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? 3

CMS is Changing 4

CMS Vision CMS is a major force and a trustworthy partner for the continual improvement of health and health care for all Americans. 5

Operating Values How we shall work together and with others? Boundarilessness Speed and Agility Unconditional Teamwork Valuing Innovation Customer Focus 6

Better Health for the Population Better Care for Individuals Lower Cost Through Improvement The “Three-Part Aim” 7

5 New Centers and Functions Added in 1 Year 1.Center for Strategic Planning, Tony Rodgers 2.Center for Program Integrity, Peter Budetti 3.Center for Medicare and Medicaid Innovation, Rick Gilfillan 4.Center for Consumer Information and Insurance Oversight, Steve Larsen 5.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 8

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 9

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

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 Hospital value-based purchasing Value-based purchasing for SNF Quality and efficiency measurement Develop a plan to implement VBP for ambulatory surgical centers Pilot testing for pay-for-performance Hospital readmissions Hospital readmissions reduction program Community-based care transitions program Healthcare acquired conditions Payment adjustment for health care-acquired conditions Payment adjustment for conditions acquired in hospitals Accountable care organizations Pediatric accountable care organization demonstration project Medicare Shared Savings Program Dual eligibles Providing federal coverage and payment coordination for dual eligible beneficiaries Preventative services Annual wellness visit providing a personalized plan Removing barriers to preventive services Evidence-based coverage of preventive services Coordination of care State option to provide health homes for enrollees with chronic conditions Demonstration project to evaluate integrated care around a hospitalization Long term care Community first choice option Removal of barriers to providing home and community based services Money follows the person rebalancing demo Protection for recipients of home and community-based services against spousal impoverishment Incentives for states to offer home community based serviced Public reporting Development of outcome measures Improvements to the physician quality reporting system -- also see Provision Public reporting of performance information Quality reporting initiative Adult health quality measures Improvements to the physician quality reporting system Quality Reporting for Long Term Care Hospitals (LTCH), inpatient rehabilitation hospitals, and hospice programs Quality reporting for PPS-exempt cancer hospitals Quality reporting for psychiatric hospitals 12

CMS Approach to Managing the Affordable Care Act 13 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 14 1.Value Based Purchasing 2.Public and Quality Reporting 3.Reduced Readmissions 4.Hospital Acquired Conditions 5.ACOs 6.Center for Medicare and Medicaid Innovation Quadrant 2 Quadrant 3Quadrant 4

OCSQ Quadrant 2: High Impact Priorities to Monitor and Maintain 1.Preventative services -- more in other CMS components -- Quadrant 2 High impact priorities to monitor and maintain 15 Quadrant 2 Quadrant 3Quadrant 4 Quadrant 1

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? 17

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,

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. 19

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? 20

21 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? 22

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 25

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. 26

 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 Concentration of Potential Donors In Nation’s Largest 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 Define, Document, and Disseminate Best Practices Accelerate Improvement Accelerate Improvement Achieve Results at a Rapid Pace Achieve Results at a Rapid Pace Build Clinical Leaders of Change Build Clinical Leaders of Change “All Teach, All Learn”

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

Measures of Success

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

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? 36

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

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.

Partnership for Patients Better Care, Lower Costs 1. Reduce harm caused to patients in hospitals. 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 the next three years. 2. 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 –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.

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) ( ) 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…

44 Working Draft - Last Modified 8/13/ :04:19 PM Hospitals:  Ascension Health and its 65 hospitals  Catholic Healthcare West and its 40 hospitals  Hospital Corporation of America and its 163 hospitals  Kaiser Foundation Hospitals and its 35 hospitals  Tenet Healthcare Corporations and its 49 hospitals  Department of Veterans Affairs and its 171 hospitals Virginia Mason Hospital & Medical Center  American Hospital Association  Federation of American Hospitals  National Association of Public Hospitals and Health Systems Clinicians:  American Academy of Pediatrics  American Academy of Family Physicians  American Board of Medical Specialties  American College of Physicians  American College of Surgeons  American Medical Association  American Nurses Association  American Society of Health-System Pharmacists  National Hispanic Medical Association Consumer Organizations:  Campaign for Better Care  National Partnership for Women and Families  National Patient Safety Foundation Unions:  AFL-CIO  UAW Retiree Medical Benefits Trust Employers  Business Roundtable  CalPERS  Catalyst for Payment Reform  The Dow Chemical Company  General Electric  Healthcare Leadership Council  Honeywell  IBM  Intel Corporation  Johnson & Johnson  Motorola Solutions, Inc.  National Business Coalition on Health  National Business Group on Health  Pacific Business Group on Health  Safeway  Starbucks  Walmart  Xerox Health Plans:  Aetna  America’s Health Insurance Plans  BlueCross BlueShield Association  Cigna  Group Insurance Commission, Commonwealth of Massachusetts  United Health Group  Wellpoint  Other Partners  Cerner Corporation  The Joint Commission  The Leapfrog Group

Our Request to You Join the Partnership for Patients Go to healthcare.gov/partnershipforpatients

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

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? 49

“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: S Baltimore, MD Phone Number: Address: 51

Question for Reflection and Action What is it about this work that makes my heart sing? 52