Center of Excellence inContinence Care

Centers of Excellence in Continence Care: Goals and Objectives

• Create a credible, legitimate vehicle to facilitate consumer access to high quality care

• Establish a fair and transparent process for all applicants, also acceptable to payers and the public at large

• Remain loyal to our mission as a patient advocate and representative.

• Own a database of patient satisfaction ratings to create and maintain benchmarks for continuous quality improvement

• Manage a self-sustaining enterprise, without undue distraction to our ongoing education programs

• Strengthen NAFC’s reputation as an independent and credible source to guide the consumer in seeking healthcare

Cases gone wrong….unexpected outcomes

Proving correct: The whispers among women

A landmark multicenter study published in 2007: Documented stringently defined success rates – including patient satisfaction scores - of 49% for the Burch and 66% for the fascial sling two years post-op, deteriorating to 22% and 30%, respectively five years out.

Many Communities Lack Specialty Trained, Experienced Doctors

And while the new subspecialty in Female Pelvic Medicine & Reconstructive Surgery, administered jointly by ABU and ABOG, will help with consistent, comprehensive fellowship training, numbers will remain small and largely contained in academic medical centers.

A Growing Interest in Measuring Consumer Perceptions

This study surveys over 250,000 households representing over 450,000 consumers in the contiguous 48 states and the District of Columbia. From the households surveyed, 3200 hospitals named by consumers are analyzed and ranked based on their Core Based Statistical Areas (CBSAs) as defined by the U.S. Census Bureau, with the winning facilities being ranked the highest: Top of mind perceptions (image, reputation, advertising recall, etc.) but not detailed, actionable data, especially for multidisciplinary care that may include community providers.

Standards for Patient Satisfaction

• Outcomes that fail to meet patient expectations and dissuade consumers from seeking diagnosis and treatment

• The focus of payers on penalties for NEVER events and readmissions instead of patient satisfaction with quality of care and outcomes

• Fragmentation, competition, and disagreement among providers as to preferred, evidence-based protocols for diagnosis and treatment

• Providers lacking experience and/or sufficient surgical training Misdiagnosis Misinformation Poorly executed choices and patient selection for certain

procedures The need for costly repeat surgeries and second opinion

Provider Centered Outcomes

Patient Centered Outcomes

Pad use Cough stress test

Voiding frequency Pelvic floor distress inventory questionnaire

Health-Related Quality of Life questionnaire

POP-Q system

Global impressions of improvement

Post-void residual urine volume

Improvement in symptoms, including new complications

Overall satisfaction, including pain management

Confidence in the treatment technology and willingness to recommend to others

Cleanliness, ease of navigating, and safety of the facility including signage, parking, etc.

Education about one’s condition and involvement in treatment plans

Satisfaction with quality of nursing care

Access to one’s doctor for appointment times and dates desired by the patient

Adequate preparation by the clinic or discharge nurse for self-care by patient

COE: Establishing a New Set of Benchmarks

The COE Requirements

1. Demonstrated commitment to excellence by upper management, in both clinical services and research.

2. Organization-wide quality improvement and safety initiatives operative.

3. Verification of experience: >150 PFD surgical cases lifetime and >100 surgical cases in the most recent 12 months by each primary operating physician, post fellowship training.

4. An organization, with a Medical Director of the Pelvic Floor Clinic/Department

5. Integrated, full-time, multi-disciplinary team including gynecologists, urologists, colorectal surgeons, gastroenterologists, nurse practitioners, physical/occupational therapists trained in PFD diagnosis and treatment

6. Full line of diagnostic and therapeutic equipment, e.g. urodynamics

The COE Requirements (cont.)

7. Fellowship trained PFD surgeons and evidence of ongoing medical society involvement

8. Standardized, clinical pathways and protocols, including perioperative care practice guidelines in writing

9. Formally trained, designated nurses and allied health professionals, e.g., SUNA or WOCN nurse training and certification.

10. Patient education materials in print and online and a demonstrated commitment to community health literacy

11. Means of computerized tracking of all PFD patients for at least two year follow-up data and analysis

12. No litigation pending or in the most recent three years involving patient harm or abuse.

1. Go to www.nafc.org, click on the logo in the lower left corner, and then click on “Process” to review the requirements. Make sure you meet case volume requirements. Two or more physicians must apply together, with a hospital where surgeries are performed.

2. Download the physician and institutional application forms. These must be returned with CVs and an organizational chart illustrating how the Center fits into the clinic’s or institution’s reporting structure.

How To Apply

The COE Application and Review Process

Step #1: Hospital ($1,500) and Physicians ($300 each) submit separate applications

Step #2: Surveys are mailed to a sample of patients (95% Confidence Level, +/- 10% Confidence Interval)

Step #3: Survey analysis and interpretation: PowerPoint presentation and discussionStep #4: Site VisitStep #5: Report and Recommendation to the CommitteeStep #6: Designation, Rejection, or 2-Year ProvisionalStep #7: Three Year Designation ($4,500 hospital fees plus $700

physician fees)

Month 1 – Obtain and complete applications. Applications are submitted with application fees ($300 MD and $1,500 hospital).Month 2 – Applications reviewed by NAFC, entered in database, and

any missing information requested.Month 3 – Applicants generate mailing list of patients and provide to

mailing house for NAFC survey.Month 4 – Survey is mailed.Month 5 – Results are tabulated. Site visit is scheduledMonth 6 – Site visit takes place. Survey results shared.Month 7 – Full report is written and submitted to Review Committee.Month 8 – Review Committee discusses and issues questions or

requests of applicants or approves.Month 9 – Press release is issued. Certificate is shipped for framing and

display. Website sections are created. Balance of fees are paid.

Timeframe for Completing Application Reviews and Center of Excellence Designation

Patient Survey Structure

Overall Patient Experience and Health Status Following Treatment

Patient Satisfaction with Facility (including scheduling, nursing staff, check-in, discharge, etc.)

Patient Satisfaction with Physician (including evidence of shared decision-making)

Two-Day Site Visit Itinerary

Each Applicant Physician Administrative Manager Nursing Supervisor, Clinic Nurses Physical Therapist Collaborative Physicians (e.g., Colorectal Surgeon) Research Nurse Coordinator Sr. VP Operations for the Facility/COO/CEO Manager of Contracting Services Director of Marketing and Media Relations Department Chairman Pelvic Floor Clinic Medical Director Patient Ombudsman/Patient Guest Services Nurse Practitioner – Patient Education or Pessary Specialist

Evidence of a demonstrated commitment to excellence, in both clinical services and in research

Quality improvement and patient safety initiatives that are fully operative

Verification of PFD experience and training claims of physician applicants

Evidence of a team that functions as an organizational unit, with its own medical director

Evidence of access to multi-disciplinary talent, with PFD training in diagnosis and treatment

Site Visit: Topics Covered

Leadership involvement in medical societies Written standards of care and clinical pathways Formally trained and/or certified nurses on staff Use of objective, up to date patient education materials and

commitment to community education Means of tracking patient outcomes >/= 2 years Full line of diagnostics and therapeutic equipment No litigation involving patient abuse or malpractice </= 3 years

Site Visit (continued)

Final COE Designation

Publicity of Centers of Excellence in Continence Care

The 2012 Review Committee

Willy Davila, MD (Cleveland Clinic) Sal Giorgianni, PharmD (Retired) Brooke Gurland, MD (Cleveland Clinic) Fatima Hakeem, PT (Woman’s Hospital) Cheryl Iglesia, MD (Washington Hospital) Peter Lotze, MD (OBGYN Associates) Alvaro Lucioni, MD (Virginia Mason) Alayne Markland, DO (UAB) Lynn Nye, PhD (Medical Minds, Inc.)

End of COE Portion of Presentation

Questions?

Mission of NAFC

As one of the world’s largest, oldest, and most prolific public education and patient advocacy organizations in the field, it is NAFC’s mission: 1) to educate the public about the causes, diagnosis categories, treatment options, and management alternatives for bladder and bowel control problems, voiding dysfunction and related pelvic floor disorders; 2) to network with other organizations and agencies to elevate the visibility and priority given to these areas; and 3) to advocate on behalf of patients who suffer from such symptoms as a result of disease or other illness, obstetrical, surgical or other trauma, or deterioration due to the aging process itself. NAFC is broadly funded by consumers, healthcare professionals and industry.

Constituency Served

- Men, Women, and Older Children and Teens

- Young mothers- Young adults who have

sustained SCI accidents- People with neurological

diseases and conditions (PD, MS, stroke survivors, etc.)

- The elderly and infirmed- Menopausal women- Post-prostatectomy men

NAFC Programs and Activities

Website traffic: >40,000 monthly

Printed patient education materials

NAFC’s Advocacy Voice

• Urging FDA approval of new, advanced medications and devices to give patients access to proven, advanced technology…and sustain their hope

• Urging AMA to assign discrete codes to new products

• Urging CMS and private payers to provide coverage and reimbursement of treatment options

Helping Consumers Find An Expert

• Consumers are increasingly distrustful of health information online:

• Competing sources of information use different metrics, methodologies and data sources, fielding contradictory and confusing quality data

• Word of mouth (50%) and physician referrals (38%) still drive the majority of doctor selection by consumers, especially when choosing specialists or facilities for medical procedures. Two in five rely on multiple sources. Only 3-11% rely on online provider databases.

Influential Trends

- The call for improving safety (IOM, 1999)

- Growing focus on patient centered healthcare

- Application of evidence-based healthcare (“Not about us without us”)

- Shifting more costs and responsibility for self-care onto the patient

Center of Excellence in Continence Care