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Board Driven Quality
Leading for Improvement
Dale W. Bratzler, DO, MPH
Professor and Associate Dean, College of Public Health
Professor of Medicine, College of Medicine
Chief Quality Officer – OU Physicians Group
University of Oklahoma Health Sciences Center
March 18, 2013
Overall Ranking
Country Rankings
1.00–2.33
2.34–4.66
4.67–7.00
AUS
CAN
GER
NETH
NZ
UK
US
OVERALL RANKING (2010)
3
6
4
1
5
2
7
Quality Care
4
7
5
2
1
3
6
Effective Care
2
7
6
3
5
1
4
Safe Care
6
5
3
1
4
2
7
Coordinated Care
4
5
7
2
1
3
6
Patient-Centered Care
2
5
3
6
1
7
4
6.5
5
3
1
4
2
6.5
Cost-Related Problem
6
3.5
3.5
2
5
1
7
Timeliness of Care
6
7
2
1
3
4
5
Efficiency
2
6
5
3
4
1
7
Equity
4
5
3
1
6
2
7
Long, Healthy, Productive Lives
1
2
3
4
5
6
7
$3,357
$3,895
$3,588
$3,837*
$2,454
$2,992
$7,290
Access
Health Expenditures/Capita, 2007
Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity).
Source: Calculated by The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International Health Policy Survey of
Sicker Adults; 2009 International Health Policy Survey of Primary Care Physicians; Commonwealth Fund Commission on a High Performance
Health System National Scorecard; and Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD,
Nov. 2009).
http://www.americashealthrankings.org/MT/2012
http://statesnapshots.ahrq.gov/snaps11/dashboard.jsp?menuId=4&state=MT&level=0
http://statesnapshots.ahrq.gov/snaps11/dashboard.jsp?menuId=4&state=MT&level=0
So why don’t we consistently provide
high quality care?
There are a lot of reasons……
• Medical science is evolving too fast for any
clinician to keep up with – regardless of how
good or smart they are
• Historically, there were no incentives to adopt
evidence-based care into practice
• Disconnect between research and translation
into bedside care
• Systems not designed for safety and quality
• No one was watching! (they are now)
Explosion of Medical Knowledge
Number of Articles (English)
3500000
3,051,188
3000000
2500000
2000000
1500000
1000000
500000
0
Articles indexed by the National Library of Medicine. http://www.nlm.nih.gov/bsd/medline_lang_distr.html
It takes too long to get evidence into
practice!
The passive strategy of guideline publication and
dissemination does not effectively change clinical
practice
– The time lag between publication of evidence and
incorporation into care at the bedside is very long
– Variations in care and delivery of care that is not
consistent with evidence-based recommendations is
well documented
Bratzler DW. Development of national performance measures on the prevention and
treatment of venous thromboembolism. J Thromb Thrombolysis 2010; 29:148-54.
• 89 pages long; 1075 references
• In reality, most physicians will never take the
time (or have the time) to read the entire
guideline
• Even if they did, this only covers one aspect of
preventing surgical infections.
Why spend the time creating and
publicly reporting national quality
measures?
Consumers are demanding
transparency!
• Consumer groups are demanding
transparency – particularly about
complications of care
• When consumer groups have a consistent
message, legislators respond…
– The Medicare Program and other agencies then
are required to create standardized measures that
reflect the quality of medical practice
2 Examples: Legislative Mandates to Report
Quality
• Medicare Prescription Drug Improvement and
Modernization Act of 2003
– Tied 0.4% of Medicare annual payment update to
the public reporting of 10 measures of hospital
quality
• Deficit Reduction Act of 2005
– Tied 2% of Medicare annual payment update to
public reporting of hospital quality measure and
gave Secretary of HHS authority to expand
measures
http://frwebgate.access.gpo.gov/cgibin/getdoc.cgi?dbname=108_cong_bills&docid=f:h1enr.txt.pdf
http://frwebgate.access.gpo.gov/cgibin/getdoc.cgi?dbname=109_cong_bills&docid=f:s1932enr.txt.pdf
Accountability works!
• There is good evidence now that when you
spotlight performance on nationally
standardized measures of quality (reporting
them in the public domain), guideline
adherence improves and performance
improves rapidly!
Public reporting and payment incentives change the way
physicians and hospitals provide care and speeds adoption of
evidence-based guidelines.
Changes in National Performance
Measurement and Reporting Drive Improvement!
Abx 60 min
Guideline Abx
97.6
100
Data source changed from independently
abstracted to hospital self-collected.
80
60
40
97.1
95.5
20
1
2
Q 005
2
2
Q 005
3
2
Q 005
4
2
Q 005
1
2
Q 006
2
2
Q 006
3
2
Q 006
4
2
Q 006
1
2
Q 007
2
2
Q 007
3
2
Q 007
4
2
Q 007
1
2
Q 008
2
2
Q 008
3
2
Q 008
4
2
Q 008
1
2
Q 009
2
2
Q 009
3
2
Q 009
4
2
Q 009
1
2
Q 010
2
20
10
Q
20
1
01
*
2
Q 002
2
2
Q 002
3
2
Q 002
4
2
Q 002
1
2
Q 003
2
2
Q 003
3
2
Q 003
4
2
Q 003
1
2
Q 004
2
2
Q 004
3
2
Q 004
4
20
04
0
Q
Percent
Abx discontinued
*National sample of 34,000 Medicare patients undergoing surgery in US hospitals
during 2001. Bratzler DW, et al. Arch Surg 2005; 140:174-82.
Improvement Door-to-Balloon Time
Acute Myocardial Infarction Patients
0
10 20 30 40 50 60 70 80 90
100
Percent of patients with D2B time less than 90 minutes
2005
2006
2007
Year
Hospital median
2008
2009
Patients
Krumholz HM, Herrin J, Miller LE, Drye EE, Ling SM, Han LF, Rapp MT, Bradley
EH, Nallamothu BK, Nsa W, Bratzler DW, Curtis JP. Improvements in door-toballoon time in the United States, 2005 to 2010. Circulation 2011; 124:1038-45.
Krumholz HM, et al. JAMA. 2009;302:767-73.
FYI - CMS Preference for Outcome Measures
Over Process of Care Measures
Hospital IQR Program
FY 2013
FY 2014
FY 2015
Payment Score
Payment Score
Payment Score
25
30
70
45
30
20 20
30
30
Process of Care
Process of Care
Process of Care
Patient Experience
Patient Experience
Patient Experience
Outcome
Outcome
Efficiency
Department of Health and Human Services. Centers for Medicare & Medicaid Services. 42 CFR Parts 412, 413, 424, et al.
Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital
Prospective Payment System and Fiscal Year 2013 Rates; Hospitals’ Resident Caps for Graduate Medical Education Payment
Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers; Final Rule.18
Federal
Register, Vol. 77, No. 170. August 31, 2012. Available at: http://www.gpo.gov/fdsys/pkg/FR-2012-08-31/pdf/2012-19079.pdf.
The Board’s Role in Driving
Improvement
Why Focus on Hospital Leadership?
• Research suggests that more engagement of of
hospital leadership (C-suite, boards, and
physicians), in cooperation with other health care
professionals in QI, is associated with higher
performance in clinical care.
– The active involvement and collaborative participation of
top level leaders is essential
– Hospital leaders must be given the knowledge and tools
to address the issue
20
Hospital Leadership Survey Conclusions
Better quality seems to be associated with:
• Board oversight through regular reports
– Focused (fewer items, Board QI committee
involved in design)
– More frequent
– Used for operational purpose
• CEO seen as a visible leader of quality improvement
efforts
• Executive compensation linked to quality targets
21
Jha A, Epstein A. Hospital governance and the quality of care. Health
Affairs 2010; 29:182-7.
22
Among our nationally representative
sample of chairs of boards from nonprofit
U.S. hospitals, a little over half identified
clinical quality as one of the two top
priorities for board oversight.
Jha A, Epstein A. Hospital governance and the quality
of care. Health Affairs 2010; 29:182-7.
23
“Among the low-performing hospitals, no respondent reported that
their performance was worse or much worse than that of the typical
U.S. hospital, while 58 percent reported their performance to be better
or much better.”
Jha A, Epstein A. Hospital governance and the quality of care. Health
Affairs 2010; 29:182-7.
24
Interacting with the Medical Staff
about Quality Measures
A few points to remember…
• The Board is responsible for the quality of
healthcare delivered and patient outcomes for
care in their hospital
– Ultimate authority in the facility
– All healthcare providers in the facility must go
through a credentialing process
National performance measures are
based on evidence!
• All measures are developed by expert panels
of physicians representing a broad variety of
specialty societies
– CMS and Joint Commission do not create the
measures – they enlist physician specialists to
review the best science
• All measures are endorsed by the National
Quality Forum
– Includes open public comment on measures
National performance measures are
continuously updated.
• Expert panels meet every three months to
review the measures, review any newly
published science, and to review all of the
feedback we get from hospitals and clinicians
across the country
– Major changes are submitted to the National
Quality Forum for re-review
For example
• Surgical measures are collected from more than 3700 hospitals
nationally
• 1.2 million operations submitted annually
• 1600 questions per month are fielded from hospitals across the
country
Clinical Infectious Diseases 2013;56(3):428–9.
My point for this discussion is……
• The national performance measures do
apply to your patients!
– They are based on best evidence with extensive
physician input
– Your patients are not sicker or different!
• Process of care measures do not require risk
adjustment
• The outcome measures are adjusted for patient
severity of illness
Clinical Infectious Diseases 2013;56(3):428–9.
My point for all of this……
• If a physician tells you that the measure does not
apply to their patient or that they don’t agree
with the performance measure, they are usually
wrong.
• Performance rates that approach 100% are
achievable!
• If there is controversy, you can always submit
questions about the case to Mountain-Pacific
Quality Health or through www.qualitynet.org
If a physician has poor performance
rates….
• And they are resistant change, ask them to
provide guidelines that support their position
– Get an external peer or expert to review
(in my experience talking to hundreds of
physicians across the country who don’t agree
with our national performance measures, it is
rare that anyone has ever sent me medical
evidence that supports their position)
You do not have to have a lot of cases
to improve quality – a single case
failure represents an opportunity to
improve your system of care!
So, if the target is usually close to
100%.......
• In the setting of low-volume measures
– You can consider treating case failures as sentinel
events
• For example, you should be able to give an aspirin to
100% of the heart attack patients that show up in your
emergency room
• If you miss with just one patient, it justifies doing a root
cause analysis to see why
– It may well be that the system failed
Prioritizing Improvement
• Focus on those topics that are common in
your facility
• Target measures with the greatest opportunity
for improvement
• Don’t try to reinvent the wheel – for most
measures there are good tool kits available
that can help you improve
• Call on local resources
Take change one case at a time.
• When there is resistance to change, focus on
one case
– Show that you can provide care a different way
and achieve good quality outcomes.
– Find a champion
– Foster a team culture
– Make sure that leadership is visible – the CEO is
engaged, reports go to the Board, everyone is
transparent about quality
Make it difficult to do the wrong
thing!
• Create the system of care so that high quality
of care does not rely solely on anyone’s
memory
– Create protocols, checklists, or pathways
– Use of standing orders
– Audit performance, provide feedback
– Compare yourself to others
Celebrate success!
The caveat……
• Although performance on performance
metrics can and should be high, the target
may not always be 100% for some measures.
To measure “perfect” performance, we would
have to have perfect performance measures
that address every possible clinical scenario
that may justify deviation from the guideline
upon which a measure is based.
– Sometimes you do have to look at the details of a
case or get expert help
Clinical Infectious Diseases 2013;56(3):428–9.
There’s no confusion about who
“owns” quality
Leaders are responsible for everything in
an organization, especially what goes
wrong.
Paul O’Neill
dale-bratzler@ouhsc.edu