider, and patient; • Testing of clinical staff in blood pressure measurement competency by teams of nurses; • Development of a highly secure, Web-based communications tool that enabled patients to communicate with their physician team 24 hours a day; • Hypertension management reports sent to physicians and office managers each month listing all high blood pressure patients, their most recent appointments, next scheduled appointment, and whether they were at goal for BP; and • Hypertension outcomes included in a formula for physician compensation. Starting with a 57 percent blood pressure control rate in 41,408 patients, RMG was able to improve its control rate to 71 percent in two years.

The Mercy Clinics high blood pressure program was an outgrowth of a major practice redesign that featured embedded nurse health coaches, who were required to attend a 30-hour certification class, within primary care practices. The program began by working with more than 13,000 diabetic patients. Nurse health coaches provided: • Registry management, including verification of complete data; • Chart reviews with assessment of patient needs and evidence-based practice guidelines to determine future tests and procedures; • Outreach to patients with poor blood pressure control; • Educational materials, a food diary, home blood pressure monitoring log and one-on-one motivational coaching to support patient self-management; and • Performance monitoring for each practice to improve outcomes. Although there was some initial physician reluctance to delegate duties to the nurse health coaches, as the nurses became a familiar part of the care team, physician acceptance increased. From April 2008 through December 2009, the percentage of patients with diabetes with blood pressure at goal increased from 61.3 percent to 73.7 percent.

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E STUD

QUALITY OUTLOOK

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Improving

quality through

ENHANCED PUBLIC REPORTING

Irene Fraser, PhD, is a political scientist who has specialized in research on Medicaid, private health insurance and healthcare delivery. Since 1995, she has been at the Agency for Healthcare Research and Quality, where she is director of the Center for Delivery, Organization, and Markets. The focus of this center and of Dr. Fraser's current work is on improving the quality and value of healthcare by strengthening the organization, structure and financing of healthcare organizations and markets. Dr. Fraser also spent eight years working on access and delivery issues at the American Hospital Association. Brent Sandmeyer, MPH, is a social science analyst at the Agency for Healthcare Research and Quality. Sandmeyer's projects focus on improving the quality of American healthcare through evidence-based quality measurement, public reporting and delivery system change. He previously worked on public reporting and quality measurement with the Oregon Healthcare Quality Corporation, an AHRQ Chartered Value Exchange. He also produced strategic planning reports on Oregon's long-term care and mental health workforce for the Northwest Health Foundation.

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A final change, and the focus of this article, is heightened public accountability in the form of comparative public reports on quality and cost for consumers.

Figure 1

■ Lowest quality quartile

The premise and promise of public reporting

In theory, greater transparency through public reporting of provider quality can drive improvements in two ways: • Informed healthcare consumers can choose higher quality health plans and providers, thereby improving their own care and ultimately rewarding quality in the marketplace. • Providers can respond to public reports by taking actions to improve their own performance.

Public reporting is also increasingly perceived as a right of consumers, even if (as is often the case) few consumers actually take advantage of it. Research has

Overall quality of care by state

■ Second quartile

■ Third quartile

■ Highest quality quartile

Source: Agency for Healthcare Research and Quality, National Healthcare Disparities Report 20122

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The Agency for Healthcare Research and Quality’s (AHRQ) most recent National Healthcare Quality and Disparities Reports indicate that healthcare delivery remains inconsistent and quality varies considerably from state to state (see Figure 1). In addition, both quality and cost vary tremendously from one healthcare provider to another. Two hospitals in the same town can have dramatically different profiles on patient safety, care outcomes and price.

Broader recognition of these challenges is changing the healthcare environment in many ways. First, providers themselves – physician practices, hospitals, health systems and others – are involved in quality improvement activities. Next, both public and private payors are reworking their payment structures in an effort to remove perverse incentives, such as paying for the extra care required after medical errors. They’re replacing them with more positive ones, such as payment based on quality rather than volume.

QUALITY OUTLOOK

Not too long ago, most people assumed that U.S. healthcare was of the highest quality and that quality would be the same no matter where someone received care. Publication of the Institute of Medicine’s landmark report, Crossing the Quality Chasm, began to dispel that comfort.1

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shown that providers do tend to pay attention and respond to their public ratings.3 Changes in consumer behavior are harder to achieve, but more transparency and better public reporting at the national and state levels provide further opportunities to improve quality.

improvement and redesign, and another 36 percent said they needed to be completely revamped.8 For transparency to be an effective consumer care improvement strategy, public reports must address three challenges: • Measure the right things the right way; • Reach consumers effectively; and • Align with quality improvement efforts.

simply redeploy metrics used in quality improvement miss the mark when it comes to meeting consumer needs. For example, many reports focus on provider adherence to particular processes of care, whereas consumers are likely to be more interested in outcomes. Additionally, the evidence linking specific processes to outcomes is not always robust or easily understood.

Nationally, public reporting is a growing priority for the U.S. Department of Health and Human Services (HHS), and in particular 2. How to achieve continuous A great deal of effort has gone into for the Centers for Medicare & Medicaid improvement within quality measures. addressing each of these goals, but in Services and AHRQ. CMS reports publicly on A tremendous amount of research and this complex and rapidly evolving hospitals, nursing homes and a number of effort has gone into measure development. environment, much work remains. other providers. States are also major proBut metrics developers will always be ducers of comparative public reports, re-examining their methods, particularly for hospitals and health Number of state public reporting mandates by hoping to provide greater precision Figure 2 plans. For example, 43 states now provider category7 based on new evidence, mandate public reporting of methodological breakthroughs, hospital quality (see Figure 2). Provider category Number of states and reports from the field on how current measures are working. Community-level public reports Hospitals 43 by quality collaboratives, such as 3. How to populate reports with Health plans 25 AHRQ’s Chartered Value Exchanges data that is credible, timely, Nursing homes 18 and the Robert Wood Johnson available and economical. Physicians 8 Foundation’s Aligning Forces for Brilliant measures with poor data Quality, complement these state efare essentially useless in public forts.4,5 And the Affordable Care Act (ACA) reporting. At present, public reports Measure the right things the right way accelerates the move to greater transparency. primarily rely on consumer surveys such In particular, the health insurance marketas the Consumer Assessment of Public reports on quality can be no better places or exchanges will give consumers than the measures and data on which they Healthcare Providers and Systems, access to a website where they can view provider data on processes of care, and are built. While this need is obvious, it isn’t quality information as part of their claims or administrative information on easy to fulfill. Many organizations – insurance selection and purchase.6 outcomes (mortality or patient safety providers, payors, quality improvement events, for instance). For the future, there is organizations and others – have been Achieving the promise of public reporting much hope that well-designed electronic developing quality measures for decades. health records will capture quality Using these measures for public reporting The 2011 AHRQ National Summit on Public information more accurately and rapidly and payment raises the bar on the need for Reporting brought together major than current techniques. HHS has several accuracy in measures. At the same time, the researchers and stakeholders (public and activities underway to accelerate and environment for developing and deploying private payors, consumers, providers and enhance this process. In the meantime, these measures is changing dramatically. others) to assess the existing quality and it is important to continue to improve effectiveness of public reports. As part of existing data, adding, for instance, more This combination of factors creates the the summit, researchers surveyed and clinical detail, such as present-on-admission following challenges for those who interviewed experts and stakeholders on and laboratory values.9 develop and/or use established measures the quality of consumer reporting. for public reporting: 4. How to report on quality when Eighty-one percent of those surveyed said 1. How to capture information that organizational forms are evolving. that even the best reports needed substantial consumers care about. Consumer Producing effective public reports of health improvement and redesign. Interviewees priorities differ from those of providers or plans or provider quality is difficult were equally critical: 50 percent said the third-party payors. Thus, reports that enough, but as the healthcare landscape best public reports needed substantial

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There are two potential paths through which public reports can improve quality: providers and consumers. Unfortunately, the consumer path is not a well-traveled one, largely because quality reports do not build on what is known about consumer decision-making, and the evidence base itself leaves something to be desired. While there have been a few notable studies, at this point the design of many public reports for consumers is not evidence-based.10 No matter how valid the measures and how accurate the data, public reports will not have significant use by consumers unless they convey desirable information in a manner, time and place that meets their needs. HHS is now engaged in a major push to improve the science of public reporting. As part of this effort, AHRQ, in partnership with CMS, is funding a family of 17 grants to fill major research gaps in: • Design and presentation; • Effective dissemination (particularly among vulnerable priority populations); and • Improvements in underlying data and methodology to make reports more timely, credible, meaningful and useful.11

In addition, AHRQ enables evidence-based public reporting through MONAHRQ (My Own Network powered by AHRQ). MONAHRQ is a free downloadable software program that allows states, communities and others to produce public reports on hospital quality using existing public data (e.g., Hospital Compare) or their own local hospital discharge data. Even when states have legislative mandates to produce public reports, launching a new report is expensive, time-consuming and requires significant expertise. MONAHRQ’s template can be used by states and others to quickly create and upload a public report that is evidence-based and meets consumer needs. At this point, eight states – Arizona, Arkansas, Hawaii, Kentucky, Maine, Nevada, Utah and Virginia – use MONAHRQ to produce public reports.

ALIGN WITH QUALITY A final challenge for public reporting is to align with quality improvement efforts. Hospitals and other providers are very engaged in quality improvement, with or without the existence of public reports for consumers. While public reports are likely to accelerate quality improvement efforts, greater alignment between public reports and these independent efforts is likely to magnify the effects of both. Tools and initiatives that facilitate use of publicly reported quality metrics for internal quality improvement can support this alignment.12

The future A major goal of the initiative is to facilitate use of the new evidence in real-world reports as quickly and efficiently as possible. With help from a public reporting workgroup at HHS, AHRQ will rapidly disseminate information to CMS and other

Public reports for consumers are here to stay. They will no doubt evolve over time, covering more types of providers, incorporating more data from electronic health records, and taking advantage of

social media and other communication technologies. To achieve the full promise of public reporting, the reports themselves will need to implement quality improvement measures that matter to consumers, reach that audience more effectively and align with broader quality improvement efforts. Effective communication and strong collaboration among providers, consumers, measure developers, researchers, and public report creators will be essential in achieving these goals. References 1. “Crossing the Quality Chasm: A New Health System for the 21st Century,” Institute of Medicine, The National Academies Press, March 2001. 2. “National Healthcare Disparities Report 2012,” U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, May 2013, http://www.ahrq.gov/research/findings/nhqrdr/in dex.html. 3. “Public Reporting as a Quality Improvement Strategy: A systematic review of the multiple pathways public reporting may influence quality of health care,” Agency for Healthcare Research and Quality, July 2012, http://effectivehealthcare.ahrq.gov/ehc/products/343/763/CQG-Public-Reporting_Protocol_20110817.pdf. 4. “AHRQ Chartered Value Exchanges (CVE): Public Reporting Web Sites,” Agency for Healthcare Research and Quality, last modified November 2012, http://www.ahrq.gov/professionals/qualitypatient-safety/quality-resources/value/cvepubrptsites/index.html. 5. Aligning Forces for Quality (AF4Q), Robert Wood Johnson Foundation, accessed June 2013, http://forces4quality.org/af4q-alliances-overview. 6. “About the Health Insurance Marketplace,” Healthcare.gov, U.S. Department of Health and Human Services, accessed May 2013. 7. “Public Reporting of Health Quality and Efficiency Data: Current and Upcoming Statutory Requirements Draft Report,” Assistant Secretary of Planning and Evaluation, January 2013. 8. AHRQ National Summit on Public Reporting, Agency for Healthcare Research and Quality, March 2011. 9. M. Pine, H.S. Jordan, A. Elixhauser, D.E. Fry, D.C. Hoaglin, B. Jones, R. Meimban, D. Warner, and J. Gonzalez. “Enhancement of Claims Data to Improve Risk Adjustment of Hospital Mortality,” JAMA 297, no. 1 (2007): 71-7. 10. “Public Reporting: Research and Data,” Agency for Healthcare Research and Quality, accessed June 2013, http://www.ahrq.gov/health-care-information/topics/topic-public-reporting.html. 11. “Building the Science of Public Reporting: Research Grants,” Agency for Healthcare Research and Quality, last modified October 2012, http://www.ahrq.gov/professionals/qualitypatient-safety/quality-resources/tools/sciencepubreport.html. 12. Geoffrey C. Lamb, Maureen A. Smith, William B. Weeks, and Christopher Queram, “Publicly Reported Quality-of-Care Measures Influenced Wisconsin Physician Groups to Improve Performance,” Health Affairs 32, no. 3 (2013): 536-43.

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Reach consumers effectively

federal agencies that produce public reports, as well as to state and private report producers.

QUALITY OUTLOOK

evolves, the measures at hand may not hold up. Simply repurposing old measures to meet new objectives may be quite complicated, time-consuming and potentially misleading. As hospitals, physician practices and others join together in accountable care organizations or patient-centered medical homes, or as entities accept bundled payments, measures must be adapted to ensure they correctly capture the unit of accountability.

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P E R S P E C T I V E S QUALITY OUTLOOK

Challenges of

CLINICAL INTEGRATION:

The impact of the Affordable Care Act on supply chain decision-making

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Aligning costs with reimbursement Implementation of the Affordable Care Act, coupled with sequestration and the corresponding reimbursement cuts, demands that healthcare providers change the way they provide care. Cost savings will have the most impact on supply chain decisions in the next year, according to respondents from Premier’s semiannual member health system survey, and that impact is felt throughout the continuum of care for both acute and non-acute facilities alike (see Figure 1). Similarly, both acute and alternate sites are focused on continuum of care integration as it affects the supply chain. The need to better align costs with reimbursement, coupled with incentives to drive higher-quality, more accountable care, has encouraged health systems to become more innovative.

“With sequestration and healthcare reform initiatives, we will have a decline in margins, so we’ve had to take a hard look at our cost structure,” says Rebecca Sykes, senior vice president, resource management, and chief information officer at the Cincinnati-based Catholic Health Partners (CHP). “We have been doing cost management for years, but one area that we didn’t focus on was resource utilization.” “That’s driven us to several initiatives to reduce utilization, including blood. Surprisingly enough, blood is a quality issue as well as a utilization issue, since new research has shown that transfusing more blood than necessary can increase complication rates.” Reducing cost in this marketplace is a necessity, says Celeste West, vice president for supply chain at Adventist Health System (Altamonte Springs, FL). “Hospitals are not getting more money, so there is greater attention to how

Figure 1

we reduce cost. Revenues are flat, our rates are flat. We used to average a 4.5 to 5 percent rate increase year over year. For the last three years, we have been around 2 percent. If your rate is flat, and your expenses stay the same, you’re not going to keep your margins, so you have to bring expenses down.” “We have a group of physicians and clinicians who have partnered with us in our office of clinical effectiveness to drive more evidencebased care and hardwire supply changes into our electronic health records. This year, after looking at the evidence, we eliminated general use of silver-coated catheters within our hospitals. Physicians who need silver-coated catheters must document their requests in the EHR system and specify the reason for the order." Facing economic challenges According to survey respondents, reimbursement cuts will have the biggest impact on their

What existing factor will have the greatest impact on your health system’s supply chain over the next year?

Cost savings goals

■ Acute only

Integrating the supply chain across the continuum of care

■ Alternate site ■ Both

Value analysis process Medical device prices Healthcare information technology Drug shortages Commodity prices Comparative effectiveness data Other 0.0%

5.0%

10.0%

15.0%

Source: Premier online survey for Economic Outlook Spring 2013 publication

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

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Celeste West, vice president, supply chain, Adventist Health System

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QUALITY OUTLOOK

“We have a group of physicians and clinicians who have partnered with us in our office of clinical effectiveness to drive more evidence-based care and hardwire supply changes into our electronic health records.”

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Figure 2

Which healthcare trends will have the greatest impact on your health system over the next 12 months? (Top 3)

Organization type Acute only

Alternate site

Both

C-suite

Non-C-suite

Comparative effectiveness research

1.5%

7.4%

2.7%

0.0%

3.3%

Consolidation among health systems

22.5%

24.4%

21.7%

31.7%

18.5%

Employer health benefits/insurance exchanges

21.0%

28.0%

24.4%

24.5%

21.5%

Focus on utilization of products and services

21.3%

20.5%

21.7%

19.4%

22.2%

Health information technology requirements (meaningful use and EHR)

32.4%

31.6%

24.5%

21.6%

35.2%

New care delivery models, such as accountable care organizations

35.6%

24.2%

47.4%

48.9%

30.6%

33.3%

24.2%

29.9%

32.4%

31.5%

Reimbursement cuts

79.6%

85.4%

73.2%

82.7%

77.8%

Uncompensated care

34.7%

41.1%

34.0%

25.2%

39.7%

Use of technology and data to connect care

18.1%

13.1%

20.5%

13.7%

19.7%

Quality improvement initiatives, such as Partnership for Patients, shared savings and bundled payments

Source: Premier online survey for Economic Outlook Spring 2013 publication

Position

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healthcare organization in the next 12 months with 83 percent of C-suite respondents and 78 percent of other respondents citing it as the largest factor (see Figure 2).

Among health system respondents with both acute and alternate sites, 39 percent are currently part of an ACO, whereas 20 percent of acute-only systems and 14 percent of alternate sites are currently part of an ACO. By the end of 2014, 72 percent of systems

Figure 3

Rebecca Sykes, senior vice president, resource management, and chief information officer, Catholic Health Partners

There is no one-size-fits-all answer to the changing healthcare landscape, however. As fee-for-service continues and different pay-for-performance models are tested, many health systems are finding ways to exist in both markets.

Brooklyn Hospital Center (Brooklyn, NY) is also evaluating options in this new environment, according to its president and CEO Richard Becker, MD. “I think the need to develop a population health strategy is in part based on your patient population,” Dr. Becker says. “In Brooklyn, one in three patients is on Medicaid, and those patients are very high utilizers, often with several comorbidities each. They’re expensive to manage acutely as inpatients, and we need to have a much tighter and broader network in order to control the expense and the risk. The end result, of course, is better care for the patient.” “In the meantime, we’re developing our physician network, developing partnerships – and to us, everyone is a potential partner – and we’re looking down the road at the

Does your health system anticipate joining or creating an ACO in the short term?

50.0% 45.0%

■ Acute only

40.0%

■ Alternate site

35.0%

■ Both

30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% We already have an ACO in place

By the end of 2013

By the end of 2014

By the end of 2015

After 2015

My health system will not be creating or joining an ACO in the foreseeable future

Source: Premier online survey for Economic Outlook Spring 2013 publication

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P E R S P E C T I V E S

Nearly half (47 percent) of respondents from health systems with both acute and alternate sites are focused on new care delivery models, such as accountable care organizations (ACOs). Thirty-six percent of acute facilities and 24 percent of alternate sites believe new care delivery models will largely impact their systems over the next year (see Figure 2).

“We are certainly exploring the ACO and other risk-based options, while also having a strong foothold in acute care.”

“We have one foot in each camp, and we are certainly exploring the ACO and other risk-based options, while also having a strong foothold in acute care,” says Sykes. “We are actually building hospitals as we speak, so we are betting in both worlds.”

QUALITY OUTLOOK

So what are health systems doing to meet these challenges? Many providers, both acute care facilities and alternate sites, are consolidating or see consolidation in their markets as a means to create more crossfunctional provider networks and reach larger patient populations (see Figure 2).

with both acute and alternate sites anticipate being part of an ACO, compared to 52 percent of acute-only systems and 39 percent of alternate sites (see Figure 3).

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Figure 4

What are the greatest barriers to clinical integration your organization faces?

■ Acute only

Lack of willingness on the part of providers

■ Alternate site ■ Both

Need for greater incentives to encourage participation Difficulties in implementation of crosscontinuum electronic health records Lack of budget to create integration among providers Lack of system-wide education on the benefits of clinical intregration Lack of providers with whom to collaborate

Other 0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Source: Premier online survey for Economic Outlook Spring 2013 publication

possibility of an ACO to support a populationbased strategy,” says Dr. Becker. Managing the patient population As health systems look at different ways to deliver patient care, they are also analyzing various options for keeping patient populations healthy by connecting care across the continuum. “I think we have done a better job with population health on the acute side,” says Bill Downey, president and CEO of Riverside Health System (Newport News, VA). “What we need to do, and what working in Premier’s QUEST collaborative has helped us do, is take that beyond the acute setting to the physician office and post-acute world.” “We’re broadening the funnel in terms of the number of people we touch,” continues Downey. “We started by looking at our own team members. How do we manage that

population risk? We’re trying to take the aggregate data we have on employees and use it to help them improve their lifestyles. We’re also working to identify how we can

with our free clinics to develop Project Care, which stratifies people based on their risk levels so that they get the best quality care for their needs in the proper settings.”

“What we need to do, and what working in Premier's QUEST collaborative has helped us do, is take population health beyond the acute setting to the physician office and post-acute world.”

Clinical integration may be the glue that holds high-quality, cross-continuum care together. Some 35 percent of C-suite survey respondents cite lack of clinical coordination of care as a driver of healthcare costs, second only to overutilization.

Bill Downey, president and CEO, Riverside Health System

get people in our community into patientcentered medical homes and have them be more engaged with their primary care physicians.” Downey continues, “And we’ve partnered

According to Sykes, “We’ve implemented our EHR at nearly all of our acute care facilities and physician offices, but it’s more difficult to implement in home health and long-term care environments, while truly sharing information seamlessly across the continuum. That kind of integration will really be critical to managing the population’s health.” When asked what barriers are hindering clinical integration, survey respondents across care sites all cited lack of willingness

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on the part of physicians and other providers as the top barrier (see Figure 4). Other barriers differ by setting: 42 percent of respondents from combination site facilities noted the need for greater incentives, compared to 35 percent of those from either acute or alternate sites. More respondents from non-acute settings (20 percent) pointed to a lack of collaborative providers, compared with acute (13 percent) or combination facilities (8 percent).

“Clinical integration is not easy,” West continues. “Physicians are taught to make autonomous decisions and determine what is right for the patient at that moment. What we have to do is coach and teach physicians that part of it is fixing the thing that is happening at that moment, but it’s also about looking across a patient’s whole care plan and making the best decision.”

“Partnerships are key to navigating today’s economic and regulatory challenges,” says Dr. Becker. “We need business partners at every level who are willing to share in the downside as well as the upside. We’re exploring all types of partnerships to drive revenue and improve patient care, including those with competing hospitals, suppliers and payors.” Such partnerships are the basis for the success of Premier’s member health systems. Through collaboratives like QUEST® and PACT™, hospitals implement successful strategies to improve quality of care and lower costs, thus enhancing supply chain decision-making. Study methodology From January – February 2013, Premier, in collaboration with Customer Care Measurement and Consulting LLC, commissioned an

The majority of respondents fall within three title categories: C-suite (29 percent), service line or practice area manager (26 percent), and supply chain or materials managers (20 percent). Nearly one-third of respondents are part of multi-hospital systems or IDNs, and respondent organizations are equally representative of urban and rural areas. Premier healthcare alliance thanks the following experts and alliance members for their contributions to this article: Dr. Richard Becker, president and CEO, Brooklyn Hospital Center Bill Downey, president and CEO, Riverside Health System Rebecca Sykes, senior vice president, resource management, and chief information officer, Catholic Health Partners Celeste West, vice president, supply chain, Adventist Health System

“Partnerships are key to navigating

today’s economic and regulatory challenges.”

Dr. Richard Becker, president and CEO, Brooklyn Hospital Center

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P E R S P E C T I V E S

“We recently hired a medical director of supply chain,” says West. “His responsibility is to work with our chief medical officers and office of clinical effectiveness to help physicians understand why we want to make changes such as standardization, and then really build those relationships so that we get better information.”

Along with greater internal partnerships and collaboration among physicians and healthcare executives, health systems have been forging external partnerships to expand capabilities and capacity for higher-quality, lower-cost care.

online survey of approximately 9,000 healthcare leaders across our membership, representing both acute and non-acute healthcare markets. The survey respondents (n=535) are representative of a cross-section of our members across geographic area and organizational size and type.

QUALITY OUTLOOK

Adventist Health System is leveraging physician leadership to engage other doctors.

Building sustainable partnerships

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TRENDS IN QUALITY IMPROVEMENT QUALITY OUTLOOK

The cost crisis:

AN UPDATE ON

IDENTIFYING

WASTE

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As part of our ongoing effort to help members streamline processes and reduce unjustified variation, Premier identified 16 categories of waste and pinpointed the average annual savings potential among providers.

Supply Usage

Quality and Safety

Staffing Effectiveness

Figure 1

Average opportunity, for those hospitals with opportunity, identified within the 16 measures

Number of hospitals

2012 Average identified opportunity

2013 Average identified opportunity

Staffing efficiency

211

$6,180,000

$5,349,000

Staffing skill mix

217

$2,380,000

$1,747,000

Overuse of overtime

252

$709,000

$1,400,000

Excessive readmissions

578

$3,830,000

$3,291,000

Overall length of stay

573

$2,630,000

$3,125,000

Lab test utilization

467

$2,230,000

$1,758,000

Imaging utilization

467

$1,520,000

$1,578,000

Respiratory therapy utilization

467

$1,500,000

$1,519,000

ICU utilization

431

$595,000

$562,000

Excessive occurence of certain surgical patient safety indicators

501

$564,000

$408,000

ICU length of stay

431

$339,000

$341,000

Blood utilization

468

$1,060,000

$324,000

Anti-infective drug usage

290

$419,000

$366,000

Central nervous system drug usage

208

$68,000

$62,000

Purchase order administration

162

$52,000

$39,000

GPO contract activation

312

N/A

$25,000

Source: A database maintained by the Premier healthcare alliance

Featured in the Spring 2012 edition of the Economic Outlook, the waste dashboard offers providers a better understanding of where they can safely remove the greatest amount of cost. The dashboard analyzes hospitals with opportunities for savings improvement by looking at three databases maintained by Premier: a clinical and efficiency database used for quality improvement, an operations database used for efficiency improvement, and a support database used for purchasing decisions.1 Premier calculated the average amount of savings that could be generated annually by a

typical 200- to 300-bed community hospital. The efficiency dashboard is customized by hospital to give the most actionable information possible. A benchmark is set based on top quartile performance, and hospitals receive quarterly reports showing areas where their organization falls below the benchmark and the magnitude of potential savings. Measures are tracked over time to show where progress has been made quarter to quarter. Since the initial release of the dashboard, we’ve taken a closer look into the specific areas of opportunity across 518 hospitals

with updated data, including a new measure related to GPO contract activation. Opportunities represented are the average of all hospitals assessed, regardless of teaching status and bed size (see Figure 1). Savings opportunities Results from the 2013 waste dashboard (data from calendar year 2012) show: • At least one savings opportunity was available for all hospitals, • 89 percent had savings opportunities in at least half of the measures, and • 8 percent had savings opportunities in all measures. O UTLO O K • QTR 3 .1 3 |

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Of the 15 metrics that were looked at in both years, nine of them have seen reductions in overall savings opportunities from 2011 to 2012. The dashboard identified the following five areas with the biggest opportunity for average annual savings per hospital (ranking of 2012 categories in parentheses).

hospitals have some opportunity in managing contract activations, the average opportunity to convert to new contracts in a timely manner is relatively small. Potential savings from optimizing resources are not spread equally among hospitals. The majority of hospitals perform much like their peers, translating to smaller opportunities. However, some hospitals have large variances compared to peer organizations. Overtime utilization – A closer look

1. Staffing efficiency, such as processes that take too long or require too many employees to complete: $5.35 million per hospital per year (compared to $6.18 million in 2012)

2. Excess 30-day readmissions: $3.29 million per hospital per year (compared to $3.83 million in 2012)

3. Inappropriate length of stay: $3.12 million per hospital per year (compared to $2.63 million in 2012)

4. Unnecessary lab testing such as blood, urine or hemoglobin tests: $1.76 million per hospital per year (compared to $2.23 million in 2012)

5. Staffing skill mix, such as a difference in the types of roles performing various functions in the organization: $1.75 million per hospital per year (compared to $2.38 million in 2012)

It’s clear that some measures represent more opportunity than others. Given that labor expense accounts for approximately 50 percent of an average hospital’s total costs, it’s not surprising that the largest opportunity is related to staffing efficiency, averaging more than $5 million. Conversely, despite the fact that most

Waste related to overtime is a prime example of variation, since 36 percent of hospitals had less than $500,000 of potential waste, compared to 6 percent with more than $5 million (see Figure 2). So what drives this disparity in opportunity? Certainly one factor is the size of the hospital, but that is not true for every measure. For example, comparing hospitals by overtime rate – overtime hours as a percentage of total paid hours – shows that nearly 60

percent had an overtime rate higher than the overall aggregate average rate of 2.6 percent (see Figure 3). Although the overall overtime rate of 2.6 percent has remained relatively unchanged over the last four years, there are exceptions. Understanding those trends can lead to improved management of staffing expense. First the good news: hospitals are controlling overtime in departments that have historically had the most overtime at the greatest overall cost. As an example, overtime in nursing units has actually decreased since 2009. Given that nursing units account for about 43 percent of overtime hours in a hospital (and an even greater proportion of the overtime dollars), this indicates hospitals are controlling unnecessary overtime and improving staff morale that can dip when mandatory overtime is imposed. Within nursing units, overtime among registered nurses (RNs) has decreased, while overtime for non-licensed clinical staff has

>6.5%

6.0-6.5%

5.5-6.0%

5.0-5.5%

4.5-5.0%

4.0-4.5%

3.5-4.0%

Figure 3

3.0-3.5%

2.5-3.0%

2.0-2.5%

1.5-2.0%

1.0-1.5%

Cost opportunity in thousands

Source: A database maintained by the Premier healthcare alliance

Number of hospitals by overtime rate

100

Source: A database maintained by the Premier healthcare alliance

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$12500 to $13000

$12000 to $12500

$11500 to $12000

$11000 to $11500

$10500 to $11000

$10000 to $10500

$9500 to $10000

$9000 to $9500

$8500 to $9000

$8000 to $8500

$7500 to $8000

$7000 to $7500

$6500 to $7000

$6000 to $6500

$5500 to $6000

$5000 to $5500

$4500 to $5000

$4000 to $4500

$3500 to $4000

$3000 to $3500

$2500 to $3000

$2000 to $2500

$1500 to $2000

$1000 to $1500

$500 to $1000

$0 to $500

TRENDS IN QUALITY IMPROVEMENT

<1.0%

Number of hospitals

Figure 2

QUALITY OUTLOOK

Number of hospitals

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Distribution of overtime utilization cost opportunity

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Figure 4

Overtime rate by job category

5.0%

––– Clerical ––– Clinical (non-licensed)

4.0%

––– LPN (licensed practical nurse) ––– PR (nursing Other)

3.0%

––– Professional (non-nursing) ––– RN (registered nurse)

2.0%

––– Support 1.0%

09 Q

10 Q

11 Q

12 Q

Source: A database maintained by the Premier healthcare alliance

Figure 5

Overtime as a percent of all hospital overtime hours

RN (registered nurse) Clinical (non-licensed) Professional (non-nursing) Clerical Other/Undefined Support PR (nursing other) Technical Management LPN (licensed practical nurse) Executive 0.0%

5.0%

Source: A database maintained by the Premier healthcare alliance

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

Trends sngle pges_Layout 1 7/31/13 3:15 PM Page 6

increased, indicating that managers are more efficiently deploying staff (see Figures 4 and 5). The bad news is that overtime rates have increased in surgical areas, facilities, and clinical support services (such as central sterile, case management and IV therapy). Overtime rates jumped 25 percent (from 3.2 percent in 2009 to 4.1 percent in 2012) for nursing professionals who are not in direct patient-care roles. While these employees account for a small percentage of overall hospital overtime hours, they are often paid at a high hourly rate. So how can you manage overtime effectively?

Key Principles of Labor Management • Lead with quality: Identify and measure quality outcome indicators before, during and after change implementation. • Understand this is a journey, and leadership must drive a consistent awareness. • Be objective: An objective, consistent, institution-wide philosophy is required. • Rapidly design and implement with timelines of six months or less via clear communication and accountability. • Achieve leadership resolve: Leadership must set the strategic direction and put in place the organizational road map for managing labor. • Standardize processes & tools for establishing, reviewing, reporting and updating labor standards. • Use benchmark & comparative information to gauge best practices. • Provide coaching support for education and facilitation. • Set aggressive targets and attainable goals. • Translate to daily operations to establish expectations and assist in evaluating the best methods to implement changes within departments. • “Variabilize” fixed costs to flex staffing in support and back office departments on a quarterly basis. Premier, Inc. Eleven principles for a complete approach to hardwiring labor management, https://www.premierinc.com/wps/wcm/connect/9b765170-07b9-4d43-ae36af2ca423b724/11+Principles+of+Labor+Management.pdf?MOD=AJPERES.

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Reference 1. Timothy J. Lowe, Eugene Kroch, John Martin, and Richard Bankowitz, "Development of a method to measure and compare hospital waste: The Premier Hospital Waste Index," Am J Med Qual (May 16, 2013): doi: 10.1177/1062860613486830.

QUALITY OUTLOOK

1. Monitor all areas of the hospital closely. Don’t rely solely on historical data to forecast future needs. Use benchmarks to ensure overtime is not out of line with other high quality peer organizations for each role within all departments. 2. Identify areas where unnecessary overtime hours are occurring within the hospital. We know that nursing units typically account for a large proportion of total overtime hours and expense. 3. Use effective scheduling and monitoring tools to learn if overtime is being used to cover scheduling gaps or if staff members are staying late. Gaps in the schedule can indicate an insufficient number of nurses on staff or simply poor scheduling. If employees are frequently staying late, there are usually opportunities to improve departmental work processes.

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Piloting a unified approach to improve quality and reduce costs

PACER With the industry moving toward higher quality and accountable patient care, there are many changes occurring in payment methodologies to spur quality outcomes beyond those associated with volume incentives.

One significant and ongoing management challenge is migrating from today’s fee-for-service payment model in a fragmented marketplace to total cost accountability for a defined patient population. This transition requires stronger hospital-physician alignment and compels health systems to improve quality and reduce costs.

Working with a multidisciplinary team from five large integrated delivery networks (LIDNs), Premier’s PACER group uses collaborative data to improve outcomes and reduce cost in specific physician preference areas. Participating LIDNs include Adventist West, Carolinas HealthCare System, Henry Ford Health System, Norton Healthcare and Methodist Health System. In a pilot program, PACER examined clinical evidence, clinical outcomes and utilization data to determine best practices and reduce unnecessary variation in cardiac stent use. For Jim Olsen, senior vice president of materials resource management at Carolinas HealthCare System in Charlotte, NC, this data-driven process is what set PACER apart from previous LIDN

collaboratives. “Over the years, we’ve focused on quality, but we couldn’t really measure it,” Olsen said. “With PACER, we have all the data from QualityAdvisor™, so we were able to concentrate specifically on outcomes. All the way through the process, our first priority was getting great patient outcomes.”

PACER engages an integrative, crossfunctional team of cardiologists, hospital administrators and supply chain leaders. This novel approach allows physicians access to sourcing and pricing information. George Hersch, vice president of material management at Norton Healthcare in Louisville, KY, emphasized the importance of including physicians in the decisionmaking process and exposing them to all aspects of sourcing strategy. “Physicians are really in control of the supplies that are used, but now that they are part of the process, I think we're starting to see a little turn that we hadn't seen before,” Hersch said. Physician preference items have long dominated health system costs, accounting for as much as 40 percent of supply

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Including physicians in the process seemed to make all the difference when it came to trying out alternatives to physician preference items.

“Dialogue and collaboration led us to see the lack of differentiation among manufacturers. This allowed us to make our decision and helped our physicians gain confidence that these products would have positive outcomes for their patients,” said Hersch.

Hersch made similar observations at his health system. “By doing the process the way we did, by taking it a little more slowly initially, we built confidence that we weren't doing something to the physicians; we were doing it with them,” he said. “The process became as important as the item that we were studying.”

Ultimately, the collaborative identified hospital and physician capability as the factors that most influenced patient outcomes. “We also found out that the choice of the stent was not what determined the outcome; it was the physician capability, the clinician capability, the hospital's capability,” said Olsen. “If the doctor is doing a great job, if the clinician is doing a great job and the hospital is doing a great job, that's where quality patient care and great outcomes come from.”

The collaborative met biweekly from December 2012 through February 2013. The group evaluated clinical evidence, clinical outcomes and utilization data to make an informed decision about cardiac stent suppliers. From there, pricing was considered before each system further explored its local and group data.

Reference 1. Eugene S. Schneller and Larry R. Smeltzer, Strategic Management of the Health Care Supply Chain (San Francisco: Jossey-Bass, 2006).

The group ultimately decided on a dual source vendor, saving 15 percent among the five LIDNs.

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Participating members found their physicians to be quite receptive to this empirical review. “Physicians are very data-driven,” said Hersch. “They're scientists. While they may be comfortable with a certain sales representative or a certain product line, and may even have a relationship with the company in some cases, they respond to clinical evidence. If the financial evidence is compelling, and they know they're going to get the same patient outcomes, then they’ll be receptive to using a different product. They just need the data and involvement in the process.”

“If physicians are involved, if they're part of bending the cost curve, then there is more buy-in at the end,” noted Olsen. “It's not a situation where we make a decision and then try to sell it to them. From the beginning, they're part of it, it's their process and the buy-in is there.”

QUALITY OUTLOOK

spend.1 Many of these items are preferred simply because of familiarity and comfort, even though options with higher quality and lower cost may be available. The PACER collaborative used QualityAdvisor and data from existing literature to help health systems make informed decisions about these products.

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Cost and case mix transparency in shoulder arthroplasty > Shoulder arthroplasty, or shoulder joint replacement, was first used in the United States to treat severe shoulder fractures in the 1950s.1 Today it’s used for a wider range of joint injuries – including arthritis, joint trauma and rotator cuff tears – when more conservative treatments have failed to relieve pain or increase mobility.

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Figure 1

U.S. shoulder implant procedures by volume, 1999-2010

100,000 90,000 80,000 Includes revision procedures

70,000 60,000 50,000 40,000 30,000

10,000 0 1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Source: Orthopedic Network News

During the procedure, the damaged parts of the shoulder are replaced with a prosthesis or implant.2 Due to enhanced products, safer procedures, increased efficacy and clinical innovations, shoulder arthroplasty has become more popular, increasing from approximately 40,000 surgeries in 2005 to 88,000 in 2010 (see Figure 1).

Figure 2

Shoulder implants for resurfacing, hemi-arthroplasty and total shoulder replacement, respectively (left to right)

Clinical innovation Currently there are several standard shoulder arthroplasties, including total and partial replacement (i.e., hemi-arthroplasty) and resurfacing. These procedures differ based on the number and structure of implant components involved. For example, a total shoulder replacement uses a humeral stem, ball and socket, while hemi-arthroplasty uses a humeral head and stem only. Resurfacing uses a humeral cap and screw (see Figure 2).

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QUALITY OUTLOOK

20,000

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Figure 3

Implant components for a reverse total shoulder replacement

The authors concluded that reverse shoulder arthroplasty, which is the highest-cost shoulder repair procedure, may be over-performed in some cases, leading to greater hospitalization expenses and an increased risk of complications.

same rate. Since variable device costs and the risk of complications resulting from the overuse or inappropriate use of these procedures presents a challenge to hospital profitability, facilities should carefully consider their surgical clearance criteria.

Case study: Cost evaluation in 18 Premier member health systems

In early 2013, a cohort of 18 Premier member hospitals collaborated to determine if there were significant differences in patient case mix and procedure type for their shoulder arthroplasty procedures. The goal was to identify potential cost savings by aligning best practices among the participating cohort.

Since many shoulder replacements are elective, health systems must closely evaluate their cost and perform the most clinically and financially appropriate procedure. With reimbursement cuts and other financial imperatives facing providers, many health systems are re-evaluating their costs to reach Medicare break-even levels.

In 2004 the Food and Drug Administration (FDA) approved reverse shoulder replacements that attach a metal ball to the shoulder bone and a plastic socket to the upper arm bone. Compared to conventional approaches, reverse shoulder replacement allows patients to use the deltoid muscle, rather than the rotator cuff, to lift their arms. The procedure uses six different implant components that can be beneficial to patients with rotator cuff tear arthropathy, a complex type of shoulder arthritis (see Figure 3).3 These additional components are also associated with higher costs. According to the American Academy of Orthopaedic Surgeons (AAOS), reverse total shoulder replacement is indicated for those with complete rotator cuff tears, cuff tear arthropathy or a prior unsuccessful shoulder replacement.4 In a literature review of 21 studies, researchers examined the causes that resulted in reverse shoulder arthroplasty (see Figure 4).5 The authors found that between 11 and 31 percent of surgeries met the suggested indications as stated by the AAOS. They also noted that surgeries for patients not meeting the guidelines appeared to have a higher risk of complications.

The FY2012 Medicare national average payment for DRG 484 (major joint and limb reattachment procedure of upper extremity w/ or w/o cc/mcc) was $11,228, which is intended to cover the medical device, indirect average length of stay (ALOS), and ancillary case costs. All four types of shoulder arthroplasty procedures (resurface, partial, total and reverse) discussed above are reimbursed at the

Figure 4

To calculate the rates, cost data from the cohort were collected, aggregated and stratified to show low, average and high device cost for each type of arthroplasty procedure. Medicare average length of stay and ancillary case costs were estimated to be approximately $1,000 per procedure. This did not take into consideration procedure complexity, regional variation or expenses associated with potential complications. To provide a benchmark for cost comparisons, the Medicare reimbursement rate for the full procedure was

Incidence of complications after reverse shoulder arthroplasty (RSA) procedure by etiology

Cause

Proportion of RSA procedures

Cuff tear arthropathy

Complication rate

40.7%

19.5%

Fracture sequela

5.2%

5.0%

Rheumatoid arthritis

2.9%

*45.0%

Acute fracture

2.3%

**36.0%

Tumor

0.8%

N/A

Revision surgery

27.6%

33.3%

Unknown

20.5%

N/A

*Only cited in two studies **Only cited in one study

Source: Matthias A. Zumstein, Miguel Pinedo, Jason Old, and Pascal Boileau, â&#x20AC;&#x153;Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: A systematic review,â&#x20AC;? Journal of Shoulder and Elbow Surgery 20, no. 1 (2011): 151.

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compared to the low, average and high device costs for the remaining arthoplasty procedures (see Figure 5).

systems, it does indicate the need for health systems to examine the clinical necessity and effectiveness of their shoulder replacement procedures.

health systems trying to meet Medicare break-even levels may want to evaluate their case mix and/or move toward lower-cost supplies. For instance, a health system with a high reverse shoulder mix will need a lower procedure cost to maintain profitability. The high-cost benchmark for total shoulder replacement also exceeded Medicare reimbursement when additional expenses were included, demonstrating another opportunity to revisit supply costs.

High and average device costs for the reverse total shoulder replacement procedure, including the ALOS and ancillary case expenses, exceeded Medicare reimbursement. Nearly half (44 percent) of all FY2012 shoulder arthroplasty cases performed in the cohort were reverse shoulder replacements; 36 percent were conventional total shoulder replacements; 15 percent partial; and 5 percent were resurfacing procedures.

References 1. “Shoulder Joint Replacement,” American Academy of Orthopaedic Surgeons, last modified December 2011, http://orthoinfo.aaos.org/ topic.cfm?topic=A00094. 2. Ibid. 3. “Reverse Total Shoulder Replacement,” American Academy of Orthopaedic Surgeons, last modified September 2010, http://orthoinfo.aaos.org/ topic.cfm?topic=A00504. 4. Ibid. 5. Matthias A. Zumstein, Miguel Pinedo, Jason Old, and Pascal Boileau, “Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: A systematic review,” Journal of Shoulder and Elbow Surgery 20, no. 1 (2011): 151.

For this collaboration, participating health systems were given the benchmarks to compare their individual supply costs and case mix with other participating systems. Although this study of 18 Premier members may not be indicative of all U.S. health

The cost for device components vary by procedure type even though the Medicare reimbursement rate remains static, so

$16,000 $14,000

■ Ancillary case

Medicare FY2012 national average payment - $11,228

■ ALOS

$12,000

■ Device cost

$10,000 $8,000 $6,000 $4,000 $2,000

Resurface

Partial

Total

High

Average

Low

High

Average

Low

High

Average

Low

High

Average

Low

Reverse

Source: A database maintained by the Premier healthcare alliance

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TRENDS IN QUALITY IMPROVEMENT

QUALITY OUTLOOK

Low, average and high cost benchmarks for shoulder arthroplasty devices compared to average Medicare payment

Figure 5

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Ventilator-associated pneumonia event reporting demands process and product evaluation > To help members provide the highest quality care while controlling costs, Premier looked to our experts, our data and the industry at large to evaluate the impact of product and process on VAP.

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Mechanical ventilation is an essential, life-saving therapy for patients with critical illnesses and respiratory failure. Studies have estimated that more than 300,000 patients receive mechanical ventilation in the United States each year. These patients are at high risk for complications and poor outcomes, including death. One of the complications that may occur in ventilated patients is ventilator-associated pneumonia (VAP).1 Consequences of VAP include:

To help members of the Premier healthcare alliance provide the highest quality care while controlling costs, we looked to our experts, our data and the industry at large to evaluate the impact of product and process on this condition. You thought VAP was under control? Here comes VAE reporting. If you believe VAP isn’t a problem for your organization, you might have to reconsider. New ventilator-associated event (VAE) measures may reveal a significant under-reporting problem. On January 1, 2013, the Centers for Disease Control and Prevention’s National Healthcare

No product can be expected to perform without proper processes and associated measurements. Klompas said that in a review of 50 ventilated patients with respiratory deterioration, three infection preventionists each came to a different conclusion about which patients had developed VAP. One concluded 20 of the patients had VAP, while the second said 15, and the third said only 11. In fact, out of the 50 ventilated patients, only seven had common surveillance-defined VAP. How could this be? According to Klompas, “Many complications of critical care present with subjective clinical signs that mimic VAP,” such as radiographic opacities, fever, abnormal white blood cell count, impaired oxygen

This is not the case with VAE. Objective measures lead clinicians through a tiered-definition process from ventilatorassociated condition (VAC) to infectionrelated ventilator-associated complication (IVAC), and finally, possible or probable pneumonia. VAE reporting includes the following criteria: • VAC: Sustained increased positive end-expiratory pressure (PEEP) or fraction of inspired oxygen (FiO2) after more than two days of stable or increased PEEP or FiO2; • IVAC: VAC and abnormal temperature or white blood cell count and more than four days of new antibiotics; • Possible pneumonia: IVAC and sputum/bronchoalveolar lavage (BAL) polymorphonuclear leukocytes or pathogenic culture; and • Probable pneumonia: IVAC and sputum/BAL polymorphonuclear leukocytes and pathogenic culture. Although many believe that VAP rates are tied to products used, an analysis of 556 Premier member health systems with data in QualityAdvisor™ indicated no significant difference in VAP rates based on selected supplier or the use of kits and/or chlorhexidine gluconate. This reaffirms that no product can be expected to perform without proper processes and associated measurements. To support member health systems in VAP prevention, identification, execution and mitigation, Premier developed a process care map (see Figure 1 at the end of this article). Member best practice: St. Anthony’s Medical Center Two-hour rounding in critical care settings reduces VAP and improves other measures. In July 2012, St. Anthony’s Medical Center (St. Louis, MO) launched a process O UTLO O K • QTR 3 .1 3 |

TRENDS IN QUALITY IMPROVEMENT

Newer, more reliable and objective clinical measures are now available for defining ventilator-associated events (VAEs), including VAP, in adults. These more robust, surveillance-defined measures are not clinical diagnoses and are not intended for use in managing patients. Instead, they should be used for more accurate and objective reporting.

Michael Klompas, MD, MPH, FRCPC, FIDSA, of Harvard Medical School Department of Population Medicine and Boston’s Brigham and Women's Hospital, recently spoke during a Premier Advisor Live® session. The topic, “CDC-NHSN's new ventilator-associated events surveillance definitions: Are you ready?” addressed the fact that traditional VAP reporting protocols lent themselves to subjectivity. Without realizing they were doing so, some facilities trying to reduce VAP may have inadvertently narrowed their interpretation of VAP signs, resulting in inaccurate reporting indicating that VAP had been eliminated from their organizations.

and increased pulmonary secretions. Those misleading symptoms caused three competent professionals to arrive at different conclusions.

QUALITY OUTLOOK

• A mortality rate of 46 percent (compared to 32 percent for ventilated patients who do not develop VAP); • Mean hospitalization costs of $99,598 (compared to $59,770 for ventilated patients without VAP); and • Mean length of stay of 23 days (9.6 additional days on a ventilator, 6.1 additional days in the intensive care unit and 11.5 additional days in the hospital).2

Safety Network (NHSN) began instituting new metrics for reporting VAE, a measure many feel will reduce the variability associated with past reporting. Experts say these metrics, which are more objective, may lead to mandatory state reporting and may potentially reduce reimbursement.

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INTERVIEW WITH JIM GLEICH

Clinical resource manager, St. Anthony’s Medical Center

Q: Why did you decide to take on this initiative now?

A: The hospital was going through a rapid process improvement initiative regarding cost, service, staffing and quality. Every dollar expense was reviewed.

Q: What roadblocks did you encounter?

A: The main one was monitoring the type of patient being ventilated and the reason for intubation. We had to make sure that standard procedure was followed in the various intensive care units.

Q: What were your keys to success?

Q: What benefit did you experience beyond reduction in VAP?

A: The patients are now assessed more precisely for additional quality measures, and the documentation is recorded more accurately. In addition, I believe the accurate follow-through of clinical interventions helps with patient and family interaction and builds satisfaction.

Q: What would you tell someone who wants to do something like this?

A: Someone has to be the leader, and the rest of the team has to be committed. Maintaining the process change, accuracy of follow-through, and compliance of timing yield the best results.

A: Making sure oral care is done as prescribed, every two hours. If staff members don’t follow a precise routine, VAP is more likely to occur.

improvement initiative. Ten teams across the organization were given 60 days to develop process improvement proposals. At the end of the period, the hospital had more than 800 proposals in hand. After a board review, all were approved, and employees were given another 60 days to begin implementation. Overall cost reduction imperatives for the health system totaled $22 million by January 2013. Supported by directional data from 556 Premier member health systems, St. Anthony’s staff hypothesized that VAP

rates were unrelated to specific product decisions. They also believed that oral care product purchases could be narrowed and standardized to improve care. To ensure CDC protocols were followed, St. Anthony’s introduced two-hour rounding in all critical care environments, back-tobasics preventive care reviews and PICC line surveillance. From July 2012 to June 2013, there were only two instances of VAP, and both patients were high-risk.

By standardizing VAP kits and single-use products such as toothbrushes, H202 oral rinses and mouth moisturizers, the organization decreased oral care spend by 80 percent. References 1. “April 2013 CDC/NHSN Protocol Corrections, Clarifications, and Additions,” CDC, http://www.cdc.gov/nhsn/PDFs/pscManual/10VAE_FINAL.pdf. 2. “Implement the IHI Ventilator Bundle,” Institute for Healthcare Improvement, last modified August 2, 2011, http://www.ihi.org/knowledge/Pages/ Changes/ImplementtheVentilatorBundle.aspx.

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decreased oral care spend by

80 percent. O UTLO O K • QTR 3 .1 3 |

TRENDS IN QUALITY IMPROVEMENT

QUALITY OUTLOOK

By standardizing VAP kits and single-use products such as toothbrushes, H202 oral rinses and mouth moisturizers, St. Anthony’s Medical Center

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VAP process care map Premier’s care process flow maps were first designed to support Premier’s QUEST® collaborative members. Since their inception, they have been leveraged by hundreds of members looking to improve patient care along current industry standards and guidelines.

Care process resources: • WHO checklist for influenza pandemic preparedness planning, World Health Organization, http://www.who.int/influenza/resources/ documents/FluCheck6web.pdf. • Hand Hygiene in Healthcare Settings, Centers for Disease Control and Prevention, http://www.cdc.gov/handhygiene/guidelines.html. • Ventilator-Associated Pneumonia Event, April 2013 CDC/NHSN Protocol Corrections, Centers for Disease Control and Prevention, http://www.cdc.gov/nhsn/PDFs/pscManual/6pscVAPcurrent.pdf • Ventilator Bundle Checklist, Institute for Healthcare Improvement, https://www.ihi.org/_layouts/ihi/ login/login.aspx?ReturnUrl=%2fknowledge%2f_lay outs%2fAuthenticate.aspx%3fSource%3d%252Fkno wledge%252FKnowledge%2520Center%2520Assets%252FTools%2520%252D%2520VentilatorBundleChecklist%255F8b5eeefe%252D7d5a%252D 470b%252Dad48

• Coffin, S.E., Klompas, M., Classen, D. et al. (2008). Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals, Infection Control and Hospital Epidemiology: 29;1, http://www.ipg.uni-linz.ac.at/qip_pneu.pdf. • Prevention of ventilator-associated pneumonia: Health care protocol, Agency for Healthcare Research and Quality, http://www.guideline.gov/content. aspx?id=3606&search=endotracheal+suctioning • Endotracheal suctioning of mechanically ventilated patients with artificial airways, Agency for Healthcare Research and Quality, http://www.guideline .gov/content.aspx?id=2399&search=endotracheal+suctioning • How-To Guide: Prevent Ventilator-Associated Pneumonia, Institute for Healthcare Improvement, http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventVAP.aspx. • Premier healthcare alliance. VAP Bundle Resources, https://www.premierinc.com/quality-safety/toolsservices/safety/topics/bundling/downloads.jsp.

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PREMIER CARE PROCESS FLOW: Harm > Hospital Acquired Condition > Ventilator-Associated Pneumonia

PREVENTION

BEGIN

Educate clinicians about non-invasive ventilation alternatives

Post-procedural briefing and documentation of plan for extubation/ continued ventilator support

Rapid/fast track extubation in OR/PACU, as appropriate

Resources included in this process map are referenced on the previous page

Minimize the duration of ventilation

Frequent oral care for all ventilated patients

Article supporting oral care

IDENTIFICATION

Daily Goals Worksheet from IHI

• Who’s intubated and why • When’s the expected extubation time – if not extubated as planned • Documentation as to indication(s) for continued intubation

CDC/WHO hand hygiene guidelines

Post-procedural briefing and documentation of plan for extubation/continued ventilator support

AHRQ endotracheal suctioning of vented patients

Strategies to prevent aspiration

AHRQ endotracheal suctioning of vented patients

VAP Bundle resources

IHI Ventilator Bundle

SHEA/IDSA Practice Recommendation to Prevent Strategies for Ventilator Associated Pneumonia in Acute Care Hospitals

HRET VAP Change Package

IHI How-to Guide for Preventing VAP

• Maintain patients in a semirecumbent position (300- 450 elevation of the head of the bed) unless there are contraindications • Use a cuffed endotracheal tube with in-line or subglottic suctioning • Avoid gastric overdistention • Avoid histamine receptor 2 (H2)–blocking agents and proton pump inhibitors for patients who are not at high risk for developing a stress ulcer or stress gastritis

Minimize contamination of equipment used to care for patients receiving mechanical ventilation

• Use sterile water to rinse reusable respiratory equipment • Remove condensate from ventilatory circuits; keep the ventilatory circuits closed during condensate removal • Change the ventilatory circuits only when visably soiled or malfunctioning

Use a standard oral care protocol for all ventilated patients

Article supporting oral care

MITIGATION

KEY MEASURES

Minimize the duration of ventilation

Standardized, criteria-based RT/RN driven weaning & extubation protocols RASS Protocol for Sustained use for Sedatives

Empower pharmacy to review orders for patients in the ICU to ensure some form of peptic ulcer disease prophylaxis and deep venous thrombosis prophylaxis is provided for all appropriate patients at all times in the ICU (unless contraindicated)

END

Process Measures:

Outcomes Measures:

% ICU patients “all or nothing” bundle compliance

Rate VAP (CMS HAC)

% compliance w/ frequent oral care protocol

Rate VAP (CDC NHSN) Mortality Cost of case with and without VAP

O UTLO O K • QTR 3 .1 3 |

TRENDS IN QUALITY IMPROVEMENT

Perform daily assessments of readiness to wean and use weaning protocols. Review all elements of the bundle during rounding

2013 CDC Ventilator-Associated Pneumonia (VAP) Event

QUALITY OUTLOOK

EXECUTION

WHO checklist

Conduct active surveillance for VAP and associated process measures in units that care for patients undergoing ventilation who are known or suspected to be high risk for VAP on the basis of risk assessment

Adhere to hand-hygiene guidelines published by the Center for Disease Control and Prevention of the World Health Organization

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13034 Ballantyne Corporate Place Charlotte, NC 28277 T 704.357.0022

444 N Capitol Street NW Suite 625 Washington, DC 20001-1511 T 202.393.0860 F 202.393.0864

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QT R 3 .1 3

FOR FURTHER INFORMATION To learn more about this publication, please visit premierinc.com/economicoutlook or email economicoutlook@premierinc.com.