Performance Measures for. What? When? How?
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1 Performance Measures for Cardiac and Pulmonary Rehabilitation: What? When? How? 5th Cardiopulmonary Rehabilitation Workshop Webinar Seoul, Korea Friday, April 29, 2011 Randal J. Thomas, MD, MS, FAACVPR, FACC, FACP, FAHA AACVPR Immediate Past President Director, Cardiovascular Health Clinic Mayo Clinic Rochester, Minnesota
2 Outline What are Performance Measures? Why in Healthcare? Why in Cardiac/Pulmonary Rehabilitation? When will we have CR and PR measures? How to implement?
3 What are Performance Measures?
4 Methods to measure components and/or outcomes of care
5 Performance Measures Patients Processes of Care Outcomes Other Factors
6 Performance Measures Structure: t Emergency response equipment in place? Process: P Number of patients screened for diabetes? Outcome: O t Re-hospitalization rate following MI?
7 Why Performance Measures?
8 Where performance is measured, performance improves. Where performance is measured and reported, the rate of improvement accelerates. -Thomas S. Monson
9 Quality Then and Now 13 th Century Guilds Industrial Revolution Wartime productivity demands Total Quality Management LEAN, Six Sigma
10 Lessons from History: Railroads 1853: Accidents, deaths 1868: Coupler invented (Janney) 1869: Air brakes invented (Westinghouse) 1908: Federal Employer s Liability Act (T. Roosevelt)
11 Why Performance Measurement in Healthcare? Gaps between ideal care and actual care
12 Crossing the Quality Chasm (2001) Whoops! A photographic celebration, Hallmark, BOK2020
13 Methods to Improve Delivery of Preventive Services Characteristics of Successful Centers Common goals Administrative support Clinician i i support Systematic design Use of data Adaptive to circumstances JAMA 2001;285:
14 Why Now? Evidence of Gaps in Care Growing Expectations Increasing Complexities of Care Effective Quality Improvement Methods
15 Performance Measures Development Construct Measurement Sets Define population, domains of care, sampling time Review literature Identify measures Determine Measure Feasibility Measure Performance
16 Performance Measures Historical so timeline e 2003: Mini-sets (ACC/AHA/AMA) Heart failure, hypertension, stable angina 2005: Methodology paper published 2005: Heart failure (ACC/AHA) 2006: STEMI/NSTEMI (ACC/AHA) 2007: Card Rehab/2º prev (AACVPR/ACC/AHA) 2007: Atrial fib (ACC/AHA/PC) 2008: STEMI/NSTEMI (ACC/AHA) 2009: 1º prevention CAD (ACC/AHA) 2010: Updated Cardiac Rehab Referral Measures
17 Do Performance Measures Improve Outcomes?
18 Heart Failure Performance Measures Fonarow, G. C. et al. JAMA 2007;297:61-70.
19 Risk-Standardized 30-Day All-Cause Hospital Mortality Rate Based on Performance on Process Measures by Quintile Bradley, E. H. et al. JAMA 2006;296:72-78.
20 Do Performance Measures Improve Outcomes? Yes, if closely linked to desired outcomes Mehta et al., Am J Med 2007;120:
21 Why Performance Measurement in Cardiac and Pulmonary Rehabilitation?
22 Why in CR and PR? Parallels train safety history Effective methods Underutilized 3 rd rd party intervenes Mandatory application Win-win-win
23 When? Now!
24 Cardiac Rehabilitation
25 Cardiac Rehabilitation/Secondary Prevention Performance Measures Updated September 2010 Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J. AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services. Circulation. September 20, DOI: /CIRCULATIONAHA Available at: Accessed on September 20, 2007.
26 CR/SP Performance Measures Eligible Patients Set A Inpatient Post-MI Post-CABG Post-PCI Stable Angina Post-Transplant Post-Valve Surgery Outpatient Set B Cardiac Rehabilitation/ Secondary Prevention Program Outcomes Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J. AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services. Circulation. September 20, DOI: /CIRCULATIONAHA Available at: Accessed on September 20, 2007.
27 Cardiac Rehabilitation Performance Measures Set A: Referral to CR A-1: In-patients referred to out-patient CR A-2: Out-patients referred to out-patient CR
28 Cardiac Rehabilitation Performance Measures Set B: Delivery of CR B-1: Medical and emergency standards B-2: Assessments of risk for CV events B-3: Risk factor assessment/treatment plan Coordination with other healthcare providers B-4: Monitor response to therapy
29 Cardiac Rehabilitation Performance Measures Endorsement National Quality Forum (May 2010) Set A only Centers for Medicaid and Medicare Services Included as part of PINNACLE data registry and Physician Quality Reporting Initiative (PQRI) Core Quality of Care Measure?
30 Pulmonary Rehabilitation
31 What About Pulmonary Effective therapy Utilization gap? Rehabilitation? Feasible to narrow the gap? Performance measures? Outcome measures? National Quality Forum shortcut?
32 What About Pulmonary Rehabilitation? Outcome Measures Quality of Life Chronic Respiratory Disease Questionnaire Functional Capacity 6 minute walk Endorsed by NQF September 2010
33 Now What?
34 Implementation Testing Ongoing Maintenance
35 Cardiac Rehabilitation Performance Measures Implementation of Set A (Referral) AACVPR Certification, Toolkit National Quality Measures Clearinghouse Data Registries ACC AACVPR Other Measures Sets ACC/AHA STEMI/NSTEMI Performance Measures AMA-PCPI CAD Performance Measures Local implementation by hospitals, clinics, practices
36 AMA Physician Consortium for Practice Improvement (PCPI): CAD Performance Measures
37 AMA Physician Consortium for Practice Improvement (PCPI): CAD Performance Measures
38 Cardiac Rehabilitation Performance Measures Implementation of Set B (CR Programs) Revision process Implementation AACVPR standards d and certification Link to reimbursement? AACVPR National Registry link
39 Registry Connections GWTG ACTION In-patient PINNACLE Out-patient ACC-AHA AHA AACVPR AACVPR
40 Cardiac Rehabilitation Performance Measures Keys to Local Implementation Consensus Systematic Plan Assess Current Performance Identify challenges (eligible patients, etc.) Implement Quality Improvement Steps Re-assess Performance (Report Performance)
41 3D D s of fch Change Desire Do Something About It! Don t t Give Up!
42 Testing and Ongoing Maintenance
43 Cardiac Rehabilitation Performance Measures Testing: Key Factors Validity: Do measures really measure what they are designed to measure? Reliability: Is the measurement reproducible? Usability: Is the measure easy to use?
44 Cardiac Rehabilitation Performance Measures Maintenance Are measures decreasing the care gap, suggesting need to maintain over time?
45 Summary What? Measures to improve outcomes Why? Reduce gaps in care When? CR PM s emerging, PR PM s starting How? Begin with basic steps of agreement and planning, then progress to bigger steps!
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