1 Paul McGann, MD CMS Chief Medical Officer for Quality Improvement Dennis Wagner, MPA Director, Quality Improvement & Innovation Group U.S. Department of Health & Human Services, Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality Presented to Healthcare Learning Collaboratives Wednesday, November 4, 2015 Aims Create Systems; Systems Create Results

Aims & Results: a choice we make every day

A leadership choice – breakthrough Aims

Emergent Strategy: Stand For Them, Enroll Others, Persist, Learn, Evolve...Fast

5 Partnership for Patients Aims Create Systems; Systems Create Results 17% Reduction in HACs, from 4,757,000 to 3,960,000 from 145 per 1,000 discharges to 121 per 1,000 discharges 39% reduction in preventable HACs – nearly at 40% goal $12B in Estimated Associated Cost Savings, $4B for 2011 and 2012 combined $8B for ,000 Lives Saved, ~15,000 lives saved for 2011 and 2012 combined ~35,000 lives saved for 2013 * Final MPSMS-based 2013 HACs, Preliminary 2013 NHSN-based HACs, and extrapolation of 2012 Data for 2013 PSI-based HACs; Partnership for Patients 12/1/14 press release

 Evidence suggesting improvement in rate. – Shift in center line observed in January – Twenty-three data points from January 2013 to November 2014 fall below the second phase center line. – Seven data points from June 2013 to October 204 fall below the second phase lower control limit.  Evidence that the level has improved since January – The average rate is shifted 0.43 (p < 0.05) lower after January 2012 than before.  Rate decreased 6.91 percent between Q and Q Aims Create Systems; Systems Create Results Major Reductions in Medicare FFS 30-Day Readmissions 6

Aims Create Systems; Systems Create Results: Achieve a 75% Organ Donation Rate in the Nation’s Largest Hospitals

8 HHS has set powerful new Aims for value-based payments within the Medicare FFS system

9 Results-Oriented Evaluation Traditional Design for Evaluation: 1.“Formative” as you go. 2.“Impact” when you finish. 3.Clean concept of “intervention” and “control”. 4.Evaluation requires “disproving” the null hypothesis. 5.Type-1 Errors are feared. 6.Type-2 Errors are accepted easily, sometimes not discussed.

10 Results-Oriented Evaluation “Formative” and “Impact” begin to merge into each other. No “clean” concept of “intervention” vs. “control”. During intervention, attempts are made to influence “all”. Requires attention to change in historical patterns, effects of alignment (multiple causes), human behavior and other factors. Type-1 errors will be revealed. Type-2 errors are to be feared.

11 Results-Oriented Evaluation Design attempts to maximize scale, flexibility, participation, and results. Accept the fact that evaluation task is more difficult & complex. Choices are made to make it easier to participate, even if evaluation task is much harder Objectives are to achieve results build a learning system that fosters continuous improvement set stage for further improvement generate new knowledge and more …this requires measuring alternative dimensions of the work.

12 Questions for Discussion and Action What is interesting/good/exciting/right about how HHS is using Aims to create systems and results? What is your own experience with how “aims create systems and create results?” What might we do to more effectively use Aims to generate better care, better health and smarter spending? What are the most important characteristics of evaluation methodologies used for these types of aims-based approaches?