HCQ P MEDICARE’S HEALTH CARE QUALITY IMPROVEMENT PROGRAM MEDICARE’S HEALTH CARE QUALITY IMPROVEMENT PROGRAM 1 1 Quality Measurement and Quality Measurement and Improvement at CMS Improvement at CMS Stephen F. Jencks MD, MPH Director, Quality Improvement Group Centers for Medicare & Medicaid Services August 23, 2004
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HCQ PMEDICARE’S HEALTH CARE QUALITY IMPROVEMENT PROGRAMMEDICARE’S HEALTH CARE QUALITY IMPROVEMENT PROGRAM
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Quality Measurement and Quality Measurement and Improvement at CMSImprovement at CMS
Stephen F. Jencks MD, MPHDirector, Quality Improvement Group
Centers for Medicare & Medicaid ServicesAugust 23, 2004
VisionVisionfor the Healthcare Systemfor the Healthcare System
The right care for every person every time.
HCQ PMEDICARE’S HEALTH CARE QUALITY IMPROVEMENT PROGRAMMEDICARE’S HEALTH CARE QUALITY IMPROVEMENT PROGRAM
Accelerate the pace of healthcare quality improvement for CMS beneficiaries
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0
50
100
150
200
0% 20% 40% 60% 80% 100%LEVEL OF PERFORMANCE
NU
MB
ER
OF
OB
SE
RV
AT
ION
S
1998-1999
2000-2001
2024-2025(Projection)
Pursuing Perfection in MedicarePursuing Perfection in MedicareHospital and Office Care (all states, 24 measures)Hospital and Office Care (all states, 24 measures)
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Improvement StrategiesImprovement Strategies
HCQ PMEDICARE’S HEALTH CARE QUALITY IMPROVEMENT PROGRAMMEDICARE’S HEALTH CARE QUALITY IMPROVEMENT PROGRAM
• Raise expectations• Foster transparency and defeat secrecy• Support and create partnerships• Promote better information systems• Improve the workforce• Shorten improvement cycles• Spread successes
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Raise ExpectationsRaise Expectations• Healthcare has come to accept the current
failure and injury rates.• There is widespread feeling that little real
change has occurred in patient safety since the IOM report To Err is Human.
• We are not very good at celebrating successes and creating and expectation of greater success.
• This is, above all, a challenge to leadership.
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Defeat SecrecyDefeat Secrecy
The most important reason for public reporting is to undermine a culture of not knowing or of concealing what we know.
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Support and Create PartnershipsSupport and Create Partnerships
• Nobody, not even CMS, can do this alone.• Partnerships are key to creating an
environment for improvement• Partners can overcome obstacles that
individual organizations cannot.
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Promote Better Information SystemsPromote Better Information Systems
• Medicine has become so complex that people can only practice safely and effectively with strong information systems support.
• CMS is promoting information systems by standardizing methods (e.g.: SNOMED), free tools, promoting implementation, and rewarding results.
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Improve the WorkforceImprove the Workforce
• Workforce adequacy, skills, and stability are keys to better care.
• Workforce stability contributes to adequate staffing and to fiscal stability.
• Work environment strongly influences workforce stability.
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Nursing HomesNursing HomesPercent Decrease in Problem Rate
+3.3%
-17.6%
-9.3%
-33.3%
Non-participant
homes
-7.8%-1.1%Pressure Ulcers
-68.3%-28.5%Physical Restraints
-26.1%-16.9%Post-acute Pain
-60.5%-46.1%Chronic Pain
Participants selecting
topic
Participant nursing homes
2020
Physician OfficePhysician Office
Mammography
Eye exam
Lipid profile
HgbA1c
Percent decrease in failure rate
2.3-0.3
0.6
29.8
20.5
Whole state
4.9
36.4
29.1
Participants
DIA
BET
ES2121
Home HealthHome Health
-5.7-5.3-3.7Emergent Care
1.5
14.1
17.1
12.8
Participants selecting
topic
Percent Decrease in Failure Rate
1.71.1Acute hospitalization
6.17.5Oral meds
7.66.8Dyspnea
6.55.5PainParticipantsNational
InpatientInpatient
28.613.3-3.314.310.325.013.96.66.1
Percent Decrease in Failure Rate1998-9 to 2000-1
Appropriate antibioticsTimely antibioticsACEI for ventricular dysfunctionLeft Ventricular AssessmentACEI for ventricular dysfunctionBeta blockers at dischargeBeta blockers at admissionAspirin at dischargeAspirin at admission
PNEU
H
RT
FAIL
HEA
RT
ATT
AC
K
Customer SatisfactionCustomer Satisfaction(“Satisfied” or “Very Satisfied”)(“Satisfied” or “Very Satisfied”)
• Nursing homes (participating) 93%• Nursing homes (not participating) 80%• Home health (participating) 95%• Home health (nonparticipating) 90%• Hospitals (for quality improvement) 93%• Hospitals (for public reporting) 86%• Physicians (participating) 93%• M+C organizations 95%
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Restraints in Nursing HomesRestraints in Nursing Homes
Physical Restraints (Intensive Group forStates that chose Physical Restraints)Physical Restraints (Non-Intensive Group forStates that chose Physical Restraints)Physical Restraints (Select Intensive Groupfor States that chose Physical Restraints)
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Provide Performance InformationProvide Performance Information
• Nursing Home, Home Health, Dialysis Compare web sites.
• Hospital Voluntary Reporting Initiative and Reporting Hospital Quality Data for Annual Payment Update
• Public reporting under Premier demonstration
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CoverageCoverage
• Welcome to Medicare Assessment Visit• Chronic care improvement pilots
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RewardsRewards
• Premier demo• Chronic care improvement pilot• Doctors Office Quality – Information
Technology
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EnforcementEnforcement
• Survey and certification of providers• Carried out by States under contract to CMS
and using CMS regulations and interpretative guidelines
• Largest impact on nursing homes but applies to all provider groups.
• Quite uneven enforcement across states.
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Variation in Overall Quality Variation in Overall Quality
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Are Ranks A Documentation Artifact?Are Ranks A Documentation Artifact?Correlation of State Ranks
1.000.450.65Inpatient
0.451.000.66Amb M+C
0.650.661.00Amb FFS
InpatientAmbM+C
AmbFFS
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3434Predictors of Overall Predictors of Overall StateState--level Qualitylevel Quality
• Single most powerful predictor of overall state quality is nursing supply, whether practicing (nursing census) or all (population census).
• Correlation of overall quality with nursing supply is 0.74 (R2=0.54). Correlation with primary care physician supply and poverty and weaker and add little to predictions based on nursing supply.
Leadership: Breakthrough PrioritiesLeadership: Breakthrough PrioritiesIntegrated CMS effort on• Vascular access in hemodialysis• Restraints and pressure ulcers in nursing
homes• Prevention of surgical complicationsStudying similar efforts for• Increase adult immunizations in selected
settings• Stabilize workforce in hospitals and nursing