The QIO 9th Scope of Work: A Content Overview Paul McGann, MD Deputy Chief Medical Officer QualNet 2007 23 October 2007 Baltimore, MD

The QIO Program has been Re-designed Framework for Accountability Content

9th Scope of Work: CONTENT 4 Themes Prevention Patient Safety Care Coordination (Patient Pathways) 4. Beneficiary Protection

Our Goals are to help providers prevent illness, decrease harm to patients, and reduce waste in healthcare

Outline Old Work vs New Work National vs Subnational Process of Development Design Principles Content of the Proposed Statement of Work Perspectives on the Scope Old Work vs New Work National vs Subnational Special Projects QIOSC-like entities Evaluation-Attribution Summary

GOALS Provide a content overview Explain how the “business model” changes how we do our work Recognize the importance of competition and efficiency Emphasize the importance of measurement How are we relevant to CMS and HHS?

9th Scope of Work History Priorities of the Secretary of Health Recommendations from External Stakeholders What do QIOs do well? What can we measure well? What is important? What interventions are backed by evidence? Recommendations from the QIO Community, and from the Department of Health and Human Services (DHHS)

9th Scope of Work History Workgroup 1: QIO/CMS Community Workgroup 2: DHHS CMS ASPE (NORC Contract) ASRT AHRQ CDC OCR OGC OL OS

9th Scope of Work Overarching Design Principles More Effective Management Measurement with Accountability Relevance to CMS and to HHS Value-Driven Health Care Disparities Reduction Health Information Technology Careful Evaluation with Attribution

9th Scope of Work: CONTENT 4 5 Themes Prevention Patient Safety Care Coordination 4. Beneficiary Protection 5. Evaluation

9th Scope of Work Levels of Understanding Less detail 4 Themes (+Evaluation) 10 “Components” 31 “Final Measures” 44 “18 & 28-month Measures” 2-300 “Detailed Measures” More detail

9th Scope of Work Component Level Prevention (3) “Core” CKD (chronic kidney disease) “Focused Disparities” Patient Safety (5) Pressure Ulcers Physical Restraints SCIP MRSA Drug Safety Care Coordination (1) Beneficiary Protection (1)

9th Scope of Work Measure Level (1) PREVENTION (10 measures) “Core” Mammography CRC Screening Influenza Vaccination Pneumococcal Pneumonia Vaccination CKD Screening for nephropathy ACE/ARB therapy to prevent progression AV Fistula rate (new dialysis pts) “Focused Disparities” HbA1c rates Lipid Examination rates Eye exam rates

9th Scope of Work Measure Level (2) Patient Safety (14 measures) MRSA 1 (infection rate) MRSA 2 (transmission rate) PrU1 (high-risk, NH) PrU3 (hospital, acquired) Physical Restraints (NH) SCIP Infection 1, 2, 3, 4, 6, 7 SCIP VTE 1,2 SCIP Cardiology 2 Care Coordination (3 measures) Global Re-hospitalization rate Pt assessment of hospital discharge performance (H-CAHPS items 17, 19, 20) Physician visit post discharge, before re-admission (within 30 days)

9th Scope of Work Measure Level (3) Beneficiary Protection (4 measures) Timely completion of case reviews Beneficiary satisfaction with complaint process Completion of satisfaction survey % QIA completion

9th Scope of Work Measure Level Total 31 final outcome measures With 18-month evaluation requirement, add 13 more measures, for total of 44 “high-level” measures Management Information System

9th Scope of Work Levels of Understanding Less detail 4 Themes (+Evaluation) 10 “Components” 31 “Final Measures” 44 “18 & 28-month Measures” 2-300 “Detailed Measures” More detail

9th Scope of Work “Detailed” Measure Level Tables have been created from the Schedule of Deliverables Quarterly and monthly frequencies Will be used by CMS Central Office and Regional Offices for active contract management Goal is to detect and to understand difficulties before they become evident at the “Outcome Measure Level” Early intervention can help avoid adverse consequences

9th Scope of Work Levels of Understanding Less detail 4 Themes (+Evaluation) 10 “Components” 31 “Final Measures” 44 “18 & 28-month Measures” 2-300 “Detailed Measures” More detail

Ways to think of the 9th Scope of Work “Levels” 4 Themes to 44 Measures, and beyond… Topic-oriented (not setting oriented) Cross-cutting themes (HIT, disparities, VDHC) Outcomes-oriented: 31 Measures Patient-Centered: 245,000 more pts screened for CKD 40,000 less pressure ulcers 20,000 more adult immunizations given What will change? (old work vs. new work) What will not be “automatic”? (“National” vs. “Subnational”)

Old Work vs. New Work theme by theme (1) PREVENTION: Mammography, Influenza Vaccination Pneumococcal Pneumonia Vaccination Colorectal Cancer Screening Chronic Kidney Disease Focused Disparities Reduction

Old Work vs. New Work theme by theme (2) PATIENT SAFETY Pressure Ulcer (new: hospital) Physical Restraints SCIP Drug Safety Focused MRSA work

Old Work vs. New Work theme by theme (3) CARE COORDINATION (note Task 1B Work in Home Health in 8th Scope of Work) BENEFICIARY PROTECTION Increasing linkage of case review to quality of care Increasing awareness of complaint process among beneficiaries Emphasis on improved efficiency

Matching the Scope to the Resources Available National Implementation “Subnational” Implementation Special Projects

National vs Subnational First, consider the “New Work”: Care Coordination: Subnational CKD: Subnational Pressure Ulcer work (in hospitals): National Focused MRSA Work: National

National vs Subnational Review of “Old Work”: Cancer Screening & Adult Immunization: National Focused disparity reduction: Subnational Patient Safety Work: National Beneficiary Protection Work: National

Special Initiative/Project Funding Projects essential to: advance quality improvement and beneficiary protection work with a focus on implementation in the 10th SOW advance 9th SOW efforts Management Objectives: CMS will more aggressively prioritize and manage special projects and results (higher efficiency) Track and maintain project results / evaluation Obtain results in time for 10th SOW Implementation (minimum 1 yr in advance) Link all projects to overall measurement strategy

Sample of 9th Scope proposed Special Projects Use of E.H.R. to improve access and quality of care for minority health Use of Electronic Prescribing technology to eliminate ADEs, reduce polypharmacy, and increase rate of generic medication prescription Preventive and chronic care quality improvement initiatives in Medicare Advantage Programs

Support for QIOs before and during the 9th Scope of Work

“QIOSC-like Entities”: Old Model PO HH NH U H QIOs

“QIOSC-like Entities”: New Model f6 f7 f4 f2 f1 f5 f3 QIOs

QIOSC-like Entities: Functional Model F1 = data analytic F2 = tool development F3 = training F4 = communications F5 = coordination of national networks & campaigns F6 = evaluation/data on specific interventions F7 = developing the business case for quality (overlap with F1)

Evaluation CONTRACT EVALUATION PROGRAM EVALUATION ATTRIBUTION OF SUCCESS TO QIO INTERVENTIONS

Evaluation “Table of Measures” Contract Evaluation “Table of Measures” Program Evaluation Independent, Outside Evaluation Contractor Independent Report on the QIO Program is a final deliverable (2011)

“Attribution” Excellent Measure Set, with continuous, high-quality data Standardized Interventions, linked to the measures More CMS control over participant selection More ability to control for confounding variables

SUMMARY 9th Scope of Work now planned Measurement system (final and interim), Support System structure, List of possible Special Studies Evaluation Strategy has been worked out in advance, with quantitative targets, some control groups Higher degree of competition has been introduced (subnational deployment) Monitoring now has greater transparency, involves both HHS and OMB regularly through contract

SUMMARY Interventions are linked to measures Independent Outside Evaluation contractor will be engaged from the beginning Final Independent Program Evaluation Report at end of contract New management strategies will be applied to continuous contract oversight, encouraging high performance throughout the contract period New contract responsive to all external stakeholders

Our Goals are to prevent illness, decrease harm to patients, and reduce waste in healthcare

Our Goals are to help providers prevent illness, decrease harm to patients, and reduce waste in healthcare