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Hospital Quality Initiative: Preparing for Public Reporting.

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Presentation on theme: "Hospital Quality Initiative: Preparing for Public Reporting."— Presentation transcript:

1 Hospital Quality Initiative: Preparing for Public Reporting

2 Presenters Cassie Sauer Director, Advocacy & Public Relations Washington State Hospital Association Evan Stults Executive Director, QIO Support Center for Communications Qualis Health Earl Kurashige, RN Project Manager Qualis Health

3 Guests Rick McNaney, Government Task Leader, QIO Communications, CMS Central Office Diana Migchelbrink, Project Officer, CMS Seattle Regional Office

4 Webcast Outline Background on the quality initiative State and national launch activities for public reporting of quality data How to leverage public reporting for your hospital’s benefit Messages and positioning your hospital’s quality improvement efforts The future of the Hospital Quality Initiative

5 Background on the Hospital Quality Initiative

6 Quality Improvement Organization (QIO) In Washington State: Qualis Health Contracts with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (DHHS) Works with health care providers to improve the quality of care

7 The Hospital Quality Initiative Voluntary program for measuring hospital quality Provides information to improve hospital quality and to help consumers make more informed decisions

8 The Hospital Quality Initiative (cont.) Supported by AHA, AMA, Federation of American Hospitals, Association of American Medical Colleges, JCAHO; also consumer, union, and business groups Measures quality in three standardized areas: heart attack, heart failure, pneumonia

9 Timeline Spring / Summer 2004: Hospitals voluntarily enroll August 2004: Hospitals submit 1 st quarter data November 2004: Hospitals submit 2 nd quarter data December 2004: 1 st quarter 2004 data posted at Mid-February to mid-March 2005: Hospitals can preview 1 st and 2 nd quarter data March / April 2005: Public reporting begins at

10 Components of the Quality Initiative Community-based quality improvement support Consumer information for informed decision-making Collaboration and partnership to leverage knowledge and resources Regulation activities by state survey agencies and CMS Incentive for hospitals to voluntarily report quality measures

11 Benefits of the Quality Initiative – Hospitals’ View Create one uniform set of quality measurements Eliminate duplication and confusion with different money- making quality programs Engage hospitals in choosing measurements that make sense Receive higher Medicare payments

12 Three Components of the Initiative Hospital Quality Alliance (HQA), formerly the National Voluntary Hospital Reporting Initiative (NVHRI) Medicare Modernization Act of 2003, providing an annual payment update incentive for reporting hospital quality data Hospital Patient Perspectives on Care Survey (HCAHPS)

13 MMA Payment Issues Fiscal years Participation allows hospitals to get full market basket update Non-participation: market basket minus 0.4%

14 Market Basket versus Market Basket Minus 0.4% Total value for Washington: $5 million annually Examples of individual hospital benefit (annual figures): –Mason General Hospital: $21,000 –Yakima Valley Memorial: $86,000 –Sacred Heart: $386,000 –Swedish: $492,000

15 Critical Access Hospitals Washington has many (37) No payment benefit Some difficulty collecting data Over 400 signed up nationwide CMS to address appropriate quality measures of care Encouraged to sign up, even if not ready to submit data

16 The Data in Hospital Compare

17 The Measures Acute Myocardial Infarction Heart Failure Pneumonia Required for Payment Incentive 523 Optional322 Total845

18 The Measures Heart attack 1.Aspirin at arrival 2.Aspirin at discharge 3.Beta-blocker at arrival 4.Beta-blocker at discharge 5.ACE inhibitor for left ventricular systolic dysfunction (LVSD) Optional: Adult smoking cessation advice/counseling Thrombolytic agent received within 30 minutes of hospital arrival PTCA received within 90 minutes of hospital arrival

19 The Measures (cont.) Congestive heart failure 1.Left ventricular function (LVF) assessment 2.ACE inhibitor for left ventricular systolic dysfunction (LVSD) Optional: Discharge instructions Adult smoking cessation advice/counseling

20 The Measures (cont.) Pneumonia 1.Mean time to first antibiotic dose 2.Pneumococcal screening and/or vaccination 3.Oxygen assessment Optional: Blood cultures performed before first antibiotic received in hospital Adult smoking cessation advice/counseling

21 Preview Your Data First, know your data Preview period is now - closes March 10 Make sure you have reviewed your data Serious problems: contact Earl Kurashige Consider sharing your data with others in your media market so you are all prepared

22 How to See Your Data QualityNet Exchange webpage Accessible to hospital’s QNet Administrators My QNet Home/HQA Preview Reports

23 Understand Your Data Review your performance data –Compare with national averages Think about how to interpret the data Consider how will the public or referral sources will interpret the data and what you can tell them Research whether you have seen improvement since you started gathering data

24 Share Information Know the staff who compiled the data for the quality initiative Inform your administrator, staff, physicians, and referral sources about Hospital Compare Involve your governing board Prepare for questions Be proactive – educate your patients and the public, promote your hospital’s quality efforts

25 Washington’s Data Washington hospitals are about average on most measures Below average on pneumococcal vaccinations

26 The Public Launch of Hospital Compare

27 National Activities March / April 2005: Web launch of Hospital Compare CMS’s launch activities for previous quality initiatives (nursing home, home health) included: –Press conferences in Washington, D.C. –Other earned and paid media –National media outreach

28 Local Activities Media release for earned media Profiles of providers’ quality improvement successes Press conference, possibly at Harborview Hospitals in other areas can work together to do a joint press conference Outreach materials for consumers

29 Purchased Advertising Qualis Health providing funds to purchase advertising with WSHA –Qualis Health and WSHA logos Message will feature collaboration and partnership Ads will refer patients to web site

30 WSHA Position WSHA Board Resolution: May 2003 Encourages hospitals to participate Affirms intention not to use any information generated for competitive marketing purposes Supports advancing best practices in health care and improving health care

31 Promote Hospital Participation Public reporting offers: –More information to help consumers make informed decisions about hospital care –More resources to help hospitals improve care –The opportunity for collaboration between hospitals, Qualis Health and WSHA Communicate your hospital’s enthusiasm for the Hospital Quality Initiative

32 If Your Data Are Good We are pleased with our performance. –Explain why you think your measures are good. These findings reflect our dedication to the care and comfort of our patients. These data represent a snapshot in time; quality is a priority that must constantly be monitored.

33 If Your Data Are Mixed We are pleased with our positive performance. We will examine those areas where there are opportunities for improvement. We have already seen improvement in xxxx. –Describe what you are doing to improve. –If you have new data, share it.

34 If Your Data Are Poor We are dedicated to the care and comfort of our patients and these data help us focus our efforts on areas to improve. We are taking all necessary action to ensure quality of care at our facility. We have already seen improvement in xxxx. –Describe what you are doing to improve. –If you have new data, share it.

35 Data Limitations We are just at the beginning of providing data on hospital quality Data are for just six months’ worth of patients on a relatively small set of measures Data should not be over- interpreted

36 Positive Positioning Develop key messages and talking points that highlight your hospital’s efforts to improve quality –In what QI efforts has your hospital participated? –What other QI activities are under way? –How have these efforts benefited your patients? –What projects have you done with Qualis Health? Frame your quality improvement efforts so that patients will relate to them

37 Positive Positioning Create a hospital quality profile –Number of patients, number of staff, awards, certification, special programs Include performance data in a success story about your hospital’s quality improvements –Patient stories and interviews can bring the data to life Find patients who can testify to your excellent care

38 Success Stories MultiCare Health System –Community Acquired Pneumonia order set Central Washington Hospital –Pre-printed Community Acquired Pneumonia Physician Orders Swedish Health Services –Five-fold improvement from early 2003

39 Media Become familiar with Hospital Compare –Review performance data during preview period and on morning of national launch Anticipate questions that may be uncomfortable Meet with local media in advance –Give them background –Share your scores –Do this with competitors!

40 What Not To Do CMS has discouraged marketing messages such as “rated #1 by Medicare” WSHA members agree not to use data for competitive marketing Be careful about promoting scores –New data every quarter –Data can shift significantly

41 The Future of Hospital Compare and Further Resources

42 Expansions of the Initiative –New voluntarily reported measures for the three initial conditions (heart attack, heart failure, and pneumonia) in early 2005 –First-time voluntarily reported measures on prevention of surgical infections may be posted publicly in mid to late 2005 –Information about patients’ perspectives on their care may be added in late 2005

43 Learn More Centers for Medicare & Medicaid Services –www.cms.hhs.gov/quality/hospital/ Qualis Health –www.qualishealth.org Washington State Hospital Association –www.wsha.org

44 Preview Hospital Compare CMS web conference March 10 from 10-11:30 a.m. (PST) Details on plans for the national rollout of the site Live question and answer session /HQIDescription.pdf /HQIDescription.pdf

45 Comments from CMS Rick McNaney, Government Task Leader, QIO Communications, CMS Central Office

46 For More Information Evan Stults, Qualis Health , ext Earl Kurashige, Qualis Health , ext Cassie Sauer, WSHA 206/

47 Questions? Comments?

48 Thank you for participating! Please fill out the evaluation.


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