Date post: | 19-Jan-2017 |
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Healthcare |
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Presented by: Martie Ross, JD, PYAPeggy Binzer, AQIPS
ALLIANCE FOR QUALITY IMPROVEMENT AND PATIENT SAFETY
Current Trends in Data Protection for Integrated Health, Centralized Peer Review Systems and Other Innovative Healthcare Programs
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We are focusing too much on medical errors and need to focus on connecting the Health Care Continuum. …Total Systems view needs to be understood more deeply and PSOs should be leading this…
-Don Berwick, Free from Harm: Accelerating Patient Safety Improvement, NPSF
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Managing the Shift from Volume to Value PSO opportunities concerning healthcare delivery reform and
structures Clinically integrated networks MACRA/bundled payments – patient registries Dashboards and data sharing arrangements Centralized peer review systems/high-reliability systems
The PSQIA privilege and confidentiality protections are the only protections for sharing performance information among unaffiliated providers or affiliated providers across state lines Protected collaboratives under section 1311 of the ACA
PSOs can dive into events data and determine interventions Share through convening Perform greater and more advanced analytics than the HEN
Martie Ross, JD
Clinically Integrated Networks and PSOs
Pursuing Worry-Free Performance Improvement
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Trends in Healthcare Delivery
Patient-centered and team-based care
Focus on healthy lifestyles, prevention, disease management
Data sharing, data mining, predictive analytics
Greater transparency Payment Quality (MIPS)
FOC
US Patient
Outcomes
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Value-Based Reimbursement
FEE-FOR-SERVICE(FFS) PAYMENTS
POPULATION-BASEDAPMs
ADJUSTED FFSPAYMENTS
APMs INCORPORATINGFFS PAYMENTS
$ $ $
Bank
A Pay For Reporting
B Pay For Performance
C Pay/PenaltyForPerformance
A Total Cost of Care Shared Savings
B Total Cost of Care SharedRisk
C Retrospective BundledPayment
D Prospective BundledPayment
A Condition-Specific Population-Based Payments
B Primary Care Population-Based Payments
C Comprehensive Population-Based Payments
A Traditional FFS
B Infrastructure Incentives
C Care Management Payments
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Clinical Integration
• Collectively define and enforce standards of care
• Coordinate patient care
Providers accountable to each other and to community
to deliver value – high-quality
care in efficient manner
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Clinically Integrated Network
• Governance• Management• Participation
Lean infrastructure
to support provider
accountability
• Promote evidence-based decision-making• Engage in performance improvement• Facilitate care coordination• Support care management
Core Functions
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Learning Lab Identify potential issues through data reporting
and analysis Pursue performance improvement through
collaborative projects and benchmarking
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The Challenge How can independent providers participating in a
CIN engage in the following without litigation risk? Implement new evidence-based guidelines Share data for performance improvement Evaluate their performance as compared to other
participants
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Case Example CIN establishes ER stroke protocol with target
response time Participants train staff on protocol Participants each report to CIN on performance
measures CIN staff identifies potential issue at one facility How to proceed
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Safety Zone
CIN affiliation with and participation in an existing PSO
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MSSP vs. PSO
Application for
Medicare Shared Savings Program
AHRQ PSO
Certification for Initial
Listing
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Accountability for Beneficiaries
MSSP Application You certify that your ACO [and]
your ACO participants… agree to become accountable for the quality, cost, and overall care of the … beneficiaries assigned to the ACO.
PSO Certification for Listing
Does the entity have policies and procedures to improve patient safety and the quality of healthcare delivery?
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Quality Assurance and Improvement Program
MSSP Application You have a qualified healthcare
professional responsible for the ACO’s quality assurance and improvement program that encompasses... Promoting evidence-based
medicine Promoting beneficiary engagement Reporting internally on quality and
cost metrics Coordinating care
PSO Certification for Listing Does the entity have policies
and procedures in place to assure the utilization of appropriately qualified staff?
Will the entity’s workforce both (a) be appropriately qualified and (b) include licensed or certified medical professionals?
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Quality Assurance and Improvement Program
MSSP Application [H]ow your ACO will require ACO
participants … [to] implement a quality assurance and improvement program including, but not limited to… processes to promote evidence-based medicine, beneficiary engagement, coordination of care, and internal reporting on cost and quality.
PSO Certification for Listing
Does the entity have policies and procedures to use PSWP to encourage a culture of safety, to provide feedback, and to provide assistance to effectively minimize patient risk?
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Internally Reporting on Quality and Cost Metrics
MSSP Application [D]escribe how your ACO defines,
establishes, implements, evaluates, and periodically updates its process… to support internal reporting on quality and cost metrics that [provides] feedback, and evaluation of ACO participant… performance.
[D]escribe how your ACO will use the internal assessments… to continuously improve your ACO’s care practices.
PSO Certification for Listing
Does the entity have policies and procedures to use PSWP to encourage a culture of safety, to provide feedback, and to provide assistance to effectively minimize patient risk?
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Data Flow
Peggy Binzer, Esq.
Using a PSO to investigate how to do a better job in a protected learning culture
Producing Better Outcomes for the Benefit of Patients
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Few Limits for the PSO Protections
Communications with other institutions; Peer review; Coordinating care; Missed or delayed diagnosis; Gap or systems analysis; Laboratory testing review; Convenings; Surveys; Real-time monitoring by the PSO; Scorecards; Clinical protocol development; FMEA; Peer meetings; Case studies; Core measures; Benchmarking; Safety culture surveys; Dashboards; Statistical analysis; Analysis of factors that affect quality; Root cause analysis; Peer conversations; Quality meetings; Real-time analysis of errors; Near misses; Interviews; Reports; Incident reports; PSO takes the signals and investigates/evaluates; Trigger tools; Event registries; Employee or visitor injury related to patient safety; Utilization; Drug compliance; Transfer gaps; Medical necessity; Second victim programs; predictive analysis
Facts in the medical
record or from
interviews
HIPAA: Written information
relied upon for treatment decisions
Administrative practices (e.g., billing)Mandatory State Reporting
Criminal Activity
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High Reliability of Care
Establish clinical guidelines and best
practices
Collect data by each facility
Review for Quality
Validate findings and best practices
Share data (reactive to proactive)
Raise standards through system-wide
learning
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Using PSO in Centralized Peer ReviewHospital System recognizes that its entities
have not been adequately addressing peer review due to lack of expertise, lack of resources, conflicts, and other reasons.
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Solution PSOPSOPSES
Conduct RCA in PSES. RCA results
reported to PSO and with other
hospital PSESsEstablish standardized
review and data collection
PSO analyzes, tracks and trends cases,
outcomes. Shares RCA improved clinical guidelines and
benchmarking with all providers
Report findings, recommendations, best practices, and cases that may
need further investigation
Cases needing additional investigation or FPPE
Adopts best practices, improves clinical guidelines, and
continually measures improvement
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Can Help Comply with External Requirements RCA can be conducted in the PSES and is PSWP. PSWP
RCA information can be used in credentialing (see rulemaking). Accrediting body may work with hospitals in PSES and improve RCA process and ensure compliance under the PSQIA’s confidentiality protections.
PSO review is canary in coal mine – if a performance problem or potential compliance issue is found, need follow up and further investigation from medical staff, compliance, and legal.
PSO does not hide poor performance. If a provider could be causing harm to patients or potentially
acting below the standard of care, the PSO must give notice to the facility to further investigate. Falls outside of the PSO at that time.
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Benefits of the PSO Data privileged and confidential Sharing learnings system-wide Result in improved procedures system-wide, continual
quality improvement for standards of care, and development of high reliability for centerpiece programs
Saves external review costs Result valuable big data – mined for publications, to
improve medical devices
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A New Kind of Transparency PSES allows the confidential sharing of case studies,
events, and solutions with affiliated and unaffiliated providers
Provider (Integrated Dashboard)
EMSPSES
Long-Term
Care PSES
Home Care PSES
Health System PSES
Ambulatory Care PSES
ExternalPSO
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Protections for the PSO A PSO cannot be compelled unless the court or
government can: Identify the specific information Prove the information is not patient safety work product Show they cannot be reasonably available from another source
Shifts the burden of proof and requires a special pleading under the rules of Civil Procedure
Privilege for PSWP in the PSO is self-effectuating, meaning cannot be challenged in court and is not therefore subject to judicial interpretation
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Innovative Models of Care Lead to Benefits
“PSQIA is flexible ‘to accelerate the development of new, voluntary provider-
driven opportunities for improvement’ and to ‘set the stage for breakthroughs in our understanding of how best to improve
patient safety.’”
Source: Patient Safety and Quality Improvement, Proposed Rule, 73 Fed. Reg. 8112, 8113 (February 12, 2008).
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Questions?