Corporate Responsibility and Health Care Quality Quality Colloquium August 19, 2008 Corporate Responsibility and Health Care Quality Lewis Morris Office of Inspector General

Board Awareness of Quality Issues “The level of knowledge of landmark Institute of Medicine (IOM) quality reports among CEOs and board chairs was remarkably low…. There were significant differences between the CEOs' perception of the level of knowledge of their board chairs and the board chairs' self-perception.” “Getting the Board on Board: Engaging Hospital Boards in Quality and Patient Safety” Joint Commission Journal on Quality and Patient Safety, Volume 32, Number 4, April 2006.

“Corporate Responsibility and Health Care Quality: A Resource for Health Care Boards” Third in a series of guides Joint public sector/private sector effort Educational information, not mandates Assists boards in exercising their fiduciary responsibilities Available at: oig.hhs.gov/fraud/docs/complianceguidance

Defining quality of care “Crossing the Quality Chasm” (IOM) definition of health care quality Safe Effective Patient-centered Timely Efficient Equitable Public and private quality initiates provide benchmarks National Quality Forum, Joint Commission, Leapfrog, CMS

Board’s Fiduciary Duty of Care Acting in “good faith” Prudent person standard Reasonably acting in the best interest of the entity “Reasonable inquiry” standard Appropriate level of due diligence to allow an informed decision Application Decision-making functions Oversight functions Corporate scandals such as Enron, Worldcom and Allegaheny Health and Educational Research Foundation have raised public awareness of the role boards must play in ensuring integrity of organizations Complexities of the health care industry increase oversight responsibilities of health care boards “Business judgment rule” protects the reasonable exercise of judgment without fear of being 2nd guessed

Duty of Care and Quality Emerging quality of care issues IOM reports Collaboration among providers of care Monitoring and reporting requirements Payment policies Significant opportunities and risks Reimbursement Transparency Public/private collaboration Government enforcement Moody’s Investor Service “As the indutry develops common metrics for measuring qulaity, our approach to hosptial bond rating will likely also evolve to incorporate these various indicators and the related trends over time.”

Duty of Care and Quality The “bottom line” Quality is an essential component of the mission of the health care providers Quality must receive the same level of Board attention as the corporation’s financial viability Quality and cost efficiency are complementary, not contradictory, elements of an effective health care system Unique opportunity for leadership and positive change

Government Enforcement and Quality Enforcement priority DOJ, OIG and State Attorneys Generals Training and collaboration Federal and state “Whistleblower” statutes Prosecutive theories Criminal violations False claims based on “failure of care” and “worthless services” Medically unnecessary services Failure to meet professional recognized standards “The IG has devoted significant resources to ensuring the integrity of the Federal health care programs. We are very proud of our accomplishments and last year, OIG recovered $2.2 billion. However, we also know that behind every claim submitted to the Medicare and Medicaid programs is a patient and the quality of the care they receive is of paramount importance and at the heart of our mission.” Failure of care theory evidence of especially egregious care systemic or widespread problems actual evidence of harm to patients Example: Colorado rehab center provided worthless services as result of chronic understaffing, where deficient services and abuse cause 6 deaths Failure to meet substandard care provided to any patient

Enforcement Tools & Sources Whistleblowers, Ombudsman, Licensure Boards Mining of quality/reimbursement data Civil penalties, criminal fines and exclusion Corporate Integrity Agreements Independent reviews and quality monitors Board certifications (e.g., Tenet Healthcare Corp.) Stipulated penalties DRA requires Medicaid providers to inform employees of FCA Data Mining of quality assessment and improvement program (required by Medciare COP). Mandatory reporting of Adverse Events in hospitals. Minimum Data set used for payment to nursing homes Hospital quality data reported top CMS OIG outreach campaign to States, including training, joint enforcement projects Quality cases cases (listed) Tenet Board requirements oversee performance of compliance staff annual review of CP effectiveness independent consultant to assist in review of CP resolution summarizing views of compliance with CIA

Suggested Questions for Directors Quality goals and institutional leadership? Understanding structures & processes Linkage between quality, peer review and compliance Board orientation and expertise? Dashboards and benchmarks Recruiting expertise Are structure and processes to oversee and improve clinical quality adequate? is there a silo approach to quality, peer review and compliance?

Suggested Questions for Directors Coordination with compliance program? Integration of regulatory compliance Quality and risk assessment/corrective actions Internal reporting and communications? “Whistleblower” protections Culture of candor

Suggested Questions for Directors Adequate resources? Staffing levels Acquisition of new technologies and services Addressing specific quality concerns and adverse events? Quality and the peer review process Responding to incidents of deficient care Board needs to understand the peer review process and ask if quality data is used when staff is recredentialed Link peer review to quality. Can’t send quality concerns off to PR and then forget about it. Peer review may have tendency to protect high admitters