Benchmarking and IT Meet Pay For Performance Demands Donna Isgett, RN, MSN Vice President of Clinical Effectiveness McLeod Health, Florence, SC Gail E. Latimer, RN, MSN Vice President and Chief Nursing Officer Siemens Medical Solutions, Malvern, PA

Page 2 Learning Objectives  Identify strategies to promote Pay for Performance  Describe the process and methodologies McLeod has employed to build it’s culture of quality evidence-based practice and transparency  Understand the role of physician and executive leadership in developing this culture  Identify CMS outcomes achieved to date as a result of the Medicare demonstration project

Page 3 Quality - Quality Everywhere 1997 Dana Farber Cancer Institute Event 2000 To Err is Human, IOM Report Healthgrades.com Business Roundtable: Leapfrog Group Crossing the Quality Chasm, IOM Report JCAHO Sentinel Event Alerts 2002 Robert Wood Johnson - Pursuing Perfection Grant CMS 7 Scopes of Work 2004 Premier/CMS Demonstration Project

Page 4 Milliken Award for Quality CMS/Premier Demonstration Project “Top Performer” Publication Features: Modern Healthcare US News and World Report USA Today McLeod Quality

Page 5 CMS/Premier Hospital Quality Incentive AMI, CABG, HF, CAP, Hip and Knee 278 participating hospitals Quality - Pay for Performance  The first national project to measure hospital performance and offer additional Medicare payment for top quality care (October, 2003)  Widely accepted quality measures(34)  27 indicators from the National Quality Forum  Public reporting

Page 6 Quality - Results that Make a Difference McLeod Regional Medical Center October September 2004 Composite Quality Score Clinical Focus AreaNational Top DecileMRMCDecile AMI95.8%98.0%1 CABG95.6%95.6%1 HF85.2%85.0%2 CAP83.5%85.8%1 Hip/Knee94.8%95.1%1

Page 7 McLeod Health at a Glance *Each point reflects the 12 month (annual) rate ending at the point's date

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Page 9 Reliability Theory Quality Core Value Physician & Executive Engagement Improvement Methodology Prioritization Core Success Factors Change Theory Core Success Factors

Page 10 Quality Core Value Core Success Factors Clinical Effectiveness: Promoting Change

Page 11 Core Values Value of Person Value of Integrity Value of Caring Value of Quality

Page 12 Quality of Service Culture of “No Blame” Leadership Support Physician Leadership Quality of Safety Quality of Science Quality Pyramid

Page 13 Quality Core Value Core Success Factors Prioritization Clinical Effectiveness: Promoting Change

Page 14 Cost LOSComplications Readmissions Prioritization: Benchmarking Assessment Mortality Opportunity

Page 15 Prioritization: National Benchmarking  Purchased Databases  Premier Perspective  Vermont Oxford  STS (Society of Thoracic Surgeons)  Public Data  Medicare website  CMS 7 scopes of work  Leapfrog Group  Healthgrades.com

Page 16 Quality Core Value Improvement Methodology Prioritization Core Success Factors Clinical Effectiveness: Promoting Change

Page 17 Methodology: GE’s Total Quality Management (TQM) Problem Solving Process (PSP) Results Oriented Process Implemented Identify & Select Problem 5. Implement Solution 4. Select/Plan Solution 3. Generate Potential Solutions 2. Analyze for Cause Problem Solving Process 6. Evaluate Solution Performance Improvement

Page 18 Quality Core Value Improvement Methodology Prioritization Core Success Factors Change Theory Clinical Effectiveness: Promoting Change

Page 19 Kotter’s Theory of Change 1. Establishing a Sense of Urgency 2. Forming a Powerful Guiding Coalition 3. Creating a Vision 4. Communicating the Vision 5. Empowering Others to Act on the Vision 6. Planning for and Creating Short-Term Wins 7. Consolidating Improvements and Producing Still More Change 8. Institutionalizing New Approaches John Kotter, Leading Change

Page 20 Quality Core Value Improvement Methodology Prioritization Core Success Factors Change Theory Physician & Executive Engagement Clinical Effectiveness: Promoting Change

Page 21 Clinical Effectiveness: Quality of the Science Design Principles:  Physician Leadership  Evidence Based  Data Driven Senior Leadership Key:  Priority of Work  Dedicated Staff  Implementation of Ideas

Page 22 Reliability Theory Quality Core Value Physician & Executive Engagement Improvement Methodology Prioritization Core Success Factors Change Theory Core Success Factors

Page 23 Intent, Vigilance and Hard Work: 10 1 Performance Level 1 (Designing basic failure prevention)  Common equipment, standard orders sheets  Personal check lists  Working harder next time  Feedback of information on compliance  Awareness and training © Institute for Healthcare Improvement

Page 24 Level 1 Changes at McLeod  Pre-printed order sets  Data feedback to physicians and hospital staff  Education to physicians and hospital staff  Pre-printed Rx scripts  Disease specific discharge sheets to include detailed instructions/meds © Institute for Healthcare Improvement

Page 25 Human Factors and Reliability Science: 10 2 Performance Level 2  Decision aids and reminders built into the system  Desired action the default (based on evidence)  Redundancy  Scheduling  Taking advantage of habits and patterns  Standardization of process © Institute for Healthcare Improvement

Page 26 Level 2 Changes at McLeod  Decision aids and reminders built into the system:  Antibiotics in Pyxis in ER and reminder on Pyxis "Blood cultures needed? Check with physician”  Decision aids and reminders built into the system:  List of all positive troponins for intervention  Desired action the default (based on evidence):  House-wide pneumonia vaccination standing order  Desired action the default (based on evidence):  Automatic printing of smoking cessation information for patients  Redundancy:  Medication check against allergies © Institute for Healthcare Improvement

Page 27 Level 2 Changes at McLeod  Taking advantage of habits and patterns  All operative antibiotics given as leaving holding area  Radiologist to contact ED physician if chest XRay positive for pneumonia  Standardization of process  All patients screened for smoking at admission and counseled on discharge © Institute for Healthcare Improvement

Page 28 Reliability Theory Quality Core Value Physician & Executive Engagement Improvement Methodology Prioritization Core Success Factors Change Theory Core Success Factors

Page 29 Key Ways IT Can Support Pay for Performance  Reliability  Hand-off communication  Patients “in the know”

Page 30 Workflow Engine The Right Information, to the Right Person, at the Right Time…

Page 31 Workflow Implemented AMI – Identify Patient w/ Monitor for Aspirin

Page 32 Workflow Engine Listening, Monitoring, and Escalating…

Page 33 Increase Accuracy and Reliability of Clinical Processes Computerized Physician Order Entry

Page 34 Increase Accuracy and Reliability of Clinical Processes Evidence-based Content

Page 35 Increase Accuracy and Reliability of Clinical Processes Hand-off Communication

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Page 37 Personal Health Cards SMART Card  A secure SMART Card contains your critical healthcare information  Allows medical providers the ability to track patients through a course of treatment that crosses multiple organizations  Authenticates the patient and provides for improved insurance processing  Delivers a scalable, portable health record – and control of patient medical data

Page 38 Healthcare Technology Utilized  PHR- Personal health record/SMART cards  Schedule appointments  Reminders  Medication history  Personal spending account  Monitoring Home Physician’s Office Hospital Insurance Provider

Page 39 Healthcare Technology Utilized Home Physician’s Office Hospital Insurance Provider  Interoperability  Electronic patient records  Referring physicians  Trends/ benchmarking  Billing

Page 40 Insurance Provider Healthcare Technology Utilized Home Physician’s Office Hospital Clinical Information System  Point of care information  Evidence-based practice  CPOE  Workflow engine  PACS/results  Trends/benchmarking

Page 41 Healthcare Technology Utilized Insurance Provider Home Physician’s Office Hospital  Clinical information  Billing codes  Payment  Trends/benchmarking