Implementing Implementing ALLALL the the consensus standards:consensus standards:

the journey so farthe journey so far

Daniel Varga, MDDaniel Varga, MDChief Medical OfficerChief Medical Officer

Norton HealthcareNorton HealthcareLouisville, KentuckyLouisville, Kentucky

OutlineOutline

What we didWhat we did Getting startedGetting started Going publicGoing public ImpactImpact EvaluationEvaluation

What we didWhat we did

Published our Published our redred--greengreen performance performance

[[www.www.NortonHealthcareNortonHealthcare.com.com 3/31/2005]3/31/2005]

On more than 200 (now 340) nationally On more than 200 (now 340) nationally recognized indicators of hospital clinical recognized indicators of hospital clinical qualityquality

VoluntarilyVoluntarily

Our report includes all the Our report includes all the consensus standards for:consensus standards for:

NQFNQF hospital carehospital care cardiac surgerycardiac surgery nursing-sensitive carenursing-sensitive care safe practicessafe practices coming soon (now here)coming soon (now here): ambulatory : ambulatory

carecare

Our report also includes:Our report also includes:

AHRQAHRQ patient safety indicatorspatient safety indicators inpatient quality indicatorsinpatient quality indicators

JCAHOJCAHO national patient safety goalsnational patient safety goals pediatric ORYXpediatric ORYX

brief description desired Audubon Norton KY U.S.% heart bypass surgeries using internal mammary artery

high 84 95 92

% heart bypass pats. given preoperative beta blocker

high 69 66 70

% heart bypass patients given preop. antibiotic on time

high 92 69 64

% heart bypass pats. w/antibiotic discontinued on time

high 80 83 48

% heart bypass pats. intubated more than 24 hours (adj)

low 26.5 18.6 9.1 8.3

List the indicators.

Say whether want high or low #.

Cardiac surgery example

Clicking on a cell opens a popup with more information ...

Show U.S. performance.

How do we compare?

…

crds06Number of heart bypass procedures per 100, that use the internal mammary artery as a graft. This is a common open heart surgery where surgeons bypass blockages of the coronary arteries using the internal mammary artery as a graft. The use of an internal mammary artery increases the likelihood of a good long-term outcome for the patient.

TechnicalIncludes inpatients discharged with any procedure of coronary artery bypass graft (CABG). Excludes patients less than 20 years of age; excludes patients discharged with any additional cardiac surgical procedure; excludes patients with any previous CABG, valve, or other cardiac surgical procedure.

(NQF HC 11 / NQF cardiac 6 / STS)

Evaluating the numbersEvaluating the numbers

If numeric and have U.S. comparison,If numeric and have U.S. comparison,compute 99% confidence interval:compute 99% confidence interval:

““BetterBetter than U.S. average” than U.S. average”““NearNear U.S. average” [within C.I.] U.S. average” [within C.I.]““WorseWorse than U.S. average” than U.S. average”

Safe practices are a self-assessment.Safe practices are a self-assessment.

safe practiceImplement a standardized protocol to prevent the mislabeling of radiographs. (NQF Safe Practice 13)

Implement standardized protocols to prevent the occurrence of wrong-site procedures or wrong-patient procedures. (NQF Safe Practice 14)

Evaluate each patient undergoing elective surgery for risk of an acute ischemic cardiac event during surgery, and provide prophylactic treatment of high-risk patients with beta blockers. (NQF Safe Practice 15)

Evaluate each patient upon admission, and regularly thereafter, for the risk of developing pressure ulcers. This evaluation should be repeated at regular intervals during care. Clinically appropriate preventive methods should be implemented consequent to the evaluation. (NQF Safe Practice 16)

Upon admission, and regularly thereafter, evaluate each patient for the risk of aspiration. (NQF Safe Practice 19)

Adhere to effective methods of preventing central venous catheter-associated blood stream infections. (NQF Safe Practice 20)

Evaluate each patient upon admission, and regularly thereafter, for the risk of developing pressure ulcers. This evaluation should be repeated at regular intervals during care. Clinically appropriate preventive methods should be implemented consequent to the evaluation. (NQF Safe Practice 16)In progress. Our hospitals use a rating scale to evaluate the risk of pressure ulcers on admission. More intense assessment of patients identified as at-risk is performed at intervals. Plan to convene a team to develop a more systematic approach after the evaluation.

Website: Questions & Website: Questions & AnswersAnswers

What is in this Quality Report? What is in this Quality Report? How were these indicators and safe practices How were these indicators and safe practices

selected? selected? Does this quality report display data about Does this quality report display data about

individual physicians? individual physicians? Is this information available for hospitals that are Is this information available for hospitals that are

not part of Norton Healthcare? not part of Norton Healthcare? Why is Norton Healthcare publishing its quality Why is Norton Healthcare publishing its quality

data? data? What does "risk-adjusted" mean? What does "risk-adjusted" mean? If a hospital's performance is red, does that mean If a hospital's performance is red, does that mean

it provides bad care? it provides bad care? How often will the data in this report be updated? How often will the data in this report be updated?

Website: Technical Website: Technical notesnotes

How did we decide when to color-code How did we decide when to color-code performance on a numeric indicator red or performance on a numeric indicator red or green? green?

Why is Hospital A “average,” and Hospital B Why is Hospital A “average,” and Hospital B “better than average,” when Hospital B has a “better than average,” when Hospital B has a worse percentage than Hospital A? worse percentage than Hospital A?

How does risk adjustment work? How does risk adjustment work? Where did these indicators come from? Where did these indicators come from? Where are the data sources for these Where are the data sources for these

numbers? numbers? What are some of the known limitations of our What are some of the known limitations of our

report on these indicators and safe practices? report on these indicators and safe practices?

Getting startedGetting started

Deciding to go public Deciding to go public

Why we did itWhy we did it ““(He’s) right! Psychotic, but absolutely right…Now (He’s) right! Psychotic, but absolutely right…Now

we could do it with conventional weapons, but that we could do it with conventional weapons, but that could take years and cost thousands of lives…I think could take years and cost thousands of lives…I think that this situation absolutely requires a really futile that this situation absolutely requires a really futile and stupid gesture be done on somebody’s part…and stupid gesture be done on somebody’s part…We’re just the guys to do it.We’re just the guys to do it.

Eric Stratton and John BlutarskyEric Stratton and John Blutarsky AKA, Otter and BlutoAKA, Otter and Bluto

Animal House, 1978Animal House, 1978

What we hope we don’t What we hope we don’t have to say to our Boardhave to say to our Board

“…“…you can’t spend your whole life you can’t spend your whole life worrying about your mistakes. You worrying about your mistakes. You *&%$*ed up. You trusted us. Hey, *&%$*ed up. You trusted us. Hey, make the best of it…my suggestion to make the best of it…my suggestion to you is to start drinking heavily.you is to start drinking heavily.

Eric Stratton and John BlutarskyEric Stratton and John Blutarsky

AKA, Otter and BlutoAKA, Otter and Bluto

Animal House, 1978Animal House, 1978

QuestionQuestion

If you know your death rate for If you know your death rate for some procedure is 2.6%, some procedure is 2.6%,

should the public know that, too?should the public know that, too?

To improve, hospitals mustTo improve, hospitals must1.1. find out what their results are.find out what their results are.2.2. analyze their results,analyze their results,

to find their strong and weak points.to find their strong and weak points.3.3. compare their results with those of other hospitals compare their results with those of other hospitals

[How?? If it’s all secret.][How?? If it’s all secret.]

4.4. welcome publicity not only for their successes, welcome publicity not only for their successes, but for their errors…but for their errors…

Such opinions will not be eccentric a few years hence.Such opinions will not be eccentric a few years hence.Dr. Ernest A. Codman Dr. Ernest A. Codman

19171917

Quote from: Quote from: The Role of Clinical Data and Risk Adjustment in Public Reporting of Hospital Performance. The Role of Clinical Data and Risk Adjustment in Public Reporting of Hospital Performance. Massachusetts Health Data Consortium. December 10, 2003.Massachusetts Health Data Consortium. December 10, 2003.RS Johannes, MS, MD, Vice President for Medical Affairs, Data & Clinical Information – Cardinal Health. RS Johannes, MS, MD, Vice President for Medical Affairs, Data & Clinical Information – Cardinal Health.

http://www.mahealthdata.org/forums/data/2003/DMUF_20031210_Johannes.pdfhttp://www.mahealthdata.org/forums/data/2003/DMUF_20031210_Johannes.pdf

Why we did itWhy we did it

Accountability as a public assetAccountability as a public asset Clinical care is, in fact, our “widget”Clinical care is, in fact, our “widget” We talk about our financials with bond raters, the press, etc.; We talk about our financials with bond raters, the press, etc.;

why not our clinical performance?why not our clinical performance? Proactively influence the the public reporting arenaProactively influence the the public reporting arena

Clinical over purely financialClinical over purely financial Transparent over proprietaryTransparent over proprietary Evidence based over arbitraryEvidence based over arbitrary

Get the organization moving in a direction that is Get the organization moving in a direction that is inherently inevitableinherently inevitable

Improve our care; “We’ll manage what we measure and Improve our care; “We’ll manage what we measure and report”report”

Why do it when the Why do it when the indicators are less than indicators are less than

perfect?perfect? Diabetes Mellitus (circa 1970)Diabetes Mellitus (circa 1970) Fasting Blood SugarFasting Blood Sugar GlycosuriaGlycosuria

Hyperlipidemia (circa 1980)Hyperlipidemia (circa 1980) Total Cholesterol < 240Total Cholesterol < 240

Systolic Hypertension (circa 1980, ?now)Systolic Hypertension (circa 1980, ?now) Who cares if the diastolic is OK ?Who cares if the diastolic is OK ?

No one manages to these standards today, but No one manages to these standards today, but management to these indicators produced management to these indicators produced demonstrable outcome improvement in their demonstrable outcome improvement in their dayday

Using the indicators made the indicators betterUsing the indicators made the indicators better

Getting startedGetting started Obtaining and keeping board and Obtaining and keeping board and

leadership commitmentleadership commitment Gave board quality committee the leadGave board quality committee the lead Moved quickly, before resistance could Moved quickly, before resistance could

organizeorganize Created sense of inevitabilityCreated sense of inevitability ““A lot of this is already out there.”A lot of this is already out there.” Committed ourselves with local media Committed ourselves with local media

months in advance. months in advance.

Getting startedGetting started Choosing what to publishChoosing what to publish

““Let’s just use AHRQ and NQF.”Let’s just use AHRQ and NQF.” Short-circuit the definition battle byShort-circuit the definition battle by

Choosing entire lists instead of Choosing entire lists instead of deciding indicator by indicatordeciding indicator by indicator

NotNot being the indicator owner being the indicator owner not not redefining the measure redefining the measure not not applying local reinterpretations of applying local reinterpretations of

exclusion criteriaexclusion criteria

Going publicGoing public

Infrastructure neededInfrastructure needed To collect, analyze, and display the dataTo collect, analyze, and display the data To analyze and improve performanceTo analyze and improve performance Our total FTE count for this work is still very Our total FTE count for this work is still very

small (10-12)small (10-12) Tips about the analysis and display of the Tips about the analysis and display of the

indicatorsindicators ““The number is what the number is.”The number is what the number is.” The importance of flagging The importance of flagging goodgood and and

badbad performance performance

ImpactImpactof implementing the consensus standardsof implementing the consensus standards

We We areare still in business. still in business. Better data; less time arguing about the Better data; less time arguing about the

measure and more time improving measure and more time improving performance.performance.

Unused data never become valid.Unused data never become valid. Even a lousy indicator can drive improvement.Even a lousy indicator can drive improvement.

Limited public reaction Limited public reaction Mostly favorable physician responseMostly favorable physician response Strong desire to be “within normal limits”Strong desire to be “within normal limits”

Perhaps the most noteworthy recent development is the surprising announcement by Norton Healthcare, the five-hospital system based in Louisville, Ky., that it will soon begin to publish the widest array of quality data of any U.S. healthcare provider. … Indicators won’t be dropped if the hospital’s performance is lagging behind …

Quality without a pointed gun. Modern Healthcare, Feb. 21, 2005. p. 22.

For decades, recalcitrant hospital operators have resisted the ideaFor decades, recalcitrant hospital operators have resisted the idea

of a public report card of their services, a kind of yardstick to of a public report card of their services, a kind of yardstick to

compare their performance to local and national data of the same compare their performance to local and national data of the same

kind. Such information would be impossible to assess fairly, kind. Such information would be impossible to assess fairly, theythey

claimed. What's more, it would confuse patients, they asserted. claimed. What's more, it would confuse patients, they asserted.

And it might be, well, negative.And it might be, well, negative.

Yes, it might be. Louisville's Norton Healthcare has defied Yes, it might be. Louisville's Norton Healthcare has defied

traditional logic with its nationally acclaimed reporting system, traditional logic with its nationally acclaimed reporting system,

which airs the hospitals' linen – both clean and dirty – for all to which airs the hospitals' linen – both clean and dirty – for all to

see. see. It is an astonishing documentIt is an astonishing document….….

Courier-JournalCourier-Journal, editorial, April 2, 2005., editorial, April 2, 2005.

EvaluationEvaluation What we’ve learned about the measuresWhat we’ve learned about the measures

Few existing tools to automate or Few existing tools to automate or streamline any of this. streamline any of this.

Comparative data are hard to findComparative data are hard to find Wide variation in clarity of definition, Wide variation in clarity of definition,

sensitivity and specificity, and ease of usesensitivity and specificity, and ease of use Too many local decisions about details of Too many local decisions about details of

collection, analysis, and displaycollection, analysis, and display[too much potential variation][too much potential variation]

EvaluationEvaluation Implementing the consensus standardsImplementing the consensus standards

Turned up the heat on improving our Turned up the heat on improving our performanceperformance

Increased alignment about what to tackleIncreased alignment about what to tackle IT agenda better alignedIT agenda better aligned Strategic capital better alignedStrategic capital better aligned Physician workforce better alignedPhysician workforce better aligned

Created new feedback about the ultimate Created new feedback about the ultimate effectiveness of attempts to improveeffectiveness of attempts to improve

Had few downsides Had few downsides [Come on in. The water’s fine.][Come on in. The water’s fine.]