7/29/2019 MOVING THE NEEDLE IN HEALTHCARE QUALITY Michelle - - PDF document

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7/29/2019 MOVING THE NEEDLE IN HEALTHCARE QUALITY Michelle - - PDF document

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7/29/2019 MOVING THE NEEDLE IN HEALTHCARE QUALITY Michelle Schreiber, MD Director, Quality Measurement and Value Based Incentives Group Centers for Medicare and Medicaid June 2019 WHO HAS THE BEST HEALTHCARE QUALITY IN THE WORLD? Who spends

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MOVING THE NEEDLE IN HEALTHCARE QUALITY

Michelle Schreiber, MD Director, Quality Measurement and Value Based Incentives Group Centers for Medicare and Medicaid June 2019

WHO HAS THE BEST HEALTHCARE QUALITY IN THE WORLD?

Who spends the most per capita for healthcare?

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MOVING TOWARD VALUE BASED CARE

  • Value = Quality + Safety + Experience / Cost

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We spend too much; get too little

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WHAT IS QUALITY

  • SAFE – Don’t harm me
  • TIMELY – Access when I need it, where I need it
  • EFFECTIVE – Right evidence based care, right setting – not overuse nor underuse
  • EFFICIENT – Eliminate waste
  • EQUITABLE – Eliminate disparities. Treat me as a person without bias
  • PATIENT‐CENTERED – No care about me, without me
  • Triple Aim (IHI)
  • Highest Quality and Good Outcomes
  • Great Care Experience
  • Care that is Affordable for all
  • (Bringing Joy to Work)

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IOM Report

SAFETY

  • IOM Report “To Err is Human” and “Crossing the

Quality Chasm”

  • Healthcare error is third leading cause of death
  • Many different types of harm – physical,

psychological, employee (staff), hospital, ambulatory

  • Systems can be developed to reduce/eliminate

error

  • ARE WE BETTER YET?

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HOSPITAL EXPERIENCE

  • Nursing communication
  • Doctors communication
  • Always receive help as soon as wanted
  • Always receive explanations about medications before getting them
  • Room and bathroom always clean
  • Room and surroundings always quiet
  • At discharge, provided information about what to do at home
  • Understood care when leaving hospital
  • Percentage of patients giving hospitals a rating of 9 or 10 (on a 10 point scale)
  • Percentage of patients who would definitely recommend the hospital

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STARS RATING FOR EXPERIENCE

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Other Experience Assessments

  • Medicare Advantage Stars Program – Member Opinion Surveys
  • Ambulatory Clinics – Ambulatory Patient Satisfaction Surveys
  • Employee Engagement and Satisfaction Surveys
  • Social Media

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HOW TO MOVE THE NEEDLE?

Promoting healthcare quality & safety

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CMS STRATEGIC PRIORITIES FOR 2019

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HOW TO MOVE THE NEEDLE?

  • Levers for Change:
  • Incentives and Penalties
  • Collaborative Improvement Initiatives
  • Payment Reform
  • Public Reporting/Transparency
  • Regulatory Requirements
  • Empowering Patients (Rise of Consumerism)

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INCENTIVES AND PENALTIES

  • Hospital – Value Based Purchasing, Hospital Acquired Conditions,

Readmissions Reduction

  • Ambulatory Surgery Centers
  • Inpatient Psychiatry
  • ESRD (Dialysis)
  • Post Acute Care
  • Ambulatory – Hospital
  • Clinician/Provider – MACRA
  • Meaningful Use/Promoting Interoperability

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Multiple Value Based Incentive Programs

COLLABORATIVE IMPROVEMENT INITIATIVES

  • HIIN – Hospital Innovation and Improvement Network (through

QIO, across country)

  • Healthcare system initiatives
  • Commercial Payer initiatives
  • Statewide initiatives
  • Local/regional initiatives

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Multiple local, state and national initiatives

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PAYMENT REFORM

  • Medicare Advantage
  • Various Accountable Care Organizations (MSSP, CPC+, Next Gen)
  • Transforming Medicaid
  • Narrow Networks
  • Marketplace Choice
  • Bundled Payments

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New and innovative models of payment

PUBLIC REPORTING

  • CMS Stars Programs and Compare sites
  • Leapfrog
  • Healthgrades
  • US News & World Report
  • State reporting
  • Yelp, Angie’s list, Consumers' Report
  • Reporting is not always aligned

May be confusing to consumers

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Many other public reports

REGULATORY REQUIREMENTS

  • CMS Conditions of Participation
  • The Joint Commission
  • Helps establish standards for quality

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EMPOWERING PATIENTS, FAMILIES AND CAREGIVERS

  • Patient and family centered care
  • Incorporating voice of the Patient and Family
  • Patient and Family Advisory Councils
  • Use of Patient Portals
  • Transparent Communication with Patients
  • eMedicare
  • My Health e‐data

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WHAT SHOULD MEASURES/MEASUREMENT SYSTEMS DO?

  • Uniformly assess evidence based quality of care (as well as utilization,

costs, other outcomes)

  • Identify care variations
  • Develop benchmarks
  • Serve as foundation for ongoing continuous cycles of performance

improvement

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A NEW APPROACH TO IMPROVING OUTCOMES

Launched in 2017, the purpose of the Meaningful Measures initiative is to:

  • Improve outcomes for patients and provide meaningful information to consumers to make

care choices

  • Reduce data reporting burden and costs on clinicians and other health care providers
  • Align across programs
  • Identify gap areas for development (opioids, nursing homes, care transitions, PROM)
  • Prioritize outcome measures
  • Innovate measures (electronic data, Patient reported)

What is the Meaningful Measures Initiative?

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Meaningful Measures Framework

HOW DO WE ENGAGE PATIENTS, FAMILIES AND CAREGIVERS IN SAFETY AND RELIABILITY

  • Consumers acting as a group could ask for changes
  • Patients do not always understand quality and safety – they assume quality and safety and rate hospitals by

experience, physical environment and friendliness

  • Patients do not always know when harm occurs – organizations not always transparent and patients view harm as

an unavoidable complication of care

  • How to engage patients in understanding and seeking quality and safety?

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Improving Patient Access to their Information

  • Blue Button 2.0
  • My Health e‐Data
  • Claims based information provided by CMS
  • Transparency of claims information mandated for other organizations that participate in CMS programs
  • Clinical data in future
  • Compare Sites modernization
  • Promoting Interoperability
  • Transparency
  • Provide claims based information
  • Prohibit data blocking (publish list of those who data block)
  • Seamless connection of health information exchanges through trusted partnership
  • Encourage providing clinical information
  • Release of testing data
  • Open Notes

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HCAHPS – seeking patient experience feedback

  • CMS Center for Medicare responsible the HCAHPS survey (Hospital Consumer Assessment of Healthcare Providers

and Systems Survey).

  • Available since 2006
  • Developed by AHRQ (Agency for Healthcare Research and Quality), measures developed using highest scientific

standards over a multistep process.

  • Employed a review of the literature, extensive consumer testing, focus groups, input from stakeholders, sizable

field testing and multiple subsequent field tests

  • Composed of 27 items that encompass critical aspects of the hospital experience)
  • Available in English, Spanish, Chinese, Russian and Vietnamese in the mail format. Takes respondents average of 7

minutes to complete.

  • Available by mail, telephone, mail with telephone follow‐up and Active interactive voice response. Investigating on‐

line methods of completion. Mode of survey can sometimes affect response (higher ratings with telephone than mail)

  • Random sampling method – between 48 hours and weeks post discharge

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Other Influencers of Patient Experience

  • Communication
  • Timeliness
  • Clean environment (How often were your room and bathroom kept clean?)
  • Quiet (How often was the area around your room quiet at night?)
  • Pain questions being removed

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Patient Reported Outcomes

  • Patient voice is essential in any measure of healthcare
  • Informed patient/caregiver can make best care choices that is meaningful to them
  • Patient representatives in many important decision making panels (such as technical expert panels)
  • However, PROM still somewhat difficult to use and need to be streamlined/easier. Generally not integrated into

electronic medical records

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Planning and Designing New Environments

  • Ensure highest standards of safety and quality
  • Infection control
  • Slip resistant, skid resistant, reduce fall risk. Flooring is important.
  • Ventilation, airflow, temperature control
  • Healing Environments
  • Clean, quiet, calming
  • Clear signage
  • Extensively wired for computer/digital needs
  • Ability for private conversations and educational opportunities (patients and providers)
  • Many different complex needs
  • Kind to the environment
  • Efficient use of space and ergonomically effective (RNs spend hours getting supplies and other non‐direct patient

care activities)

  • Build places that are most efficient and effective in care delivery (right care, right place, right time…)

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Focused on patients and families at the center of care

OTHER WAYS TO INFLUENCE ENGAGING PATIENTS AND CLINICIANS?

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Please reach out with questions or comments: michelle.schreiber@cms.hhs.org