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

2. 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

3. 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%

4. 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

5. 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

6. PPL Meeting Document

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

8. 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

9. 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)

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

11. Sentara Quality Care Network