Healthcare Quality: DHHS Don Wright, MD MPH Deputy Assistant Secretary for Healthcare Quality Office of Healthcare Quality Office of the Assistant Secretary for Health Office of the Secretary U.S. Department of Health and Human Services Washington, DC

Presentation Overview 1. Partnership for Patients 2. Initiative to Prevent Healthcare-Associated Infections 3. Changing Landscape 3. Linking Payment to Quality 4. What’s Ahead for HAI Elimination

Current State of Patient Safety Massive variation in the quality of care No appreciable change in rates of all-cause harm and preventable readmissions A decade of hard work yielding pockets of success (targeted interventions, isolated settings) System-wide frustration and poorly coordinated efforts in response Opportunity with the Affordable Care Act to move from insurance reform to reform the delivery system

Partnership for Patients: Better Care, Lower Costs Objectives: Keep patients from getting injured or sicker. Keep patients from getting injured or sicker. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to Achieving this goal would mean approximately 1.8 million fewer injuries to patients with more than 60,000 lives saved over three years. Help patients heal without complication. Help patients heal without complication. By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 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. By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 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.

Area of focus: Hospital-Acquired Conditions 1. Adverse Drug Events (ADE) 2. Catheter-Associated Urinary Tract Infections (CAUTI) 3. Central Line-Associated Blood Stream Infections (CLABSI) 4. Injuries from Falls and Immobility 5. Obstetrical Adverse Events 6. Pressure Ulcers 7. Surgical Site Infections 8. Venous Thromboembolism (VTE) 9. Ventilator-Associated Pneumonia (VAP) 10. All Other Hospital-Acquired Conditions

Next Steps To learn more about the Partnership for Patients & related events, activities and materials: hip/index.html. To learn more about the Partnership for Patients & related events, activities and materials: hip/index.html. hip/index.html hip/index.html To sign the pledge: To sign the pledge:

Initiative to Prevent Healthcare-Associated Infections

The Burden Each year, 1 in 20 U.S. hospital patients acquires an HAI This is 1.7million infections, and 100,000 lives lost every year Hospital-acquired HAIs alone are responsible for $28 to $33 billion dollars in preventable healthcare expenditures every year. The vast majority of these infections can be eliminated by implementing known prevention practices.

HHS Action Plan created in response to GAO

Incentives and Oversight Lead: Centers for Medicare and Medicaid Services (CMS) Phase I (2008-Present) Phase II (2009-Present) Phase III Working Group (2011) Federal Steering Committee for the Prevention of Healthcare-Associated Infections Long-Term Care Lead: CMS Prevention & Implementation Lead: Centers for Disease Control and Prevention (CDC) Research Lead: Agency for Healthcare Research and Quality Information Systems & Technology Co-Leads: Office of the National Coordinator for Health IT & CDC Evaluation Lead: Office of Healthcare Quality Outreach & Messaging Lead: Office of Healthcare Quality Ambulatory Surgical Centers Co-Leads: Indian Health Service & CDC End-Stage Renal Disease Facilities Lead: CMS Influenza Vaccination of Healthcare Personnel Co-Leads: CDC & National Vaccine Program Office Working Group Structure of the HAI Steering Committee

HHS Action Plan for the Prevention of Healthcare-Associated Infections Phase 1 Phase 1 Original focus on acute care hospitals Original focus on acute care hospitals Targeted CAUTI, SSI, VAP, CLABSI, MRSA & C. difficile Targeted CAUTI, SSI, VAP, CLABSI, MRSA & C. difficile Phase 2 (under development): Phase 2 (under development): Ambulatory Surgical Centers Ambulatory Surgical Centers End-Stage Renal Disease Facilities (Hemodialysis Centers) End-Stage Renal Disease Facilities (Hemodialysis Centers) Flu Vaccination of Healthcare Personnel Flu Vaccination of Healthcare Personnel Phase 3 (under development) – Long-Term Care Phase 3 (under development) – Long-Term Care Phase 4 (to be determined) – Ambulatory? Phase 4 (to be determined) – Ambulatory?

Measuring Progress Toward Action Plan Goals Metric Source National 5-year Prevention Target On Track to Meet 2013 Targets? Bloodstream infections NHSN 50% reduction Adherence to central-line insertion practices NHSN 100% adherence Data not yet available* Clostridium difficile (hospitalizations) HCUP 30% reduction Clostridium difficile infections NHSN 30% reduction Data not yet available* Urinary tract infections NHSN 25% reduction Data not yet available* MRSA invasive infections (population) EIP 50% reduction MRSA bacteremia (hospital) NHSN 25% reduction Data not yet available* Surgical site infections NHSN 25% reduction Surgical Care Improvement Project Measures SCIP 95% adherence Metric Source National 5-year Prevention Target On Track to Meet 2013 Targets? Bloodstream infectionsNHSN50% reduction Adherence to central-line insertion practices NHSN100% adherence Data not yet available* Clostridium difficile (hospitalizations)HCUP30% reduction Clostridium difficile infectionsNHSN30% reduction Data not yet available* Urinary tract infectionsNHSN25% reduction Data not yet available* MRSA invasive infections (population)EIP50% reduction MRSA bacteremia (hospital)NHSN25% reduction Data not yet available* Surgical site infectionsNHSN25% reduction Surgical Care Improvement Project Measures SCIP95% adherence *2009 or 2009 – 2010 is the baseline period.

Each state identified at least 2 priority prevention measures for surveillance in support of the HHS HAI Action Plan State Prevention Plan Priorities

Changing Landscape of HAI Prevention 1. State Reporting 2. Research 3. Incentives

Disclosures of HAI rates required DC* State-level Public Reporting HAI Legislation, 2004

Disclosures of HAI rates required DC* State-level Public Reporting HAI Legislation, 2011

Changing Landscape of HAI Prevention Over 4,500 healthcare facilities have enrolled in CDC’s National Healthcare Safety Network (NHSN) as of April NHSN is providing CLABSI data for the CMS Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals as a first step in implementing the Affordable Care Act.

Changing Landscape of HAI Prevention $34 Million to Expand Fight Against Healthcare-Associated Infections $34 Million to Expand Fight Against Healthcare-Associated Infections Goal: To help expand efforts to fight HAIs in hospitals, ambulatory care settings, end-stage renal disease facilities, and long-term care facilities. Goal: To help expand efforts to fight HAIs in hospitals, ambulatory care settings, end-stage renal disease facilities, and long-term care facilities. AHRQ has collaborated with CDC, CMS, and NIH to identify research gaps to improve HAI prevention. AHRQ has collaborated with CDC, CMS, and NIH to identify research gaps to improve HAI prevention. Complete list of institutions and projects funded available at: Complete list of institutions and projects funded available at:

Positive Incentives for Excellence National Awards Program National Awards Program Cleveland Clinic Cardiovascular ICU recognized last week with The Sustained Improvement Award (CLABSI) Cleveland Clinic Cardiovascular ICU recognized last week with The Sustained Improvement Award (CLABSI) recognizes progress in implementing systems showing sustained and consistent reductions over a period of 18 to 24 months recognizes progress in implementing systems showing sustained and consistent reductions over a period of 18 to 24 months

Changing Landscape of HAI Prevention AHRQ recently awarded $5.8M to Health Research & Educational Trust AHRQ recently awarded $5.8M to Health Research & Educational Trust Funds will help States support staffing needs at hospitals participating in On the CUSP: Stop BSI Funds will help States support staffing needs at hospitals participating in On the CUSP: Stop BSI CUSP is a comprehensive unit-based safety program to reduce central line-associated bloodstream infections and catheter-associated UTIs CUSP is a comprehensive unit-based safety program to reduce central line-associated bloodstream infections and catheter-associated UTIs Builds on the foundation of the Michigan Keystone Project Builds on the foundation of the Michigan Keystone Project

Changing Landscape of HAI Prevention American Recovery and Reinvestment Act of 2009 (ARRA) American Recovery and Reinvestment Act of 2009 (ARRA) Created opportunities for building the state-level infrastructure for HAI prevention. Created opportunities for building the state-level infrastructure for HAI prevention. Administered by CDC and CMS Administered by CDC and CMS enhanced state capacity to reduce and prevent HAIs, enhanced state capacity to reduce and prevent HAIs, focusing on the Action Plan goals, focusing on the Action Plan goals, enhanced state capacity to inspect ambulatory surgical centers. enhanced state capacity to inspect ambulatory surgical centers.

Linking Payment to Quality and Healthcare-Associated Infections

CMS Programs Planning to Link Payment to Quality Value Based Purchasing and Accountable Care Organizations are two important steps to revamping payment for care and services are paid Rewarding better value, outcomes, and innovations instead of merely volume Measures should rely on a mix of the following: – Standards – Process measures – Outcomes – Patient experience measures  Care Transitions and Changes in Patient Functional Status Goal is to quickly move to using primarily outcome and patient experience measures using risk adjustment as appropriate

CMS Programs Planning to Link Payment to Quality – Hospital Value-Based Purchasing (HVBP) – End Stage Renal Disease Quality Incentive Program (ESRD QIP) – Accountable Care Organizations (ACO)

Introduction: Proposed Hospital Value-Based Purchasing (VBP) Program Required by Congress under Section 1886(o) of the Social Security Act Next step in promoting higher quality care for Medicare beneficiaries CMS views value-based purchasing as an important driver in revamping how care and services are paid for, moving increasingly toward rewarding better value, outcomes, and innovations instead of volume Note: Details presented here are proposals and are subject to change in the Final Rule. Comment period ended on March 8, 2011

Proposed Hospital Value-Based Purchasing (VBP) Measure Topics Acute Myocardial Infarction (AMI) Heart Failure (HF) Pneumonia (PN) Surgical Care Improvement Project (SCIP) Healthcare-Associated Infections, as defined by the Secretary’s HAI Action Plan Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey

Proposed FY 2013 Domains and Measures/Dimensions

Measures Proposed for FY 2014 Hospital VBP Program (1 of 3) Measures Proposed for FY 2014 Hospital VBP Program (1 of 3) Proposed Hospital -Acquired Condition Measures: 1. Foreign Object Retained After Surgery 2. Air Embolism 3. Blood Incompatibility 4. Pressure Ulcer Stages III & IV 5. Falls and Trauma: includes Fracture, Dislocation, Intracranial Injury, Crushing Injury, Burn, Electric Shock 6. Vascular Catheter-Associated Infections 7. Catheter-Associated Urinary Tract Infection (CAUTI) 8. Manifestations of Poor Glycemic Control Proposed Hospital -Acquired Condition Measures: 1. Foreign Object Retained After Surgery 2. Air Embolism 3. Blood Incompatibility 4. Pressure Ulcer Stages III & IV 5. Falls and Trauma: includes Fracture, Dislocation, Intracranial Injury, Crushing Injury, Burn, Electric Shock 6. Vascular Catheter-Associated Infections 7. Catheter-Associated Urinary Tract Infection (CAUTI) 8. Manifestations of Poor Glycemic Control

Proposed Hospital VBP Measures for FY 2014 (2 of 3) Proposed Hospital VBP Measures for FY 2014 (2 of 3) Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSI), Inpatient Quality Indicators (IQI), and Composite Measures: 1. PSI 06 – Iatrogenic Pneumothorax, adult 2. PSI 11 – Post-Operative Respiratory Failure 3. PSI 12 – Post-Operative Pulmonary Emboli (PE) or Deep Vein Thrombosis (DVT) 4. PSI 14 – Postoperative Wound Dehiscence 5. PSI 15 – Accidental Puncture or Laceration 6. IQI 11 – Abdominal Aortic Aneurysm (AAA) Repair Mortality Rate (with or without volume) 7. IQI 19 – Hip Fracture Mortality Rate 8. Complication/Patient Safety for Selected Indicators (composite) 9. Mortality for Selected Medical Conditions (composite) Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSI), Inpatient Quality Indicators (IQI), and Composite Measures: 1. PSI 06 – Iatrogenic Pneumothorax, adult 2. PSI 11 – Post-Operative Respiratory Failure 3. PSI 12 – Post-Operative Pulmonary Emboli (PE) or Deep Vein Thrombosis (DVT) 4. PSI 14 – Postoperative Wound Dehiscence 5. PSI 15 – Accidental Puncture or Laceration 6. IQI 11 – Abdominal Aortic Aneurysm (AAA) Repair Mortality Rate (with or without volume) 7. IQI 19 – Hip Fracture Mortality Rate 8. Complication/Patient Safety for Selected Indicators (composite) 9. Mortality for Selected Medical Conditions (composite)

Measures Proposed for FY 2014 Hospital VBP Program (3 of 3) Measures Proposed for FY 2014 Hospital VBP Program (3 of 3) MORT-30-HF: Heart Failure (HF) 30-Day Mortality Rate MORT-30-PN: Pneumonia (PN) 30-Day Mortality Rate Proposed Mortality Measures MORT-30-AMI: Acute Myocardial Infarction (AMI) 30-Day Mortality Rate MORT-30-HF: Heart Failure (HF) 30-Day Mortality Rate MORT-30-PN: Pneumonia (PN) 30-Day Mortality Rate

Anticipated HAI Expansion in Future Years (subject to regulation proposal) – Central Line-Associated Blood Stream Infection (CLABSI) – Surgical Site Infection – MRSA – Clostridium Difficile – Catheter -Associated Urinary Tract Infection – Central Line Insertion Protocol (CLIP)

ESRD Quality Incentive Program is…. A program designed to improve the quality of care for beneficiaries by changing the way dialysis facilities in the ESRD Program are reimbursed Designed to monitor and improve the quality of care furnished to ESRD beneficiaries The first pay-for-performance program in a Medicare prospective payment system A program that continues a long history of work by CMS to improve the quality of care for beneficiaries with ESRD Efforts to improve beneficiary quality of care include: – Dialysis Facility Compare – Fistula First Breakthrough Initiative

ESRD QIP Future Measures Under Consideration Committed to adding quality measures that will look at additional aspects of an individual’s health in dialysis Some areas under consideration include: – Bone and mineral metabolism – Access infection rates (including healthcare acquired infections) – Dialysis adequacy –(Kt/V instead of URR) – Vascular access rates Committed to developing additional quality measures for future years to better assess the quality of care provided by dialysis facilities – Kt/V = (dialyzer clearance of urea X dialysis time) / volume of distribution of urea

Role of Accountable Care Organizations Another key delivery system reform is the encouragement of Accountable Care Organizations (ACOs). ACOs facilitate coordination and cooperation among providers to improve the quality of care for Medicare beneficiaries and reduce unnecessary costs.

What is an Accountable Care Organization? An organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it For ACO purposes, “assigned” means those beneficiaries for whom the professionals in the ACO provide the bulk of primary care services. Assignment will be invisible to the beneficiary, and will not affect their guaranteed benefits or choice of doctor. A beneficiary may continue to seek services from the physicians and other providers of their choice, whether or not the physician or provider is a part of an ACO.

What forms of organizations may become an ACO? The statute specifies the following: 1) Physicians and other professionals in group practices 2) Physicians and other professionals in networks of practices 3) Partnerships or joint venture arrangements between hospitals and physicians/professionals 4) Hospitals employing physicians/professionals 5) Other forms that the Secretary of Health and Human Services may determine appropriate. An organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it.

What quality measures will ACOs be assessed on? Subject to the proposed program’s regulations, they will include measures in such categories as clinical processes and outcomes of care, patient experience, and utilization (amounts and rates) of services.

How would an ACO qualify for shared savings? For each 12-month period, participating ACOs that meet specified quality performance standards will be eligible to receive a share of any savings if the actual per capita expenditures of their assigned Medicare beneficiaries are a sufficient percentage below their specified benchmark amount.

ACO Current Status – CMS plans to hold a listening session to hear stakeholder ideas on ACOs this summer. Further details about this listening session, to be held as a special open door forum, will be posted by June 11. – We plan to establish the program by January 1, Agreements will begin for performance periods, to be at least three years, on or after that date. – Further details for the shared savings program will be provided in a Notice of Proposed Rulemaking which CMS expects to publish this fall.

Looking Ahead IPPS rule CMS to use NHSN data for Hospital Compare Affordable Care Act $500 million for care transitions Release of 2011 Action Plan Development of Phase III – Long-Term Care Partnering to Heal: Teaming Up Against Healthcare Associated Infections Consumer Media Campaign

For more information Office of Healthcare Quality 200 Independence Ave, SW Room 716G Washington, DC Telephone (202) Subscribe to the HAI listserv