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, MPH

Director, Quality Improvement Group

Centers for Medicare & Medicaid Services

August 23, 2004

VisionVisionfor the Healthcare Systemfor the Healthcare System

The right care for every person every time.

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MissionMissionCMS Quality Improvement ProgramsCMS Quality Improvement Programs

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

MBE

R O

F O

BSER

VATI

ON

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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2 0 2 4

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Improvement StrategiesImprovement Strategies

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Seven Key StrategiesSeven Key Strategiesfor Culture Changefor Culture Change

• 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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Shorten Improvement CyclesShorten Improvement Cycles

• Improvement is real but the pace is far too slow.

• The length of the improvement cycle is one of the key determinants of the pace of change.

• The long cycles in CMS and other payers and purchasers contribute to long cycles in providers.

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Spread SuccessesSpread Successes

• To transform the system we must spread successes from the few to the many.

• For example, today, – the most successful thousand nursing homes in

the country are virtually restraint-free, – the most successful half of nursing homes have

a collective restraint rate of about 2.5%.

• But the national rate remains above 8%.

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The

Toolkit

PATI-ENT

SUPPORTSTANDARDMETHODS

PROMOTE

OR CREATE

PARTNERSHIPS

PR

OV

IDE

TE

CH

NIC

AL

AS

SIS

TA

NC

E

STRENGTHEN

WORKFORCE

PROVIDEPUBLIC

INFORMATION

STRUCTURE

COVERAGE AND

PAYMENTS

RE

WA

RD

D

ES

IRE

D

PE

RF

OR

MA

NC

E

ESTABLISH &

ENFORCE

REQUIRE-

MENTS

1616THE TOOLKIT WITHIN THE CMS SYSTEM

IDENTIFY IMPROVEMENT OPPORTUNITIES AND SELECT APPROPRIATE IMPROVEMENT INTERVENTIONS

ADOPT OR DEVELOP MEASURES

COLLECT & ANALYZE DATA

SELECT PRIORITY AREAS

MANAGE PROCESS IN PARTNERSHIP WITH STAKEHOLDERS

ESTABLISH&

ENFORCE STANDARDS

STRUCTURE COVERAGE

AND PAYMENTS TO IMPROVE

CARE

SUPPORT STANDARD METHODS

GIVE CONSUMERS

INFOR-MATION

AND ASSISTANCE

TO MAKE CHOICES

PROMOTE OR CREATE

COLLABORA-TIONS ANDPARTNER-

SHIPS

GIVE PLANS,

DOCTORS&

PROVIDERS TECHNICAL

ASSISTANCE

REWARD DESIRED

PERFORM-ANCE

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StandardsStandards

• Health Information Technology

• Clinical Guidelines

• Performance Measures

• Coverage and Payment procedures

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PartnershipsPartnerships

e-Health Partnerships

• Surgical Care Improvement Partnership

• Corporate Nursing Home Improvement Collaborative

• Fistula First

• National Quality Forum

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Technical AssistanceTechnical Assistance

Quality Improvement Organizations

Nursing HomesNursing HomesPercent Decrease in Problem Rate

Non-participant

homes

Participant nursing homes

Participants selecting

topic

Chronic Pain -33.3% -46.1% -60.5%

Post-acute Pain

-9.3% -16.9% -26.1%

Physical Restraints

-17.6% -28.5% -68.3%

Pressure Ulcers

+3.3% -1.1% -7.8%

2020

Physician OfficePhysician Office

Percent decrease in failure rateWhole state Participants

HgbA1c 20.5 29.1

Lipid profile 29.8 36.4

Eye exam 0.6 4.9

Mammography -0.3 2.3

DIA

BE

TE

S2121

Home HealthHome HealthPercent Decrease in Failure Rate

National Participants

Participants selecting

topic

Pain 5.5 6.5 12.8

Dyspnea 6.8 7.6 17.1

Oral meds 7.5 6.1 14.1

Emergent Care -3.7 -5.3 -5.7

Acute hospitalization

1.1 1.7 1.5

InpatientInpatient Percent Decrease in Failure Rate1998-9 to 2000-1

Aspirin at admission 6.1

Aspirin at discharge 6.6

Beta blockers at admission 13.9

Beta blockers at discharge 25.0

ACEI for ventricular dysfunction 10.3

Left Ventricular Assessment 14.3

ACEI for ventricular dysfunction -3.3

Timely antibiotics 13.3

Appropriate antibiotics 28.6 P

NE

U

H

RT

FA

IL

HE

AR

T A

TT

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

0

2

4

6

8

10

12

14

16

18

2002Q2 2002Q3 2002Q4 2003Q1 2003Q2 2003Q3 2003Q4 2004Q1

Quarter

QM

sc

ore

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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Interstate VariationInterstate Variation

Eight Current DomainsEight Current Domains

Domain Population SampleAmbulatory clinical

FFS StateM+C Plan

Dialysis FFS ProviderHome health FFS ProviderInpatient FFS StateNursing home FFS & M+C ProviderConsumer perception

FFS StateM+C Plan

Overall: sum of standardized scores

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Quartile

First (13)Second (13)Third (13)Fourth (12)

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

Amb FFS

AmbM+C Inpatient

Amb FFS 1.00 0.66 0.65

Amb M+C 0.66 1.00 0.45

Inpatient 0.65 0.45 1.00

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Predictors of Overall Predictors of Overall State-level QualityState-level 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 Priorities

Integrated 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

homes• Colon cancer screeing