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Get ready for emphasis on quality measures
Take a team approach to improve processes
Public reporting of quality measures is likely to increase in the near future, and hospitals should get ready, asserts Carolyn Scott, director of collaborative services and CEO work groups for clinical excellence with VHA Inc., an Irving, TX-based health care cooperative.
In 2005, the Centers for Medicare & Medicaid Services (CMS) plans to expand the 10 quality indicator measures in its public reporting sector to between 17 and 22 measures, she points out.
"The burden is not going to lessen. It’s going to be greater. The quicker we can get a handle on improving quality indicators now, the more prepared we’ll be for additional measures," Scott adds.
The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) already provides a financial incentive for prospective payment system hospitals to voluntarily report quality of care information. Those who submit data will be eligible to receive full Medicare payment for health care services under MMA. Those who did not submit data will receive a 0.4% reduction in annual Medicare payments.
"The trend in public reporting is well on its way with JCAHO [the Joint Commission on Accreditation of Healthcare Organizations] publicly reporting some quality indicators for hospitals. We’re only going to see more of that happening as we go along," adds Earl Kurashige, RN, project manager for Qualis Health, a nonprofit health care quality improvement company based in Seattle.
Beginning in 2005, hospital quality data will be available on a consumer web page, Hospital Compare, which is part of www.medicare.gov.
Quality improvement means involving all the people in the health care delivery system, Kurashige points out. "It’s not just doctors and not just hospitals. We can’t just point the finger at one group and say you need to do better. It’s a team effort," he says.
The team approach to improving quality is a paradigm shift for health care providers, notes Kurashige. "Everyone working together to improve health care of the individual can have a big influence on the care and quality," he says.
Scott and Kurashige work with hospitals on quality improvement projects, particularly those relating to the CMS and JCAHO quality indicators, where most hospitals focus because they are the center of attention in health care.
They agreed to share strategies with Hospital Case Management, pointing out the techniques will work for any quality improvement project.
The first step in driving improvement is starting at the top, Scott asserts.
"If you really want to drive improvement or change in the organization, senior management must be involved and actively engaged. The senior leadership needs to be engaged and make others realize that this is a priority," she says.
Involve people on the quality improvement task force who work directly with the patients whose care you want to improve.
For instance, if you are dealing with cardiac issues, involve the head of cardiac services, the head of the emergency department, the director of the cardiac catheterization lab, and a leader from the intensive care unit.
"It must be a collaborative effort. Member of the task force learn from each other as well as from the materials you provide," Scott says.
Along with the administration’s backing, hospital staff need to have one of their peers championing the cause, she adds.
Don’t choose a champion who is new to the team or someone who wants to work his or her way to the top, Scott suggests. Find someone that everyone on the team looks up to and respects. Anytime you implement something new, it’s important to involve the physician champion in the planning process, she adds.
"To get adequate physician buy in, they need to see how what is being done will be of benefit to them. They will resist if they think it’s more work or if their autonomy is being taken away," Scott explains. Setting goals and assigning responsibility for meeting quality measures is important. "Things fall through the cracks if there is no specific responsibility," she says.
Case managers should play a very large part in assuring that the quality of care continues to improve, Kurashige notes. "In many cases, we want to be sure that those patients who are in the hospital have sufficient information on how to take care of themselves when they are discharged, especially if they go home and have home health agencies provide care for them. Case managers certainly do the brunt of that work in handling discharge management," he says.
Case managers can be invaluable when it comes to making sure that the quality indicators are met, Scott adds.
"By reviewing the charts and reminding staff about the requirements of some measures, they can help drive improvement. Sometimes the staff are just too busy to remember everything they need to do," she says.
Case managers have been the key in process improvement in many hospitals, Scott says. "For the cardiac-related core measures, a big issue for case managers is identifying which patients are heart failure patients and which are AMI [acute myocardial infarction] patients. Heart failure patients can be anywhere throughout the hospital after being admitted for many different reasons," she explains.
Early identification of these patients and early engagement of the case managers is vital so case managers can flag the chart, conduct a concurrent review, and remind staff if any indicators are missed. "If case managers have to do retrospective review and something didn’t get documented, it shows up in the statistics as a missed opportunity. Case managers need to be able to review the charts concurrently when the patient is in-house," she says.
In some hospitals, the pharmacist assigned to the floor assumes the role of case manager for drug-related issues, such as aspirin, ACE inhibitors, or beta-blockers.
Smoking cessation counseling is another area where case managers are invaluable in tracking that the counseling has been done, Scott says.
The most successful groups with smoking cessation indicators are groups that have an automated admissions process during which a patient is asked if he or she has used tobacco within the last year, she says. If the answer is yes, the patient automatically is referred to the people within the hospital who do the counseling, such as respiratory therapy or cardiac rehabilitation staff.
Scott works with the CEO work groups for clinical excellence, bringing the CEOs of its member hospitals together and working with them on areas where they want to drive improvement. After receiving input from the CEOs, she convenes the task forces from participating organizations to address the identified areas of need.
"Because of public reporting, coupled with pay for performance, many of them select to work on AMI, heart failure, community acquired pneumonia, and surgical infection prevention," she says.
VHA sets goals for compliance on each performance measure. Hospitals that perform at 90% or more on every single measure are called green light hospitals. Those performing at 80% to 90% are yellow light hospitals. Any performance less than 80% is considered to be red light.
"That is how we set goals and develop at thresholds," Scott notes.
The hospitals that participate in VHA’s quality initiatives enter their data every quarter using a web-based tool.
"Within our work groups, the data are not blind. It’s no secret who is performing well and who is struggling. Those who need improvement on a certain measure can ask their counterparts at hospitals doing well on the measure for extra help," she says.
Qualis compiles hospital data from JCAHO, CMS, and other organizations and distributes them to participating hospitals, showing them how they compare to state, regional, and national data. The company has just finished its first round of meetings for each of the five regions in the state of Washington. The topics covered at regional meetings are suggested by participating hospitals and are specific to the needs of that region.
In some cases, the hospitals are asked to present programs on quality as well.
"We ask the hosting hospital to showcase their quality program and share what they are doing to help raise the bar for everyone else. The goal is not to create an atmosphere of competition. The intent is to raise the bar for quality, and we’re emphasizing a cooperative endeavor to achieve that," Kurashige says.
If hospitals discover that their rates are low in one of the quality indicators, Qualis suggests simple methods they can use to help improve their rates, especially for national reporting of data, he says. "We do this so others can gather the information that is presented and start one of their own programs or enhance a program they already have," Kurashige explains.
The regional meetings have been very popular with participating hospitals, he says.
"We ask them what quality issues they are interested in hearing about and what kind of speakers, data, and tools they would like to have to help improve quality. When we follow up with the hospitals, they express appreciation to have the opportunity to share information that can help them improve quality," he adds.