Quality Improvement Leadership Council Group Metrics October 3, 2012 Gaylord National Harbor Washington, D.C. Sentara Medical Group

What are you measuring now? Share your measures, dashboards? Medical Affairs Committee Transformation of Care Distribution Analysis Meaningful Use Physician Quality Reporting System NRC Customer Satisfaction Survey Tool

SMG Transformation of Care Data from June 2012 (except readmits and generic usage which are through May)   Goal reached Improvement but short of goal Goal not reached Wave 1 IM: Wave 1 FP: Wave 2 FP: SIMP-Kempsville SFMP-First Colonial SFMP-Prov Rd SFMP-Independence SFMP-Chimney Hill Measures 2011 Base 2012 YTD 2012 Goal 1. MyChart patients. 4,477 5,282 5,317 4,579 5,007 5,299 5,572 6,203 6,262 3,203 3,653 3,762 2,956 3,553 3,436 2. 30-day all-cause readmission rates following discharge to home for Medical Diagnosis. Definition: the average of the monthly readmission percentage for patients discharged to home for medical diagnosis. 14.0% 13.0% 9.8% 16.0% 13.6% 14.8% 18.0% 16.2% 16.7% 15.0% 13.9% 3. ED visit rates (med - ED visits/1000 patients/month). Definition: The monthly average. 16.4% 15.4% 15.6% 8.6% 8.3% 8.2% 11.5% 11.1% 10.9% 12.0% 10.3% 11.4% 13.8% 14.1% 4. D5 (all-or-none) measure. Definition: the percentage of diabetic patients with BP<140/90 AND HbA1c<8 AND LDL<100 AND nonsmoker AND Aspirin (if existing vascular disease and not contraindicated). 28.0% 29.7% 31.0% 41.5% 45.6% 44.5% 30.5% 32.3% 33.5% 27.3% 30.1% 30.3% 24.0% 25.7% 27.0% 5. Generic prescription usage rate. Optima Population only. 81.9 83.6 82.5* 77.3 79.1 79.3 80.5 81.2 78.5 80.6 82.2 6. Jul-Dec: Improved Diabetic Eye Exam rates by implementing developed methodology. Definition: The number of diabetic patients with an Eye Exam documented in Health Maintenance as of the extract date. The baseline was the December data. 57.0% 52.9% 60.0% 67.0% 65.2% 70.0% 47.0% 62.7% 50.0% 48.0% 55.4% 51.0% 41.0% 40.7% 44.0% 7. Improve patient satisfaction as measured by SMG Patient Satisfaction Survey 77.7 85.4 79.7 85.6 89.8 87.6 74.5 77.0 76.5 80.3 83.2 83.9 82.7 85.9 8. Rate of 7-day follow up visit with PCP after Hospital Discharge for Medical Diagnosis 31.9% 31.6% M 37.9% 40.4% 27.9% 28.8% 33.2% 34.1% 9. ACP for VIP Population 2.0% 20.4% 3.4% 23.9% 13.4% 1.8% 22.1% 11.8% 1.6% 11.6% 1.9% 21.0% 11.9%

Ischemic Vascular Disease Customer Satisfaction SMG MAC Scorecard Diabetes   2010 2011 All SMG 2012 All SMG Goal YTD July 2012 All SMG Actual HEDIS Commercial Top 25% HEDIS Commercial Top 10% HbA1c (<8.0) 70% 72% 71% 66% LDL (<100) 54% 52% 51% 55% BP (<140/90) 69% 73% 74% 75% Microalbumin 59% 61% 63% 62% 84% 88% Eye Exam 33% 42% 44% 45% Ischemic Vascular Disease 68% Adult Preventive Screening *Breast Cancer 47% 78% *Colon Cancer 39% 48% 50% *Cervical Cancer 32% 46% 79% 82% Customer Satisfaction Combined NRC Picker Top 25% NRC Picker Top 10% Rate your provider ---- 79.1% 80.0% 83.3% 86.8% 92.2% Recommend this office 91.2% 93.4% 90.7% 94.2% 96.8% *Screenings are undercounted due to documentation process in Epic

SMG Transformation of Care Measures 2011-Base YTD Performance 2012-Goal 1. MyChart patients 1206 1511 1446 2. 30-day all-cause readmission rates 0.16 0.086 0.154 3. ED visit (ED visits/1000 patients/month) 7.7 7.65 7.5 4. D5 (all-or-none) 0.254 0.3403 0.269 5. Generic prescription usage rate 0.804 0.813 0.814 6. Improved Diabetic Eye Exam rates 0.56 0.6837 0.59 7. Improve patient satisfaction (SMG Survey) 0.877 0.857 0.897 8. Rate of 7-day follow up visit after Hospital Discharge 0.156 0.3077 9. ACP for VIP Population 0.114 0.5 0.214 10. Medical Home Meetings (Wave 3) Meets Goal Improvement but Short of Goal Not meeting Goal

PPL Meeting Document

Do you have measures for specialties? Meaningful Use Physician Quality Reporting System NRC Customer Satisfaction Survey Tool

PQRS Measure # Measure Title Provider/Division 1 Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus FAMILY MEDICINE, INTERNAL MEDICINE, ENDOCRINOLOGY 2 Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus 3 Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus 6 Coronary Artery Disease (CAD): Antiplatelet Therapy Sentara Cardiology Specialists, Williamsburg Intensivist, Sentara Long Term Care 20 Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician Virginia Ortho & Sports Medicine, Sentara Surgery Specialists, Sentara Metabolic and Weight Loss Surgery Center, Vascular & Transplant Specialists (excluding N.P.'s) 21 Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin Virginia Ortho & Sports Med , Sentara Surgery Specialists 22 Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac Procedures) Virginia Ortho & Sports Medicine, Sentara Surgery Specialists, Sentara Metabolic and Weight Loss Center 23 Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) Sentara Surgery Specialists, Sentara Metabolic and Weight Loss Center, Vascular & Transplant Specialists 24 Osteoporosis: Communication with the Physician Managing On-going Care Post-Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older Sentara Hand Surgery Specialists, Sentara Orthopedic Trauma 30 Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics Sentara Anesthesiology Specialists (MDs and CRNAs) 31 Stroke and Stroke Rehabilitation: Deep Vein Thrombosis (DVT) Prophylaxis for Ischemic Stroke or Intracranial Hemorrhage Sentara Neurology Specialists, Sentara Hospital Medicine Physicians, Intensivist, Sentara Pulmonary Specialists Physician Assistants 32 Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy Sentara Hospital Medicine Physicians 36 Stroke and Stroke Rehabilitation: Rehabilitation Services Ordered Sentara Neurology Specialists 41 Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older Sentara Rheumatology Specialists 47 Advance Care Plan Intensivist, Pulmonary Physicians Assistants, Sentara Neurology Specialists, Sentara Hospital Medicine Physicians 71 Breast Cancer: Hormonal Therapy for Stage IC–IIIC Estrogen Receptor/ Progesterone Receptor (ER/PR) Positive Breast Cancer Sentara Surgery Specialists 76 Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol Intensivist, Pulmonary Physicians Assistants, Sentara Anesthesiology Specialists (MDs ONLY), Sentara Surgery Specialists 106 Major Depressive Disorder (MDD): Diagnostic Evaluation 107 Major Depressive Disorder (MDD): Suicide Risk Assessment 108 Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy 110 Preventive Care and Screening: Influenza Immunization Princess Anne ENT & Allergy, Sentara Pulmonary, Sentara Pulmonary Physician Assistant 111 Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older Sentara Pulmonary, Sentara Pulmonary Physician Assistant 121 Adult Kidney Disease: Laboratory Testing (Lipid Profile) Sentara Long Term Care 124 Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR) All Epic Sites 126 Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy- Neurological Evaluation Virginia Podiatry

PQRS (continued) 127 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention- Evaluation of Footwear Virginia Podiatry 128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Sentara Metabolic and Weight Loss Surgery Center, Sentara Cardiology Specialists, Sentara Surgery Specialists, Sentara Orthopedic Trauma 130 Documentation of Current Medications in the Medical Record Emergency Medicine, Sentara Cardiology Specialists, Sentara Neurology Specialists, Sentara Physical Medicine, Sentara Physical Medicine, Sentara Hand Surgery Specialists, Sentara Neurosurgery Specialists, Advanced Heart Failure, Sentara Orthopedic Trauma Specialists, Sentara Metabolic and Weight Loss Surgery Center 131 Pain Assessment and Follow-Up Sentara Surgery Specialists-Leigh 142 Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or Analgesic Over-the-Counter (OTC) Medications Virginia Ortho & Sports Med, Sentara Physical Medicine 148 Back Pain: Initial Visit (Back Pain Measures Group) Sentara Pain Management, Sentara Interventional Pain Management 149 Back Pain: Physical Exam (Back Pain Measures Group) 150 Back Pain: Advice for Normal Activities (Back Pain Measures Group) 151 Back Pain: Advice Against Bed Rest (Back Pain Measures Group) 158 Carotid Endarterectomy: Use of Patch During Conventional Carotid Endarterectomy Vascular & Transplant Specialists 163 Diabetes Mellitus: Foot Exam 172 Hemodialysis Vascular Access Decision-Making by Surgeon to Maximize Placement of Autogenous Arterial Venous (AV) Fistula 183 Hepatitis C: Hepatitis A Vaccination in Patients with HCV Sentara Dermatology Specialists, Sentara Infectious Diseases Specialists 184 Hepatitis C: Hepatitis B Vaccination in Patients with HCV Sentara Dermatology Specialists, Sentara Infectious Diseases Specialists 186 Chronic Wound Care: Use of Compression System in Patients with Venous Ulcers 189 Referral for Otologic Evaluation for Patients with a History of Active Drainage From the Ear Within the Previous 90 Days Sentara Hearing and Balance Center 190 Referral for Otologic Evaluation for Patients with a History of Sudden or Rapidly Progressive Hearing Loss 193 Perioperative Temperature Management Sentara Anesthesiology Specialists(MDs and CRNAs) 194 Oncology: Cancer Stage Documented Sentara Surgery Specialists 204 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic Sentara Neurology Specialists, Vascular & Transplant Specialists 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Emergency Medicine, Virginia Ortho & Sports Medicine, Princess Anne ENT & Allergy, Pulmonary, Sentara Physical Medicine, Advanced Heart Failure, Sentara Ortho Trauma Specialists, Sentara Surgery Specialists 246 Chronic Wound Care: Use of Wet to Dry Dressings in Patients with Chronic Skin Ulcers Sentara Long Term Care 201 Ischemic Vascular Disease (IVD): Blood Pressure Management Control (Ischemic Vascular Disease (IVD) Measures Group) Sentara Cardiology Specialists (CCL) Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic (Ischemic Vascular Disease (IVD) Measures Group) Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (Ischemic Vascular Disease (IVD) Measures Group)

What measures are you working on for the future? Sentara Quality Care Network

Sentara Quality Care Network