Lisa Hancock Quality Presentation For

Boston Children’s Hospital July 2008

What are the goals of IU Medical Group’s quality improvement program? What metrics and benchmarks are used to measure progress towards each of these performance goals? How is each goal specifically linked to management accountability?

IU Medical Group’s goals for our patients are to:• Decrease Mortality • Decrease Morbidity• Increase Patient Satisfaction• Improve Patient Safety

• IU Medical Group utilizes the University Healthcare Consortium for benchmarks in mortality, morbidity and safety. Our patient satisfaction information utilizes the Regenstrief organization, and the Pickar survey.

• Each Clinical Chair will be asked to report their departments progress on these goals to the Board at least annually.

Where we were…

Where we are now…UHC Results for IU Hospital

2007 Rank 2008 Goal

Mortality (35%) 17 12-15

Effectiveness (35%) 62 25-30

Safety (20%) 6 3-5

• In 2007 Methodist ranked #1 in the UHC database out of all Academic

Medical Centers

• IU Hospital moved up to #29 with the addition of the latest quarter. 

• IU Hospital was among the most improved of all the 82 hospitals evaluated. 

How does IU measure and improve the quality of patient care? Who are the key management and clinical leaders responsible for these quality and safety programs?

IU Medical Group measures and improves the quality of patient care with the following metrics:

• UHC Reports:– Quality and Safety Management Report (QSMR)– Hospital Quality Measures Report (HQMR)– Clinical Outcomes Report– Key Indicator Report– Quality and Accountability Report

• Patient and Referring Physician Satisfaction Surveys

• Clarian Quality Matrix

• Wishard Hospital Incentive Program

• Each of the 19 clinical departments are responsible for ensuring the quality and safety of their departments.

University Hospital Category Summary

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Quality Matrix Items--Improvements

• Success stories– Surgical Quality Committee

• Reducing complications, mortality & readmissions

• Improving patient throughput

• Beginning to use NSQIP risk adjusted data

– Central line blood stream infection teams in progress– UHC Palliative Care Benchmarking Study– Clinical Documentation Improvement Program– Engagement of Department of Medicine

Case exampleSurgical - Complications of anesthesia - Adults (Rate per 1000)AHRQ• Definition: Cases of anesthetic overdose, reaction, or endotrachial

tube misplacement per 1,000 surgery discharges.• Denominator: All surgical discharges 18 years and older or MDC 14

defined by specific DRGs. Exclude patients with codes for poisoning due to anesthetics (E8551, 9681-4, 9687) and any diagnosis code for active drug dependence,

• active non-dependent abuse of drugs, or self-inflicted injury.• Numerator: Discharges with ICD-9-CM diagnosis codes for

anesthesia complications in any secondary diagnosis field per 1,000 discharges.

• Target: AHRQ expected rate (O/E ratio of 1.0). Rank and Top-10 based on O/E ratios.

Performance was substantially worse than target

How are IU’s quality assessment and improvement processes integrated into overall corporate policies and operations? Are clinical quality standards supported by operational policies? How does management implement and enforce these policies? What internal controls exist to monitor and report on quality metrics?

• Our faculty adheres to the policy and procedures of the health care entities in which they practice. These include, but are not limited to Clarian’s downtown hospitals, Wishard Health System, the Roudebush VA Medical Center, Clarian West, and Clarian North.

• The Compliance Committee of the IU School of Medicine enforces the compliance of the practices of the school.

• The IUMG Credentialing Committee credentials all IUMG providers.

• The Medical Management Committee of IUMG SC has been charged by the IUMG – SC Board to develop, implement, and review all the quality and safety activities of the organization.

IU Medical Group – Specialty CareMedical Management Committee

July 17, 2008

NEXT MEETING: Thursday, August 21st, 2008, Medical Sciences Building, Daly Center 122C-D

Herbert Cushing MD MS 164 Bill Wooden MD EH 232 Jeffrey M. Rothenberg MD

UH 2440 David Kovach MD FH 204

David Crabb M.D EH 317 Michael A. Kraus MD UH 1115 Daniel A. Rushing MD RT 473 Deanna Willis MD LO 200

Lisa Hancock RN LO 401 Richard T. Miyamoto M.D RI 0860 Mike Ober MD UH 2100 Keith Lillemoe MD EH 203

John Fitzgerald LO 401 Darrell WuDunn MD RO 301 David Posey MD ROC 4300

Henry Pitt MD RT 130d

Val Jackson MD UH0663 Michael Lykens MD EH 312 Steve Hugenberg MD LO 545

Agenda Item

PQRI results for IUMG -Jan through May 2008

Policy Review-Identification and Monitoring of Quality Issues-Ongoing Monitoring of Complaints and Quality Issues

Regenstrief Survey ResultsJul ’06-Jan ‘08

Credentials Committee 2nd Quarter 2008 Results

Health Care Notification Network Overview

Does the IUMG board have a formal orientation and continuing education process that helps members appreciate external quality and patient safety requirements? Does the board include members with expertise in patient safety and quality improvement issues?

• The IUMG – SC Medical Director meets with each of the Department Chairs, or their designee to share and review the departments quality and safety data and develop improvement plans when necessary.

• The IUMG – SC Board includes members with expertise in patient quality and safety.

Physician Education and Training

Partnership between Medical Education, IUSOM, & Quality Residents, Faculty, New medical staff, & Medical students.

Orientations for all new interns, 3rd year med students, new faculty on staff.

Ongoing training with quality and safety lunches, intersessions for med students, orientation for new faculty mid-year.

Core curriculum Quality, Safety, Medical Equipment, Cerner, Regulatory

Compliance, Infection Control, Medication Safety, etc. Designed for orientation & on-going information sharing

What information is essential to the board’s ability to understand and evaluate the organization’s quality assessment and performance improvement programs? Once these performance metrics and benchmarks are established, how frequently does the board receive reports about the quality improvement efforts?

• The IUMG – SC Board requires each of the Clinical Departments to report at least annually to report on the following:

• Mortality• Morbidity• Satisfaction• Safety

• CMS Physician Voluntary Reporting Program (PQRI)

• EMR implementation

• Communication with referring physicians and patients

Physician Quality Reporting Initiative (PQRI)

• PQRI establishes a financial incentive for eligible professionals to participate in a voluntary quality reporting program. Eligible professionals who successfully reported PQRI quality measures may earn an incentive, of 1.5% of total allowed charges for covered Medicare physician fee schedule services.

• If no more than three 2007 PQRI quality measures were applicable, each measure must have been reported in at least 80% of the cases in which the measure was reportable.

• 27,811 PQRI measures were reported on from July – December 2007

• 84% of those reported measures were for Medicare patients• Anesthesia, Dermatology, Emergency Medicine, Primary Care,

Medicine, Ophthalmology, Orthopaedic Surgery, and Surgery reported measures. These groups met the 30 minimum patient/encounter episode to qualify for participation.

• 5% of the reported PQRI measures did not meet the performance requirement.

PQRI Results Example

Anesthesia • 19 providers reported: • 819 Total patients were reported on that antibiotics

were given w/in 1 hour prior to surgery– 717 Medicare patients (88% of the patients reported on)– 453 Medicare patients had documentation that antibiotics

were given w/in 1 hour prior to surgery• 63% of Medicare patients were given antibiotics w/in 1

hour prior to surgery• 36% of Medicare patients did not have the

documentation that antibiotics were given, but were successfully reported on.

Case example

Otolaryngology wanted to report on the following CMS measures:

• Acute Otitis Externa-Topical Therapy (ages 2 and older)

• Acute Otitis Externa-Pain Assessment (ages 2 and older)

• Acute Otitis Externa-Systemic Antimicrobial Therapy, Avoidance of Inappropriate Use (ages 2 and older)

Case example

• How many Medicare patients, age 2 or greater have a diagnosis of Acute Otitis Externa?

• How many Medicare patients, age 2 months to 12 years, have Otitis Media with Effusion?

Case ExampleData query

• Otolaryngology PQRI Data Date: 5/9/08 Detail Filter: Group Department Name - Txn = 'OTOLARYNGOLOGY' and Invoice DOS - Txn between 2007-04-12 and 2008-04-12 and Orig Pmt FSC Report Category 1 - Txn = 'MEDICARE' and ( DX1 ICD9-CM Code - Txn in ( '380.10' , '380.11' , '380.12' , '380.13' , '380.22' , '381.10' , '381.19' , '381.20' , '381.29' , '381.3' , '381.4' ) or DX2 ICD9-CM Code - Txn in ( '380.10' , '380.11' , '380.12' , '380.13' , '380.22' , '381.10' , '381.19' , '381.20' , '381.29' , '381.3' , '381.4' ) or DX3 ICD9-CM Code - Txn in ( '380.10' , '380.11' , '380.12' , '380.13' , '380.22' , '381.10' , '381.19' , '381.20' , '381.29' , '381.3' , '381.4' ) or DX4 ICD9-CM Code - Txn in ( '380.10' , '380.11' , '380.12' , '380.13' , '380.22' , '381.10' , '381.19' , '381.20' , '381.29' , '381.3' , '381.4' ) or DX5 ICD9-CM Code - Txn in ( '380.10' , '380.11' , '380.12' , '380.13' , '380.22' , '381.10' , '381.19' , '381.20' , '381.29' , '381.3' , '381.4' ) or DX6 ICD9-CM Code - Txn in ( '380.10' , '380.11' , '380.12' , '380.13' , '380.22' , '381.10' , '381.19' , '381.20' , '381.29' , '381.3' , '381.4' ) )

How does IU’s quality assessment and improvement processes coordinated with its corporate compliance program? How are quality of care and patient safety issues addressed in the organization’s risk assessment and corrective action plans?

• The IUMG faculty are integral to promoting corporate compliance, as well as to risk management and organizational reputation. All employees and faculty are encouraged to use the confidential hotline numbers to report compliance issues anonymously. The use of the hotline is not limited to compliance, and can be used for quality and safety concerns as well.

• IUMG collaborates with each of our hospital partners in

their risk assessment and corrective action programs

What processes are in place to promote the reporting of quality concerns and medical errors and to protect those who ask questions and report problems? What guidelines exist for reporting quality and patient safety concerns to the board?

• IUMG encourages all employees and faculty to utilize the confidential compliance hotlines to report any issue. This includes the University, Clarian, Wishard, and the VA. All quality and safety issues are investigated by the Medical Director, and are reviewed by the Medical Management Committee, which reports to the IUMG – SC Board. All such reports are handled in a confidential

manner.

Are human and other resources adequate to support patient safety and clinical quality? How are proposed changes in resource allocation evaluated from the perspective of clinical quality and patient care? Are systems in place to provide adequate resources to account for differences in patient acuity and care needs?

• Resources are assessed at least on an annual basis. Our Board has recently allocated additional resources for quality and safety.

• IUMG – SC utilizes the UHC case mix index to benchmark the acuity of our patients.

Does IU’s competency assessment and training, credentialing, and peer review processes adequately recognize the necessary focus on clinical quality and patient safety issues?

• IUMG – SC reviews malpractice complaints, the National Practitioner Databank, patient satisfaction, credentialing and physician specific complaints. The Credentialing Committee and the Medical Management Committee review and act on this information and report to the Board.

How are “adverse patient events” and other medical errors identified, analyzed, reported, and incorporated into IU’s performance improvement activities? How do management and the board address quality deficiencies without unnecessarily increasing the organization’s liability exposure?

• IUMG – SC is linked to the Risk Management departments of each of our affiliated hospitals. We also assist with the following:

• Indiana State Department of Health Reportable Events• JCAHO Sentinal Events• Internal investigations and Reviews of adverse events

Questions?

Lisa Hancock, RN, MHA

Director of Quality Care

IU Medical Group - Specialty Care

ph. 317-278-9907

fax 317-278-9926

lcox@iupui.edu