Stephen Jencks (SFJ) Speech at PRO/CMS Kansas City Region HCQIP Conference Approximately 10-11:30am EDT October 25, 2001 NB: These notes are an informal record – they are not a transcript. In SOW7, we will experience wrenching change, will not have enough money, we will be doing many things we have never done before, but we can succeed. We will have to work together better to do this. It is essential that we find ways to save money. We will have far too much to do with the resources that we will have. Not have expensive annual reports published by each PRO. We should not have 53 different 800 numbers. OIG report gives an idea of how poorly this is working, in addition to being expensive, these are not always answered, and not always answered well. Easier to do quality control if we have a single one. Not have as much independent replication of analysis, the same analytic tasks being done over and over by each PRO staff. Will have more specialization, particular PROs specializing and serving all PROs. Must streamline activities that we do. First step is KPMG report on case review, start of a long process. Wants all the PROs work with each other in a single system. Sharing of information. A lot more time spent on what this meeting is intended to do. If this meeting is unable to accomplish this end, we will keep trying to get it right. QIO Evaluation. This will also change. Three foundational parts: Performance based evaluation will continue. Add customer survey – customers include providers and practitioners and consumers, but not fully worked out yet. Third part will be "contribution to the system" – a lot more to be figured out on this, but we intend to reward PROs for contributing to the system. Structure. The term "Peer Review Organizations" has a lot of baggage, and people don’t know what they are. Will use "QIOs" in the future, "some PROs" are using this term already. A national QI Advisory Committee will be established if we can get authority under FACA. Consumer Advisory Committee will be required for each QIO. Most have them. Real push for greater Board diversity – leadership is not coming from CMS but is coming from PROs that have done it: Not want QIO boards to look like a 1900 Rotary Club meeting Need to look more like America Not be so dominated by physicians as many are now – job of QIOs is too now far too multifaceted for a physician board to have all the requisite breadth. Some things don’t change. HCQIP name will stay, as will our goal to improve health of population. Many PROs have made partnerships a way of doing business White House wants CMS to use community based partnerships more, we need to do it to save money in program. We’ve spent billions on setting up relationships with individual providers partnerships up, if we don’t have them now, we aren’t going to get them now. Not affordable to duplicate efforts, need to get every doctor and hospital working on same projects, same processes Burden is greatest barrier to quality improvement today, used to be indifference. Particularly impressed with what AZ has accomplished with MCOs, getting them working together. Some will say, "how can we force them to participate?" but we have found ways to do this. Common message includes: Promoting the Business Case for Improvement Will soon have results from a study we’re doing now. The problem is not that Q costs money, it saves money. But the challenge that it doesn’t necessarily save money for those that make the investment. Need to create demand for improved quality Community coalition may be able to make consumers into active partners. [At this point, SFJ polls audience, notes that about half are using consolidated approach to ambulatory projects, in which all topics are being worked on in each location.] Most of the inpatient projects are already done this way, the heart of it is medication mgt. New topics in SOW7. Stroke is dropping out of SOW7: JCAHO decided not to have PRO measures, this undermines hospitals’ willingness to collect the data Having a lot of trouble reliably abstracting A Fib measure Nifedipine: we’ve declared victory Could still work with anti thrombotic therapy, but want to line up with the JCAHO. Surgical Site Infection: New topic Will address a series of problems – reducing post op UTI, post op site infection, post op pneumonias. Nursing Homes (HNs) and Home Health About a third of PROs doing NH projects today All QIOs will do this in SOW7 5 state pilot starting in January 2002 Will publish performance sometime around October 2002 on every NH Every QIO will be involved in an intensive media program, will be a big challenge. PRO communications shops are not experienced at this new work. Every QIO will be working on community based QI projects with NHs Measures will be on the Web, don’t know them all yet. Expect from conversations with NH industry there will be strong interest (HHAs too, will release this a year later) Because of lack of NH infrastructure, need a new approach. Standing Orders project is an example of creating systems that need to be implemented in NHs. We have never done anything like this before, combining media campaign with QI effort. The pilots will be very helpful, and wish we had more time, but political leadership has moved this to front burner. Patient Safety Key for new Administration Core activity already for the PROs Need a monitoring system Carotid Endarterectomy project we’ve been discussing is competing for resources, and may not be a national project as a result. It may be a better use of resources to focus all QIOs on the general surgery QI effort, for example, this effort links up better with an existing national American College of Surgeons (ACS) project. Ambulatory Ed Wagner’s chronic disease and prevention model is something we hope to be in a position to implement nationally in SOW8 – not ready in time for SOW7. MCO efforts need to be integrated fully into QIO efforts to be fair to physicians, avoid duplicative efforts. Disparities effort Significant change will be to include rural underservice as an equally important marker of disparities as others we’ve been working on. Media campaign Unclear how much control at QIO level. Best guess is that there will be a lot of national materials prepared, national focus group testing of messages, national media buying contract – these elements more efficiently done nationally. But QIOs will see a lot of ability to tailor the messages locally, promote their local HCQIP efforts. We don’t know how much money, but in NHs will probably spend as much on media effort as on improvement projects. Getting consumers activated through a media campaign is not a worked out effort. Pilots in the 5 states start in April, results being available by October will be a great challenge. In October 2/3 of PROs will still be in SOW6, so we’ll have to have a contract mod, use unspent funds. By the end of SOW7 Expect to be reliant almost entirely on hospital abstracted data, not CDACs CDACs are too costly to use for provider level data, very slow, and improvement cycle depending on them. Credibility of their accuracy is not there among the providers and the PROs too – validating the data is common, this amounts to rework. Helping the hospitals to do this themselves is the key. Will still be voluntary approach – CMS is not saying they will require data collection. But the JCAHO has, several States have, the National Q Forum is talking this way, in terms of endorsing a national measures set next year. The national trend among PROs and hospitals is for PROs to persuade and assist hospitals to do their own abstraction. Hospitals and their associations are increasingly aware of and adapting to this trend. This will save money, improve knowledge and commitment to the data. PROs are showing this will work. Identifies IFMC efforts as exemplary in this regard. Beneficiary Protection Complaint process lawsuit unlikely to be resolved in less than a year. Have to reinvent the process, irrespective of the lawsuit. Three pronged approach: Mediation – a new thing to do How investigate complaints. Tells story. Woman takes husband to ED with chest pain. He died. The PRO found no quality problem. She also complained to the licensing board, and they went onsite to investigate. She asked for protocol for managing chest pain in the ED, and there wasn’t one. Steve says you could read charts forever and not realize that this place had no system for managing chest pain. We need a new way to approach these cases. Seeking legislative clarification. Law has seemingly contradictory provisions – confidential peer review process, and report results to complainants. Want Congress to resolve this by clarifying the law putting emphasis on resolving complaints, working on system changes. Example of Data Driven Public Policy PEPP data suggests we are not reducing payment errors nationally Coding errors impact on trust fund is one tenth of one percent of HI Trust Fund, could never get enough of a sample to identify whether we made a difference in this. Billing errors are mostly about observation admissions. This is not a PRO issue so much as a problem of clarifying language so hospitals know what to do. A policy issue. But still not where the big money is. Admissions necessity is the big area, maybe $2 billion a year, twenty times the coding errors cost to the HI Trust Fund. Look at where these are concentrated: see they are exactly where you know there is a great deal of dispute over whether to admit patients: back pain, chest pain, GI problems. Coral Initiative found 70% agreement between case reviewers [in looking at admissions necessity?]. You’d expect 50% by chance. We stopped doing case review for quality improvement for exactly these reasons. Henry Krakauer used to characterize case review as "trying to measure a jellyfish with a slinky." What we are planning to do is continue to monitor payment error, do limited number of projects where we are clear on the right thing to do. But otherwise will back off and do pilots to examine certain questions, such as admission for chest pain (where the science is good but not implemented). Voluntary hospital public reporting system Confidentiality is a foundational issue for us. People won’t report unless it is confidential. Some identifiable data has gone out of PROs inappropriately. Medical records have disappeared and the PRO hasn’t taken substantive action to recover them. We have currently a person shopping around for a PRO to share Part B data with him to help his research effort (encourages PROs not to work with him). Models Project A PRO CEO has worried about this project being destructive to PRO innovation. But the doctors say the same thing when we try to get them to use protocols. Our purpose is to allow us to work together better, to sharpen definitions, to permit information exchange regarding what is working. There is no way to learn about the effectiveness of what we’re doing without good definitions. These are not going to be required approaches. Not meant to lock QIOs into using a particular model throughout their contract when they say they are starting there. Change our culture Book Shirley Kellie recommends: "Common Knowledge" Author says it doesn’t work to get all the data in one place, a data warehouse. By contrast, get people talking to one another, sharing ideas, works. She says also that sharing information is how you get culture change, not start with trying to create a new culture to promote sharing. We’ll remove competition between PROs in SOW7, but that won’t stop competition. We will also implement a series of awards, give these out at the AHQA TC. We will give as many as are warranted. No money involved. Awards will be: First: Innovation in making information available – Second: Excellence in internal management improvement by Rapid Cycle Improvement Third: Excellence in learning from others. Fourth: Contributing to program excellence by identifying and reporting things that did not work. Question and Answer Period. Laiben Q: Oryx project shows that even small hospitals have to hire several staff to do abstraction. Can we use some of the CDAC money to help hospitals with costs? SFJ: Unlikely. But a lot of technical assistance from the QIO and auditing and improving reliability can reduce the hospitals and other providers costs. Q: Some hospitals, even large ones, drop out because of abstraction costs. A real problem. SFJ: When we get an NQF measure set, we will see if enough employers get behind it to make a business case for investing the resources in getting the data. We are moving to a political tipping point. Simmens Q: What about developing community coalitions around problems identified by the community, rather than what we bring to them as topics? SFJ: We cannot own a partnership. We can contribute to its successes, we can tell a coalition what we can contribute. For example, childhood immunizations is too far from our objectives for us to help them. But if a coalition suggested depression topic, we might be able to bridge the gap with a special study. Must be win win [for us too]. Q: If hospitals didn’t have to pay JCAHO for data collection, they’d have money to do abstraction. Now that the PRO and Oryx indicators are the same, what about not have PROs give the data to the JCAHO, what discussion is underway on this? SFJ: Every PRO should be asking whether it is in their interest to be an Oryx vendor. We should be asking if a redefined Oryx vendor role makes sense for every PRO. It is inconceivably inefficient to gather the data twice. MPRO Q: Hospitals will only abstract once, for Oryx vendor. How will the hospital and the PRO get to see the data? Sample sizes will be too small for public disclosure. SFJ: This question should be asked by the hospital. If the Oryx vendor said to the hospital that you cannot have your own data back, the hospital ought to go get another vendor. Do we need a full size Medicare data sample? Probably not. In QISMC we are concluding that a project that includes Medicare beneficiaries is good enough to show us that it is improving care for Medicare. Q: PEPP SFJ: All PROs will be monitoring error rates. A few PROs will focus in on admissions issues. We don’t have this all worked out. SFJ: Our goal is to have a draft of the SOW7 out for comment by the middle of November.