QM The Quality Maagemet Pla A Practical, Patiet-Cetered Template Jue 2011 Primary Authors Dale S. Beso, MD, FACPE Peyto G. Towes, Jr., MHSA Special Cotributor Daiel Dobbs
About the Authors DALE S. BENSON, MD, CPE, FACPE Dale S. Beso, MD, CPE, FACPE is a family physicia ad physicia executive. He most recetly served as Vice Presidet of Iovatio, Quality, ad Practice Maagemet, as well as Director of the Leadership Developmet Istitute, at AltaMed Health Services i Los Ageles (CA). Prior to that, Dr. Beso was Vice Presidet of Physicia Practice Maagemet ad Vice Presidet of Ambulatory Care for the Mercy Health System i Chicago. He fouded HealthNet Commuity Health Ceters i Idiaapolis (IN) i 1969, ad for 30 years he served as that etwork s Executive Director. Dr. Beso has authored or co-authored may published works, icludig the Joit Commissio book Quality Assurace i Ambulatory Care; the Jossey-Bass book Excellece i Ambulatory Care; the America Hospital Publishig Compay book Measurig Outcomes i Ambulatory Care; ad umerous articles ad moographs. He has lectured extesively o leadership, quality, ad efficiecy i the ambulatory settig ad has taught more tha 80 semiars o maagig quality. PEYTON G. TOWNES, JR., MHSA Peyto G. Towes, Jr., MHSA is a health care maager, programs ad resources developer, ad cosultat / traier. He is curretly Presidet of Ambulatory Iovatios, Ic. (Idiaapolis, IN), a provider of multiple resources for ambulatory care orgaizatios. For 13 years, Mr. Towes was Assistat Director ad Director of Program ad Commuity Developmet at HealthNet Commuity Health Ceters i Idiaapolis. He has served as both Board Presidet ad Director of Busiess Developmet for the Idiaa Primary Health Care Associatio (IPHCA) ad was Assistat Registrar ad Marketig Represetative for a major group practice i the Washigto (DC) area. Mr. Towes has authored or co-authored several books, icludig Quality Assurace i Ambulatory Care (the Joit Commissio), Excellece i Ambulatory Care (Jossey-Bass Publishers), ad others. I additio, he has developed a umber of articles ad olie ewsletters o health care ad other topics. O behalf of NACHC, he has authored atioally-distributed moographs; co-developed quality-based webiars ad traiig semiars; ad created istructioal videos ad DVDs. Mr. Towes has also bee a featured speaker at cofereces ad semiars. DAN DOBBS Da Dobbs is Presidet of Overdrive Health Iformatics, Ic., a provider of Health Iformatio Techology (HIT) services to ambulatory care orgaizatios. He has more tha 25 years of busiess ad admiistrative experiece i the areas of iformatio techology, egieerig, ad marketig. For 18 years, he had icreasig maagerial resposibilities at a divisio of Geeral Motors Corporatio i Aderso (IN). He is a frequet subject matter expert ad speaker o performace maagemet ad iteractive dashboard techology for orgaizatios such as NACHC ad the Harvard School of Public Health. He also serves o the Board of Directors of the Idiaa Health Iformatio Maagemet Systems Society (IHIMSS). 2 Natioal Associatio of Commuity Health Ceters
AMBULATORY INNOVATIONS, INC. Ambulatory Iovatios (AI) is a 16-year-old resources compay that provides expert systems (hard copy ad olie), cosultatio / traiig, ad outsourced services to the ambulatory care field, icludig Commuity Health Ceters ad related orgaizatios. AI s pricipals ad atioal etwork of from-the-field Associates (cliical ad maagerial) are recogized experts i a wide rage of importat fuctioal areas related to ambulatory care. Based i Idiaapolis (IN), the compay has special expertise i Quality Maagemet ad related fuctios, as well as i Telephoe Triage. OVERDRIVE HEALTH INFORMATICS, INC. Overdrive Health Iformatics provides cuttig-edge Health Iformatio Techology (HIT) ad related performace improvemet services that help ambulatory care orgaizatios achieve optimal sustaiable performace through actioable Busiess Itelligece (BI). The compay offers a spectrum of high-level tools primarily real-time, iteractive, customizable dashboards ad related improvemet expertise to eable Commuity Health Ceters ad others to achieve cosistetly excellet patiet care ad busiess operatios. The compay s missio is to help orgaizatios overdrive their total performace. ACKNOWLEDGEMENTS The authors wish to thak the expert ad dedicated health care professioals who graciously allowed themselves to be iterviewed for this moograph: Bruce D. Agis, MD, MPH Medical Director AIDS Istitute New York State Departmet of Health New York NY J. Kevi Carmichael, MD Chief of Service El Rio Special Immuology Associates El Rio Commuity Health Ceter Tucso AZ Deis S. Freema, PhD Chief Executive Officer Cherokee Health Systems Koxville TN Michael R. Lardiere, LCSW Director Health Iformatio Techology / Seior Advisor Behavioral Health Natioal Associatio of Commuity Health Ceters (NACHC) Bethesda MD Debbie Lester, LMSW Director Istitute for the Advacemet of Commuity Health Urba Health Pla Brox NY Vira Little, PsyD, LCSW-r, SAP Vice Presidet Psychosocial Services & Commuity Affairs The Istitute for Family Health New York NY Bill McFeature, PhD Director SVCHS Itegrative Behavioral Health Care Services Southwest Virgiia Commuity Health Systems Bristol VA Cheryl Modica, PhD, MPH, BSN Cosultat Natioal Associatio of Commuity Health Ceters (NACHC) Bethesda MD 3 Natioal Associatio of Commuity Health Ceters
About NACHC The Natioal Associatio of Commuity Health Ceters (NACHC) is the oly atioal health care orgaizatio dedicated exclusively to expadig health care access for the medically uderserved through the commuity health ceter model. I this role, NACHC represets ad supports the collective missio ad iterests of the atiowide etwork of more tha 1,200 commuity, migrat, homeless, ad public housig health ceter orgaizatios, which serve 20 millio patiets via 7,500 sites i all 50 states, Puerto Rico, the District of Columbia, the U.S. Virgi Islads, ad Guam. NACHC s missio is To promote the provisio of high quality, comprehesive ad affordable health care that is coordiated, culturally ad liguistically competet,ad commuity directed for all medically uderserved populatios. I fulfillig its missio, NACHC Serves as the major source for iformatio, data, research, ad advocacy o key issues affectig commuity health ceters ad the delivery of health care for the medically uderserved ad uisured i America; Provides educatio, traiig. techical assistace, ad leadership developmet to health ceter staff, boards, ad others to promote excellece ad cost-effectiveess i health delivery practice ad commuity goverace; ad Builds parterships ad likages that stimulate public ad private sector ivestmet i the delivery of quality health care services to medically uderserved commuities. NACHC works closely through a shared missio with all 50 states, State/Regioal Primary Care Associatios, ad key strategic parters, icludig Commuity HealthVetures ad Capital Lik. For more iformatio about NACHC ad this Moograph, please cotact: Kathy McNamara kmcamara@achc.com 4 Natioal Associatio of Commuity Health Ceters
Purpose Two critical ad rapidly covergig issues lead may health ceter leaders today to feel very much as though they are, i the words of the old Chiese curse, livig i iterestig times. These issues are 1) a expadig umber of ew iitiatives as Commuity, Migrat, Homeless ad Public Housig Health Ceters (health ceters) play a icreasigly importat role i the atio s health system, ad 2) related calls for ever-greater accoutability. New iitiatives brig substatial ew challeges. Oe challege is simply the smooth itegratio of additioal cliical programs ito the already impressive array of health ceter primary care services. Aother is providig services through icreasigly sophisticated models of care, such as the Patiet Cetered Medical Home. Yet aother is doig all this withi the cotext of ew techologies ad expaded reportig madates. With this simultaeous oslaught of ew iitiatives, developig care models, icreasig accoutability, ad advacig techology, health ceters ofte feel overwhelmed. But what if there were a orgaizig priciple that deployed a relatively simple istrumet to help health ceters effectively redesig their practices (icludig existig services ad ew program iitiatives), eablig the pieces to fall clealy ito place o matter what the program might be? It turs out that there is such a orgaizig priciple for such is the role of quality. Ad there is a directly related istrumet familiar to all health ceters, the Quality Maagemet (QM) Pla, which helps health ceters seamlessly itegrate ew programs, models, ad techologies with the primary care services they have log provided. A clear QM Pla that uderlies a comprehesive Quality Maagemet program ca be a real boo, both i maagig ew madates ad i esurig that health ceters are truly effective agets i improvig idividual ad commuity health. The aim of this moograph is to provide a basic blueprit for the QM Pla of a typical mid-sized health ceter, which ca the easily be modified as eeded to accommodate both small ad larger, more complex orgaizatios. This moograph models a comprehesive approach to Quality Maagemet that ca accommodate a wide rage of iitiatives, icludig ew programs relatig to specialty care ad/or broader commuity-orieted services. Drivers The simultaeous twi dyamics of ew iitiatives ad icreasig accoutability are drive by umerous forces at the atioal level, icludig developig HIV/AIDS strategies, ew behavioral health iitiatives, the emergece of Patiet Cetered Medical Homes, ad atioal Health Iformatio Techology (HIT) Meaigful Use criteria. Recet evets esure that these dyamics will cotiue well ito the future. Federal programs brigig sigificat ew opportuities for health ceters otably the America Recovery ad Reivestmet Act (PL111-5, commoly kow as the Stimulus Package ) ad the Patiet Protectio ad Affordable Care Act (PL111-148, geerally called Health Care Reform ) will cotiue to carry with them icreasig visibility, accoutability, ad scrutiy for health ceters of all types ad sizes. 5 Natioal Associatio of Commuity Health Ceters
Overview The QM Pla described here provides essetially a plug ad play model that will work with virtually all health ceter programs. It fosters a coceptual practice redesig that, while ot uduly hard to implemet, will help itegrate ad esure accoutability for ew iitiatives with a miimum of orgaizatioal disturbace. For each program primary care to specialty services health ceters ca use the same structure, the same approach to quality, ad the same quality categories template for orgaizig metric moitorig ad quality improvemet activity. All of the pieces come together to make up the overall corporate Quality Maagemet program. This moograph addresses, as examples, both primary care ad two cliical iitiatives which while certaily ot ufamiliar to health ceters might iitially appear to be outside the purview of a ormal primary care focus. Both address specific populatios, cosistet with the atioal Triple Aim iitiative (described below.) The first iitiative, HIV-related services, represets a growig opportuity for health ceters; while a umber of health ceters have excellet HIV programs, may others have yet to itegrate HIV services ito their cliical set. The secod, Behavioral Health, presets the challege of itegratig multiple professioal disciplies withi the optimal settig for broader commuity-based care. Our template will address elemets of both cliical programs most critically at the metric level as examples of how a commo quality-based framework ca help a health ceter quickly itegrate seemigly disparate programs. The QM Pla s orgaizig cocept, idetified here as broad quality categories ecompassig specific metrics, is based i the teets of the Patiet Cetered Medical Home (PCMH) model. The quality categories described below alig well with fudametal PCMH characteristics described by The Joit Commissio, the Bureau of Primary Health Care (BPHC), the Agecy for Healthcare Research ad Quality (AHRQ), ad the Joit Priciples of the Medical Home developed by the four primary care medical societies (the America College of Physicias, the America Academy of Family Practice, the America Academy of Pediatrics, ad the America Osteopathic Associatio). The template described i this moograph is also cosistet with the atioal Triple Aim quality model, first espoused by Dr. Doald Berwick ad his colleagues: Improvig the experiece of care Improvig the health of populatios Reducig per capita costs of health care These three aims ofte show as Egagemet, Populatio Health, ad Value clearly itegrate the Patiet Cetered Medical Home cocept. While Triple Aim is essetially a macro model (addressig the overall health care system), the QM Pla methodology i this moograph will eable a health ceter to cotribute fully from its micro level to those overarchig atioal goals. The Quality Maagemet Pla proposed below is straightforward. It actively ivolves the Goverig Board, health ceter leadership, idividual program maagers, ad ultimately all frot-lie 6 Natioal Associatio of Commuity Health Ceters
staff. It clearly defies roles, resposibilities, ad orgaizatioal accoutabilities. Ad it provides a comprehesive yet maageable approach to metric moitorig, through improvemet methodologies that have stood the test of time. Throughout this moograph, you will see special otes that explai, clarify, or expad upo a primary poit i the text. For ready idetificatio, these essetially parethetical asides are show i italics ad are preceded by a special Notes ico that looks like this: THE QUALITY MANAGEMENT PLAN This moograph describes how a effective Quality Maagemet (QM) Pla uderlies a health ceter s overall Quality Maagemet program. It icludes five iterrelated sectios: The Purpose ad Scope of the QM program The orgaizatioal Structure of the QM program Three fudametal compoets for maagig quality APPENDIX: Examples of health ceter QM Committees; the Nola Accelerated Improvemet Method; the Five Whys methodology; iteral roles i Quality Maagemet; ad a sample electroic quality reportig mechaism. This moograph also icludes four program-specific Metric Paks, usig the quality categories template described i Sectio IV (below), for Primary Care, HIV, Behavioral Health, ad Meaigful Use, as examples of how the categories provide a cosistet framework for metrics addressig specific programs. The term metric is used throughout this moograph. I the field, the term measure is also used, ofte to mea virtually the same thig. While a umber of orgaizatios have developed highly specific ad techical defiitios for these terms, the defiitios are as yet ot etirely cosistet across orgaizatios. For our purposes, a metric is simply a importat program idicator the orgaizatio has chose to measure. The diagram that follows is essetially a schematic of this moograph, showig how all of its movig parts work together: A framework of quality categories reflectig the basic teets of the Patiet Cetered Medical Home. (This framework, also referred to as a template, cotributes both to orgaizig key performace metrics withi each health ceter program ad to itegratig these ito the overall Quality Maagemet effort.) 7 Natioal Associatio of Commuity Health Ceters
The Health Ceter Quality Maagemet Pla STRUCTURE OF PROGRAM MANAGEMENT OF QUALITY Three Fudametal Compoets The Four Priciples Defiitio of Quality Accoutability Itersectig Orgaizatioal Etities Cliical Providers QUALITY ASSESSMENT QUALITY IMPROVEMENT TRACKING & REPORTING Moitorig Evaluatio Process Improvemet QM Committee Reegieerig CEO/Quality Coucil Root Cause Aalysis Goverig Board METRIC PAKS The Quality Categories Template Goal Established Quality Actio Poit Determied Data Collected 8 Natioal Associatio of Commuity Health Ceters
I. Purpose ad Scope of the Quality Maagemet Program The purpose of the health ceter s Quality Maagemet program is to assure ogoig excellece i the quality ad safety of the care ad services the CHC delivers. Board ad staff are committed to improvig the health of patiets ad their commuity. The health ceter accomplishes this by cotiually moitorig (measurig) ad improvig the excellece of patiet care ad orgaizatioal operatios. The ultimate goal is for each program to provide care that is safe, effective, patiet orieted, timely, efficiet, ad equitable, ad i so doig to both provide a true Patiet Cetered Medical Home ad esure that quality goals are cosistet with the atioal Triple Aim iitiative. The six characteristics show above i bold were oted by the Istitute of Medicie i its 2001 report, Crossig the Quality Chasm: A New Health System for the 21st Cetury. The scope of the QM program is comprehesive; quality ad safety must exted to all facets of the orgaizatio cliical, maagerial, admiistrative, ad facility-related. Accordigly, the Pla addresses each of the health ceter s cliical programs; the precepts of the Patiet Cetered Medical Home model; atioal Meaigful Use criteria; ad requiremets / guidelies of The Joit Commissio, the Natioal Committee for Quality Assurace (NCQA), the Bureau of Primary Health Care (BPHC), the Health Resources ad Services Admiistratio (HRSA), ad the Federal Tort Claims Act (FTCA). It also addresses exteral services provided to patiets through writte agreemets; high priority busiess process issues; ad partership opportuities withi the broader commuity. The Quality Maagemet program also esures orgaizatioal compliace with appropriate policies cocerig Cofidetiality ad Coflict of Iterest, as well as with all Health Isurace Portability ad Accoutability Act (HIPAA) requiremets. Although ot ecessarily part of the formal QM Pla, health ceters have multiple other systems that cotribute to quality ad safety, icludig utilizatio review, risk maagemet, credetialig / re-credetialig, ad so forth. Some state health departmets ad some maaged care plas require formal documetatio of these systems; however, the systems themselves eed ot be specifically icluded as compoets of the QM Pla. II. Structure of the Quality Maagemet Program The structure of the Quality Maagemet program flows from four uderlyig priciples: A effective QM program must be based o a fuctioal defiitio of quality. The QM program must esure accoutability at all levels. There must be clear differetiatio of resposibilities betwee health ceter leadership ad the QM Committee(s). Cliical providers must play a key role i quality maagemet, ad this role should be made as efficiet ad effective as possible. (The term cliical providers as defied here icludes ayoe with idepedet authority to write prescriptios.) 9 Natioal Associatio of Commuity Health Ceters
I additio, a focus o quality must permeate the etire orgaizatio. All health ceter staff must costatly thik quality ad must geuiely feel that quality is a itegral compoet of everyoe s job descriptio. This midset must flow from the orgaizatio s leaders. Frot-lie staff must fully uderstad that they ca at ay time make suggestios for metrics, should actively help take advatage of improvemet opportuities, ad will be costatly kept iformed of ogoig quality progress. A. A Fuctioal Defiitio of Quality The quality process begis with the orgaizatio s missio, visio, strategic pla, ad core values. All quality-related activities are focused o desigig, implemetig, moitorig, ad improvig a total system that actively itegrates these costructs ad ca deliver ehaced outcomes. A health ceter must first defie quality before it ca assess ad improve quality. The followig fuctioal defiitio of quality is a good example of oe that ca be specifically adopted by the Board as part of its resposibility for commissioig the Quality Maagemet program. This defiitio isolates the aspects of quality that ca be moitored ad costatly improved through the ceter s Quality Maagemet program, with the ultimate goal of ehacig outcomes of all types. Quality is the degree of excellece of the ceter s processes, provider ad support staff performace, decisios, ad huma iteractios. Dale Beso MD, CPE, FACPE Thus, through orgaizatio-wide Quality Maagemet activities, the ceter will focus o moitorig ad improvig patiet care (ad related busiess) processes; provider ad support staff performace; decisios havig the potetial to impact patiet (ad orgaizatioal) health; ad ogoig huma iteractios, both with patiets ad amog all ceter persoel. B. Accoutability The Board of Directors is ultimately accoutable for the level of quality ad safety at the ceter. This accoutability begis with the Board s iitial approval of the defiitio of quality ad the Quality Maagemet Pla, ad progresses through re-approval of the QM Pla at least every three years (more ofte if substatial chages are made i the Quality Maagemet program). The Board receives ad acts upo periodic reports developed through the QM program, ad it esures the availability of resources ad systems ecessary to support all QM activities. May Boards appoit a Board QM Committee charged with moitorig the ogoig effectiveess of the health ceter s QM program ad commuicatig QM results ad issues to the Board. These Committees customarily meet every other moth ad are staffed by the Director of Quality or the CEO (or both). The Board holds the health ceter s Chief Executive Officer (CEO) accoutable for orgaizatioal quality ad safety. The CEO regularly reports to the Board o quality; this ca be doe through the Board QM Committee, if oe exists. 10 Natioal Associatio of Commuity Health Ceters
The health ceter s Director of Quality has operatioal resposibility for the QM program ad reports to the CEO. Each Quality Maagemet Committee reports to the Director of Quality. A frequet mistake is havig the Director of Quality report to the Chief Medical Officer rather tha the CEO. Quality ivolves the etire orgaizatio, ot just the cliical compoet; thus, the CEO should supervise the Director of Quality. The Chief Medical Officer (CMO) is accoutable to the CEO for the quality ad safety of the cliical program, the performace of the provider staff, ad the provider performace assessmet / improvemet compoet of the QM program. C. Itersectig Roles: Leadership / Quality Coucil ad QM Committee(s) I this moograph, leadership refers to those withi the orgaizatio havig true decisio makig authority that is, leaders ad maagers resposible for program effectiveess withi their defied area of resposibility. Thus, the term ecompasses the CEO ad other top executive staff, divisio heads, ad departmet maagers. The Quality Coucil described below would iclude staff with leadership or maagemet resposibility ad authority. O the other had, the QM Committee is comprised of frot lie employees who do ot have leadership or maagemet resposibility; examples would iclude (but ot be limited to) medical assistats, frot desk staff, health educators, providers (ot icludig the CMO), ad staff urses. It is appropriate for supervisors to sit o the QM Committee, sice their role is to supervise performace rather tha to develop / maage programs. With that defiitioal distictio as backgroud, let s cosider the roles ad resposibilities of the key members of the quality team. Leadership: Withi each ceter, the effectiveess of the QM program is the direct resposibility of leadership. It is the leaders resposibility to develop, support, ad operate the Quality Maagemet program. The leaders, with the support ad assistace of the Director of Quality, accomplish the followig: 1. Select ad prioritize metrics to moitor, with a performace goal for each; 2. Determie acceptable performace thresholds (quality actio poits) for each metric; 3. Esure that all ecessary data are supplied to the appropriate QM Committee(s); 4. Maage ogoig improvemet activity; ad 5. Assume ultimate resposibility for resolvig idetified quality ad safety problems, as well as takig advatage of ay other opportuities to improve. Ofte these resposibilities are assumed by a Quality Coucil (as described below). While staff members at all levels, from supervisors ad maagers to frot-lie employees, should always be ecouraged to suggest metrics to moitor, it is the orgaizatio s leadership that is ultimately resposible for choosig specific metrics that will be measured. Quality Coucil: I a typical mid-sized-to-large health ceter, a overseeig Quality Coucil might cosist of (for istace) six to eight leaders, icludig members of the Executive Staff ad the CMO, appoited by the CEO to serve oe or more oeyear terms. This Quality Coucil would assume 11 Natioal Associatio of Commuity Health Ceters
leadership resposibilities outlied above for developig, supportig, ad operatig the QM program; i doig so, it would oversee all orgaizatioal quality activity, icludig actively addressig ay corporate-level issues relatig to quality ad patiet safety. The Quality Coucil would geerally be expected to meet mothly ad would ormally be chaired by the Director of Quality, who would report Quality Coucil activity directly to the CEO. A Quality Coucil is especially useful i larger programs with multiple site-specific Quality Maagemet Committees. Smaller orgaizatios may ot eed a Quality Coucil; i this istace, leaders would fulfill their resposibilities idividually ad the orgaizatio s QM Committee would report directly to the Director of Quality (or whoever is fulfillig that fuctio withi the orgaizatio). QM Committee: It is the QM Committee(s) s resposibility to actively moitor QM activity (withi the total orgaizatio if there is oly oe Committee, or for a specific program / site if the health ceter has multiple QM Committees), ad to report o this activity. The QM Committee, with the support ad assistace of the Director of Quality, esures that: 1. The chose metrics are beig moitored; 2. Necessary data are beig collected; 3. Metrics ot meetig pre-established performace thresholds are beig moved ito the quality improvemet phase of activity; 4. Quality improvemet is beig actively carried out; ad 5. Idetified quality-related problems are fully resolved. (See the Appedix for a listig of some typical QM Committees withi a health ceter.) There must be clear separatio of duties ad resposibilities betwee leadership ad the QM Committee(s). A QM Committee is ot resposible for overseeig the total Quality Maagemet program, or is it resposible for actually solvig quality-related problems. Rather, leadership operates the overall program ad is resposible for cotiual program oversight, as well as for esurig results of quality improvemet activities. The QM Committee s role is to moitor the program (or its assiged portio of it) through ogoig metric review. A Iteral Roles Chart defiig the roles of leadership ad the QM Committee(s) withi the overall QM program ca be foud i the Appedix. Each QM Committee should be broadly represetative of the staff (either of the overall health ceter or of the Committee s specific program, depedig o the complexity of the orgaizatio). It could, for example, cosist of five or six frot-lie staff members appoited by the Director of Quality to oe or more oe-year terms. The Committee should be cross-fuctioal. Each QM Committee chooses its ow Chair; meets mothly to actively moitor the QM program withi its assiged area of resposibility; ad reports o results, issues, ad program effectiveess. D. The Vital Role of Cliical Providers i Quality Maagemet Cliical providers are critical to the quality ad safety of the total health ceter program. (Agai, as used here, cliical providers are those professioals with idepedet authority to write prescriptios.) Providers ot oly give excellet care, but they also esure by moitorig / measurig / improvig processes, performace, decisios, ad huma iteractios that their care is of the highest possible quality. 12 Natioal Associatio of Commuity Health Ceters
Providers participate i specific activities, described below, that are madated by the FTCA deemig process. These activities geerally apply to licesed idepedet practitioers as defied by The Joit Commissio. Accordig to the Joit Commissio s 2011 Comprehesive Accreditatio Maual, a Licesed Idepedet Practitioer for Ambulatory Care Programs is defied as follows: A idividual permitted by law ad by the orgaizatio to provide care, treatmet, ad services without direct supervisio. A licesed idepedet practitioer operates withi the scope of his or her licese, cosistet with idividually grated cliical privileges. Whe stadards referece the term licesed idepedet practitioer, this laguage is ot to be costrued to limit the authority of a licesed idepedet practitioer to delegate tasks to other qualified health care persoel (for example, physicia assistats ad advaced practice registered urses) to the extet authorized by state law or a state s regulatory mechaism or federal guidelies ad orgaizatioal policy. 1. Cliical Guidelies. The providers idetify ad adopt/adapt specific evidece-based cliical guidelies icludig, but ot limited to, health promotio, disease prevetio, ad cliical outcome metrics that are grouded i atioal stadards. The provider staff cotiually moitors the program for guidelie effectiveess. Multiple sources exist for evidece-based guidelies. As oe example, a excellet resource is the Web site for the Natioal Guidelie Clearighouse, sposored by the Agecy for Healthcare Research ad Quality (AHRQ). collectio ad evaluatio of patiet records ad are coducted by licesed professioals uder the supervisio of the CMO. 3. Provider Performace Improvemet Activity. The CMO appoits provider represetatives to the appropriate Quality Maagemet Committee, as well as to process improvemet or reegieerig teams as eeded. The CMO is ultimately resposible for resolvig idetified cliical problems, as well as for performig ogoig quality improvemet i the cliical area. 4. Itegratio with the Orgaizatio-wide QM Program. Provider-specific assessmet ad improvemet activities are itegrated ito the overall QM program via the CMO s active leadership (participatio o the Quality Coucil, for istace) ad through itegratio of cliical quality activity reports ito the overall reportig structure for all Quality Maagemet Committees. III. Three Fudametal Compoets for Maagig Quality The Quality Maagemet Pla should address three fudametal compoets for ogoig maagemet of quality. The first compoet is quality assessmet; the secod is quality improvemet; ad the third is trackig improvemet activity ad reportig o program effectiveess. 2. Peer Review ad Cliical Guidelies Audits. The Chief Medical Officer is resposible for esurig that Peer Review Audits ad Cliical Guidelies Audits are coducted as scheduled, ad that these Audits periodically assess the appropriateess of utilizatio of services ad the quality ad safety of those services. Audits are based o systematic A. Quality Assessmet Each Quality Maagemet Committee is charged with moitorig predetermied metrics of quality ad safety, as selected by the health ceter s leadership (i cojuctio with their program maagers, ad ofte with the iput of frot-lie staff). 13 Natioal Associatio of Commuity Health Ceters
As oted above, a metric is simply a carefully defied program measure either process or outcome that is actively ad cotiuously reviewed (i.e., measured ad moitored) to determie the level of performace for that particular item. Leadership, with staff iput, provides each Quality Maagemet Committee with exterally valid, evidece-based metrics for moitorig. This moograph s template addresses eight broad metric categories (each icludig oe or more metrics) that alig with the fudametal teets of the Patiet Cetered Medical Home model, as show i Sectio IV. These categories apply to both traditioal primary care QM activity ad to specialty programs such as HIV ad Behavioral Health. Through this mechaism, we ca geerate system-wide cotiuity. Sources for metrics iclude, but are certaily ot limited to, UDS process ad outcome cliical measures, the Natioal Quality Forum (NQF), NCQA HEDIS measures, health ad busiess pla requiremets, ad metrics developed by various professioal societies ad/or peer review orgaizatios. BPHC recommedatios regardig patiet satisfactio, access, quality of cliical care, quality of the workforce, work eviromet, cost, productivity, health status, ad outcomes are also excellet potetial metric sources. Other resources iclude the Istitute of Medicie s six Aims for Improvemet (care that is safe, effective, patiet-cetered, timely, efficiet, ad equitable); Pay for Performace criteria; The Joit Commissio s Natioal Patiet Safety Goals; Meaigful Use criteria; ad the Patiet Cetered Medical Home model. Although the broad metric categories remai costat, the metrics themselves reflect each program represeted by a QM Committee. These metrics relate to processes, performace, outcomes, appropriateess of decisios, ad patiet satisfactio. Metrics should reflect the uiqueess of the health ceter (or program) ad its specific patiet populatio. The objective is to iitially develop or adopt a miimum of oe metric for each broad category refereced i this template, the to gradually add others as the orgaizatio s QM program matures ad the ceter moves up the quality progress ladder. For each chose metric, leadership establishes a goal ad a related pla for performace measuremet. A Quality Coucil could be used for these fuctios. Leadership also establishes a predetermied performace threshold (the quality actio poit) at which the QM Committee takes actio to refer the metric (i most cases to the program maager most directly ivolved) for improvemet activity. Data are collected, displayed, ad reported routiely, usig charts ad graphs wheever helpful. Data are aalyzed to idetify treds, patters, ad performace levels that suggest opportuities for improvemet. Aalysis is based o predetermied bechmarks, quality actio poits, ad statistical quality cotrol techiques. This part of the QM Pla describes how measuremet data are evaluated ad how a decisio is made to iitiate quality improvemet activity. BPHC-provided tred reports ca be quite useful here. B. Quality Improvemet I its QM Pla, a health ceter documets the improvemet methodologies it will use. We suggest three that are straightforward, frequetly used, ad fuctioal: process improvemet, re-egieerig, ad root cause aalysis. For each, a team is appoited by the appropriate program leader / maager. The Director of Quality esures that the teams are appropriately traied ad adequately supported. 14 Natioal Associatio of Commuity Health Ceters
1. Process Improvemet. While a umber of process improvemet methodologies exist, the Nola Accelerated Model for Improvemet is a excellet choice. This relatively straightforward model icorporates the classic PDSA (Pla, Do, Study, Act) cycle for testig ad implemetig improvemet optios. Whe a opportuity for improvemet is idetified, leadership appoits a improvemet team ad charges the members with makig improvemets usig the Nola methodology. (See the Appedix for more detail o this very useful tool.) There are other acceptable methodologies, as well, such as Six Sigma ad the Lea model. No matter which method is selected, the key is simply that process improvemet is istitutioalized ad actively addressed o a ogoig basis. 2. Re-egieerig. Whe major process improvemet is called for, whe certai processes are fudametally dysfuctioal, or whe process improvemet activity is otherwise usuccessful, a reegieerig team is appoited ad traied to create a all-ew process. Each team is assiged a facilitator skilled i reegieerig methods ad techiques. 3. Root Cause Aalysis. Root cause aalysis is used primarily for i-depth aalysis of a adverse icidet (or setiel evet ). However, it ca also help i better uderstadig a process, as the first step i improvemet of that process. The Five Whys methodology ca be quite useful i ucoverig root causes. See the Appedix to lear how to perform a Five Why s aalysis. C. Trackig Improvemet Activity ad Reportig QM Data Whe a QM Committee idetifies a quality issue ad refers it to leadership to orgaize a improvemet team, the Committee the tracks ad reports o progress util improvemet has bee fully realized. Whe improvemet activity is complete, the Committee periodically re-aalyzes related performace ad/or outcomes data to esure that improvemet is sustaied. The health ceter s quality reportig system for both iteral ad exteral trackig ad reportig cotributes sigificatly to ogoig accoutability ad is thus a importat compoet of quality maagemet. While trackig ad reportig ca be doe maually, the growig complexity of this effort, the rapidly icreasig volume of quality-related data, ad ever more urget calls for sharig / itegratio of iformatio strogly poit to the adoptio of electroic reportig mechaisms. A example of how routie iteral quality reportig could be accomplished electroically is show i the Appedix. Reportig of quality activity ad its results begis with each QM Committee. Data from each Committee are made available to the Quality Coucil (or Director of Quality). The data are the collated ad preseted to the CEO, who periodically shares quality reports with the ceter s Board. Icluded i these iteral reports are: 1. Idetificatio of the metrics; 2. Specific metric measuremets relative to preestablished goals ad quality actio poits; 3. Improvemet activities iitiated; ad 4. The ogoig results of quality improvemet. 15 Natioal Associatio of Commuity Health Ceters
QM Committee members geerally see the greatest detail, eablig them to costatly aalyze ad address idicators ad related issues. The Quality Coucil (icludig the CEO) sees less groud-level detail but is kept iformed o curret metrics ad how performace is improvig over time. Fially, the Board geerally sees a broad quality overview. For both the Quality Coucil / CEO ad the Board, further drill-dow data ca be made available if desired. Fially, it is importat that all staff ultimately see the results of quality activity. Sice quality is a orgaizatio-wide affair, reports of both critical quality issues ad related improvemets require orgaizatio-wide distributio. This ca be accomplished electroically via iteral email or itraet, through paper-based summaries haded out i staff meetigs, by postig quality reports i commo areas, ad so forth. The precise mechaism is less importat tha the madate simply put, everyoe workig i a health ceter should be kept iformed of quality issues beig addressed, progress o those issues, ad improvemets geerated by the quality process. A importat corollary is the idea of celebratig successes. Fixig logstadig problems, geeratig better processes ad outcomes, ad geerally takig full advatage of opportuities for real improvemet are sigificat achievemets, ad leaders eed to esure that staff kow this ad are cogratulated for their role i makig thigs better. Celebratios eed ot be Hollywood productios; simple thigs like brigig special treats to meetigs or sedig otes of appreciatio to employees will do the job icely. The importat thig is to brig closure to successful improvemets while simultaeously creatig ivestmet i future quality efforts. I additio to iteral reportig, quality maagemet results are also periodically reported whe required to exteral etities. These iclude the Bureau of Primary Health Care, State Health Departmets, program-specific state ad federal agecies (e.g., for HIV programs), ad others. IV. Framework For Orgaizig Performace Metrics A health ceter s QM program should cotiually moitor both fudametal primary care metrics ad program-specific quality metrics for iitiatives addressig specific populatios of focus (such as HIV patiets). The metric set examples provided i this moograph are called Metric Paks. Each Metric Pak is orgaized by eight broad categories that alig closely with the philosophy of the Patiet Cetered Medical Home; these categories thus serve as a appropriate template for both primary care ad populatiospecific programs. This template ca help health ceters easily itegrate both existig programs ad ew iitiatives ito the orgaizatio s overall QM program i a way that focuses o program-specific metrics while esurig cotiuous aligmet with Patiet Cetered Medical Home precepts. The QM program s objective is to moitor oe or more metrics i each of the eight broad categories, for all programs beig addressed. The idea is to start with a few metrics i each category, the to add more as the QM program matures. Program-specific metrics ca be developed withi these eight broad categories for such cliical services as detal, materal health, substace abuse, school-based cliics, etc. The resultig Metric Paks, as show i this moograph for the cliical programs of Primary Care, HIV, ad Behavioral Health, ca the be plugged ito the overall QM program. I a mid-sized health ceter, these metrics could be moitored by separate Primary Care, HIV, ad Behavioral Health QM Committees. 16 Natioal Associatio of Commuity Health Ceters
Below is the PCMH-based template that assigs metrics to eight broad categories, together with the uderlyig PCMH cocepts for each category. I the specific Metric Paks (collectios of program-specific metrics placed ito the eight broad categories template) that follow, we suggest metrics that could be addressed withi each category for both traditioal Primary Care ad as examples of itegratio of ew iitiatives HIV ad Behavioral Health. Because it is a critical iitiative cuttig across multiple programs, we have also created a Meaigful Use Metric Pak. These metrics are also cosistet with the PCMH model ad thus fit well ito the template. They ca be supplemeted or replaced as Meaigful Use progresses through its plaed future Levels. Health ceter leadership ca add, delete, or modify metrics i each Metric Pak. To maitai the uderlyig PCMH foudatio, however, the cotiual focus should be o creatig metrics withi the broad categories of the template. Agai, the key is that this template provides a relatively simple PC- MH-cetered framework ito which a health ceter ca easily drop ew metrics relatig to both existig programs ad ew iitiatives. The Quality Categories Template for Assessmet ad Improvemet Below are the eight broad categories for orgaizig metrics withi the cotext of a Patiet Cetered Medical Home care model. A defiitio is provided for each category, together with importat cocepts uderlyig that category. Although the QM program focuses primarily o the quality of cliical patiet care, we have also icluded oe template category focusig o the quality of busiess processes. There are two reasos for this. First, busiess processes represet a sigificat potetial source of both savigs ad utapped reveues. Secod, while patiet care is clearly the poit of the sword, it is udeiably true that ay importat health ceter process ultimately has the potetial to impact that care; a sword s effectiveess, after all, depeds early as much o its hilt as o its poit. Followig the category descriptios below are the program-specific Metric Paks cotaiig sample metrics for each chose program, as example of how to use the QM Pla to help itegrate both existig services ad ew iitiatives. Here are the eight broad categories ad their uderlyig cocepts: 1. Access ad Cycle Time Defiitio: Ease ad timeliess with which health care services ca be obtaied, icludig the efficiecy of the patiet visit. Cocepts: Ehaced access; ope schedulig; expaded hours, icludig eveigs ad weekeds; access to specialty care ad other resources eeded to provide care; more efficiet cycle times. 17 Natioal Associatio of Commuity Health Ceters
2. Comprehesive, Coordiated, ad Itegrated Care Defiitio: A comprehesive, coordiated, cotiuous, ad whole perso pla of care for a particular patiet, progressig without iterruptio; icludes referrals, test results, ad record trasfer. Services are well itegrated with other health care ad commuity resources. Cocepts: Care plaig ad maagemet; cotiuous care; comprehesive ad whole perso (physical, metal ad social) care; cotiuity of care, with referral ad test trackig; coordiatio of care with other providers, icludig coordiated iformatio flow; ehaced commuicatio with providers, patiets, families, ad the commuity; strog commuity likages. 3. Cliical Quality ad Safety Defiitio: Treatmet is cosistet with predetermied performace ad safety guidelies or geerally accepted evidece-based stadards. Health outcomes meet predetermied safety ad effectiveess goals. Cocepts: Evidece-based cliical processes; cliical decisio support tools; appropriate diagostic tests ad therapeutic procedures; chroic disease maagemet; cliical outcomes; medicatio maagemet; patiet safety. 4. Prevetio ad Health Promotio Defiitio: Compliace with predetermied guidelies for prevetio, early detectio, ad health / lifestyle / self maagemet educatio. Cocepts: Health promotio; disease prevetio; health ad disease maagemet educatio; lifestyle behaviors; self maagemet traiig ad support; prevetive services. 5. Patiet ad Commuity Relatioships Defiitio: Care is patiet cetered, with a desigated persoal provider leadig a iterdiscipliary team. Care is give withi the cotext of strog commuity likages ad parterships. Cocepts: Patiet cetered care; traied iterdiscipliary care teams with defied roles ad resposibilities; a o-goig healig relatioship with a persoal physicia ad care team; a physicia ad team collectively take resposibility for ogoig care; relatioships with patiet s family, as appropriate; culturally ad liguistically appropriate care; strog commuity likages ad parterships. 6. Health Iformatio Techology Defiitio: Health iformatio techology cotributes to the quality, safety, ad efficiecy of care. Cocepts: New optios for ehaced commuicatio (patiets, physicias, staff); a systems- based approach; electroic patiet, test, ad referral trackig; utilizatio metrics; electroic prescribig; health iformatio exchage; patiet educatio; o-cliical systems. 7. Patiet Satisfactio ad Loyalty Defiitio: The degree to which healthcare services ad resultig health status meet patiet expectatios ad create loyalty. Cocepts: Patiet satisfactio surveys; the patiet experiece; patiet cetered care; feedback regardig expectatios met; patiet participatio i decisio makig; compassioate ad culturally effective care; patiet loyalty surveys. 18 Natioal Associatio of Commuity Health Ceters
8. Busiess Process Quality Defiitio: Effectiveess, efficiecy, ad results of the processes cotributig to the successful busiess of the health ceter. Cocepts: Maximized reveue; operatioal efficiecy; aliged ad supportive paymet systems; recogized added value of Patiet Cetered Medical Home care model. 19 Natioal Associatio of Commuity Health Ceters
Sample Health Ceter Metric Paks Collectios of Program-Specific Metrics, Usig the PCMH-Based Quality Categories Template for a Quality Maagemet Program Specific Health Ceter Programs (Used as Examples): Primary Care HIV Behavioral Health Care Meaigful Use Level 1 20 Natioal Associatio of Commuity Health Ceters
The Metric Pak for each example program (o the followig pages) icludes sample metrics for quality assessmet ad improvemet activity. The uderlyig broad categories provide a opportuity to orgaize quality aroud the fudametal precepts of the PCMH care model eablig cosistecy across all of a orgaizatio s programs. The orgaizatio should establish its ultimate goal for each metric. The goal should iclude cosiderable stretch; i fact, it is frequetly 100% compliace. Although ot specifically show i the Metric Paks, leadership should also establish a quality actio poit for each metric. This serves as the ceter s curret acceptability threshold for that metric; it is geerally less tha the ultimate goal ad reflects what the orgaizatio ca live with at the curret time. It is the poit above which the ceter may ot eed to exped major resources for a all-out improvemet project. For istace, if the ultimate goal of the metric is 100% compliace, the target for the curret year may be 85%. Failure to reach the quality actio poit should virtually always result i quality improvemet activity. I the spirit of cotiuous improvemet, curret performace (uless it s 100%) wo t be the fial stoppig poit. At least oce per year, leadership should reevaluate the quality actio poit ad adjust it as appropriate presumably upward. The ultimate goal will remai 100% compliace. I additio to assigig metric goals ad related quality actio poits, leadership should also clarify the mechaics of data gatherig for each selected metric. This icludes specifyig the appropriate data source, who compiles the data, ad how relevat data are geerated. Oly through rigorous aalysis of hard data ca the QM Committee adequately moitor ad evaluate metric performace. As oted, the Metric Paks cotai examples of oe or two metrics for each category i the template. There is certaily o requiremet to use these samples; you may already have (or wish to create) others more relevat to what you are tryig to accomplish i your ow program(s). The key is to start with oe or two metrics i each broad category, the add others as your QM program matures. As you review the Metric Paks below, refer as eeded to the category Defiitios ad uderlyig Cocepts provided o pages 17-19. For a alterative perspective, a listig of the metrics for each of the eight PCMH-based quality categories immediately follows the four program-based Metric Paks. 21 Natioal Associatio of Commuity Health Ceters
Metric Pak: PRIMARY CARE METRIC Access & Cycle Time Access to primary care whe eeded Cycle time GOAL 100% of patiets report that they are able to access care whe eeded. The average visit cycle time is 45 miutes or less. Comprehesive, Coordiated & Itegrated Care Cogestive Heart Failure (CHF) 100% of CHF patiets o diuretics or digoxi have follow-up lab tests performed medicatio follow-up per guidelies. Referral follow-up 100% of referrals made by a referral urse are tracked for patiet follow-through. Cliical Quality & Safety Hypertesio lab assessmet Medicatio recociliatio Prevetio & Health Promotio Asthma self-maagemet goals BMIs i childre Patiet & Commuity Relatioships Easy access to patiet s desigated provider ad team Commuity parterships Health Iformatio Techology Readily accessible medicatio-specific iformatio Health maiteace forms Patiet Satisfactio & Loyalty Results of care Patiet willigess to retur Busiess Process Quality Days i accouts receivable (A/R) Cost per medical visit 100% of hypertesio patiets have serum creatiie ad cholesterol documeted withi the past 12 moths. 100% compliace is achieved with Natioal Patiet Safety Goals of accurately ad completely recocilig medicatios across the cotiuum of care o all patiets. Self-maagemet goals are established ad documeted o 100% of asthma patiets. 100% of childre with elevated BMIs are offered specific obesity itervetio. 100% of patiets report success i seeig their desired provider or team member o the preferred day. At least oe ew formal commuity likage is developed each year. 100% of primary care patiets have a readily accessible drug profile that is curret ad complete. Electroic health maiteace forms are curret ad complete for 100% of patiets. 100% of patiets report satisfactio with results of visit(s) to the health ceter. 100% of patiets report that they would always retur to the health ceter eve if a particular visit does ot go well. Orgaizatio meets mothly target for days i A/R. Orgaizatio meets mothly targets ad is withi BPHC guidelies. 22 Natioal Associatio of Commuity Health Ceters
Metric Pak: HIV METRIC GOAL Access & Cycle Time Easy access to Case Maager 100% of HIV patiets report success i seeig desired Case Maager o preferred day. Rapid HIV testig Rapid HIV tests are provided ad results are reported durig the same visit to 100% of health ceter patiets. Comprehesive, Coordiated & Itegrated Care Detal referrals Retetio i care 100% of HIV patiets have a detal referral aually. 100% of HIV patiets are see at least twice aually, with visits at least 60 days apart. Cliical Quality & Safety Viral load or CD4 cout Maximum viral cotrol Prevetio & Health Promotio Risk couselig TB screeig Patiet & Commuity Relatioships Case Maagemet referrals Desigated persoal provider Health Iformatio Techology CD4 cout ad viral load documetatio Drug profile documetatio Patiet Satisfactio & Loyalty Receptio area Satisfactio with Case Maager Busiess Process Quality Collectio rate Required certificates ad cosets Viral load / CD4 cout measured at least twice aually o 100% of HIV patiets. 100% of HIV patiets achieve maximal viral cotrol at least six moths post-atiretroviral therapy (ART) iitiatio. 100% of health ceter patiets determied to be at risk for HIV ifectio based o a sexual history receive risk couselig. 100% of HIV patiets have a aual PPD scree. 100% of HIV patiets report that their Case Maagers assist them i obtaiig services ot provided at their cliic/program. 100% of HIV patiets report that they are always able to see their desigated provider or team member whe eeded. CD4 cout ad viral load are documeted i the most recet four progress otes i 100% of HIV patiets electroic charts. 100% of HIV patiets have a documeted drug profile i their electroic chart based upo patiet-specific iformatio. 100% of HIV patiets report that the receptio area is clea, safe, comfortable ad respectful of privacy cocers. 100% of HIV patiets report that they are comfortable ad satisfied with their Case Maager. 80% of charges billed for HIV services are collected. 100% of HIV program-required eligibility ad iformed cosets are completed. 23 Natioal Associatio of Commuity Health Ceters
Metric Pak: BEHAVIORAL HEALTH METRIC Access & Cycle Time Sessio time Total patiet visit cycle time GOAL Sessio time for 90% of Behavioral Health Care (BHC) patiet visits should be o more tha thirty miutes (+/- five miutes). 90% of BHC patiets will leave the health ceter o more tha oe hour from etry time. Comprehesive, Coordiated & Itegrated Care Duratio of treatmet Outpatiet follow-up For 80% of BHC patiets, duratio of treatmet should be 8-12 weeks. 100% of BHC patiets discharged from i-patiet care receive at least oe follow-up outpatiet visit with a BH provider withi 30 days of discharge. Cliical Quality & Safety PHQ-9 (Patiet Health Questioaire) scores Use of itegrated cliical pathways Prevetio & Health Promotio Prevetio focused referrals Substace abuse Patiet & Commuity Relatioships Same-day service - primary care ad behavioral health care Commuity-based social services Health Iformatio Techology Patiet iformatio i Electroic Health Record (EHR) Exteral reports Patiet Satisfactio & Loyalty Patiet recommedatio Commuicatio with patiets Busiess Process Quality Collectio rate Reimbursemet of BHC services 90% of depressed patiets show a 50% decrease i PHQ-9 scores withi six moths after treatmet is iitiated. Itegrated cliical pathways are established ad utilized i 80% of BHC patiets. 80% of BHC patiets are offered prevetio focused educatio or referrals per guidelies. 100% of patiets are screeed for substace abuse at geeral itake. 90% of applicable patiets are provided same-day primary care ad BHC services. Needed social services for 100% of BHC patiets are arraged i the commuity withi two weeks of Behavioral Health itake. BHC iformatio is fully itegrated ito the patiet s EHR for all BHC patiets. 100% of BHC reports to exteral etities are geerated through electroic reportig systems. 100% of BHC patiets report that they would recommed the health ceter s BHC services to family ad frieds. 100% of BHC patiets report that practitioers ad staff liste itetly, uderstad fully, ad explai clearly. 80% of charges billed for BHC services are collected. 100% of available reimbursemets are received through case maagemet fee structures ad capitatio cotracts. 24 Natioal Associatio of Commuity Health Ceters
Metric Pak: MEANINGFUL USE LEVEL 1 METRIC Access & Cycle Time Patiet electroic access GOAL At least 10% of all uique patiets are provided timely electroic access to their health iformatio withi four busiess days of Electroic Health Record (EHR) update. Comprehesive, Coordiated & Itegrated Care Patiet remiders Remiders are set to at least 20% of patiets 65 ad over or 5 years ad youger. Trasitio of care summary Provide summary of care record for at least 50% of trasitios of care ad referrals. Cliical Quality & Safety Computerized Physicia Order Etry (CPOE) Maiteace of problem list Prevetio & Health Promotio Recordig of smokig status Immuizatio registries data submissio Patiet & Commuity Relatioships Electroic copy of health iformatio Sydromic surveillace data trasmissio Health Iformatio Techology Recordig of demographics Patiet lists (by coditio) CPOE used for at least oe medicatio order RE: at least 30% of all uique patiets havig oe or more medicatios i their medicatio list. At least 80% of uique patiets have at least oe problem list etry (or oe ) recorded as structured data. Smokig status is recorded for at least 50% of all patiets age 13 ad older usig structured data. Perform at least oe test of certified EHR techology s capacity to submit electroic data to immuizatio registries. At least 50% of all patiets who request a electroic copy of their health iformatio are provided it withi three busiess days. Perform at least oe test of certified EHR techology s capacity to provide electroic sydromic surveillace data to public health agecies. At least 50% of all patiets have required demographics recorded as structured data. Geerate at least oe report listig patiets with a specific coditio. Patiet Satisfactio & Loyalty (No specific Meaigful Use Level 1 metrics.) Busiess Process Quality (No specific Meaigful Use Level 1 metrics.) 25 Natioal Associatio of Commuity Health Ceters
ACCESS & CYCLE TIME Defiitio: Ease ad timeliess with which health care services ca be obtaied, icludig the efficiecy of the patiet visit. Cocepts: Ehaced access; ope schedulig; expaded hours, icludig eveigs ad weekeds; access to specialty care ad other resources eeded to provide care; more efficiet cycle times. METRIC Primary Care Access to primary care whe eeded Cycle time GOAL 100% of patiets report that they are able to access care whe eeded. The average visit cycle time is 45 miutes or less. HIV Easy access to Case Maager 100% of HIV patiets report success i seeig desired Case Maager o preferred day. Rapid HIV testig Rapid HIV tests are provided ad results are reported durig the same visit to 100% of health ceter patiets. Behavioral Health Sessio Time Total patiet visit cycle time Meaigful Use Level 1 Patiet Electroic Access Sessio time for 90% of Behavioral Health Care (BHC) patiet visits should be o more tha 30 miute (+/- five miutes). 90% of BHC patiets will leave the health ceter o more tha oe hour from etry time. At least 10% of all uique patiets are provided timely electroic access to their health iformatio withi four busiess days of Electroic Health Record (EHR) update. 26 Natioal Associatio of Commuity Health Ceters
COMPREHENSIVE, COORDINATED, & INTEGRATED CARE Defiitio: A comprehesive, coordiated, cotiuous, ad whole perso pla of care for a particular patiet, progressig without iterruptio; icludes referrals, test results, ad record trasfer. Services are well itegrated with other health care ad commuity resources. Cocepts: Care plaig ad maagemet; cotiuous care; comprehesive ad whole perso (physical, metal ad social) care; cotiuity of care, with referral ad test trackig; coordiatio of care with other providers, icludig coordiated iformatio flow; ehaced commuicatio with providers, patiets, families, ad the commuity; strog commuity likages. METRIC Primary Care Cogestive heart failure (CHF) medicatio follow-up Referral follow-up HIV Detal referrals Retetio i care Behavioral Health Duratio of treatmet Outpatiet follow-up Meaigful Use Level 1 Patiet remiders Trasitio of care summary GOAL 100% of CHF patiets o diuretics or digoxi have follow-up lab tests performed per guidelies. 100% of referrals made by a referral urse are tracked for patiet follow-through. 100% of HIV patiets have a detal referral aually. 100% of HIV patiets are see at least twice aually, with visits at least 60 days apart. For 80% of BHC patiets, duratio of treatmet should be 8-12 weeks. 100% of BHC patiets discharged from i-patiet care receive at least oe follow-up outpatiet visit with a BH provider withi 30 days of discharge. Remiders are set to at least 20% of patiets 65 ad over or 5 years ad youger. Provide summary of care record for at least 50% of trasitios of care ad referrals. 27 Natioal Associatio of Commuity Health Ceters
CLINICAL QUALITY & SAFETY Defiitio: Treatmet is cosistet with predetermied performace ad safety guidelies or geerally accepted evidece-based stadards. Health outcomes meet predetermied safety ad effectiveess goals. Cocepts: Evidece-based cliical processes; cliical decisio support tools; appropriate diagostic tests ad therapeutic procedures; chroic disease maagemet; cliical outcomes; medicatio maagemet; patiet safety. METRIC Primary Care Hypertesio - lab assessmet Medicatio recociliatio HIV Viral load or CD4 cout Maximum viral cotrol Behavioral Health PHQ-9 (Patiet Health Questioaire) scores Use of itegrated cliical pathways Meaigful Use Level 1 Computerized Physicia Order Etry (CPOE) for medicatio orders Maiteace of problem list GOAL 100% of hypertesio patiets have serum creatiie ad cholesterol documeted withi the past 12 moths. 100% compliace is achieved with Natioal Patiet Safety Goals of accurately ad completely recocilig medicatios across the cotiuum of care o all patiets. Viral load / CD4 cout measured at least twice aually o 100% of HIV patiets. 100% of HIV patiets achieve maximal viral cotrol at least six moths post-atiretroviral therapy (ART) iitiatio. 90% of depressed patiets show a 50% decrease i PHQ-9 scores withi six moths after treatmet is iitiated. Itegrated cliical pathways are established ad utilized i 80% of BHC patiets. CPOE used for at least oe medicatio order RE: at least 30% of all uique patiets havig oe or more medicatios i their medicatio list. At least 80% of uique patiets have at least oe problem list etry (or oe ) recorded as structured data. 28 Natioal Associatio of Commuity Health Ceters
PREVENTION & HEALTH PROMOTION Defiitio: Compliace with predetermied guidelies for prevetio, early detectio, ad health /lifestyle / self-maagemet educatio. Cocepts: Health promotio; disease prevetio; health ad disease maagemet educatio; lifestyle behaviors; self-maagemet traiig ad support; prevetive services. METRIC Primary Care Asthma self-maagemet goals BMIs (body mass idex) i childre HIV Risk couselig TB screeig Behavioral Health Prevetio focused referrals Substace abuse Meaigful Use Level 1 Recordig of smokig status Immuizatio registries data submissio GOAL Self-maagemet goals are established ad documeted o 100% of asthma patiets. 100% of childre with elevated BMIs are offered specific obesity itervetio. 100% of health ceter patiets determied to be at risk for HIV ifectio based o a sexual history receive risk couselig. 100% of HIV patiets have a aual PPD scree. 80% of BHC patiets are offered prevetio focused educatio or referrals per guidelies. 100% of patiets are screeed for substace abuse at geeral itake. Smokig status is recorded for at least 50% of all patiets age 13 ad older usig structured data. Perform at least oe test of certified EHR techology s capacity to submit electroic data to immuizatio registries. 29 Natioal Associatio of Commuity Health Ceters
PATIENT & COMMUNITY RELATIONSHIPS Defiitio: Care is patiet cetered, with a desigated persoal provider leadig a iterdiscipliary team. Care is give withi the cotext of strog commuity likages ad parterships. Cocepts: Patiet cetered care; traied iterdiscipliary care teams with defied roles ad resposibilities; a o-goig healig relatioship with a persoal physicia ad care team; a physicia ad team collectively take resposibility for ogoig care; relatioships with patiet s family, as appropriate; culturally ad liguistically appropriate care; strog commuity likages ad parterships. METRIC Primary Care Easy access to patiet s desigated provider ad team Commuity parterships HIV Case Maagemet referrals Desigated persoal provider Behavioral Health Same-day service - primary care ad behavioral health care Commuity-based social services Meaigful Use Level 1 Electroic copy of health iformatio Sydromic surveillace data trasmissio GOAL 100% of patiets report success i seeig their desired provider or team member o the preferred day. At least oe ew formal commuity likage is developed each year. HIV patiets report that their Case Maagers assist them i obtaiig services ot provided at their cliic/program. HIV patiets report that they are always able to see their desigated provider or team member whe eeded. 90% of applicable patiets are provided same-day primary care ad BHC services. Needed social services for 100% of BHC patiets are arraged i the commuity withi two weeks of Behavioral Health itake. At least 50% of all patiets who request a electroic copy of their health iformatio are provided it withi three busiess days. Perform at least oe test of certified EHR techology s capacity to provide electroic sydromic surveillace data to public health agecies. 30 Natioal Associatio of Commuity Health Ceters
HEALTH INFORMATION TECHNOLOGY Defiitio: Health iformatio techology cotributes to the quality, safety, ad efficiecy of care. Cocepts: New optios for ehaced commuicatio (patiets, physicias, staff); a systems- based approach; electroic patiet, test, ad referral trackig; utilizatio metrics; electroic prescribig; health iformatio exchage; patiet educatio; o-cliical systems. METRIC Primary Care Readily accessible medicatio-specific iformatio Health maiteace forms HIV CD4 cout ad viral load documetatio Drug profile documetatio Behavioral Health Patiet iformatio i electroic health record (EHR) Exteral reports Meaigful Use Level 1 Recordig of demographics Patiet lists (by coditio) GOAL 100% of primary care patiets have a readily accessible drug profile that is curret ad complete. Electroic health maiteace forms are curret ad complete for 100% of patiets. CD4 cout ad viral load are documeted i the most recet four progress otes i 100% of HIV patiets electroic charts. 100% of HIV patiets have a documeted drug profile i their electroic chart based upo patiet-specific iformatio. BHC iformatio is fully itegrated ito the patiet s Electroic Health Record for all BHC patiets. 100% of BHC reports to exteral etities are geerated through electroic reportig systems. At least 50% of all patiets have required demographics recorded as structured data. Geerate at least oe report listig patiets with a specific coditio. 31 Natioal Associatio of Commuity Health Ceters
PATIENT SATISFACTION & LOYALTY Defiitio: The degree to which healthcare services ad resultig health status meet patiet expectatios ad create loyalty. Cocepts: Patiet satisfactio surveys; the patiet experiece; patiet cetered care; feedback regardig expectatios met; patiet participatio i decisio makig; compassioate ad culturally effective care; patiet loyalty surveys. METRIC Primary Care Results of care Patiet willigess to retur HIV Receptio area Satisfactio with Case Maager Behavioral Health Patiet recommedatio Commuicatio with patiets GOAL 100% of patiets report satisfactio with results of visit(s) to the health ceter. 100% of patiets report that they would always retur to the health ceter eve if a particular visit does ot go well. 100% of HIV patiets report that the receptio area is clea, safe, comfortable ad respectful of privacy cocers. 100% of HIV patiets report that they are comfortable ad satisfied with their Case Maager. 100% of patiets report that they would recommed the health ceter s BHC services to family ad frieds. 100% of BHC patiets report that practitioers ad staff liste itetly, uderstad fully, ad explai clearly. Meaigful Use Level 1 No specific metrics. 32 Natioal Associatio of Commuity Health Ceters
BUSINESS PROCESS QUALITY Defiitio: Effectiveess, efficiecy, ad results of the processes cotributig to the successful busiess of the health ceter. Cocepts: Maximized reveue; operatioal efficiecy; aliged ad supportive paymet systems; recogized added value of Patiet Cetered Medical Home care model. METRIC Primary Care Days i accouts receivable (A/R) Cost per medical visit HIV Collectio rate Required certificates ad cosets Behavioral Health Collectio rate Reimbursemet of BHC services GOAL Orgaizatio meets mothly target for days i A/R. Orgaizatio meets mothly targets ad is withi BPHC guidelies. 80% of charges billed for HIV services are collected. 100% of HIV program-required eligibility ad iformed cosets are completed. 80% of charges billed for BHC services are collected. 100% of available reimbursemets are received through case maagemet fee structures ad capitatio cotracts. Meaigful Use Level 1 No specific metrics. 33 Natioal Associatio of Commuity Health Ceters
APPENDIX A. Examples of Orgaizatioal QM Committees Primary Care QM Committee Materal Health QM Committee School-Based Cliics QM Committee HIV QM Committee Detal QM Committee Meaigful Use QM Committee Behavioral Health QM Committee B. Nola Accelerated Model for Improvemet With the Nola Accelerated Model for Improvemet, developed by Thomas W. Nola, PhD, Seior Fellow at the Istitute for Health Care Improvemet, process improvemet teams are appoited by maagemet. The teams are charged with improvig a process by developig resposes to three fudametal questios: a. What are we tryig to accomplish? (Settig Aims) b. How will we kow that a chage is actually a improvemet? (Establishig Metrics) c. What chages ca we make that will result i improvemet? (Selectig Chages) The team the desigs ad implemets (with the support of maagemet) the Pla-Do-Study-Act (PDSA) cycle to test improvemet ideas. The improvemet pla must iclude both a baselie measuremet ad a built-i mechaism to determie the effectiveess (ad, whe appropriate, the replicability) of the improvemet. The QM Committee ad the Quality Coucil moitor progress of the improvemet activity. If the PDSA cycle is successful, the resultig chage is the implemeted. C. The Five Whys Method for Assessmet With the Five Whys method, the team cosiders why the issue beig explored occurred. They the take that iitial aswer ad ask Why? agai. With each successive step, the team asks Why? agai, util it has bee asked five times. This approach eables the team to dig deeply ito the source of the issue, geerally resultig i a better uderstadig ad, thus, a more fuctioal solutio. 34 Natioal Associatio of Commuity Health Ceters
D. Delieatio of Roles: Quality Coucil / Quality Maagemet Committee QUALITY MANAGEMENT ROLES QUALITY COUNCIL (Health Ceter Leaders ad Director of Quality) QM COMMITTEE(S) (Frot-lie staff represetatives) 1. Delieate orgaizatioal scope of care; idetify key processes ad related metrics (structure, process, outcome). 2. Idetify goal, quality actio poit, ad data source for each metric. 3. Assig metrics to appropriate categories i the specific Metric Pak. 4. Appoit appropriate committees, i cojuctio with the Director of Quality. 5. Maage data collectio ad provide data to QM Committee(s) as eeded. 6. Maage Quality Improvemet activities: Assig resposibility for improvemets. Maage Process Improvemet, Reegieerig, ad Root Cause Aalysis projects. Solve problems. Istitutioalize improvemets. Develop policies ad procedures as eeded. 1. Assist leadership i idetificatio of key processes ad related metrics (structure, process, outcome). 2. Quality Assessmet phase: Esure that appropriate metrics are beig actively moitored. Assess metric measuremet data. Refer idetified quality deficiecies to leadership for Quality Improvemet actio. 3. Quality Improvemet phase: Support ad moitor all Quality Improvemet activities, icludig Process Improvemet, Re-egieerig, ad Root Cause Aalysis. Evaluate effectiveess of QI activities, ad documet improvemets. 4. Report up through Quality Maagemet chaels. 7. Report to CEO ad Board through Corporate Quality Committee or Director of Quality. 8. Periodically evaluate overall QM Program. 35 Natioal Associatio of Commuity Health Ceters
E. A Sample Electroic Reportig System Below is a example of a electroic QM reportig system that could be attached to (or become part of) a Practice Maagemet system or Electroic Health Record. I order of decreasig detail, it shows QM Committee, Quality Coucil / CEO, ad Board-level views of tracked quality metrics, related Goals, ad quality actio poits. I this sample system, the level of reportig is selected by clickig the appropriate tab (i the view immediately below, the Quality Committee tab has bee selected); the category of metric is the chose from the dropdow meu at the top right of the scree; ad specific associated metrics (mapped to the selected categories) appear i the drop-dow meu at the upper left of the scree. Oce all selectios have bee made, the uderlyig data populates the gauges, graph, ad table. Performace is highlighted by color, with gree idicatig acceptable performace, yellow idicatig cautio, ad red idicatig a quality problem (opportuity to improve). The QM Committee sees the most detail, eablig members to cotiuously aalyze, uderstad, ad address the ogoig dyamics ad issues related to each specific metric. As show below, the Committee sees curret metric performace (compared to goal), mothly ad year-to-date treds, caledar year tredig, ad the detailed data uderlyig these results ad treds. 36 Natioal Associatio of Commuity Health Ceters
The Quality Coucil (leadership) view, show below, provides less detail specifically elimiatig the data table uderlyig the visuals but still iforms o curret performace metrics ad how each is tredig over time. The Board view (below) gives Board members a geeral quality overview i basic dashboard format, showig results for multiple metrics simultaeously. It also uses a gree-yellow-red schema, depedig o whether metric performace is acceptable (gree), margial (yellow), or uacceptable (red). Fially, while there is o sample view specifically for frot-lie employees, all staff should be kept cotiually apprised regardig quality issues, the status of metrics over time, ad the results of quality improvemet activities. This ca be accomplished by sharig ay or all of the above reports, at leadership s discretio, with staff groups either i hard copy or electroically. Reports ca also be distributed i all-staff meetigs, ad hard copies ca be posted i commo staff areas such as break rooms. 37 Natioal Associatio of Commuity Health Ceters