1. Corporate Responsibility and Health Care Quality
Quality Colloquium
August 19, 2008
Corporate Responsibility and Health Care Quality
Lewis Morris Office of Inspector General

2. Board Awareness of Quality Issues
“The level of knowledge of landmark Institute of Medicine (IOM) quality reports among CEOs and board chairs was remarkably low…. There were significant differences between the CEOs' perception of the level of knowledge of their board chairs and the board chairs' self-perception.”
“Getting the Board on Board: Engaging Hospital Boards in Quality and Patient Safety” Joint Commission Journal on Quality and Patient Safety, Volume 32, Number 4, April 2006.

3. “Corporate Responsibility and Health Care Quality: A Resource for Health Care Boards”
Third in a series of guides
Joint public sector/private sector effort
Educational information, not mandates
Assists boards in exercising their fiduciary responsibilities
Available at:
oig.hhs.gov/fraud/docs/complianceguidance

4. Defining quality of care
“Crossing the Quality Chasm” (IOM) definition of health care quality
Safe
Effective
Patient-centered
Timely
Efficient
Equitable
Public and private quality initiates provide benchmarks
National Quality Forum, Joint Commission, Leapfrog, CMS

5. Board’s Fiduciary Duty of Care
Acting in “good faith”
Prudent person standard
Reasonably acting in the best interest of the entity
“Reasonable inquiry” standard
Appropriate level of due diligence to allow an informed decision
Application
Decision-making functions
Oversight functions
Corporate scandals such as Enron, Worldcom and Allegaheny Health and Educational Research Foundation have raised public awareness of the role boards must play in ensuring integrity of organizations
Complexities of the health care industry increase oversight responsibilities of health care boards
“Business judgment rule” protects the reasonable exercise of judgment without fear of being 2nd guessed

6. Duty of Care and Quality
Emerging quality of care issues
IOM reports
Collaboration among providers of care
Monitoring and reporting requirements
Payment policies
Significant opportunities and risks
Reimbursement
Transparency
Public/private collaboration
Government enforcement
Moody’s Investor Service
“As the indutry develops common metrics for measuring qulaity, our approach to hosptial bond rating will likely also evolve to incorporate these various indicators and the related trends over time.”

7. Duty of Care and Quality
The “bottom line”
Quality is an essential component of the mission of the health care providers
Quality must receive the same level of Board attention as the corporation’s financial viability
Quality and cost efficiency are complementary, not contradictory, elements of an effective health care system
Unique opportunity for leadership and positive change

8. Government Enforcement and Quality
Enforcement priority
DOJ, OIG and State Attorneys Generals
Training and collaboration
Federal and state “Whistleblower” statutes
Prosecutive theories
Criminal violations
False claims based on “failure of care” and “worthless services”
Medically unnecessary services
Failure to meet professional recognized standards
“The IG has devoted significant resources to ensuring the integrity of the Federal health care programs. We are very proud of our accomplishments and last year, OIG recovered $2.2 billion. However, we also know that behind every claim submitted to the Medicare and Medicaid programs is a patient and the quality of the care they receive is of paramount importance and at the heart of our mission.”
Failure of care theory
evidence of especially egregious care
systemic or widespread problems
actual evidence of harm to patients
Example: Colorado rehab center provided worthless services as result of chronic understaffing, where deficient services and abuse cause 6 deaths
Failure to meet
substandard care provided to any patient

9. Enforcement Tools & Sources
Whistleblowers, Ombudsman, Licensure Boards
Mining of quality/reimbursement data
Civil penalties, criminal fines and exclusion
Corporate Integrity Agreements
Independent reviews and quality monitors
Board certifications (e.g., Tenet Healthcare Corp.)
Stipulated penalties
DRA requires Medicaid providers to inform employees of FCA
Data Mining of quality assessment and improvement program (required by Medciare COP).
Mandatory reporting of Adverse Events in hospitals.
Minimum Data set used for payment to nursing homes
Hospital quality data reported top CMS
OIG outreach campaign to States, including training, joint enforcement projects
Quality cases cases (listed)
Tenet Board requirements
oversee performance of compliance staff
annual review of CP effectiveness
independent consultant to assist in review of CP
resolution summarizing views of compliance with CIA

10. Suggested Questions for Directors
Quality goals and institutional leadership?
Understanding structures & processes
Linkage between quality, peer review and compliance
Board orientation and expertise?
Dashboards and benchmarks
Recruiting expertise
Are structure and processes to oversee and improve clinical quality adequate?
is there a silo approach to quality, peer review and compliance?

11. Suggested Questions for Directors
Coordination with compliance program?
Integration of regulatory compliance
Quality and risk assessment/corrective actions
Internal reporting and communications?
“Whistleblower” protections
Culture of candor

12. Suggested Questions for Directors
Adequate resources?
Staffing levels
Acquisition of new technologies and services
Addressing specific quality concerns and adverse events?
Quality and the peer review process
Responding to incidents of deficient care
Board needs to understand the peer review process and ask if quality data is used when staff is recredentialed
Link peer review to quality. Can’t send quality concerns off to PR and then forget about it. Peer review may have tendency to protect high admitters