The Culture of Healthcare Quality Measurement and Improvement Lecture b This material (Comp2_Unit7b) was developed by Oregon Health and Science University,

The Culture of Healthcare

Quality Measurement and Improvement

Lecture b

This material (Comp2_Unit7b) was developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number

IU24OC000015.


Learning Objectives• Define healthcare quality and the major types of quality

measures: structural, process, and outcome measures (Lecture a)

• Describe the current state of healthcare quality in the United States (Lecture a)

• Discuss the current healthcare quality measures used in various healthcare settings in the US, including those required for the HITECH meaningful use program (Lecture b)

• Describe the role of information technology in measuring and improving healthcare quality (Lecture c)

• Describe the results of current healthcare quality efforts in the US (Lecture c)

2Health IT Workforce Curriculum Version 3.0/Spring 2012

The Culture of Healthcare Quality Measurement and Improvement

Lecture b

Sampling of Current Quality Programs and Measures

• Warning: There are many sets and acronyms, and they change constantly– We are still “early” in the science of quality improvement (Berwick,

2008)– “Science” defined in an IOM report (2006)– Many measurements in use (Damberg, 2011) but still need

improvement (Pronovost, 2011)

• Many measures have been developed, reflecting various perspectives– AHRQ maintains clearinghouse www.qualitymeasures.ahrq.gov– Growing consensus that standard sets are needed for each perspective

• We will view them from following perspectives– Health plans– Outpatient– Inpatient– Quality measures in HITECH Stage 1 meaningful use program



Lecture b

Quality Reporting for Health Plans

• Called out because of historic role• Health Plan Employer Data and Information Set

(HEDIS) by NCQA provides 60 measures that evaluate health plans, particularly health maintenance organizations

• NCQA annual reports calculate lives saved based on outcomes from adherence



Lecture b

HEDIS Categories and Example Measures

• Effectiveness of care– Childhood and adult immunizations– Use of beta blockers after myocardial infarction– Screening for various types of cancer– Comprehensive diabetes care

• Access/availability of care– Access to preventive health services– Availability of primary care providers– Initiation of prenatal care

• Satisfaction with care– Member satisfaction surveys

• Use of service– Rate trends



Lecture b

Reporting for Outpatient Setting

• In US, major efforts led by Centers for Medicare and Medicaid Services (CMS, www.cms.hhs.gov) in Medicare program

• Physician Quality Reporting System (PQRS, formerly PQRI, http://www.cms.hhs.gov/pqri/)– Extra 1% reimbursement for reporting on large number of

measures (194 in 2011)– Also receive 0.5% for maintenance of certification– Bonus changes to penalty starting in 2015

• Electronic Prescribing (eRx) Incentive Program (http://www.cms.gov/ERxIncentive/ )– Extra 1% reimbursement for use of e-prescribing– Bonus continues through 2013; penalty starts in 2012

• These quality measures are separate from meaningful use regulations, for which the Government Accountability Office (GAO, 2011) has criticized CMS for inconsistencies across the programs



Lecture b

Some example PQRS measures

• Hemoglobin a1c poor control in diabetes mellitus– Percentage of patients aged 18 to 75 years with diabetes

mellitus who had most recent hemoglobin A1c greater than 9.0%

• Thoracic surgery: recording of clinical stage for lung cancer and esophageal cancer resection– Percentage of surgical patients aged 18 years and older

undergoing resection for lung or esophageal cancer who had clinical TNM staging prior to surgery

• Weight assessment and counseling for children and adolescents– Percentage of children 2 to 18 years of age whose weight

is classified based on BMI percentile for age and gender



Lecture b

Reporting for inpatient setting

• Hospital Quality Alliance (HQA, www.hospitalqualityalliance.org) – Collaboration among CMS, Joint Commission, and

others to create a starter set of quality measures for various conditions

– In Hospital Compare Project, hospitals voluntarily provide quality information that can be accessed via a Web site–www.hospitalcompare.hhs.gov

– Consists of two programs based on reporting to CMS• Inpatient Quality Reporting (IQR) – for HQA data; not

participating results in 2% Medicare reimbursement reduction• Hospital Consumer Assessment of Healthcare Providers and

Systems (HCAPHS) – reporting of patient satisfaction at hospitals



Lecture b

HQA Categories and Examples• Myocardial infarction

– Aspirin at arrival and discharge– Inpatient mortality

• Heart failure– Discharge instructions– Evaluation of left ventricular systolic function

• Pneumonia– Time to blood cultures and antibiotics– Pneumococcal and influenza vaccinations

• Surgical infection prevention– Prophylactic antibiotics– Prophylaxis for deep venous thrombosis

• Children’s asthma care– Reliever medication while hospitalized– Home Management Plan of Care Document



Lecture b

Other Inpatient Quality Initiatives

• National Surgical Quality Improvement Program (NSQIP – www.acsnsqip.org)

– Effort of American College of Surgeons to measure, risk-adjust, and improve quality of surgical care

• University HealthSystem Consortium (UHC – www.uhc.edu)

– Quality measurements to benchmark academic medical centers

– Measured by “green dots” and “red dots” (½ to 2)



Lecture b

Clinical Quality Measures and “Meaningful Use” (Blumenthal, 2010)

• One of the five healthcare goals for meaningful use is improving quality, safety, and efficiency

• One of the 15 core measures for eligible professionals (EPs) is reporting of clinical quality measures to CMS or the states

• One of the 14 core measures for eligible hospitals (EHs) is reporting of clinical quality measures to CMS or the states



Lecture b

Specific Quality Measures in Meaningful Use Criteria

• EPs must report on– 3 core measures

• Can substitute alternate core measures if denominator of any core measure is 0

– 3 of 38 additional measures• EHs must report on 15 measures• Reporting by attestation in 2011 and provision of

data in 2012 and beyond• CMS aims to align all quality reporting programs,

i.e., PQRI, CHIPRA, IQR, etc.



Lecture b

EP core/alternative quality measures

• Core– Hypertension: Blood Pressure Measurement– Preventive Care and Screening Measure Pair: a)

Tobacco Use Assessment, b) Tobacco Cessation Intervention

– Adult Weight Screening and Follow-up• Alternative

– Weight Assessment and Counseling for Children and Adolescents

– Preventive Care and Screening: Influenza Immunization for Patients 50 Years Old or Older

– Childhood Immunization Status



Lecture b

EP additional quality measures (1-12)

1. Anti-depressant medication management: (a) Effective Acute Phase Treatment, (b)Effective Continuation Phase Treatment

2. Appropriate Testing for Children with Pharyngitis3. Asthma Assessment4. Asthma Pharmacologic Therapy5. Breast Cancer Screening6. Cervical Cancer Screening7. Chlamydia Screening for Women8. Colorectal Cancer Screening9. Controlling High Blood Pressure10. Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD

Patients with Prior Myocardial Infarction (MI)11. Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-

Cholesterol12. Coronary Artery Disease (CAD): Oral Antiplatelet Therapy

Prescribed for Patients with CAD



Lecture b

EP additional quality measures (13-25)13. Diabetes: Blood Pressure Management

14. Diabetes: Eye Exam

15. Diabetes: Foot Exam

16. Diabetes: Hemoglobin A1c Control (<8.0%)

17. Diabetes: Hemoglobin A1c Poor Control

18. Diabetes: Low Density Lipoprotein (LDL) Management and Control

19. Diabetes: Urine Screening

20. Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care

21. Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy

22. Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

23. Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

24. Heart Failure (HF): Warfarin Therapy Patients with Atrial Fibrillation

25. Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: a) Initiation, b) Engagement



Lecture b

EP additional quality measures (26-38)26. Ischemic Vascular Disease (IVD): Blood Pressure Management

27. Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control

28. Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic

29. Low Back Pain: Use of Imaging Studies

30. Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer

31. Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients

32. Pneumonia Vaccination Status for Older Adults

33. Prenatal Care: Anti-D Immune Globulin

34. Prenatal Care: Screening for Human Immunodeficiency Virus (HIV)

35. Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation

36. Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients

37. Smoking and Tobacco Use Cessation, Medical Assistance: a) Advising Smokers and Tobacco Users to Quit, b) Discussing Smoking and Tobacco Use Cessation Medications, c) Discussing Smoking and Tobacco Use Cessation Strategies

38. Use of Appropriate Medications for Asthma



Lecture b

EH quality measures• Anticoagulation overlap therapy• Emergency Department Throughput – admitted patients – Admission decision time to

ED departure time for admitted patients• Emergency Department Throughput – admitted patients – Median time from ED

arrival to ED departure for admitted patients• Incidence of potentially preventable venous thromboembolism • Intensive Care Unit venous thromboembolism prophylaxis• Ischemic or hemorrhagic stroke – Antithrombotic therapy by day 2• Ischemic or hemorrhagic stroke – Rehabilitation assessment• Ischemic or hemorrhagic stroke – Stroke education• Ischemic stroke – Anticoagulation for atrial fibrillation/flutter• Ischemic stroke – Discharge on anti-thrombotics• Ischemic stroke – Discharge on statins• Ischemic stroke – Thrombolytic therapy for patients arriving within 2 hours of

symptom onset• Platelet monitoring on unfractionated heparin• Venous thromboembolism discharge instructions• Venous thromboembolism prophylaxis within 24 hours of arrival



Lecture b


Summary – Lecture b

• Many different healthcare quality measures are used in a variety of settings from health plans to inpatient to outpatient

• Health plans most commonly have quality assessed using the HEDIS measures of NCQA

• Outpatient settings most often use measures in the PQRS program

• Inpatient settings have a variety of measures, but most commonly used are those of the HQA

• One of the core meaningful use criteria for EPs and EHs is a series of quality measures



Lecture b


References – Lecture bReferences• Anonymous. (2006). Performance Measurement: Accelerating Improvement. Washington, DC: National

Academies Press. • Anonymous. (2011). CMS Should Address Inconsistencies in Its Two Incentive Programs That Encourage the

Use of Health Information Technology. Washington, DC: Government Accountability Office. Retrieved from http://www.gao.gov/new.items/d11159.pdf

• Berwick, D. (2008). The science of improvement. Journal of the American Medical Association, 299, 1182-1184. • Blumenthal, D., & Tavenner, M. (2010). The “meaningful use” regulation for electronic health records. New

England Journal of Medicine, 363, 501-504. • Damberg, C., Sorbero, M., Lovejoy, S., Lauderdale, K., Wertheimer, S., Smith, A., . . . Schnyer, C. (2011). An

Evaluation of the Use of Performance Measures in Healthcare. Santa Monica, CA: RAND Corp. Retrieved from http://www.rand.org/pubs/technical_reports/TR1148.html

• Pronovost, P., & Lilford, R. (2011). A road map for improving the performance of performance measures. Health Affairs, 30, 569-573.



Lecture b

The Culture of Healthcare Quality Measurement and Improvement Lecture b This material (Comp2_Unit7b) was developed by Oregon Health and Science University,

Documents

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improvement lecture

oregon health

department of health

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various healthcare settings

us lecture c

measures warning