OPTA 2018 Presentation Handout Slides · Design, implement and study innovative care delivery models ... Input Team Lead for Quality Assurance KT Associate Director of Education and

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Creating a Clinician-Driven Quality Assurance Program Within an Academic Medical Center’s

Ambulatory Rehabilitation DepartmentJohn DeWitt, PT, DPT, SCS

Lindsay Harmon-Matthews, PT, DPT, OCS, MPHMichael Martin, PT, MPT, OCS

Disclosures

John DeWitt, Lindsay Harmon-Matthews and Michael Martin have no financial disclosures that would be of

potential conflict of interest with this presentation.

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Objectives• Provide an overview of the importance

of Quality and Outcomes (QO) Programs in PT

• Outline steps to create a Quality and Outcomes (QO) program

• Define metrics to implement a successful QO program

• Describe how to utilize and leverage technology to measure the program’s success

• Design methods to leverage technology in the development and analysis of a QO program

• Cite examples of positive results

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OSUWMC Ambulatory Rehabilitation

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Academic Medical Center

7 Hospitals, 3 Magnet Hospitals,1,321 Beds

9 Multi-specialty Centers

60,000 inpatient admissions

1.7 million outpatient visits

>35 affiliations or community hospital partnerships

7 Health Sciences Collegeson a Single Campus

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OSUWMC’s Ambulatory Rehab Department

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Ambulatory Rehab

Outpatient Rehab

Ortho & Neuro PT

OT & SLP Services

Sports Medicine Sports PT

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Ambulatory Rehab’s Growth

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2018

15 facilities, >180 clinical

staff

190,000 annual visits

2004

1 facility, 7 staff

Creating a Quality and Outcomes Program

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Defining Quality

Quality “Then:” Regulatory Compliance Passing an Audit

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Defining Quality

Quality “Now:” Institute of Medicine DomainsEffectivenessEfficiencyEquityPatient CenterednessSafety Timeliness

https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/understand/index.html

http://www.ihi.org/resources/Pages/ImprovementStories/AcrosstheChasmSixAimsforChangingtheHealthCareSystem.aspx

http://www.who.int/management/quality/assurance/QualityCare_B.Def.pdf

https://www.ncbi.nlm.nih.gov/books/NBK222271/10

QO Programs demonstrate our identity:

How do we do what we do? Utilize evidence-based practice

Who are we?

Describe our role in pt care as movement

experts

What do we do?

Show ethical

decision making

Why do we do what we do?

Justify clinical decision making

Design, implement and study innovative care delivery models Inform and create change “Right Intervention, Right Patient, Right Time”

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QO Programs demonstrate the Value of Care:

Effective good clinical/functional outcomes

Patient-centered excellent patient experience

Efficient controlled costs

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QO Programs also assist with:

Maintaining regulatory compliance Coding/Billing standards Authorization requirements CMS & payer guidelines

Justifying reimbursement

Making operational decisions Staffing Program development Resource management

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Knowledge Translation

(putting info into practice)



Output(outcomes,

behavior change)

Output(outcomes,

behavior change)

Input(who we

are)

Input(who we

are)

Our Path to Quality and Outcomes

Our Path to Quality and Outcomes

Input Team Lead for Quality Assurance

KT Associate Director of Education and Professional Development

Output Team Lead for Evidence Based Practice

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Needs Assessment

• Rationale

• Business Justification

Position Creation

• Position priorities

• Position description

• Framework

Program Development

• Team

• Program objectives

• Key contacts

• Leveraging Technology





Output(outcomes,

behavior change)

Output(outcomes,

behavior change)

Input(who we

are)

Input(who we

are)

Safety and Compliance!

Prior lack of system awareness of therapy regulations Coding/Billing Reimbursement Contractual negotiations Authorization

Growth of department necessitated expansion of clinical QA team

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Needs Assessment

• Rationale


Team Lead for Quality Assurance

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QA Business Justification

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Development of Residencies and Fellowship programs

Various individual programs and groups dedicated to EBP No continuity or connection to overall

mission

Need for defined leadership and strategic plan

Need for formalized mode of “filtering” and translating info collected

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Needs Assessment

• Rationale


Associate Director for Professional Development

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Growth of department and multiple special interest groups

Lack of formal clinician education

No standard for care delivery across locations and clinicians

Required more comprehensive approach to handling unexpected outcomes

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Needs Assessment

• Rationale


Team Leads for Evidence Based Practice

1.) Year 1: Lead P2P committee; create plan for a systematic identification of needed competencies and roll-out for education; work with team to identify plan for the collection of outcomes (Patient and Clinician specific) translated to changes in care/behavior; identify individual variances in quality or outcomes (e.g. poor pt outcomes) and work with clinic manager to address; visit sites with special interest group contacts to roll out new CPGs, competencies, etc.

2.) Year 2 and beyond: Assuming available registry data (or an alternative understanding through outcomes survey assessment, etc.), identify variances with expected benchmarks (intra-clinic or PT comparison, comparison with national benchmarks, etc.) and implement plans to change our treatment approach in response to these variances. Present outcomes and implementation to state and/or national professional meeting. Identify and publish clinical practice guideline in national clearinghouse or professional journal.

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Needs Assessment

• Rationale



Process Improvement and Technology’s Role

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• Measure the Impact

• Adjust, Implement, & Examine

• Test at Pilot Sites

• Identify Priorities

Plan Do

StudyAct

Using Technology in PDSA Cycles

Plan Understand

baseline statusSet improvement

targets

Do Test at pilot sites

Study Monitor impact

Act Adjust and examine

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Plan Automated reports Electronic

summaries

Do May involve tech

Study Reports, Excel, etc.

Act Adjust based on

analysis

Technology & Iterative Cycles

Optimizing processes with technology Identify clinic need Connect tech capabilities with clinic workflow

Identifying challenges with technology Use staff feedback

Troubleshooting with technology team Clear communication is key

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Leveraging Technology to Expand the QA Program

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G-code Functional Limitation Reporting “G-codes”

Medicare Plan of Care Certifications “Rehab Certs”

Medicare Therapy Cap/Threshold “KX Modifiers”

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QA Program & Technology

• Payer guideline compliance

• EMR changes

• Documentation consistency

Plan – determine baseline status?

Do – staff education or EMR changes?

Study – impact on compliance rates?

Act – continued monitoring?

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• EMR changes


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Plan: Information Warehouse reports Work queues Customized Epic reports

Do: Workflow maps EMR improvement staff education

Study & Act: Analyze data from Plan phase

compared to Do phase Continued weekly and monthly audits

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• EMR changes


IT Systems Analyst

Revenue Cycle Team

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Epic Capabilities

Flowsheet Updates

Billing Language

Report Requests


• Chart audits


• EMR changes


Using Technology to grow Knowledge Translation and

Outcomes Initiatives

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KT & Outcomes Technology

• Guideline Development

• PRO Initiative

• Survey /Compliance Audit

• Develop outcome-based KT projects

• CPG committee formation

• Examine current KT culture

Plan Do

StudyAct

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• PRO Initiative

Plan – Examine current KT practices and opportunities

Schutte, 2015 PTinMOTION

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• PRO Initiative

Plan – Examine current KT practices and opportunities

Schutte, 2015 PTinMOTION

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• PRO Initiative

Develop an EBP initiative to: Identify Clinical Practice Guidelines Educational training Competency assessment Limit, but not eliminate variability in

patient care

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• PRO Initiative

Do – CPG committee formation

P2P Steering

Committee (Ambulatory

Services)

Physical Therapy

PT

PT

PT

PT

PTA, AT

Occupational Therapy OT

Speech Therapy SLP

SLP: Clinical Swallow Eval

Sports PT: Autologous Chondrocyte Implantation

OP PT: Cervical radiculopathy

OT: Wrist assessment

Neuro PT: Long term management of BI/CVA

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• PRO Initiative

Do – Education

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Study – Survey Staff and examine PROs

Question Strongly disagree

Disagree Somewhat disagree

Neither agree nor disagree

Somewhat agree

Agree Strongly agree

Information was accurate

0% 0% 0% 0% 2% 41% 56%

Formatting was clear 0% 2% 2% 0% 2% 47% 46%Guideline will improve clinical practice

2% 2% 4% 4% 13% 39% 35%

Guideline was applicable to current practice

2% 0% 2% 2% 9% 37% 48%

Educational Session Feedback

Strongly agree (24%)

Agree (46%)

Disagree (7%)

Somewhat agree (12%)

Neither agree or disagree (9%)

Effectiveness Rating: 76/100

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• PRO Initiative

Act – Develop KT projects specific to outcomes

Proposed new CPGs

Development of two “Evidence-based Practice Coordinators”

We a way to measure out

success!

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• PRO Initiative

Administration

EBP Team Leads

QIResearchers

IT

Outcome Leadership Committee

32%

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• PRO Initiative

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• PRO Initiative

SMR (PT) OPR (PT/OT/SLP)Body-region specific • Oswestry Disability

Index (ODI) Neck Disability Index

(NDI) quickDASH Lower Extremity

Functional Score (LEFS)

PROMIS Physical Function

Condition-specific• (MSIS-29, PDQ 39,

DHI, LCI, CGS, SIS, QOLIBRI, WHO-BREF)

• Ortho: body-region specific PROs

• Women’s health: PSFS (OPR & SMR)

• OT/SLP: PSFS PT: PROMIS Physical Function

Collection Rates• Every encounter Eval, every10th visit,

D/C

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March: Vision Casting (OLC)

April: Pilot Testing

July: Go Live

Sept: Tablets Nov: Re-group OLC

May: Go live Prep(OLC)

Oct: Feedback gathered

Dec. Revision of PRO

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PRO Initiative – Automated Reports

32%

87%

90%

60,000 (July-Feb)

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PRO Initiative – Tell the Story to the patient

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PRO Initiative – EMR Integration

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Clinician Education Initiatives

Online courses CPG education “Carmen” “Buckeye Learn”

Podcasts and web-based meetings Ongoing education Standardized message across sites and

distance

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Meeting Structures

Need to Know In person meeting Online competenciesCompliance update, required CPG info

Good to Know Web-based meetingEfficiency and EMR updates

Nice to Know Optional meeting with podcast available Newsletters Email blasts

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Putting it All Together

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Input

(who we are)

Input

(who we are)


(putting info into

practice)


(putting info into

practice)

Output

(outcomes, behavior change)

Output

(outcomes, behavior change)

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QA Program Results from Technology Improvements

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QA Program – Compliance Results

Improved compliance & consistency

G-codes at Eval: >60% decrease in # of errors

Rehab Certifications: Error rate <2%

KX Modifiers: 101 denials prevented (>$45K)

Documentation, workflows, communication

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G-code Error Types at Evaluation

0

5

10

15

20

25

30

35

40

Jan‐16

Feb‐16

Mar‐16

Apr‐16

May‐16

Jun‐16

Jul‐16

Aug‐16

Sep‐16

Oct‐16

Nov‐16

Dec‐16

Jan‐17

Feb‐17

Mar‐17

Apr‐17

May‐17

Jun‐17

Number of Errors

Month

Trends in G‐code Error Types at Evaluation January 2016 ‐ June 2017

Missing G‐codes

G‐codes on wrong date

Incorrect G‐codes

Total Errors

FY16 Q3-Q4 compared to FY17 Q3-Q4:• 91 fewer total errors• 62.8% decrease in total errors

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Eval G-code Denials - Process Improvement

FY17 Goals: <10% first pass error rate ↓ # G-code errors at evaluation

Plan: Implemented Close Encounter Points in Epic at

evaluation/re-evaluation July-Sept 2016

Trialed at pilot site, starting May 2016

Results: 62.8% ↓ in total errors FY17 Q3-Q4 compared to FY16 Q3-Q4

FY17 goal achieved!58

Rehab Cert – Process Improvement

FY17 Goals: ≤2% first pass error rate overall

Plan: Implemented Close Encounter Point in Epic at

evaluation to warn clinicians the Rehab Cert is needed July-September 2016

Trialed at pilot site, starting May 2016

Results: Consistently at or below target after implementing

Close Encounter Point

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QA Program – Department Results

Financial Return on Investment Reimbursement rate increased

Medical Center Collaboration Alternative Payment Models Revenue Cycle Initiatives

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Outcomes Program Results from Technology

Improvements

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PRO Results

Improved PRO capture rate

Tablet technology

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Recommendations and Future Directions

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Design, implement and study innovative care delivery models Inform and create change “Right Intervention, Right Patient, Right Time”

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QO Programs demonstrate the Value of Care:

Effective good clinical/functional outcomes

Patient-centered excellent patient experience

Efficient controlled costs

Future QO Goals

Effective Care – Outcomes Analysis Functional and PRO status at discharge Will drive Clinical Practice Guideline development and

revision

Patient-centered Care - PRO Data Change over time for a specific condition Will inform staff education needs

Are we measuring what we intend to measure? Are additional patient-centered outcomes needed?

Efficient Care – Episode Analysis Number of visits in episode Number of charges in episode Clinical Practice Guideline adherence

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Outcomes Leadership Committee

Senior Director, Ambulatory Rehab

Associate Directors of Sports Med Rehab and Outpatient Neuro Rehab

Associate Director of Education and Professional Development

Dedicated IT Senior Systems Consultant

Team Lead for Quality Assurance


Dedicated PhD Researchers and Outcomes Staff Clinical Outcomes Research Coordinator Program

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Additional Rehab Teams

EMR Stakeholders Group

EMR Super Users

Quality Ambassadors

Paper to Practice Committee

Sub-specialty Clinical Teams

Clinical Outcomes Research Coordinators

IT Systems Consultant

Operational Leaders

Data Warehouse Managers

Revenue Cycle Groups

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Our Vision

Working as a team, we will shape the future of rehabilitation, wellness, and prevention through the following: Collection and analysis of outcomes, quality, and

compliance. Translation and dissemination of knowledge to

create changes in clinical care. Reporting outcomes to identify best practice and

needs

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Thank You!

Lindsay Harmon-Matthews,Team Lead for Quality Assurance

Office: 614-688-9175Lindsay.Harmon-

[email protected]

Michael Martin,Senior Director, Ambulatory

RehabilitationOffice: 614-688-8951

[email protected]

John DeWitt,Associate Director for Education and

Professional DevelopmentOffice: 614-366-0926

[email protected]

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References & Suggested Reading

Outcomes & Value

Fritz, J.M. (2012). Physical therapy in a value-based healthcare world. Journal of Orthopedic and Sports Physical Therapy, 42(1), 1-2. doi:10.2519/jospt.2012.0101

Jette, A. (2016). Toward systems science in rehabilitation. Physical Therapy, 96(3), 270-271.

Hoyer, E.H., Needham, D.M., Miller, J., Deutschendorf, A., Friedman, M., Brotman, D.J. (2013). Functional status impairment is associated with unplanned readmissions. Archives of Physical Medicine and Rehabilitation, 94, 1951-1958.

Lentz, T.A., Harman, J.S., Marlow, N.M., & George, S.Z. (2017). Application of a value model for the prevention and management of chronic musculoskeletal pain by physical therapists. Physical Therapy, 97(3), 354-364.

Porter, M.E., Larsson, S., & Lee, T.H. (2016). Standardizing patient outcome measures. The New England Journal of Medicine, 374(6), 504-506.

Porter, M.E. (2010). What is value in heath care? The New England Journal of Medicine, 363(26), 2477-2481.

Westby, M.D., Klemm, A., Li, L.C., & Jones, C.A. (2016). Emerging role of quality indicators in physical therapist practice and health service delivery. Physical Therapy, 95. doi: 10.2522/ptj.20150106

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Quality Improvement

Ferguson, T.B. (2012). The Institute of Medicine Committee report “best care at lower cost: the path to continuously learning health care.” Circulation: Cardiovascular Quality and Outcomes, 5. Retrieved from http://circoutcomes.ahajournals.org/

Gawande, A. (2010). The checklist manifesto: How to get things right. New York: Metropolitan Books.

Hyzy, R., Posa, P., & Scales, D.C. (2012). System-level quality improvement initiatives: lessons from keystone and other large-scale projects. Seminars in Respiratory and Critical Care Medicine, 33(4), 370-374.

James, B.C. & Savitz, L.A. (2011). How Intermountain trimmed health care costs through robust quality improvement efforts. Health Affairs, 30(6), 1185-1191.

Scoville, R. & Little, K. (2014). Comparing Lean and Quality Improvement. IHI White Paper. Cambridge, MA: Institute for Healthcare Improvement. (Available at ihi.org).

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Other Systems’ Best Practice Models

Delitto, T., Fitzgerald, K., & Irrgang, J. (2016). Proceedings from Center on Health Services Training and Research (CoHSTAR) Summer Institute: CoHSTAR Summer Institute on Health Services Research. “Model 2: University of Pittsburgh (pragmatic trials).” Boston, MA.

Duncan, P. & Johnson, M. (2016). Proceedings from Center on Health Services Training and Research (CoHSTAR) Summer Institute: CoHSTAR Summer Institute on Health Services Research. “Model 3: BAYADA Home Health Care (healthcare industry collaboration).” Boston, MA.

Fritz, J. & Brennan, G. (2016). Proceedings from Center on Health Services Training and Research (CoHSTAR) Summer Institute: CoHSTAR Summer Institute on Health Services Research. “Model 1: the Utah experience (integrated health care systems).” Boston, MA.

Jette, D. & Stilphen, M. (2016). Proceedings from Center on Health Services Training and Research (CoHSTAR) Summer Institute: CoHSTAR Summer Institute on Health Services Research. “Model 5: Cleveland Clinic (hospital/academic collaboration).” Boston, MA.

Jette, A. & Friedman, M. (2016). Proceedings from Center on Health Services Training and Research (CoHSTAR) Summer Institute: CoHSTAR Summer Institute on Health Services Research. “Model 6: Johns Hopkins (hospital/academic collaboration).” Boston, MA.

Mor, V. & Ottenbacher, K. (2016). Proceedings from Center on Health Services Training and Research (CoHSTAR) Summer Institute: CoHSTAR Summer Institute on Health Services Research. “Model 4: HSR using existing data (Medicare and other large data sets).” Boston, MA.

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Documents

OPTA 2018 Presentation Handout Slides · Design, implement and study innovative care delivery models ... Input Team Lead for Quality Assurance KT Associate Director of Education and