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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Provider Implementation of PPRs --
Florida Public Reporting of PPRs
Keith Mitchell PhD and Caroline Piselli, RN, MBA; 3M Health Information Systems
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Agenda
Pay for Performance and Potentially Preventable Readmissions (PPRs)
Florida Provider Proactive Approach to PPR Public Reporting
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Pay for Performance
Providers Payers
P4P
Consumers
QUALITYPAYMENT
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Readmissions beyond Florida
…situations in which patients return to the hospital within days or months of their initial hospitalization
Cause may be related to a patient’s treatment during the first hospitalization, or it may be the result of a secondary condition, suggesting possible quality problems in the hospital care receive during the initial visit or problematic transitions between hospital and the outpatient care setting
(Quality Matters: Hospital Readmissions: March/April 2008)
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Readmissions in the News beyond Florida
17.6% of Medicare patients were readmitted to the hospital within 30 days of discharge, accounting for $15 Billion in spending in 2005
(MedPac Report to Congress, Promoting Greater Efficiency in Medicare, June 2007)
Study of patients admitted to hospital with preventable admissions: 19.4% = at least 1 preventable readmission within 6 months
(Agency for Healthcare Research and Quality Study: B Friedman and J Basu (2004) The Rate and Cost of Hospital Readmissions for Preventable Conditions, Medical Care Research and Review 61, 225-240)
Commercial Population Example PacifiCare Health Systems Inc review in 2005-2006 Readmission rates at hospitals ranged from 0-44% (avg. 10%)(Quality Matters: Hospital Readmissions: March/April 2008)
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© 3M 2007. All rights reserved.
Potentially Preventable Hospital Readmission Rates (MedPAC 2007)
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Florida: 1st PPR Public Reporting!
Opportunity for collaborations/ partnerships to:Understand the data/ reports and impact
Determine potential reasons for PPRs
Drill down to root cause analyses
Create innovative approaches to improve outcomes together
Provide ‘lessons learned’ for the other 49 States…
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
So, What Should Florida Hospitals Do Now?
Reports will be public soon…
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
State Adoption Process/ Opportunity
Tracking/ReportingAwareness Education
Impact/ Gap Analysis
Implementation/Improvement
Speed and Momentum Vary with:
Public Reporting
Payment
Today
Soon1. Replicate Reports2. Understand
where you stand and potential opportunities.
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Recommended Provider Proactive Approach to PPR Public ReportingAppoint Interdisciplinary
Leaders- “Change Agents”
Educate OrganizationUnderstand Public Reports
(Peer Comparisons)
Analyze Impact/ Gaps
Communicate Offensively
Documentation/ Coding Service Lines Reasons PPRs
Internal Stakeholders
External Constituents
Initiate Focused Quality Improvement
Clinical Operations
Track, Monitor, Continue Focused Improvement Approach
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Recommended Provider Proactive Approach to PPR Public ReportingAppoint Interdisciplinary
Leaders- “Change Agents”
Educate OrganizationUnderstand Public Reports
(Peer Comparisons)
Analyze Impact/ Gaps
Communicate Offensively
Documentation/ Coding Service Lines Reasons PPRs
Internal Stakeholders
External Constituents
Initiate Focused Quality Improvement
Clinical Operations
Track, Monitor, Continue Focused Improvement Approach
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Include functional integration of Clinical Care Documentation & Coding Decision Support IT Operations Quality/ Case Management Discharge Planning FOCUS
Delegate responsibility and accountability for:
Coordination of organization-wide goals
Tracking and execution of control plan in conjunction w/ ancillary accountability
Gain insights into public perception of your hospital
Where does my hospital stand? How do I compare to others?
Emphasize internal and external importance/ implications
Clinical Quality Market Share
Focus upon opportunities for improvement and integration
Pre-admission and Discharge planning
Cross functional/ specialty coordination
Appoint Interdisciplinary Leads- “Change Agents”
Educate Organization Understand Public Reports
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Recommended Provider Proactive Approach to PPR Public ReportingAppoint Interdisciplinary
Leaders- “Change Agents”
Educate OrganizationUnderstand Public Reports
(Peer Comparisons)
Analyze Impact/ Gaps
Communicate Offensively
Documentation/ Coding Service Lines Reasons PPRs
Internal Stakeholders
External Constituents
Initiate Focused Quality Improvement
Clinical Operations
Track, Monitor, Continue Focused Improvement Approach
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Validate accurate documentation/coding within key areas
Implement improvement programs as needed
Emphasize – complete and accurate codified data provides the foundation from which public data is reported and improvement decisions are made
Consider a concurrent model
Analyze Impact/ Gaps
Documentation/ Coding
Analyze service lines and sub-service lines –e.g:
Rates Intervals #’s of chains PPRs % of discharges Top 10 Medical,
Surgical, other Top Reasons for
Readmits Severity Adjustments Linkage to financial
indicators (cost, charges)
Analyze reasons for PPRs Determine potential areas
of improvement Focus on measurable
indicators Track reasons over time “Repeaters”
Service Lines Reasons for PPRs
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
FloridaHealthFinder.gov New PPR Reports soon
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
General Guidelines for PPRs
PPR if related to complications of
prior surgery
PPR except conditions
clearly unrelatedSurgical
Not PPR unless initial medical
diagnosis clearly should have resulted
in surgery
PPR except if clearly unrelated acute
eventsMedical
SurgicalMedicalInitial Discharge
Readmission
PPR if related to complications of
prior surgery
PPR except conditions
clearly unrelatedSurgical
Not PPR unless initial medical
diagnosis clearly should have resulted
in surgery
PPR except if clearly unrelated acute
eventsMedical
SurgicalMedicalInitial Discharge
Readmission
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
PPR Reason Codes: Medical Readmission
A Medical readmission is considered clinically related to the initial admission if the reason for the readmission falls into the following categories:
Medical readmission for1. Continuation or recurrence of the reason for the initial admission, or for a condition closely
related to the reason for the initial admission • e.g. a readmission for diabetes following an initial admission for diabetes
2. Acute decompensation of a chronic problem that was not the reason for the initial admission but was plausibly the result of inadequate care during the initial admission or inadequate outpatient follow-up care • e.g. a readmission for diabetes in a patient whose initial admission was for an acute
MI 3. Acute medical complication plausibly related to care during the initial admission. A
readmission for an acute medical problem was not considered clinically related unless it could have been a consequence of care provided in the initial admission. • e.g. Patient readmitted for a UTI infection ten days after a hernia repair, the
infection was likely related to the use of a foley catheter during the initial admission.
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
PPR Reason Codes: Surgical Readmissions
A Surgical readmission is generally preventable unless they meet 1 of 2 criteria for a clinical relationship to the initial admission:
A readmission for a surgical procedure to address a:4. Continuation or a recurrence of the problem causing the initial
admission • e.g. a patient readmitted for an appendectomy following an
initial admission for abdominal pain and fever
5. Complication resulting from care during the initial admission • e.g. a readmission for drainage of a post- operative wound
abscess following an initial admission for a bowel resection
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Example: Surgical Initial Admission with Surgical PPR
Patient ID Hospital Admit Discharge LOS Status
Days Post Adm
PPR Type
IA APR DRG
RA APR DRG RA APR DRG Desc Pdx Pdx Desc Reason
Pat 1 A 16-Jan-06 21-Jan-06 5 01 0 IA 173 173 Other vascular procedures 44020 Atherosclerosis of native arteries of the extremities, unspecifiedPat 1 A 30-Jan-06 02-Feb-06 3 01 9 RA 173 791 O.R. procedure for other complications of treatment99832 Disruption of external operation wound 5Pat 1 B 27-Feb-06 28-Mar-06 29 06 25 OA 460 460 Renal failure 5845 Acute renal failure with lesion of tubular necrosis CR, but outside readmission window
Surgical Initial Admission for APR DRG 173 Other Vascular Procedures with a Surgical PPR
Only Admission- 25 days post admission:APR DRG 460- Renal FailureProcedure - Acute renal failure with lesion of tubular necrosis
Readmission- 9 days post admission:APR DRG 791- O.R. procedure for other complications of treatmentProcedure - Disruption of external operation wound
Initial Admission:APR DRG 173- Other Vascular ProceduresProcedure - Atherosclerosis of native arteries of the extremities, unspecified
Reason #5Complication resulting from
care during the initial
admissionReason Clinically
relevant but outside
readmission window
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Example: Medical Admission with Medical PPR
Patient ID Hospital Admit Discharge LOS Status
Days Post Adm
PPR Type
IA APR DRG
RA APR DRG RA APR DRG Desc Pdx Pdx Desc Reason
Pat 1 A 08-Oct-05 11-Oct-05 3 01 0 IA 194 194 Heart failure 4280 Congestive heart failurePat 1 A 21-Oct-05 26-Oct-05 5 01 10 RA 194 194 Heart failure 4280 Congestive heart failure 1Pat 1 B 17-Nov-05 23-Nov-05 6 06 22 OA 133 133 Pulmonary edema & respiratory failure 51881 Acute respiratory failure CR, but outside readmission window
Pat 1 B 13-Dec-05 22-Dec-05 9 06 20 IA 139 139 Other pneumonia 486 Pneumonia, organism unspecifiedPat 1 A 29-Dec-05 03-Jan-06 5 06 7 RA 139 194 Heart failure 4280 Congestive heart failure 2Pat 1 B 11-Jan-06 19-Jan-06 8 03 8 RA 139 133 Pulmonary edema & respiratory failure 51881 Acute respiratory failure 1Pat 1 B 15-Feb-06 20-Feb-06 5 06 27 OA 133 133 Pulmonary edema & respiratory failure 51881 Acute respiratory failure CR, but outside readmission window
Pat 1 B 10-Mar-06 03-Apr-06 24 03 18 IA 221 221 Major small & large bowel procedures 1538 Malignant neoplasm of other specified sites of large intestinePat 1 A 13-Apr-06 24-Apr-06 11 03 10 RA 221 460 Renal failure 5849 Acute renal failure, unspecified 3
Pat 2 E 13-Oct-05 15-Oct-05 2 01 0 IA 194 194 Heart failure 4280 Congestive heart failurePat 2 E 29-Oct-05 03-Nov-05 5 06 14 RA 194 194 Heart failure 4280 Congestive heart failure 1Pat 2 E 14-Nov-05 15-Nov-05 1 02 11 RT 194 194 Heart failure 4280 Congestive heart failure 1Pat 2 F 15-Nov-05 19-Nov-05 4 01 0 IA 175 175 Percutaneous cardiovascular procedures w/o AMI42731 Atrial fibrillationPat 2 E 27-Nov-05 29-Nov-05 2 51 8 RA 175 194 Heart failure 4280 Congestive heart failure 2Pat 2 E 29-Nov-05 03-Dec-05 4 51 0 RA 175 045 CVA & precerebral occlusion w infarct 43491 Cerebral artery occlusion, unspecified with cerebral infarction 2
Medical Initial Admission for APR DRG 194 Heart Failure with Medical PPR
Readmission 8 days post admission:APR DRG 133 Pulmonary edema & respiratory failure w/ acute respiratory failure
Reason #1Continuation or recurrence of the reason for the initial admission, or for a
condition closely related to the reason for the initial admission
Only Admission 27 days post admission:APR DRG 133 Pulmonary edema & respiratory failure w/ acute respiratory failure
Reason Clinically relevant but outside readmission
window
Initial Admission:APR DRG 194- Heart Failure w/ CHF followed by Readmission 10 days post admission:APR DRG 1940 Heart Failure w/ CHF
Reason #1Continuation or recurrence of the reason for the initial admission,
or for a condition closely related to the reason for the initial admission
Only Admission 22 days post admission:Pulmonary edema & respiratory failure w/ acute respiratory failure
Reason Clinically relevant but outside readmission
window
Initial Admission:APR DRG 139 Other pneumonia w/ pneumonia, organism unspecified followed byReadmission 7 days post admission:APR DRG 194 Heart failure w/ CHF
Reason #2Acute decompensation of a chronic problem that was not the reason for the initial admission but was plausibly the result of inadequate care during the
initial admission or inadequate outpatient follow-up care
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Example: Admission Procedure with Medical PPR
Admit Discharge LOS Status
Days Post Adm
PPR Type
IA APR DRG
RA APR DRG RA APR DRG Desc Pdx Pdx Desc Reason
12-Dec-05 14-Dec-05 2 01 0 IA 221 221 Major small & large bowel procedures 1540 Malignant neoplasm of rectosigmoid junction21-Dec-05 28-Dec-05 7 06 7 RA 221 221 Major small & large bowel procedures 9974 Digestive system complications, not elsewhere classified 130-Dec-05 31-Dec-05 1 01 2 RA 221 111 Vertigo & other labyrinth disorders 7804 Dizziness and giddiness ?15-Jan-06 19-Jan-06 4 01 15 RA 221 721 Post-operative, post-traumatic, other device infections 99859 Other postoperative infection 322-Feb-06 24-Feb-06 2 01 34 OA 223 223 Other small & large bowel procedures V552 Attention to ileostomy CR, but outside readmission window
06-Jul-06 12-Jul-06 6 01 0 IA 221 221 Major small & large bowel procedures 1541 Malignant neoplasm of rectum12-Jul-06 19-Jul-06 7 06 0 RA 221 721 Post-operative, post-traumatic, other device infections 99859 Other postoperative infection 326-Jul-06 30-Jul-06 4 06 7 RA 221 252 Malfunction, reaction & complication of GI device or procedure56962 Mechanical complication of colostomy and enterostomy 309-Aug-06 23-Aug-06 14 06 10 RA 221 221 Major small & large bowel procedures 9974 Digestive system complications, not elsewhere classified 1
09-Jan-06 13-Jan-06 4 01 0 OA 791 791 O.R. procedure for other complications of treatment 9986 Persistent postoperative fistula, not elsewhere classifiedFirst admission without a subsequent PPR within window
08-Feb-06 14-Feb-06 6 06 26 OA 226 226 Anal procedures 566 Abscess of anal and rectal regions CR, but outside readmission window
17-Apr-06 20-Apr-06 3 01 62 IA 221 221 Major small & large bowel procedures V553 Attention to colostomy30-Apr-06 05-May-06 5 06 10 RA 221 721 Post-operative, post-traumatic, other device infections 99859 Other postoperative infection 301-Jun-06 06-Jun-06 5 02 27 TA 248 248 Major gastrointestinal & peritoneal infections 56722 Peritoneal abscess07-Jun-06 10-Jun-06 3 01 1 OA 254 254 Other digestive system diagnoses 6191 Digestive-genital tract fistula, female Admission without a subsequent PPR within window
01-Jul-06 04-Jul-06 3 02 21 TA 721 721 Post-operative, post-traumatic, other device infections 99859 Other postoperative infection04-Jul-06 06-Jul-06 2 01 0 IA 813 813 Other complications of treatment 9986 Persistent postoperative fistula, not elsewhere classified20-Jul-06 29-Jul-06 9 06 14 RA 813 791 O.R. procedure for other complications of treatment 9986 Persistent postoperative fistula, not elsewhere classified 5
Admission for APR DRG 221 Maj Small & Large bowel Proc with a Medical PPR
Readmission 10 days post admissionAPR DRG 221 Major small & large bowel procedures w/ digestive system complications,
not elsewhere
Reason #1Continuation or recurrence of the reason for the initial admission,
or for a condition closely related to the reason for the initial admission
Patient 2- Hospital AInitial Admission:APR DRG 221- Major small & large bowel procedures w/ malignant neoplasm of rectum
followed byReadmission 0 days post admission: APR DRG 721 Post-operative, post-traumatic, other device infections w/ other
postoperative infection followed byReadmission 7 days post admission:APR DRG 252 Malfunction, reaction & complication of GI device or procedure w/
mechanical complication of colostomy and enterostomy
Reason #3Acute medical complication plausibly related to care during the initial admission. A readmission for an acute medical problem was not considered clinically related unless it could have been a consequence of care provided in the initial admission.
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Example: Medical Initial Admission with Surgical PPR
Hospital Patient ID Admit Discharge LOS Status
Days Post Adm
PPR Type
IA APR DRG
RA APR DRG RA APR DRG Desc Pdx Pdx Desc Reason
A Pat 1 14-Apr-06 18-Apr-06 4 01 0 OA 244 244 Diverticulitis & diverticulosis 56211 Diverticulitis of colon (without mention of hemorrhage)A Pat 1 12-Jun-06 15-Jun-06 3 01 55 IA 254 254 Other digestive system diagnoses 5641 Irritable Bowel SyndromeA Pat 1 28-Jun-06 02-Jul-06 4 01 13 RA 254 254 Other digestive system diagnoses 5641 Irritable Bowel SyndromeA Pat 1 06-Sep-06 11-Sep-06 5 01 66 IA 251 251 Abdominal pain 78904 Abdominal pain, left lower quadrantA Pat 1 20-Sep-06 05-Oct-06 15 03 9 RA 251 221 Major small & large bowel procedures56081 Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)
Medical Initial Admission for APR DRG 251 Abdominal Pain with a Surgical PPR
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© 3M 2007. All rights reserved.
Report #1: Overall Rates of Potentially Preventable Readmission ( PPRs )
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© 3M 2007. All rights reserved.
Report #2: PPRs Admissions by Service Line
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Report #3: Admission Reasons by Service Line
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© 3M 2007. All rights reserved.
Report #4: PPRs Admissions by Service Line
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Report #5: PPRs Patient-level Details
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Recommended Provider Proactive Approach to PPR Public ReportingAppoint Interdisciplinary
Leaders- “Change Agents”
Educate OrganizationUnderstand Public Reports
(Peer Comparisons)
Analyze Impact/ Gaps
Communicate Offensively
Documentation/ Coding Service Lines Reasons PPRs
Internal Stakeholders
External Constituents
Initiate Focused Quality Improvement
Clinical Operations
Track, Monitor, Continue Focused Improvement Approach
29
3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
How Will You Proactively Understand PPRs?…eventually prevent PPRs?
http://student.bmj.com/issues/99/11/education/images/oliver_howes.gif
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Carefully examine areas in need of improvement
Pre-admit process details (e.g. elective admits)
Clinical Practice Discharge & Post-discharge
• Multi-faceted
Implement ‘readmission mitigation’ strategies for key areas
Include multi-disciplinary clinical team Focus and build Avoid ‘boiling the ocean’
Initiate Focused Quality Improvement
Clinical
Collect data once and repurpose it many times
Prioritize most important – focused operational improvements
Cost/benefit analysis
Operations
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Example: NQF National Priorities Survey- January 2008
Top 3 Conditions-Lead to most sizeable gains in improvement
-- Diabetes-- Healthcare Acquired Infections-- End of Life Care
NQF Survey : National Priorities Partners Survey Council Data, Jan 10, 2008; Karen Adams, PhDCouncils representing Consumers, Health Plans, Health Professionals, Provider Organizations, Public/Community Health Agencies, Purchasers, QMRI, Supplier,Industry &Other
Top 3 Cross-Cutting Strategies:-- Care Coordination-- Health Information Technology-- Medication Reconciliation
Top Recommendations:Stakeholders: Broad range across the continuumImplementation: Concrete goals within a roadmapBurden: Include administrative/ documentationSystems Approach: Process/Outcomes coupled w/ human capacityIT: EHRs w/ registries, interoperability, reportingHealth Lifestyle/Prevention: Value/reward for early detection/ preventionEpisodes of Care: measure acrossEfficiency: Incorporate w/ effectiveness
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© 3M 2007. All rights reserved.
P4P- A Provider Proactive Approach (Hypothesis)
Success in payment reform …will require unprecedented levels of collaboration across
the entire system of care. “Hospitals and physicians have a substantial obligation… to knock down barriers to improving quality and
effectiveness.
Modern Healthcare, 3/3/08 issue: “A Quality incentive at a crossroads- P4P summit features debate on limits, potential of bonus pay for meeting
benchmarks- quote from Tom Priselac, president and CEO of Cedars-Sinai Medical Center, LA, CAL
Key Tools: Risk Adjustment, Preventable Com
plications,
Readmissions, Continuum
of Care Outcomes
Autocoding/And/ or working DRG
Ope
ratio
nal Q
ualit
y S
yste
m
OperationalPractice
Improvement
Quality (Process/ Outcomes)/
Financial Metrics
IntegratedDecisionSupport
Clinical Practice Improvement
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© 3M 2007. All rights reserved.
Example: The Virtuous Circle of Hospital Admissions
“Shifting the focus of servicesTackling some typical scenarios
Authorities can find themselves trapped in 'vicious circles' of providing crisis-driven services which are neither effective for the service users and carers concerned nor an effective use of their resources.
In these circumstances, authorities have to identify how they can inject a different dynamic into the system of care to turn 'vicious' into 'virtuous' circles of activity. “
Source: Improvement and Development Agency: makingendsmeet.idea.gov.uk/idk/aio/5221438, makingendsmeet.idea.gov.uk/idk/core/page.do?p...
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Some Additional Challenges
**Used with Permission by George Isham, Health Partners
Hypothesis:Improvement of Outcomes
Measures may positively impact performance across hospitals, physicians, health plans, states, etc……
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Recommended Provider Proactive Approach to PPR Public ReportingAppoint Interdisciplinary
Leaders- “Change Agents”
Educate OrganizationUnderstand Public Reports
(Peer Comparisons)
Analyze Impact/ Gaps
Communicate Offensively
Documentation/ Coding Service Lines Reasons PPRs
Internal Stakeholders
External Constituents
Initiate Focused Quality Improvement
Clinical Operations
Track, Monitor, Continue Focused Improvement Approach
37
3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Continually educate and update key stakeholders
Gain insights
Communicate Offensively
Internal Stakeholders
Communicate hospital accomplishments and expertise
Multi-venue Integrated approach
External Constituents
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Recommended Provider Proactive Approach to PPR Public ReportingAppoint Interdisciplinary
Leaders- “Change Agents”
Educate OrganizationUnderstand Public Reports
(Peer Comparisons)
Analyze Impact/ Gaps
Communicate Offensively
Documentation/ Coding Service Lines Reasons PPRs
Internal Stakeholders
External Constituents
Initiate Focused Quality Improvement
Clinical Operations
Track, Monitor, Continue Focused Improvement Approach
39
3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Establish baseline information, reports, data Continually track and communicate to interdisciplinary teams Understand outcomes data and potential relationships Focus and continue learning…
Track, Monitor, Continue Focused Improvement Approach
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3M Health Information Systems, Inc.
© 3M 2007. All rights reserved.
Questions?