Your Quality Improvement Plan Your Health Care Plan ………………………………………………………………..and stuff like that Marti Wolf, RN, MPH Clinical Programs Director North Carolina Community Health Center Association

Session Description Clinical Quality measures are popping up in many areas and under many identities- Meaningful Use, Patient Centered Medical Home, UDS, FTCA and others. A good organizational plan for quality improvement integrates all areas of operations and all of the forms quality takes while minimizing effort.

Objectives What’s a Health Care Plan? What’s a Quality Plan? Clinical UDS??? Meaningful Use Medical Home

Words From HRSA Quality is a focus area nationally and at HRSA Assessment of QI plans showed areas for improvement Invest in your QI infrastructure Clinical quality and beyond Focus on implementation This work never ends

Benefits of an Effective QI Plan Roadmap for HC organization Leadership, focus, & prioritization Efficient coordination of staff & resources Better outcomes Satisfy external requirements HRSA, State Third-party quality accreditation and recognition

Benefits of QI Plan Federal Tort Claims Act deeming Health centers and free clinics ECRI resources Data collection and analysis UDS, patient survey, EHB Health Information Technology Adoption, meaningful use, health info exchange Quality Third party quality recognition Aligning technical assistance for PCMH transformation CMS

QI Plan- Define Quality  Phillip Crosby- Doing the right thing right the first time and every time. Ensuring Quality is a Risk Management Plan Institute of Medicine Definition of Quality: The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. STEEEP SAFE TIMELY EFFECTIVE EFFICIENT EQUITABLE PT CENTERED

Quality Safe Effective Patient-Centered Timely Efficient Equitable Safe: avoiding injuries to patients from the care that is intended to help them; Effective - providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit; Patient-Centered - providing care that is respectful of and responsive to individual patient preferences, needs and values and ensuring that patient values guide all clinical decisions; Timely - reducing waits and sometimes harmful delays for both those who receive and those who give care; Efficient - avoiding waste, especially of equipment, supplies, ideas and energy; Equitable - providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socio-economic status

QI Plan 2-3 pages General Concepts Written = Commitment What do you mean by Quality? Provides Structure for your QI Program Quality Improvement Committee Who is on the Committee Terms of Service? Ad hoc members? How often do they meet? Documentation (agenda, minutes)

QI Plan Methodology Data Collection Plan How data is collected Lean, 6 Sigma, PDSA, Root Cause Analysis, etc, etc, etc Data Collection Plan How data is collected Internal and external sources of data Core components (stay general) Patient satisfaction Staff satisfaction HRSA measures Other regulatory measures Business Plan measures HCP is where specifics come into play- where you identify specific measures, same as business plan

QI Plan Content/Authority Use of Date Communication Plan QI activities in all areas of operation Audits Frequency Use of Date QI purpose (not punitive) Communication Plan Staff Board Management Patients

Quality: FTCA Deeming Federal Program Requirement in the Health Center Program Quality Improvement/Assurance Plan: Health center has an ongoing Quality Improvement/ Quality Assurance (QI/QA) program that includes clinical services and management, and that maintains the confidentiality of patient records. The QI/QA program must include: Continued- next slide…

a clinical director whose focus of responsibility is to support the quality improvement program and the provision of high quality patient care; periodic assessment of the appropriateness of the utilization of services and the quality of services provided or proposed to be provided to individuals served by the health center; and such assessments shall: be conducted by physicians or by other licensed health professionals under the supervision of physicians; be based on the systematic collection and evaluation of patient records; and identify and document the necessity for change in the provision of services by the health center and result in the institution of such change, where indicated. (Section 330(k)(3)(C))

Elements of your Quality Plan: FTCA recommended 1. QI teambuilding and responsibility across a range of staff types 2. Self-assessment of areas to target 3. Setting concrete goals 4. Identifying strategies for improvement 5. Data collection and analysis 6. Evaluation and dissemination of lessons learned 7. Integration with operations and other quality related activities

IHI Triple Aim Quality of Care Cost of Care Patient Experience

Perspectives on Quality Medical Administrative Patient Even working with some standard definitions, there are varying perceptions of Quality. As a health care provider or support staff- what is your Personal definition of quality care? Getting the patient in and out of the office all in the same day? Making sure they have all of their vital signs taken and recorded on the right form? Having a complete medication record on the chart? Getting lab work done on time? Drawing the lab work in one stick? Same visit- what is the patient’s perception of quality? That they didn’t wait very long in the waiting room? That they were called by name? that the receptionist made eye contact and actually smiled? That the provider asked about the family? Not many know that they got an ARB instead of an ACE, or that they need to be on a Beta blocker post MI. Their perception of quality medical care is that they feel better. Again it’s a difference between medical and patient perception: cure vs healing. And finally, what about our admin staffs. They perceive quality in terms of productivity- did you crank out the right number of visit today? Is any of the staff going to charge them for overtime because they missed lunch or had to work late because of walk ins or an emergency?

Quality Results of Quality Improved Outcomes Improved efficiency and productivity Staff and patient satisfaction Our vision of Quality should give us a goal- to improve- to strive for excellence. Let’s sidestep and talk about various perceptions of quality- still congruous with our definition of doing the right thing right, the first time and every time.

QI includes Risk Management Credentialing and Privileging Current clinical standards of care   Provider credentials and privileges  Risk management procedures   Patient grievance procedures  Incident management Confidentiality of patient records

Demonstrating Quality Patient Centered Medical Home Patient Centered Health Home Initiative Meaningful Use

Quality - Food for Thought Consistency requires you to be as ignorant today as you were a year ago . -Bernard Berenson

Health Care Plan/Clinical UDS PAL 2010-12 for the 2011 measures that will be reported when you submit in 2012 Trimester of entry into care LBW 2 year old immunization Diabetes- A1c HTN- BP <140/90

ENOUGH TO TRACK! 2011 Clinical UDS New and Revised Measures 2010 UDS manual- clinical measures start on p 49 http://bphc.hrsa.gov/healthcenterdatastatistics/reporting/ call archive http://bphc.hrsa.gov/healthcenterdatastatistics/reporting/2010m anual.pdf Program Requirements #8 HCP Template

Risk Management

Disclaimer Risk Management is like liver. The more you chew it, the bigger it gets.

PROTECT AGAINST LOSS Risk Management “Identify and plan for potential and actual risks… in terms of facilities, staff, clients, financial, clinical and organizational well-being”. (NACHC, 2003)

RM in Ambulatory Care “Identify and plan for potential and actual risks… in terms of facilities, staff, clients, financial, clinical and organizational well- being”. (NACHC, 2003)

RM in Ambulatory Care How to pay for losses Policy and Procedures Review and evaluation of effectiveness Annual employee training System of anonymous reporting Methods for investigating Corrective actions

RM in Amb Care: Hot Topics Credentialing and Privileging Medical Records Confidentiality Backup (paper or electronic) Documentation Legibility

Meaningful Use CORE - EP Eligible Professional (EP) Core Objectives (All 15 Must Be Implemented) 1. Use computerized prescriber order entry (CPOE) for medication orders directly entered by any licensed health care professional who can enter orders into the medical record per state, local, and professional guidelines. 2. Implement drug–drug and drug–allergy interaction checks. 3. Maintain an up-to-date problem list of current and active diagnoses. 4. Generate and transmit permissible prescriptions electronically. 5. Maintain active medication list.

Meaningful Use CORE - EP 6. Maintain active medication allergy list. 7. Record all of the following demographics: preferred language, sex, race, ethnicity, and date of birth. 8. Record and chart changes in the following vital signs: height, weight, blood pressure, calculate and display body mass index (BMI), and plot and display growth charts for children 2–20 years, including BMI. 9. Record smoking status for patients 13 years old or older. 10. Report ambulatory clinical quality measures to the CMS or, in the case of Medicaid EPs, the states.

Meaningful Use CORE - EP 11. Implement one clinical-decision-support rule relevant to specialty or high clinical priority along with the ability to track compliance with that rule. 12. Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies) upon request. 13. Provide clinical summaries for patients for each office visit. 14. Capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results) electronically among providers of care and patient authorized entities. 15. Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities.

EP Menu Objectives (Must Implement 5 of 10) Implement drug formulary checks. Incorporate clinical laboratory test results into EHR as structured data. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach. Send patient reminders per patient preference for preventive/follow-up care. Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, and allergies) within 4 business days of the information being available to the EP. Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient, if appropriate. The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation. The EP who transitions a patient to another setting of care or provider of care or refers that patient to another provider of care should provide summary care record for each transition of care or referral. Capability to submit electronic data to immunization registries or immunization information systems and actual submission in accordance with applicable law and practice. Capability to submit electronic syndromic surveillance data to public health agencies and actual submission in accordance with applicable law and practice.

Clinical Quality Measures for EPs (Must Report 6 Total; 3 of 6 From Core or Alternate Set and 3 of 38 From Additional Set) Core Set Hypertension: blood pressure measurement Preventive care and screening measure pair: tobacco-use assessment and tobacco cessation intervention Adult weight screening and follow-up Alternate Core Set Weight assessment and counseling for children and adolescents Preventive care and screening: influenza immunization for patients 50 years or older Childhood immunization status

Additional Set (minus oncology) Diabetes: eye examination Diabetes: urine screening Diabetes: foot examination Diabetes: poor hemoglobin A1c control (>9.0%) Diabetes: hemoglobin A1c control (<8.0%) Diabetes: low-density-lipoprotein (LDL) cholesterol management and control Diabetes: blood pressure management Diabetic retinopathy: documentation of presence or absence of macular edema and level of severity of retinopathy Diabetic retinopathy: communication with the physician managing ongoing diabetes care Primary open-angle glaucoma: optic nerve evaluation

Additional Set 11. Heart failure (HF): angiotensin-converting-enzyme inhibitor or angiotensin receptor blocker therapy for left ventricular systolic dysfunction (LVSD) 12. HF: β-blocker therapy for LVSD 13. HF: warfarin therapy for patients with atrial fibrillation 14. Coronary artery disease (CAD): β-blocker therapy for patients with prior myocardial infarction 15. CAD: oral antiplatelet therapy 16. CAD: drug therapy for lowering LDL cholesterol 17. Ischemic vascular disease (IVD): blood pressure management 18. IVD: use of aspirin or another antithrombotic 19. IVD: complete lipid panel and LDL cholesterol control

Additional Set 20. Asthma assessment 21. Asthma pharmacologic therapy 22. Use of appropriate medications for asthma 23. Controlling high blood pressure 24. Antidepressant medication management: effective acute phase treatment and effective continuation phase treatment 25. Appropriate testing for children with pharyngitis 26. Chlamydia screening for women 27. Cervical cancer screening 28. Breast cancer screening 29. Colorectal cancer screening

Additional Set 30. Smoking and tobacco-use cessation, medical assistance: advising smokers and tobacco users to quit, discussing smoking and tobacco use cessation medications, and discussing smoking and tobacco use cessation strategies 31. Initiation and engagement of alcohol and other drug dependence treatment 32. Prenatal care: screening for human immunodeficiency virus 33. Prenatal care: anti-D immune globulin 34. Low back pain: use of imaging studies 35. Pneumonia vaccination status for older adults

Resources An Introduction to Quality Assurance in Health Care. Healthy North Carolina 2020: A Better State of Health http://www.publichealth.nc.gov/hnc2020/ Institute for Healthcare Improvement http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Measures/ Improving Chronic Illness Care http://www.improvingchroniccare.org 2011 New and Revised Clinical Measures http://www.cms.gov/QualityMeasures/03_ElectronicSpecifications.asp An Introduction to Quality Assurance in Health Care. Avedis Donabedian. 2003. Oxford University Press The Improvement Guide. Jerry Langley, et al.1996. Jossey-Bass Publishers. Continuous Quality Improvement in Health Care. McLaughlin and Kaluzny

Resources Meaningful Use Stage 1 Clinical Quality Measures http://www.hrsa.gov/healthit/meaningfuluse/MU%20Stage1%20CQM/index.html