: Take This Job and Love It! Peggy Hoosier, M.Ed., RT (R) (M) Sr. Vice President of Professional Education Advanced Health Education Center,Ltd. 2011 State of 2011 Driving Forces in Health Care: Money Cost Control Increase Efficiency Improve Quality of Care State of 2011 Money Cost Control Same Number if mammograms during reduced hours Less staff to perform mammograms State of 2011 Increase Efficiency Increase work load Perform exams more efficiently What about quality? Shoot em & Scoot em State of 2011 Improved Quality of Care Public Expectations Patient s Expectations Quality Expectations Personal Expecations The American Health care consumer has become more knowledgeable and informed regarding his or her care and is demanding more for the dollars expended on health care. 1
US Leads in Medical Errors Thirty-four percent of U.S. patients received wrong medication, improper treatment or incorrect or delayed test results during the last two years, the Commonwealth Fund found. The Swiss Cheese Model of Accident Causation (Reason, 1990) Barriers to Accidents Leadership Excessive cost cutting staffing reduction Drive to Reduce Hospital Days Long Working hours Policies/ Procedures Colleague Admitted Patient Poor Coordination & Communication Available Resources Deficient training program Inexperienced X-Ray Tech Communication Failed to review allergies Wrong X-ray marker used Wrong procedure performed Latent Errors US Leads Way in Medical Errors, S. Heavy, Common Dreams, November 23, 2005 Failures in the System Accident & Injury Wrong Site Surgery Medication Error Fall Healthcare Spending 15 to 20 % of overall annual spending is for imaging procedures 50 to 60 % of radiology spending is attributable to high tech imaging 30 to 50 % over utilization estimate up to 700% practice pattern variability Industry Influences for Quality Healthcare Reform Managed Care Quality Initiatives Insurance Provider s World Health Organization US health system has mediocre outcomes for patients when measured by WHO standard indicators Overall rank of the US in the WHO survey ----#37 Country at #36 = Costa Rica Who is #1? France New England Journal of Medicine 2003 study by E McGlynn, PhD, et al Correct patient care is delivered 55% of the time! 2
Healthcare Reform Focus on Quality Improvement Institute for Healthcare Improvement (IHI) Trigger Tools A trigger tool is a retrospective analysis tool based on a set of red flags prompting investigation of patient's records for unintended harm from medical treatment and care Quality Improvement is derailed by: Organizational inertia Leadership buy off Disinterested governance Medical Politics Fatigue and resistance from staff Time for a change? Insurance Providers Happening in all healthcare Already happened in mammography model for other modalities Voluntary in other modalities first was voluntary The 4 most common errors in radiology: WRONG SITE COMPLICATIONS MEDICAL ERRORS DELAY IN RX 12% result in harm to the patient. JC Tracks Causes of Sentinel Events & Medication Errors 2005 2006 Communication listed as cause in 65 to 80% of errors. Other rising area is leadership, or lack thereof, so will be focus in future. United Healthcare Memo Insurers such as United Healthcare and Blue Cross got behind standards for quality to make sure imaging providers measured up Accreditation was the best method to implement quality standards 3
This error rate has led the insurers to stop paying for poor quality care: United Healthcare not to pay if medical imaging facility not accredited Blue Cross/Blue Shield to stop paying for Never Events, wrong surgical procedures, leaving foreign objects in body after surgery Medicare to stop paying for certain conditions as of 9/1/08,i.e. decubitus ulcers Pay For Performance P4P The pay for performance model means that those medical facilities that exceed the quality standards can get more reimbursement. The cost containment model no longer can be applied and may be the wave that sinks the hospital s ship. Health Care Tsunami Surfers who make things happen Swimmers who watch things happen Sinkers who wondered what happened Pay For Performance P4P The pay for performance model means that those medical facilities that exceed the quality standards can get more reimbursement. The cost containment model no longer can be applied and may be the wave that sinks the hospital s ship. Health Care Tsunami Surfers who make things happen Swimmers who watch things happen Sinkers who wondered what happened Health Care Tsunami Cost control = no margin no mission P4P versus = no outcomes no income Signals the end of blind health care purchasing. 4
Political Financial Psycho-Social : Fact or Fiction screening saves lives and improves outcomes In the best hands, the average detection rate of cancer in a screening setting is about 90-93% NOT! Mammographic error is the cause of the greatest amount of litigation against radiology; average settlements $200,000 Insurance companies pay poorly for mammograms Residents are NOT choosing mammography Image quality has improved but at what cost New York Times New York Times takes mammographers to task 6/27/02 Radiologists are the "weakest link" and a dangerous "loophole" in the fight against breast cancer, according to a front- page article appearing in today's New York Times. The article levels a number of grievances at the imaging community, including lack of skills necessary to read mammograms; not actually meeting U.S. breast screening standards; and a dearth of self-policing. "The federal mammography standards have eliminated many of the most egregious abuses and have made the breast x- rays much easier to read," the article stated. "But an examination by The New York Times has found that they have largely failed to remedy what many experts say is the biggest problem of all: the skill of the doctors who interpret those x-ray films. Spotting Breast Cancer: Doctors Are Weak Link By MICHAEL MOSS Ten years after the federal government set out to clean up a mammography industry awash in scandal, many women are still getting inaccurate examinations at clinics bearing the federal seal of approval. The federal mammography standards have eliminated many of the most egregious abuses and have made the breast X-rays much easier to read. But an examination by The New York Times has found that they have largely failed to remedy what many experts say is the biggest problem of all: the skill of the doctors who interpret those X-ray films. Not politically correct to stop performing mammography Commitment to do it Community service Influences everything you do in mammography Small community providing mammography at what cost? Political Financial Emotional Expectations are high! 5
Cost of Providing Services Physical Resources Human Resources Compliance Cost Diagnostic Imaging: Screening Continues to Lose Money Follow-up for benign findings accounts for disproportionate chunk of overall costs Follow-up biopsy greatly increases the cost of breast screening, regardless of whether the ultimate findings are benign or malignant Cost of Providing Study Design Outpatient Center: 4 sites, 6 Radiologist 215,888 Studies between 2001-2003 Variable Cost Film Vs Fixed Cost Cost of Physician Services Average Radiologist read 86 per day Cost of Providing Calculated Cost per Exam Site: $48.57 Overhead $23.11 Physician $18.39 Total = $90.17 At that time average reimbursement was $85.88 IOM REPORT 2005 Institute of Medicine Summary of Recommendations $90.17 - $85.88 = $4.29 Lost on every examination 6
Summary of Recommendations to Improve Breast Imaging Quality Improve mammography interpretation: Revise and standardize the required medical audit component of MQSA. Facilitate a voluntary advanced medical audit with feedback Designate specialized Breast Imaging Centers of Excellence Demonstration and evaluation projects. Further study the effects of CME, reader volume, double reading, and CAD Revise MQSA regulations, inspections and enforcement: Modify regulations to clarify the intent and address current technology. Streamline inspections and strengthen enforcement for patient protection. Recommendation #1 The medical audit component of MQSA should be revised and standardized to make it more meaningful and useful. A) The required basic medical audit of mammography interpretation should be enhanced to include the collection of three core measures for internal review at the mammography facility as follows: Positive predictive value 2 (PPV²; proportion of women recommended for biopsy (BIRADS 4,5) who are subsequently diagnosed with breast cancer Cancer detection rate per 1,000 women Abnormal interpretation rate (women whose mammogram interpretation leads to additional imaging or biopsy) The group of women that facilities are required to track should include not only women with BI-RADS 4 and 5 assessments, (what most facilities are currently doing) BUT ALSO, all women for whom additional imaging is recommended (cat 0) to facilitate resolution of all cases so that women for whom biopsy is recommended at final assessment will be included in the calculation of PPV². 7
B) All performance measures (PPV² cancer detection, and abnormal interpretation rate) should be stratified by screening and diagnostic mammography C) Facilities should have the option of combining medical audit measures for physicians interpreting at multiple facilities to allow for more meaningful data D) Audit data collection and analysis should be verified at FDA inspection, but not collected by FDA E) Reimbursement rates for mammography should be increased to account for the additional costs of these new audit procedures Recommendation #2 Facilities should be encouraged to participate in a voluntary advanced medical audit with feedback. This should be facilitated by incentives for participation and the formation of a data and statistical coordinating center. A) In addition to all tracking, measurements, and assessments in the enhanced basic required audit described in Recommendation 1, the voluntary advanced audit should include the collection of patient characteristics and tumor staging information from pathology reports. B) A central data and statistical coordinating center, independent of a regulatory authority, should be established to collect and analyze the advanced audit data provide feedback to interpreting physicians for quality assurance and interpretation improvement Increase funding to provide for (1) data collection, analysis and feedback; (2) appropriate hardware and software for data management; (3) appropriate information technology support personnel for data maintenance. The coordinating center should: Help develop, implement, and evaluate corrective action plans for interpreting physicians who do not achieve performance benchmarks. Routinely release aggregate summary date on interpretive performance, including recall rates, PPV² and cancer detection. The coordinating center should: Electronically collect data Analyze Report advanced-level audit data Provide regular feedback to interpreting physicians. 8
Test different methods of delivering audit results to improve interpretative performance. Undertake studies of randomly selected facilities using required basic audit procedures to ascertain the impact of these new measures on interpretative quality. Protect from discoverability the data collected for purposes of quality assurance. Medical Outcomes Audit What it is. The ONLY way to measure mammographic performance in a manner that includes not only technical but also interpretive capabilities of the system. CLINICAL PRACTICE GUIDELINES N0.13 STRONG RECOMMENDATION: Certain essential raw data and derived data should be obtained for a meaningful medical audit. THE MEDICAL OUTCOMES AUDIT ESSENTIAL ELEMENTS Raw (uncompressed) data recommended as minimum requirements. It's necessary to calculate derived data for a meaningful audit analysis Derived data is calculated from raw data Audit analysis has been useful as determinants of -> prevalent vs incident cancer rates -> predictive value of findings -> significance of risk factors ELEMENTS NECESSARY TO DEVELOP OR EVALUATE MEDICAL OUTCOME AUDIT PROGRAMS DEFINE regular procedures, methods, or ways in which you can collect information about your patients DECIDE the content or type of information you want to collect about your patients DECIDE which patients will be eligible for inclusion in the following process. MEDICAL OUTCOMES AUDIT DETERMINE the time frames used to collect your patient information SELECT the definitions for each piece of information you choose to collect ESTABLISH methods or ways to interpret or understand what your outcome data can tell you DECIDE how to use the data as a source of feedback to improve mammography quality Three Major Goals of Screening Using the raw audit data, derived data can be calculated to provide quantifiable evidence in the pursuit of the three major goals of screening mammography.: 1. Finding a high percentage of the cancers that exist in a screening population Measurement: Cancer detection rate & sensitivity 2. Finding cancers within an acceptable range of requests for recall and request for biopsy, in an effort to minimize cost and morbidity Measurement: Recall rate and positive predictive value 3. Finding a high percentage of small node negative cancers, which are more likely to be curable Measurement: Rates of minimal cancers found, axillary lymph node positivity % 9
Expanding the Medical Beyond the Basics First time exam, or repeat exam Mammographic assessment and recommendation Routine follow-up of category 1 and category 2 Short interval follow-up of category 3 Cancer data Mammographic findings: mass, calcifications indirect signs of malignancy Expanding the Medical Beyond the Basics Derived data to be calculated True negatives; false negatives Sensitivity Specificity Cancer detection rate Prevalent vs. incident Overall Rates within various age groups Medical Audit Goals False Positives & Call Backs Identify False Negatives Procedures that increase risk of a False Positive 1.Long time between mammograms 2. Not comparing the mammogram to the previous exam at Work When a mammogram is not compared to a previous mammogram, the risk of a false-positive increases by 74% HIPAA & Release of Information for MQSA Purposes Two Frequently Raised Issues 1. Protection of Patient Information during MQSA Inspections 2. Whether medical entities can release patient biopsy information to mammo facilities for purposes of the MQSA medical outcomes audit without obtaining patient authorization 10
at Work at Work HIPAA & Release of Information for MQSA Purposes Release of Biopsy Information Medical Entities Section 164.512(b) of the HIPPA regulations allow a covered entity (e.g., referring physician, pathology department, surgeon: To release patient biopsy information to a mammography facility for purposes of MQSA medical outcomes audit without patient authorization because the disclosure: 1. is to "a person subject to FDA jurisdiction" 2. concerns an FDA regulated product or activity for which the mammography facility has responsibility 3. relates to the quality, safety or effectiveness of the product or program HIPAA & Release of Information for MQSA Purposes Protection of Patient Information during MQSA Inspections Section 164.512(b) & (d) of the HIPPA regulations allow a mammography facility to release patient information to an MQSA inspector without patient authorization because MQSA inspectors are performing health oversight activities required by law. at Work An imaging center in Nebraska is involved in litigation over possible violations of the privacy provisions HIPAA If the reminder postcards show the patient s names and addresses as well as your practice s name and address, you may accidentally disclose PHI that could subject you to civil and criminal penalties What Is Quality? Quality is planned and systematic actions that provide the optimum achievable care Or "Getting people to do better all the worthwhile things they ought to be doing anyway. Quality is defined in mammography more than in any other area of imaging! Some Organizations demanding quality management in our industry are: If quality is to be managed, it must be defined... as conformance to requirements. If nonconformance to requirements is noted, there is an absence of quality. JC OSHA Insurance Providers MQSA 11
Quality Management Quality management focuses on the needs of and expectations of customers and the continuous improvement of the product. This applies to radiology as it does to Fortune 500 industries. Quality Management in Quality Control is the part of the QA program that deals with techniques used in monitoring and maintenance of technical elements Continuous Quality Improvement Focuses on the process or system in which employee operate Problems & variability main cause of poor quality Quality Management in Nuts & Bolts of QM Quality Assurance:: An all-encompassing management program Ensure excellence Systematic collection and evaluation of data TQM is based upon the following premises: Due to their knowledge of job conditions, those workers closest to the problem are more likely to know what is wrong with the process and how to fix it. Every person in an organization wants to to be a valuable contributor and do a good job. Such opportunities provide the employee a sense of ownership and reduce the adversarial relationship between workers and management. Quality Management in 80/20 Principle asserts that a minority of causes, inputs, or effort lead to a majority of results, outputs or rewards. Processes, not people are the root of quality problems. Structured problem solving using statistical means produces better long term solutions. TQM 12
Quality Management in QA PROGRAM DEVELOPMENT To develop a QA program, first delineate the scope of care Next identify the important aspects of care and prioritize based on: Practicing in an environment of fear is counterproductive and leads to poor performance. 80% of the problems are the result of 20% of the causes of all the problems. 1. High volume procedures 2. High risk procedures 3. Problem Prone 4. Needs of patient/families Quality Management in Cycles for Improving Performance in CQI (or whatever today s acronym is for the process) Identify the problem Collect your data Design Measure Assess Improve Quality Management in Quality Control is the part of the QA program that deals with techniques used in monitoring and maintenance of technical elements Continuous Quality Improvement Focuses on the process or system in which employee operate Problems & variability main cause of poor quality Quality Management in Quality Management in Cycles for Improving Performance in CQI Identify the area target for improvement What in your department could improve the delivery of care? Cycles for Improving Performance in CQI Collect the data Is a real problem or is it perceived? Are you always behind because of patients scheduled in the wrong slot? Tract it for several weeks and see what the data tells you! 13
Quality Management in Cycles for Improving Performance in CQI Assess Asses the data, talk with the parties involved and document the progress of the program. Sometimes this may be the end of the line! Some initiatives aren t successful. Quality Management in Cycles for Improving Performance in CQI Design a program If the problem is real, then ask these three questions: Will addressing the problem 1) reduce cost 2)increase efficiency 3)improve quality of care If the answer is yes, it is a target for quality improvement! Use structured problem solving; involve the people who provide the service Quality Management in Quality Management in Cycles for Improving Performance in CQI Measure After you have designed an intervention and put the plan in place, re-evaluate by collecting data Cycles for Improving Performance in CQI Improve Celebrate your successes! The process can be a morale booster for everyone involved in the process. Remember everyone wants to do a good job! So, where should we be looking? Access is care timely and appropriate? Outcomes state of patient s health resulting from care received. Patient s experience and perception of the quality of care. Major Aims for Quality Care 1. Safe care should not injure patient 2. Effective avoiding underuse and overuse of services 3. Patient centered respectful and responsive care to include needs, values, preferences of patient 4. Timely reduced waiting and delays for both those who receive or give care 14
Major Aims of Quality Care 5. Efficient - avoiding waste of equipment, supplies, ideas, and energy 6. Equitable care that does not vary in quality because of gender, ethnicity, geography, or socioeconomic status. National Radiology Data Registry (NRDR) The ability to document the quality of services delivered by your facilities to interested third parties The ability to measure impact of changes in practice The ability to implement a data-driven quality improvement program National Radiology Data Registry (NRDR) By submitting your data to NRDR, your practice will be provided with: Detailed and graphic reports in a standardized format for comparing quality A tool for targeting specific areas of improvement An accurate reflection of practice patterns National Radiology Data Registry (NRDR) National Oncology PET Registry (NOPR) CT Colonoscopy Registry (CTC) General Radiology Improvement Database (GRID) National Database (NMD) Dose Index Registry (DIR) IV Contrast Extravasations Registry (ICE) National Database (NMD) ACR launched an updated version of the National Database in 2009 Database developed and is based on BI- RADS NMD will collect data from mammography facilities and provide benchmarks on outcomes such as cancer detection rates and positive predictive value National Database (NMD) NMD leverages data that radiology practices are already collecting under federal mandate by providing them with comparative information for national and regional benchmarking. Participants receive semi-annual feedback reports that include Important benchmark data such as : Cancer Detection Rates Positive Predictive Value Recall Rates 15
National Database (NMD) ACR User Guide posted in October, 2010 Data Submission Software for audit must be NMD certified and conform to the format as outlined by the ACR Aggregate Reports At the end of each reporting period, your facility will be provided with a report comparing your data with aggregated data from other NMD facilities. (NMD) Outcomes Measures Diagnostic PPV (2) Measure Description: The percentage of diagnostic mammograms recommended for biopsy or surgical consultation. ( BI-RADS Category 4 or 5 that result in a tissue diagnosis of cancer within 12 months) Screening PPV (2) Measure Description: The percentage of screening mammograms recommended for biopsy or surgical consultation. ( BI-RADS 0, 4 or 5 that result in a tissue diagnosis of cancer within 12 months). (NMD) Outcomes Measures Cancer Detection Rates Measure Description: The percentage of screening mammograms that were interpreted as positive (BI-RADS 0, 4 or 5) and result in a tissue diagnosis of cancer within 12 months Abnormal Interpretation Rate Measure Description: The percentage of screening mammograms interpreted as positive (BI-RADS 0, 4 or 5) Breast Imaging Centers of Excellence BICOE ACR Breast Center of Excellence Designation Facility must be accredited by ACR or FDA approved state accrediting body and obtain Stereotactic Breast Biopsy by the ACR and Breast Ultrasound by the ACR including the Ultrasound-Guided Breast Biopsy module Opportunity How does sharing data help advance the practice of mammography? It provides results on how you measure up and provides data analysis that is the impetus for change. 16