1. Welcome to Healthcare Quality Week INSERT Name of Organization

2. 2 We’re Celebrating! Healthcare Quality Management Professionals Healthcare Quality achievements in our organization And we’re raising awareness about how important quality is in everyday practice

3. It’s all part of Healthcare Quality Week sponsored by NAHQ Who is NAHQ?

4. National Association for Healthcare Quality  National Association for Healthcare Quality Leading organization for professionals working in healthcare quality management (6000 members) −Members work in hospitals, day surgery centers, large clinics, nursing homes and other sites

5. What do they do?  National Association for Healthcare Quality Promotes, supports, educates, and advocates for Healthcare Quality professionals and their career field Serves as a leading national voice on the topic of Quality in Healthcare Publishes Journal for Healthcare Quality Offers Certified Professional in Healthcare Quality Credential (8000+ CPHQs) −More than 8,000 professionals have earned the CPHQ Hosts leading quality educational events, such as webinars and the National Quality Summit

6. Let’s talk about quality here—what do you think is the biggest improvement?  Slide for speakers insert quality achievements at their institutions

7. That’s great input. And it’s important. Because the regulatory landscape is shifting- and it requires change.

8. THE STATE OF HEALTHCARE QUALITY Let’s talk about how we got here.

9. It started with a report…  Institute of Medicine “To Err Is Human,”1999 Estimated that medical errors cause as many as 100,000 preventable deaths a year Recommended healthcare organizations create and maintain strong safety cultures “Safety should be an explicit organizational goal that is demonstrated by strong leadership on the part of clinicians, executives and governing bodies.”

10. Followed by a national movement and all the attendant research, examination, and exploration that was required to start fixing the issue

11. Which resulted in…  In 2012, NAHQ issued a Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems  It offered recommendations for best practices to enhance quality and improve safety. “Without a strong safety culture, frontline providers and management may fail to identify a concerning pattern of performance or a single event or may hesitate to report them.” −Susan Goodwin, past president, NAHQ (2012)

12. The recommendations weren’t just good practice. They were good business.

13. The Safety Culture Imperative  Focus on accountability and expectations  Encourage and protect reporting of quality and safety concerns  Ensure transparent and accurate data collection and reporting  Respond effectively to patient concerns  Foster teamwork and communication

14. So where has all this work taken us?

15. Since the IOM Report…  U.S. Centers For Disease Control tracks national progress on infection control 44 percent decrease in central-line associated bloodstream infections (2008-2012) 20 percent decrease in infections related to 10 common surgical procedures (2008-2012) 4 percent decrease in MRSA (2011-2012) 2 percent decrease in hospital-onset C. diff infections (2011-2012)

16. And here at our facility…  Speakers can show quality improvement statistics at their institutions here.

17. But there is much left to be done

18. Much to do…  CDC: 99,000 deaths from healthcare-associated infections in 2012  In 2012, Los Angeles Times reported a new national report card (Leapfrog Group) showing: 47 percent of 2,652 hospitals graded received a C or below, including many big name institutions  Agency for Healthcare Research and Quality (AHRQ) Safety gains from health information technology have largely failed to materialize

19. Locally, our goals include…  Speakers can cite goals and objectives for enhancing quality and patient safety at their institutions

20. What do the regulators require us to do?

21. Healthcare Reform and Quality  Enactment of Affordable Care Act 2010 put healthcare quality management center stage  To survive providers must transform from a focus on patient volume to value-based care  Organizations must compete in a new system Rewards quality of care provided, rather than the number of procedures performed

22. And most significantly, providers will now be paid based on quality

23. Quality-based Payments  Medicare and other payers now scrutinize quality of care levels  Poor performance penalized Reimbursements are lowered for excessive readmissions High rates of healthcare-associated infections will be penalized in 2015

24. And there are new types of healthcare organizations

25. Accountable Care Organizations  Physicians agree to adhere to outcomes goals  Cost savings shared with physicians  Emphasis on population-based care Wellness and prevention  Goal is to reduce expensive ED visits and hospital admissions—to provide the right care at the right time

26. So it’s clear that ACA has brought about change

27. Quality is now a major factor in our business model  Financial incentives are driving change Payers shifting to quality-based reimbursements  Medicare and Medicaid now determine good performance Assess clinical outcomes Check patient evaluation surveys Financial incentives have heightened the importance of healthcare quality management

28. 5 And that means there are five things we must do…

29. Build and maintain strong safety cultures to continuously: Improve quality of care Optimize patient safety 1

30. Establish accountability for integrity of quality and safety programs 2

31. Create systems to continuously improve 3

32. Report quality and safety data accurately 4

33. Remove barriers to success 5

34. Importance of Research  Healthcare quality management research is expanding as clinicians realize growing need to document quality improvement outcomes  Journal for Healthcare Quality NAHQ’s bimonthly journal strives to advance healthcare quality practice in diverse and changing environments Focus is on evidenced-based outcomes

35. Those are big goals. Let’s talk about how we can get there.

36. How Our Quality Management Team Can Help  We’ll show you what is required. Ensure the organization meets or exceeds quality and safety standards set by −Affordable Care Act −Accrediting bodies −Major insurers  We’ll ensure comprehensive, transparent and accurate reporting of information  And we’ll help ensure rapid and effective responses to quality and patient safety concerns

37. How do we do that?  Lead continuous improvement initiatives  Monitor clinical processes and patient outcomes  Report quality concerns and possible safety risks  Collect and analyze quality and safety data

38. We also…  Ensure process management We conduct audits −Check documentation against standards of Joint Commission and other entities Practice risk management −Actions to identify, evaluate and reduce risk of injury to patients and staff And most importantly, we provide assistance and training −Help staff make improvements and understand compliance needs

39. How do we improve the practice of Quality?  Integrate new, evidence-based practices  Assure compliance with quality standards of accreditation organizations Such as CMS, Joint Commission, DNV and public reporting entities  Promote supportive safety culture

40. Quality Team Assures Standards Are Followed  Health care facilities must follow standards of care To maintain accreditation and be eligible for payments by Medicare and Medicaid  Joint Commission Grants accreditation to hospitals and other providers −Based on its standards for evaluating functions essential for providing safe, high quality care.

41. It’s really important stuff. So let’s talk about our goals.

42. Our Quality Goals at _________  Cite quality healthcare quality management/patient safety goals at your institution

43. Here’s what we’ve achieved so far…  Cite and describe quality management achievements in your organization

44. Here are the folks who have helped lead the quality charge.

45. Meet our Team  Introduce your healthcare quality management team members and describe their roles and responsibilities  Cite team members contact information

46. Now you know us. How can we work with you?

47. Thoughts for the Future  Here the presenters can suggest specific areas for potential collaborations appropriate for their institutions

48. Thank You!