HCAHPS, Value-Based Purchasing and A Culture of Always

Objectives HCAHPS, Value-Based Purchasing and A Culture of Always Karen Cook, RN BSN www.studergroup.com 1. Describe the history and current usage of the CAHPS family of surveys and other relevant outpatient experience surveys 2. Articulate the atmosphere surrounding public reporting, Value-Based Purchasing and financial impact to reimbursement 3. List three evidence-based practices that will build a culture of safety, improve core measures, and favorably impact the patient perception of quality care www.studergroup.com/sgna2013 http://www.medicare.gov/hospitalcompare Hospital CAHPS Home Health Care CAHPS In-Center Hemodialysis CAHPS Clinician and Group CAHPS Family Eval of Hospice Care Health Plan CAHPS Ambulatory Surgery CAHPS Outpatient Diagnostic CAHPS (under CMS consideration) HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems HCAHPS Quick Facts What is HCAHPS Why is it important? How will it be used? A standardized survey tool to measure the patient s perception of quality care provided during their experience while a patient at an acute-care hospital. The patient perception of care is publicly reported with other quality metrics on the Hospital Compare website. http://www.medicare.gov/hospitalcompare The information will be used to enhance public accountability, provide meaningful data for improvement efforts as well as provide comparisons between hospitals to help consumers choose a hospital and will be linked to reimbursement after July, 2011. Over 3,800 hospitals Frequency-based scale Only top-box publicly reported for comparisons Survey 48 hours to 42 days post discharge Expanded survey required with January, 2013 discharges Core Survey questions 1-25 and About You questions 26-32 For additional details on the new HCAHPS items from CMS, please see Page 5 of the HCAHPS Quality Assurance Guidelines v7.0: http://www.hcahpsonline.org/qaguidelines.aspx. 1

Who is Eligible? All payers not just Medicare Eligible patients all medical, surgical or maternity care patients with a different admission and discharge date except the following: Patients under 18 years old Excluded service lines (Primary psychiatric dx, rehab, skilled nursing) Patients who die in the hospital setting Patient with a foreign address Patients admitted from a corrections facility Patients discharged to hospice care, nursing homes, SNF Swing bed within hospital and skilled nursing facilities Documented No Publicity patients Other patients excluded by law in your state Patient Perspective of Clinical Quality Communication with doctors Communication with nurses Their perception of Responsiveness of hospital staff your performance Pain management is a reportable and Communication about medicines tangible reflection Discharge information of your Cleanliness of hospital environment reputation Quietness of hospital environment Transitions of care Overall rating of hospital Willingness to recommend the hospital Patient-Centered Care and Mortality Clear Connection between Patient-Centered Care and Clinical Quality Outcomes Percent of Patients Surviving 1 0.98 0.96 0.94 0.92 0.9 0.88 0.86 0.84 0.82 0.8 0.997 0.997 0.992 Figure 11 Percent of AMI Patients Surviving To One Year Post Discharge Stratified by Level of Patient-Centered Care (PCC) 0.989 0.987 0.978 Low PCC (n=372) 0.981 0.957 0.970 0.944 High PCC (n=371) 0.962 0.960 0.930 0.906 0.903 Level of PCC was defined using the composite average of Picker dimension scale scores (see Fig. 8.1). Low PCC = bottom fifth of the distribution (scores <=56.85); high PCC = top fifth of the distribution (scores >=97.14). 0.954 0.951 0.949 0.946 1 2 3 4 5 6 7 8 9 10 11 12 Months After Discharge 0.895 0.890 0.879 0.938 0.871 HCAHPS Rating AMI CHF PNA Surgery Lowest quartile 93.5 82.7 88.5 82.8 Second quartile 94.5 85.2 90.1 84.3 Third quartile 94.6 85.9 90.7 85.2 Highest quartile 95.3 86.0 90.8 85.7 P value for trend <0.001 <0.001 <0.001 <0.001 Compared Hospital Quality Alliance (HQA) scores for the Quality of Clinical Care to HCAHPS Global Rating A different source: Glickman SW et al, Patient Satisfaction and Its Relationship with Clinical Quality and Inpatient Mortality in Acute Myocardial Infarction, Circa Cardiovasc Qual Outcomes 2010;3:188-195. Source: Jha et al. New England Journal of Medicine 359, no. 18 (2008): 1921-1931. High Patient Perception of Care Equals Lower Preventable Readmissions CAHPS Surgical Care Survey (NQF Endorsed 6/12) 1/5 of Medicare Beneficiaries are readmitted within 30 days with an annual cost of $17.4 Billion 2.6% Acute MI 3.1% Heart Failure 2.3% Pneumonia The Surgical Care Survey composites represent the experiences of respondents in these areas: Information to help you prepare for surgery (2) Surgeon communicates with patients before surgery (4) Surgeon s attentiveness on day of surgery (2) Information to help you recover from surgery (4) Surgeon communicates with patients after surgery (4) Helpful, courteous, respectful staff at surgeon s office (2) Overall rating of surgeon (1) Source: The American Journal of Managed Care; Relationship Between Patient Satisfaction With Inpatient Care and Hospital Readmission Within 30 Days; 2011; Vol. 17(1) Note: Created by American College of Surgeons and focuses on the surgeon, not the facility 2

Federal Register CMS Request for Information 1/25/13 Regarding hospital outpatient surgery departments (HOSDs) and ambulatory surgery centers (ASCs), as well as patient-reported outcomes from surgeries or other procedures performed in these settings. Relevant topic areas such as communication between patients and health care providers; access to care; customer service; provision of pre- and post-surgical care information; access to follow-up care; care coordination; patient preferences; environment; and safety. CMS is developing this survey and plans to submit it to AHRQ for recognition as a CAHPS survey. National safety priorities will be a focus #2 Focus will be on patient and family engaged as partners in their care #3 Promoting effective communication and coordination of care National Quality Strategy Affordable Care Act Section 3011 1. Making care safer by reducing harm caused by the delivery of care 2. Ensuring that each person and family are engaged as partners in their care 3. Promoting effective communication and coordination of care 4. Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease 5. Working with communities to promote wide use of best practices to enable health living 6. Making quality care more affordable for individuals, families, employers and governments by developing and spreading new health care delivery models Comments to CMS from ACG, AGA and ASCE Physician Quality Reporting System (PQRS) For 2013 and beyond, CMS proposes a new gastroenterology PQRS measure, > Endoscopy and Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients, > Participation by a Physician or Other Clinician in a Systematic Clinical Database Registry that Includes Consensus Endorsed Quality Patient experience data collected in 2014 would potentially be the first data made available on Physician Compare no earlier than 2015. Physician Compare Website Information on physician performance will be publicly available no later than Jan, 2013 Provides comparable information on quality and patient experience measures with respect to physicians enrolled in the Medicare program: A. Measures collected under the Physician Quality Reporting System B. An assessment of patient health outcomes and the functional status of patients C. An assessment of the continuity and coordination of care and care transitions, including episodes of care and risk-adjusted resource use D. An assessment of efficiency E. An assessment of patient experience and patient, caregiver, and family engagement F. An assessment of the safety, effectiveness, and timeliness of care http://www.gastro.org/advocacy-regulation/regulatory-issues/acg_aga_asge_comment_letter_cms-1590-p.pdf http://www.medicare.gov/find-a-doctor/provider-search.aspx Current Satisfaction Survey From ASGE Site Consider Clinician-Group Survey > Access to Care > Doctor Communication > Doctor Rating > Access to Specialists > Health Promotion/Education > Shared Decision Making > Health/Functional Status 3

CGCAHPS Domain Comparison Questions Objectives Physician Communication (6 questions) During Your Most Recent Visit Did this provider explain things in a way that was easy to understand? Did this provider listen carefully to you? Did this provider give you easy to understand instructions about taking care of these health problems or concerns? Did this provider seem to know the important information about your medical history? Did this provider show respect for what you had to say? Did this provider spend enough time with you? Response o Yes, definitely o Yes, somewhat o No o Top Box = Yes, definitely 1. Describe the history and current usage of the CAHPS family of surveys and other relevant outpatient experience surveys 2. Articulate the atmosphere surrounding public reporting, Value-Based Purchasing and financial impact to reimbursement 3. List three evidence-based practices that will build a culture of safety, improve core measures, and favorably impact the patient perception of quality care Overview Value-Based Purchasing (VBP) FY 2014 Domains and Measures/Dimensions Clinical Outcome Domain What is VBP Another word for Pay-for-Performance, this is a program intended to transform healthcare by fostering a joint clinical and financial accountability system. Why is it important? How will it be used? This new payment system will change CMS from a passive payer of services into an active purchaser of value which is high quality, affordable, safe healthcare. Hospitals will be reimbursed based on their performance, not just reporting, of quality metrics, including the patient perception of quality. If you perform better you ll be paid more Better = patient-centered, efficient, quality care This is the new outcome domain; based on risk adjusted mortality rates for patients admitted with these conditions 2013 and 2014 Process of Care Measures Measure ID Measure 2013 National Threshold 2014 National Threshold 2013 National Benchmark 2014 National Benchmark Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival 0.6548 0.8066 0.9191 0.9630 AMI 7a AMI 8a 0.9186 0.9344 1.0000 1.0000 Primary PCI Received Within 90 Minutes of Hospital Arrival HF 1 Discharge Instructions 0.9077 0.9266 1.0000 1.0000 Blood Cultures Performed in the Emergency Department Prior to Initial Anti-biotic Received in Hospital 0.9643 0.9730 1.0000 1.0000 PN 3b Initial Antibiotic Selection for CAP in Immunocompetent Patient 0.9277 0.9446 0.9958 1.0000 PN 6 Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision 0.9735 0.9807 0.9998 1.0000 SCIP Inf 1 SCIP Inf 2 Prophylactic Antibiotic Selection for Surgical Patients 0.9766 0.9813 1.0000 1.0000 Prophylactic Antibiotics Discontinued Within 24 Hours After SCIP Inf 3 Surgery End Time 0.9507 0.9663 0.9968 0.9996 Cardiac Surgery Patients with Controlled 6AM Postoperative NEW SCIP Inf 4 Serum Glucose 0.9428 0.9634 0.9963 1.0000 Postoperative Urinary Catheter Removal on Post Operative SCIP Inf 9 Day 1 or 2 N/A 0.9286 N/A 0.9989 Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period 0.9500 0.9565 1.0000 1.0000 SCIP Card 2 Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered 0.9307 0.9462 0.9985 1.0000 SCIP VTE 1 SCIP VTE 2 Green = increased threshold from 2013 Red = decreased threshold from 2013 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery 0.9399 0.9492 1.0000 0.9983 GI Procedures Account for 32.7% of ASC Total Volume Affordable Care Act - Section 10301(a) requires a plan to implement Value-Based Purchasing in ASC by January, 2011 Will follow framework and structure of Hospital program Source: ASC Value-Based Purchasing Implementation Plan, Note to Congress, Jan 2011. 4

ASGE Comments About VBP AND Physician Quality Reporting System Penalty in 2015 ASGE proposed the following measures currently under NQF review as most appropriate for endoscopic ASCs as would help distinguish quality differences between ASCs and other Hospital Outpatient Departments: 1. Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients 2. Colonoscopy Interval for Patients with a History of Adenomatous Polyps Avoidance of Inappropriate Use 3. Comprehensive Colonoscopy Documentation 1% 1.25% 1. 5% 1. 75% 2% 1% 2% 3% 3% 3% ASGE also proposed developing a measure of patient experience to help gauge the overall quality of care delivered to Medicare beneficiaries by ASCs Objectives 1. Describe the history and current usage of the HCAHPS survey and CAHPS Surgical Survey 2. Articulate the atmosphere surrounding public reporting, Value-Based Purchasing and financial impact to reimbursement 3. List three evidence-based practices that will build a culture of safety, improve core measures and favorably impact the patient perception of quality care High Impact Initiative #1 Engage and Train ALL Staff What Is A Moment of Truth? Conduct Moment of Truth Exercise Moments of Truth are events, observations, and interactions that create impressions. Moments of Truth create impressions in five areas. 5

Leader Rounding on Patients to Validate Quality Four Communication Goals 1. I m the leader. I m responsible for the quality of care 2. Harvest and deliver compliments when earned 3. Coach behaviors real-time 4. Assess quality, safety and experience of the patient with service recovery if needed Two Key Follow-up Questions 1. What did I learn about the quality of care? 2. What must I do with that information? Rounding in Waiting Room Engage families/caregivers Reduce anxiety Keep informed Identify learners for help at home Be responsive, reliable and empathetic Track trends/themes High Impact Initiative #2 Key Words at Key Times WHY? Key words reflect a communication style that improves the quality of information provided by every person in every interaction. This makes care safer, patients less anxious and informed about their care. > Identify key times (defining moments that occur during times of vulnerability that create memorable experiences (positive or negative) > Train and validate all employees on why it is critical to build trust, make a connection and instill confidence Key Words: Listen, Explain, Courtesy, Respect I am washing my hands for your safety. May I come in? Tell me what you know about this procedure. Who will help you when you go home? Let s put their name on your white board so we make sure and involve them in your treatment plan. (Learner may be different than patient) Excellent quality care to me means we are managing your pain. I want to be sure I explain things to you. Let me close the curtain for your privacy. For your comfort, I ordered pain medicine... I want to keep you informed What questions can I answer before I leave? You are in good hands with these nurses. AIDET is an Acronym Five Fundamentals of Communication Focus on the A & I to show courtesy and respect and reduce anxiety Focus on the D & E to educate on treatment/ process and to increase compliance A I D E T Acknowledge Introduce Duration Explanation Thank You Tool Key Words: Post-Discharge Phone Call WHY? A telephone call made to a patient within 24-72 hours after an interaction with Inpatient, Outpatient or ED services will help ensure a safe transition home and reduce unnecessary re-admissions. Goal is 100% of patients receive a discharge phone call Did your discharge instructions answer all your questions? Is there anything preventing you from taking your medications as ordered? Track attempt/complete rate and link results to quality outcomes/readmissions 6

Evidence-Based Problem Tip #3: Follow Evidence-Based Leadership SM Model 58% of patients discharged don t know their diagnosis and don t understand their care plan (Mayo Clinic Proceedings, 2010) 44% of patients were not aware of their discharge date (Mayo Clinic Proceedings, 2005) Objective Evaluation System Leader Development Must Haves SM Performance Gap Standardization Accelerators Aligned Goals Aligned Behavior Aligned Process 81% of patients requiring assistance with basic functional needs at home failed to receive a home care reference and 68% said no one talked to them about home care (Patient Education and Counseling 59. No 1, 2005) 30% less likely to be re-admitted if included in care plan about discharge before leaving (AHRQ Re-Engineering Discharge Project, 2010) Implement objective accountability system Better align training to outcomes Sequence tools and techniques Retain High Performers, Coach Mid Performers, Help deal with low performers Hardwire consistency Ongoing Validation! References Federal Register Medicare Program; Request for Information To Aid in the Design and Development of a Survey Regarding Patient Experiences With Hosp 2013 Medicare Physician Fee Schedule Proposed Rule Summary Prepared for the American Society for Gastrointestinal Endoscopy Updated October 2012 http://www.healthcare.gov/center/authorities/health_reform_a nd_hhs.html Report to congress: Medicare ASC Value-Based Purchasing Implementation Plan https://federalregister.gov/a/2013-01300 http://www.hcahpsonline.org/qaguidelines.aspx 7