Quality Measurement and Improvement at CMS

HCQ PMEDICARE’S HEALTH CARE QUALITY IMPROVEMENT PROGRAMMEDICARE’S HEALTH CARE QUALITY IMPROVEMENT PROGRAM

11

Quality Measurement and Quality Measurement and Improvement at CMSImprovement at CMS

Stephen F. Jencks MD, MPHDirector, Quality Improvement Group

Centers for Medicare & Medicaid ServicesAugust 23, 2004

VisionVisionfor the Healthcare Systemfor the Healthcare System

The right care for every person every time.


33MissionMission

CMS Quality Improvement ProgramsCMS Quality Improvement Programs

Accelerate the pace of healthcare quality improvement for CMS beneficiaries


44

0

50

100

150

200

0% 20% 40% 60% 80% 100%LEVEL OF PERFORMANCE

NU

MB

ER

OF

OB

SE

RV

AT

ION

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)


55


66

Improvement StrategiesImprovement Strategies


77Seven 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


88

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.


99

Defeat SecrecyDefeat Secrecy

The most important reason for public reporting is to undermine a culture of not knowing or of concealing what we know.


1010

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.


1111

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.


1212

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.


1313

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.


1414

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%.


1515The Toolkit

PATI-ENT

SUPPORTSTANDARDMETHODS

PROMOTE

OR CREATE

PARTNERSHIPS

PRO

VIDE

TE CH

NIC

AL

AS SIS TA

NC

E

STRENGTHEN

WORKFORCE

PROVIDEPUBLIC

INFORMATION

STRUCTURE

COVERAGE AND

PAYMENTS

REW

AR

D

DES

IRED

PE

RFO

RM

AN

CE

ESTABLISH &

ENFORCE

REQUIRE-

MENTS

1616THE TOOLKIT WITHIN THE CMS SYSTEM

IDENTIFY IMPROVEMENT OPPORTUNITIES ANDSELECT APPROPRIATE IMPROVEMENT INTERVENTIONS

ADOPT OR DEVELOP MEASURES

COLLECT & ANALYZE DATA

SELECT PRIORITY AREAS

MANAGE PROCESS IN PARTNERSHIPWITH 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


1717

StandardsStandards

• Health Information Technology• Clinical Guidelines• Performance Measures• Coverage and Payment procedures


1818

PartnershipsPartnerships

e-Health Partnerships• Surgical Care Improvement Partnership• Corporate Nursing Home Improvement

Collaborative• Fistula First• National Quality Forum


1919

Technical AssistanceTechnical AssistanceQuality Improvement Organizations

Nursing HomesNursing HomesPercent Decrease in Problem Rate

+3.3%

-17.6%

-9.3%

-33.3%

Non-participant

homes

-7.8%-1.1%Pressure Ulcers

-68.3%-28.5%Physical Restraints

-26.1%-16.9%Post-acute Pain

-60.5%-46.1%Chronic Pain

Participants selecting

topic

Participant nursing homes

2020

Physician OfficePhysician Office

Mammography

Eye exam

Lipid profile

HgbA1c

Percent decrease in failure rate

2.3-0.3

0.6

29.8

20.5

Whole state

4.9

36.4

29.1

Participants

DIA

BET

ES2121

Home HealthHome Health

-5.7-5.3-3.7Emergent Care

1.5

14.1

17.1

12.8

Participants selecting

topic

Percent Decrease in Failure Rate

1.71.1Acute hospitalization

6.17.5Oral meds

7.66.8Dyspnea

6.55.5PainParticipantsNational

InpatientInpatient

28.613.3-3.314.310.325.013.96.66.1

Percent Decrease in Failure Rate1998-9 to 2000-1

Appropriate antibioticsTimely antibioticsACEI for ventricular dysfunctionLeft Ventricular AssessmentACEI for ventricular dysfunctionBeta blockers at dischargeBeta blockers at admissionAspirin at dischargeAspirin at admission

PNEU

H

RT

FAIL

HEA

RT

ATT

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%

2424

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)


2626

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


2727

CoverageCoverage

• Welcome to Medicare Assessment Visit• Chronic care improvement pilots


2828

RewardsRewards

• Premier demo• Chronic care improvement pilot• Doctors Office Quality – Information

Technology


2929

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.


3030

Interstate VariationInterstate Variation

Eight Current DomainsEight Current Domains

M+CFFSFFS & M+CFFSFFSFFSM+CFFSPopulation SampleDomain

Overall: sum of standardized scoresPlanStateConsumer

perception

ProviderNursing homeStateInpatientProviderHome healthProviderDialysisPlanStateAmbulatory

clinical


3232

QuartileFirst (13)Second (13)Third (13)Fourth (12)

Variation in Overall Quality Variation in Overall Quality


3333

Are Ranks A Documentation Artifact?Are Ranks A Documentation Artifact?Correlation of State Ranks

1.000.450.65Inpatient

0.451.000.66Amb M+C

0.650.661.00Amb FFS

InpatientAmbM+C

AmbFFS


3434Predictors of Overall Predictors of Overall StateState--level Qualitylevel 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 PrioritiesIntegrated 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

Documents

Quality Measurement and Improvement at CMS