2011 Douglas T. Miller Symposium Dennis Wagner, Acting Director, Office of Clinical Standards and Quality Centers for Medicare & Medicaid Services April 29, 2011

Plan for This Segment “Gestalt” Overview of CMS, Health Reform and Quality Improvement Quality Improvement Lessons from the Organ Donation Breakthrough Collaborative Partnership for Patients Discussion

Questions to Run On What is happening at CMS? What is going on with the implementation of healthcare reform – especially on quality? What can we learn from the success of the national organ donation quality improvement work? What is the Partnership for Patients? What is my advice for CMS?

CMS is Changing

CMS Vision CMS is a major force and a trustworthy partner for the continual improvement of health and health care for all Americans.

How we shall work together and with others? Operating Values How we shall work together and with others? Boundarilessness Speed and Agility Unconditional Teamwork Valuing Innovation Customer Focus

The “Three-Part Aim” Better Health for the Population Better Care for Individuals Lower Cost Through Improvement

5 New Centers and Functions Added in 1 Year Center for Strategic Planning, Tony Rodgers Center for Program Integrity, Peter Budetti Center for Medicare and Medicaid Innovation, Rick Gilfillan Center for Consumer Information and Insurance Oversight, Steve Larsen Federal Coordinated Health Care Office, Melanie Bella Center for Medicare, Jon Blum Center for Medicaid, CHIP, and S&C, Cindy Mann Office of Clinical Standards and Quality, Dennis Wagner & Paul McGann, MD

Office of Clinical Standards and Quality Levers for Safety, Quality & Value Contemporary Quality Improvement Transparency, Public Reporting & Data Sharing Incentives Regulation National & Local Coverage Decisions Demonstrations, Pilots, Research, Grants, Innovation

Office of Clinical Standards and Quality Levers for Safety, Quality & Value Contemporary Quality Improvement: Quality Improvement Organizations Transparency, Public Reporting & Data Sharing: Hospital Inpatient Quality Reporting Program Incentives: Hospital Value Based Purchasing Regulation: Conditions of Participation (OPOs, Hospitals, 14 other provider types) National & Local Coverage Decisions: Coverage for Preventative Services Demonstrations, Pilots, Research, Grants, Innovation: Diabetes Self Management in Mississippi 10 10

Affordable Care Act Some Key CMS Accountabilities Major, Ongoing Demonstration & Testing Authority & Resources (CMMI) Accountable Care Organizations Value Based Purchasing Programs Health Insurance Exchanges Expanded Medicaid Programs Care Transitions to Reduce Readmissions Expanded Quality Reporting Programs Expanded Preventative Services ….and Much More

Affordable Care Act Provision with Quality Focus Value based purchasing 3001 - Hospital value-based purchasing 3006 - Value-based purchasing for SNF 3014 - Quality and efficiency measurement 10301 - Develop a plan to implement VBP for ambulatory surgical centers 10326 - Pilot testing for pay-for-performance Hospital readmissions 3025 - Hospital readmissions reduction program 3026 - Community-based care transitions program Healthcare acquired conditions 2702 - Payment adjustment for health care-acquired conditions 3008 - Payment adjustment for conditions acquired in hospitals Accountable care organizations 2706 - Pediatric accountable care organization demonstration project 3022 - Medicare Shared Savings Program Dual eligibles 2602 - Providing federal coverage and payment coordination for dual eligible beneficiaries Preventative services 4103 - Annual wellness visit providing a personalized plan 4104 - Removing barriers to preventive services 4105 - Evidence-based coverage of preventive services Coordination of care 2703 - State option to provide health homes for enrollees with chronic conditions 2704 - Demonstration project to evaluate integrated care around a hospitalization Long term care 2401 - Community first choice option 2402 - Removal of barriers to providing home and community based services 2403 - Money follows the person rebalancing demo 2404 - Protection for recipients of home and community-based services against spousal impoverishment 10202 - Incentives for states to offer home community based serviced Public reporting 10303 - Development of outcome measures 10327 - Improvements to the physician quality reporting system -- also see Provision 3002 10331 - Public reporting of performance information Quality reporting initiative 2701 - Adult health quality measures 3002 - Improvements to the physician quality reporting system. 3004 - Quality Reporting for Long Term Care Hospitals (LTCH), inpatient rehabilitation hospitals, and hospice programs 3005 - Quality reporting for PPS-exempt cancer hospitals 10322 - Quality reporting for psychiatric hospitals

CMS Approach to Managing the Affordable Care Act Quadrant 1 High impact, high complexity program areas to manage Quadrant 2 High impact priorities to monitor and maintain Quadrant 4 Tertiary priorities to minimize resources and conserve focus Quadrant 3 Secondary priorities to monitor and manage

OCSQ Quadrant 1: High Impact, High Complexity Program Areas to Manage Value Based Purchasing Public and Quality Reporting Reduced Readmissions Hospital Acquired Conditions ACOs Center for Medicare and Medicaid Innovation 7- 8-9-10-11-12-13 Quadrant 2 Quadrant 4 Quadrant 3

OCSQ Quadrant 2: High Impact Priorities to Monitor and Maintain Preventative services -- more in other CMS components -- Quadrant 2 High impact priorities to monitor and maintain Quadrant 1 Quadrant 2 Quadrant 4 Quadrant 3

What Will the Affordable Care Act Look Like on the Front Lines? Increasing measurement of quality, efficiency & value Public reporting and sharing of data Reimbursement linked to quality improvement, efficient service delivery and cost reduction thru improvement Increasing integration of delivery systems and coordination of care across settings Greater role in addressing public health issues Greater use of health information technology Creation of a learning environment in healthcare 16

New Tools, New Incentives, New Penalties, New Organizations What does it all mean?

Value-Based Purchasing and Linking Payment to Quality “A major, overarching theme in the Affordable Care Act is one of measurement, transparency, and altering payment to reinforce, not simply volume of services, but the quality of the effects of those services. Instead of payment that asks, “How much did you do,” the Affordable Care Act clearly moves us toward payment that asks, “How well did you do?” and, more important, “How well did the patient do?” That idea is at the heart of Value-Based Purchasing. It is not just a CMS idea; it is one increasingly pervading the agenda of all payers.” Don Berwick, CMS Administrator, April 4, 2011

New Tools, New Incentives, New Disincentives, New Organizations What does it all mean? Doing the right things for patients will become easier and doing the wrong things will become more difficult.

Questions for Quick Reaction and Discussion What do you like about what you see in this high level gestalt? What does CMS need to do more of, better, differently?

The Healthcare Quality/Value Challenge U.S. spends more per capita on healthcare than any other country in the world Quality is often inferior to that of other nations Significant variation in quality and cost by geographic location Serious disparities in the quality of health care by race, and socioeconomic status

How do we make quality better?

How do we make quality better? Improvement as a Strategy Customer-Mindedness Process-Mindedness Employee-Mindedness Statistical Thinking Supplier-Mindedness Continual Improvement (PDSA) Leadership

How do we make quality better? -- Stages of Facing Reality -- Stage 1. “The data are wrong” Stage 2. “The data are right, but it’s not a problem” Stage 3. “The data are right; it is a problem; but it is not my problem.” Stage 4. “I accept the burden of improvement”

How do we make quality better? Clear Intent – Will Proven Practices – Ideas Focused, Constant Action -- Execution

How do we make quality better? Clear Intent – Will Proven Practices – Ideas Focused, Constant Action – Execution Our work on organ donation is an extraordinary national example of what is possible.

Concentration of Potential Donors In Nation’s Largest Hospitals 50% of eligible donors are found in 206 hospitals 75% of eligible donors are found in 483 hospitals 90% of eligible donors are found in 846 hospitals

Tremendous Variation in Donation Rates in 300 Largest Hospitals

Collaborative Model An intensive, full-court-press to facilitate breakthrough transformations in the performance of organizations, based on what already works. Designed To: Define, Document, and Disseminate Best Practices Accelerate Improvement Achieve Results at a Rapid Pace Build Clinical Leaders of Change “All Teach, All Learn”

Identify Change Concepts Collaborative Engine Enroll Participants Select Topic Prework Identify Change Concepts S A D P S A D P Planning Group LS 1 LS 2 LS3 Support System ListServe Site Visits & Filming Conference Calls Rapid Sharing Data Reporting Website

Measures of Success

Organ Donation in USA Jan 1999 – Apr 2007 (Monthly) Wisconsin Hospitals and OPO Led the Nation In Generating Major National Results Collaborative Start Date Organ Donation in USA Jan 1999 – Apr 2007 (Monthly)

UWHC OPO Performance Rates by Year OPO Conversion Rate: (Eligible Donors/Eligible Deaths) OPO Adjusted Conversion Rate: (Eligible Donors + Other Donors/Eligible Deaths + Other Donors)

What made it work? Including the Customer: Donor Families and Recipients Clear, Ambitious, Achievable Aims Transparent About Data and Practice Model for Improvement and Collaborative Methodology Teaming Nationally to Work Smarter, Faster Creating Bolder, Thoughtful Agendas for Action Rapid Testing & Change Using Proven Practices Doing More Of What Works Relentless Pursuit of Improvement, Never Settling for the Status Quo

Questions for Discussion and Action What are our key insights about the organ donation improvement work? How can we take this further? What can we learn and apply to our current challenges and opportunities with healthcare reform?

Partnership for Patients: An Overview April 2011

The Affordable Care Act Improves Health Care Quality The Affordable Care Act (ACA) is best known for fixing broken health insurance laws and helping to cover millions of previously uninsured Americans. What many people don’t know is all of the ways the new law is also reducing costs while improving the experience of being a patient, being a caregiver, and being a health care provider. The Partnership for Patients: Better Care, Lower Costs is one example of how Secretary Sebelius is using provisions of the ACA to make health care in America safer, more efficient, and less costly.

Meet Josie King I want to share with you the story of Josie King and her mother Sorrel. In 2001, Josie was admitted to Johns Hopkins Hospital for second and third degree burns after climbing into a hot bath. She healed well and was almost ready to go home, but then died from severe dehydration and misused narcotics. Human errors. Her mother, Sorrel King, recalls being bent on vengeance. She says she “wanted to take the hospital apart brick by brick.” But instead she focused her energy on making sure that this never happened to another family. She formed a foundation in Josie’s name and has spent the last decade working with clinicians to improve patient safety in hospitals.

Unfortunately, Josie King’s story is not rare. On any given day, 1 out of every 20 patients in American hospitals is affected by a hospital-acquired infection. Among chronically ill adults, 22 percent report a “serious error” in their care. 1 out of 7 Medicare beneficiaries is harmed in the course of their care, costing the federal government over $4.4 billion each year. Despite pockets of success -- we still see massive variation in the quality of care, and no major change in the rates of harm and preventable readmissions over the past decade. We can do much better – and we must. Unfortunately, in spite of heroic advocacy by clinicians and families like Sorrel’s, Josie’s story is still not rare. How does this happen? Numerous inputs Complex Science Chaotic System Human factors

Partnership for Patients Better Care, Lower Costs Reduce harm caused to patients in hospitals. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010.  Achieving this goal would mean approximately 1.8 million fewer injuries to patients with more than 60,000 lives saved over the next three years. Improve care transitions. By the end of 2013, preventable complications during a transition from one care setting to another would be decreased such that all hospital readmissions would be reduced by 20% compared to 2010. Achieving this goal would mean more than 1.6 million patients would recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge. Potential to save up to $35 billion dollars over three years. Achieving these two goals will not only save lives and greatly reduce injuries to millions of Americans – it will also result in savings of billions of dollars that help put the nation on the path to having a more sustainable health care system. We already have XXX# hospitals, etc that have joined the partnerships.

How Will Change Actually Happen? There is no “silver bullet” We must apply many incentives We must show successful alternatives We must offer intensive supports Help providers with the painstaking work of improvement

We Know Major Improvement Is Possible 150 New Jersey health care facilities reduced pressure ulcers by 70% Rhode Island reported a 42% decrease in Central Line-Associated Bloodstream Infections (CLABSI) (2006-2007) More than 65 Institute for Healthcare Improvement Campaign hospitals reported going more than a year without a ventilator-associated pneumonia in at least one unit. Ascension Health sites participating in a 2007 peri-natal safety initiative achieved birth trauma rates that were at or near zero. And much more… We’re confident that we can make these changes – we know that it’s possible. The major challenge is to expand pockets of success to nationwide success. That’s where we’re targeting our attention in both the private and public sectors.

Some of our Partners Hospitals: American Medical Association Johnson & Johnson Ascension Health and its 65 hospitals American Nurses Association Motorola Solutions, Inc. American Society of Health-System Pharmacists National Business Coalition on Health Catholic Healthcare West and its 40 hospitals National Hispanic Medical Association National Business Group on Health Hospital Corporation of America and its 163 hospitals Pacific Business Group on Health Safeway Kaiser Foundation Hospitals and its 35 hospitals Consumer Organizations: Starbucks Campaign for Better Care Walmart Tenet Healthcare Corporations and its 49 hospitals National Partnership for Women and Families Xerox Department of Veterans Affairs and its 171 hospitals Virginia Mason Hospital & Medical Center National Patient Safety Foundation Health Plans: Aetna Unions: America’s Health Insurance Plans American Hospital Association AFL-CIO BlueCross BlueShield Association Federation of American Hospitals UAW Retiree Medical Benefits Trust Cigna National Association of Public Hospitals and Health Systems Group Insurance Commission, Commonwealth of Massachusetts Employers Business Roundtable United Health Group Clinicians: CalPERS Wellpoint American Academy of Pediatrics Catalyst for Payment Reform American Academy of Family Physicians The Dow Chemical Company Other Partners General Electric Cerner Corporation American Board of Medical Specialties Healthcare Leadership Council The Joint Commission Honeywell The Leapfrog Group American College of Physicians IBM American College of Surgeons Intel Corporation

Our Request to You Join the Partnership for Patients Go to healthcare.gov/partnershipforpatients The Partnership for Patients is truly a partnership. In order to achieve our ambitious goals we’ll need a broad coalition of hospitals, clinicians, employers, labor unions, advocacy organizations and states to join with us. So please join the Partnership by signing the pledge. To learn more about the Partnership, to sign the pledge, and for additional resources please visit our website.

Core Topics in Improvement Improvement as a Strategy Customer-Mindedness Process-Mindedness Employee-Mindedness Statistical Thinking Supplier-Mindedness Continual Improvement (PDSA) Leadership

“Meeting and Exceeding the Needs and Expectations of Customers” Defining “Quality” “Meeting and Exceeding the Needs and Expectations of Customers”

Learning about the Customer Observe Survey Use your own experience Ask!

As a Customer… What is the #1 thing you would like CMS to improve? What is the #1 thing you want CMS to keep the same?

“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.” –Margaret Mead

Contact Information   Dennis Wagner Acting Director, Office of Clinical Standards and Quality Centers for Medicare and Medicaid Services Office of Clinical Standards and Quality 7500 Security Blvd., MSC: S3-02-01 Baltimore, MD 21244-1850 Phone Number: 410-786-6841 E-mail Address: dennis.wagner2@cms.hhs.gov

Question for Reflection and Action What is it about this work that makes my heart sing?