1. 2011 Douglas T. Miller Symposium
Dennis Wagner, Acting Director, Office of Clinical Standards and Quality
Centers for Medicare & Medicaid Services
April 29, 2011

2. 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

3. 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?

4. CMS is Changing

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

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

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

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

9. 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

10. 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 10

11. 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

12. 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 3002
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

13. CMS Approach to Managing the Affordable Care Act
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

14. OCSQ Quadrant 1: High Impact, High Complexity Program Areas to Manage
Value Based Purchasing
Public and Quality Reporting
Reduced Readmissions
Hospital Acquired Conditions
ACOs
Center for Medicare and Medicaid Innovation
Quadrant 2
Quadrant 4
Quadrant 3

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

16. 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

17. New Tools, New Incentives, New Penalties, New Organizations
What does it all mean?

18. 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, 2011

19. 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.

20. 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?

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

22. How do we make quality better?

23. How do we make quality better?
Improvement as a Strategy
Customer-Mindedness
Process-Mindedness
Employee-Mindedness
Statistical Thinking
Supplier-Mindedness
Continual Improvement (PDSA)
Leadership

24. 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”

25. How do we make quality better?
Clear Intent – Will
Proven Practices – Ideas
Focused, Constant Action -- Execution

26. 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.

27. Concentration of Potential Donors In Nation’s Largest Hospitals
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

28. Tremendous Variation in Donation Rates in 300 Largest Hospitals

29. 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
Accelerate Improvement
Achieve Results at a Rapid Pace
Build Clinical Leaders of Change
“All Teach, All Learn”

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

31. Measures of Success

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

34. 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)

35. 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

36. 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?

37. Partnership for Patients: An Overview
April 2011

38. 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.

39. Meet Josie King
I want to share with you the story of Josie King and her mother Sorrel. In 2001, Josie was admitted to Johns Hopkins Hospital for second and third degree burns after climbing into a hot bath. She healed well and was almost ready to go home, but then died from severe dehydration and misused narcotics. Human errors. Her mother, Sorrel King, recalls being bent on vengeance. She says she “wanted to take the hospital apart brick by brick.” But instead she focused her energy on making sure that this never happened to another family. She formed a foundation in Josie’s name and has spent the last decade working with clinicians to improve patient safety in hospitals.

40. 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.
Unfortunately, in spite of heroic advocacy by clinicians and families like Sorrel’s, Josie’s story is still not rare.
How does this happen?
Numerous inputs
Complex Science
Chaotic System
Human factors

41. Partnership for Patients Better Care, Lower Costs
Reduce harm caused to patients in hospitals. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010. 
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.
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 2010.
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.
Achieving these two goals will not only save lives and greatly reduce injuries to millions of Americans – it will also result in savings of billions of dollars that help put the nation on the path to having a more sustainable health care system.
We already have XXX# hospitals, etc that have joined the partnerships.

42. 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

43. 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…
We’re confident that we can make these changes – we know that it’s possible. The major challenge is to expand pockets of success to nationwide success. That’s where we’re targeting our attention in both the private and public sectors.

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

45. Our Request to You Join the Partnership for Patients
Go to healthcare.gov/partnershipforpatients
The Partnership for Patients is truly a partnership. In order to achieve our ambitious goals we’ll need a broad coalition of hospitals, clinicians, employers, labor unions, advocacy organizations and states to join with us. So please join the Partnership by signing the pledge.
To learn more about the Partnership, to sign the pledge, and for additional resources please visit our website.

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

47. “Meeting and Exceeding the Needs and Expectations of Customers”
Defining “Quality”
“Meeting and Exceeding the Needs and Expectations of Customers”

48. Learning about the Customer
Observe
Survey
Use your own experience
Ask!

49. 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?

50. “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

51. 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:

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