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Real Quality: A Recipe for Healthier Patients and Happier Doctors Christian Dankers, MD, MBA Associate Chief Quality Officer Partners HealthCare System Session 9:
Real Quality: A Recipe for Healthier Patientsand Happier Doctors
Christian Dankers, MD, MBAAssociate Chief Quality OfficerPartners HealthCare System
Session 9:
Agenda
• Learning objectives.
• Quality improvement framework.
• Challenges with existing quality measurement system.
• Partners HealthCare approach to measurement and improvement.
• Questions and answers.
Learning Objectives
Assess the value and shortcomings of current quality
metrics.
Evaluate new criteria to use to develop
clinically-meaningfulmetrics.
Identify best practices for deploying new metrics to achievepopulation health
goals.
Recognize the financial, efficiency
and patient outcome benefits of precise, real-time insights.
Partners HealthCare System Members
Partners HealthCare is an integrated system consisting of the following:• Two large academic medical centers
(Massachusetts General Hospital and Brigham and Women’s Hospital).
• Seven community hospitals.• Five community health centers.• Five major multispecialty ambulatory sites.• Inpatient and outpatient psychiatric and
rehabilitation specialty services.• Homecare.• 73,000 employees, including 6,500 physicians.
Population Health
Experience of Care
Clinician Satisfaction
Per Capita Cost
Mortality Disease burden Health/functional statusPatient experiences
Patient safety Healthcare effectiveness
Total cost per member per month
The Triple Aim, Plus One
Model based on IHI.
Poll Question # 1
On average, how many hours are spent per physician on the reporting of quality measures each year?
a) 385 hoursb) 485 hoursc) 585 hoursd) 685 hourse) 785 hours
To Improve, We Must MeasureHow is quality measurementcurrently used?
1. To inform clinical care(quality improvement).
2. To ensure meeting a minimum standard(regulatory).
3. To inform decision making(transparency).
4. To incentivize behaviors(pay for performance and transparency).
Two Important Findings
Casalino LP, et al. Health Affairs 2016.
0 20 40 60
%
Physician Practices Perceptions of Quality Measures
Measures represent quality of care (% moderately or very representative)
Extent of group use of quality scores to focus QIactivities
(% frequently or very frequently used)
Overall Primary Care Cardiology Orthopedics
Measure Proliferation Is Well-Recognized
“Evidence mount[s] that even superb and motivated professionals [have] come to believe that the boatloads of measures, and the incentives to “look good,” [have] led them to turn away from the essence of their work.”
–Robert M. Wachter, Interim Chairman,
UCSF Dept. of Medicine, New York Times 2016
One Example: CMS Incentive ProgramsHospital Readmissions
Reduction Program30-day readmission rates for:• Acute myocardial infarction• Congestive heart failure• Pneumonia• Elective total knee/hip arthroplasty• Chronic obstructive pulmonary disease• Coronary artery bypass graft
Value-Based PurchasingPatient Experience• Overall hospital rating• Communication with nurses• Communication with doctors• Communication about medications• Discharge information• Responsiveness of staff• Pain management• Cleanliness and quietness
Efficiency• Medicare Spend Per Beneficiary
Effectiveness• AMI thrombolytic therapy• AMI mortality• CHF mortality• Pneumonia mortality• Influenza immunization• Elective delivery prior to 39 weeks
Safety• PSI 90 (composite measure)• Central Line Associated Bloodstream Infections (CLABSI)• Catheter Associated Urinary Tract Infections (CAUTI)• Surgical Site Infection (SSI)• Methicillin Resistant Staph Aureus (MRSA) bacteremia• Clostridium Difficile (C. Diff) infection
HAC
Reduction
Program
Why So Much Hospital and Primary Care Focus?
Translating Better Measurement to Better Care
More clinically relevant
measures.
Increased buy-infrom
clinicians.
Increased investment
in toolsand effort.
Improve on clinically relevant
measures.
Better care.
More Clinically Relevant MeasuresDefining Successful Measurement
MotivatingPoor performance makes stakeholders concerned.
AvailableMetrics accessible and not excessively costly to gather.
AccurateCorrectly conveys the delivery of clinical care and outcomes.
UnifyingBuy in from stakeholders that this represents core mission.
ActionableMetrics easily used to guide discussion and initiate change.
Balanced and ParsimoniousLimited number of metrics convey what is needed to know.
Previous State100% of quality metrics areclaims-based HEDIS measures. New Quality Metrics for Primary Care
New Quality Metrics for
Specialty Care
1/3 ofQuality metrics are Primary Care based.
2/3 of Quality metrics are SpecialtyCare based. Future State
All quality metricsEHR-basedclinically accurate measures.HEDIS for Primary Care
Claims-based EHR-based
More Clinically Relevant MeasuresAmbulatory Quality Measurement Road Map
Predictive modeling allows us to determine whether our efforts will yield benefits.
In this example, smokingcessation activities would reduce this population’s10-year risk of death or MI by 1%.
Increased Buy-In From Clinicians Cardiac Risk Reduction
Increased Buy-in from CliniciansSafety Registries
From this….
Test Results Referrals Medications
Lung nodules
Abnormal GFR
Abnormal PSA
Positive FOBT
Colonoscopy
Exercise Test
Mammogram
Oncology
Annual labs
Elderly meds
Opioids
Adherence
To this….
Poll Question # 2
If you were going to have knee surgery, which metric would be most relevant to you in choosing a provider?
a) Average cost of surgeryb) Average length of stayc) Average patient improvement in functiond) Rate of infection/reoperatione) Mortality rate
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PROMs: Total Knee Replacement: Relief from Knee PainOur patients report, on average, little to no knee pain one year after knee replacement.
Patients usually have severe knee pain beforesurgery.
Knee pain improves rapidly over the first few months after surgery …
After one year, many of our patients are nearly pain free.
… and continues to improve over thecourse of a year.
This graph measures the severity of your knee pain before a total knee replacement and after a total knee replacement.A higher score means you feel better and have less pain. Most patients see a dramatic increase in their scores fromless than 40 out of 100 before surgery up to almost 90 out of 100 one year after surgery, representing very little pain.The vertical line a time 0 represents the time of surgery.
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Prostatectomy PROMs: Multiple DimensionsBowel Symptoms
IncontinenceVitality
“Hormonal” Symptoms
Urinary IrritationSexual Dysfunction
Translating Better Measurement to Better Care
More clinically relevant
measures.
Increased buy-in from
clinicians.
Increased investment
in toolsand effort.
Improve on clinically relevant
measures.
Better care.
• Leadership engagement.• Transparency.• Policy and incentives.• Training and education.• EHR and electronic tools.• Process improvement.
Increased Investment in Tools and EffortPartners’ Quality Transparency Website
Data and screenshots available at www.partners.org
Increased Investment in Tools and Effort:Other Transparency Initiatives
Patient Experience Surveys Patient Notes
Increased Investment in Tools and Effort: CareDecisions.Partners.org
Increased Investment in Tools and Effort:A Word About Policies
Increased Investment in Tools and Effort:Clinical Process Improvement Leadership Program
Cummings BM, et al. What Makes a Project Successful? Measuring Success of Local Quality Improvement Projects. Abstract IHI National Meeting, 2016.
Increased Investment in Tools and Effort:Data Analytics Tools
• Allow analysis of practice or individual MD performance.
• Facilitates benchmarking.
Improve on Clinically Relevant Measures Results: Successful Quality Improvement
1009080706050403020100 CRC Breast Ca Cervical Ca HTN-BP CVD-Lipid DM-Lipid DM-BP
Screening Screening Screening Control Control Control Control% S
cree
ned
or A
chie
ving
Targ
et
Sep-16 July-18
Improve on Clinically Relevant Measures Results: Successful Quality Improvement• Managing acute stroke.• Improving care for mechanically ventilated patients.• Chest pain care in the emergency department.• Orthopedic hip and knee replacement and post-acute care.• Use of opioids post-cesarean section.• Collecting patient safety events related to the EMR.• Measuring social risk factors and health equity.• Innovative approaches to assessing patient experiences.• Improving care for chronic kidney disease.
