Category Archives: Quality Outcomes

Quality of care; pay for performance; quality-based reimbursement; case mix index; quality scores; quality report cards; data analytics; value-based purchasing; performance ratings; mortality rates; hospital report cards; POA; present-on-admission; HACs; hospital-acquired conditions; PPRs; potentially preventable readmissions; SOI; severity of illness; ROM; risk of mortality; healthcare reform; HealthGrades; P4P; potentially preventable complications; PPCs; state initiatives; federal funding

Accuracy Matters

Thinking about all of the various quality initiatives currently out there or under development, I can’t help but think about what we DO with all of this information. Certainly accuracy is important for accurate quality scores, but isn’t accuracy important for a more basic and important reason?

Prior to joining 3M, I was employed as a nurse manager at a 600+ bed hospital. I was responsible for the CCU, CVICU and CV step-down units. Early on in my tenure, the quality and infection control departments presented statistics to the nurse managers on our infection rates by unit. To say it was concerning would be an understatement. We were tasked with developing a meaningful strategy to reduce the incidence of hospital-acquired infections and our strategy was two-fold: education and surveillance. We educated all stakeholders on the current statistics and the hospital protocols for reducing hospital acquired infections. Continue reading

Four Mistakes My Doctors Make with High Deductible Plans

A year ago my family changed to a high deductible health plan and started using a health savings account. Because we expect to pay higher upfront out-of-pocket expenses, we pay careful attention to the network requirements and out-of-pocket thresholds. Our local providers, though, seem to manage patients with high-deductible plans as if they were no different from traditional PPO plans.

There are several things I wish my providers would do differently, and not just to make it easier for me to manage my family’s health care. My providers inadvertently increased administrative time, delayed payment, and resulted in denials and write-offs. They would do better if they adapted their processes in light of the different plan requirements. Here are four suggestions for avoiding the mistakes my doctors made with my high-deductible plan: Continue reading

Who Will Win at Population Health Management?

Healthcare by transaction is dead. This economic model cannot be sustained. The new frontier involves aligning care providers across the continuum so they can think differently – and act differently. Successful population health management involves the strategic use of data to deliver the right care to the right population at the right time. Instead of managing the health of an individual episodically, providers will be challenged to manage the health of a group of individuals over time. The shift from volume to value requires providers to take on accountability for the total cost of care, the quality of care and the outcomes of care – rather than simply provide services when people are sick. Continue reading

Integrating Sociodemographic Factors into Risk Adjustment: Important Considerations for NQF’s “Robust Trial Period”

Why is it necessary that risk adjustment incorporate sociodemographic factors for my diabetic schizophrenic patients who have unstable housing?

Healthcare is fundamentally about people. That’s why, at the end of the day, it is the differences and disparities among individuals that are at the heart of the challenge facing the National Quality Forum (NQF) as it debates incorporating sociodemographic factors into risk adjustment.

Here’s a real-life example of the importance of SES factors to risk adjustment: Robert is a diabetic patient of mine who is schizophrenic with episodes of psychosis. He has difficulty with his meds in part because his housing situation is not stable. From time to time he is homeless. If there is any possibility of stabilizing his diabetes, he will need additional case management time over and above a diabetic schizophrenic who does not have the added SES burden. The case manager would not just deal with “medical” issues like making sure that Robert is taking his meds every day but also working with Robert to address conflict with neighbors that in turn are making him extremely anxious. In this case, the neighbors were extremely rowdy with loud music. The case manager was able to defuse the situation – when the neighbors were told by the housing authority to move. The same challenge applies to my asthmatic patients who live in substandard housing and are exposed to different allergens than those impacting middle-class asthmatics. In this situation, the case manager might help with making sure that insects exacerbating the asthma attacks are eliminated from the apartment. Continue reading

Alert Fatigue: The Implications for Reducing Preventable Hospital-Acquired Conditions

Blog post by Krysten Brooks, RN, BSN, MBA

Hospitals across the country have launched a wide-range of initiatives to reduce hospital-acquired conditions (HACs), but despite their efforts, a quarter of the nation’s hospitals face reimbursement penalties according to a preliminary analysis released in June by CMS that scored hospitals based on rates of acquired conditions and patient complications. While Medicare’s HAC Reduction Program plans to release final scores later this year, the healthcare organizations facing penalties can expect to lose approximately one percent of each Medicare payment from October 1, 2014 through September 30, 2015, translating into billions of dollars in lost reimbursement.

The Medicare penalties will undoubtedly hit some organizations hard, and these hospitals are moving quickly to analyze avoidable complications and intervene to improve quality. Facilities are also auditing clinical documentation for completeness and accuracy and examining documentation workflow to analyze process breakdowns and problems. Continue reading

New Partnerships and New Metrics for Better Population Health

“How do we achieve better population health?”

This is the question on the minds of health care leaders across the country today.

At a recent 3M health care executive conference in Saint Paul, Minnesota, representatives from health plans, hospitals, Medicaid and several non-profit organizations gathered to discuss patient-centered models of care as a way to achieve better population health outcomes.

But attendees didn’t walk away with a clear-cut answer to the question “how do we achieve better population health?” There is no such thing. Instead, they left with affirmation that better population health is going to require (1) new collaborative partnerships and (2) thoughtful consideration of the right metrics for measuring population health. Continue reading

The Ethics of Quality…Should Hospitals Be Incentivized to Improve Quality?

I believe most human beings have some sort of a moral compass, especially in the healthcare arena. I might be naïve in my view but I believe most healthcare professionals choose to work in health care to care for others. As part of that drive, I also believe that we informally and formally have always assessed the care we give and look for opportunities to improve — often acting as a Monday morning arm chair quarterback review. As part of that review, many root cause analyses and written protocols for care and/or critical pathways have been developed to ensure patients received the best quality and most efficient health care. Continue reading

Flaunt Your (Quality) Assets

“That’s it baby. When you got it, flaunt it. Flaunt it!”

The famous line is shouted by theater producer Max Bialystock in the 1968 movie The Producers. It could just as easily be the advice of strategists to health systems and hospitals today. When you got good quality, flaunt it. Show it off in the marketplace.

The key is to demonstrate quality—which, like beauty, lies in the eye of the beholder. Some hospitals and health systems might feel they don’t have much to show off, but rankings aren’t the only measure of quality in health care. Continue reading

Four Things Providers Need Before They Can Embrace Value-Based Payment

The concept that payment for health care should be based on quality and clinically meaningful outcomes is not new, but the current breadth, variety and rapid adoption of value-based models is unprecedented. Value-based payment models now include accountable care organizations (ACOs), patient-centered medical homes (PCMHs), bundled and episode-based payments, and pay for performance structures.

There are now more than 600 Medicare and non-Medicare ACOs. This is more than a 300% increase from the end of 2011 when the first 32 Medicare ACOs were announced, at which time there were approximately 160 private sector ACOs. The increase in PCMHs is no less remarkable with a 5-year increase from 28 in 2008 to nearly 6,000 in late 2013 – and that only includes those with NCQA accreditation.

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Getting their Money’s Worth…Value-Based Purchasing

Value-based purchasing further emphasizes the ripple effect and spider web of CDI, HIM and Quality. Everyone “knows” about value-based purchasing, but what is it comprised of?

Value-based purchasing (VBP) is both a broad and narrow quality measurement tool. Broadly defined, pay for performance (P4P)/ VBP is payer-developed metrics to measure value compared to reimbursement given. Two examples are accountable care organizations (ACOs) and bundled payments. A narrow definition is a program mandated by the Affordable Care Act of 2010 and administered by CMS. VBP has been in development for almost 10 years but was formally introduced for FY 2013. Through the Medicare program, incentive payments are made to hospitals based on either how well they perform or improve against their own baseline on each domain comprising VBP. There are four domains: clinical process of care, patient experience of care, outcome (FY 2014 forward) and efficiency (FY 2015 forward). Each domain is assigned an associated weight. For example, in FY 2015 clinical process is 20 percent of the total VBP score, patient experience is 30 percent, outcome is weighted at 30 percent and efficiency rounds it out at 20 percent. Continue reading