1 © 2004 TMIT IHI National Quality Forum Charles Denham, MD Franck Guilloteau Carol Ferguson, RN Leapfrog NQF Safe Practices Survey: A Road Map to Patient.

9 © 2004 TMIT 9 The Facts: Where are we? Facts Regarding Harm and Adverse Events: From 98,000 to 195,000 deaths – little progress in 5 yrs 1 From 1 out of 4 admissions have an ADE 2 Facts Regarding JCAHO: Extremely Negative GAO Report on JCAHO 3 Federal Bills Moving Power From JCAHO to CMS 4-5 Sources: 1.HealthGrades Quality Study: Patient Safety in American Hospitals. July, 2004. 2.Rozich JD, Haraden CR, Resar RK. Adverse Drug Event Trigger Tool: A Practical Methodology for Measuring Medication Related Harm. Quality and Safety in Healthcare. 2003;12:194-200. 3.U.S. Government Accountability Office. CMS Need Additional Authority to Adequately Oversee Patient Safety in Hospitals. Washington, D.C. July, 2004. 4.H.R. 4877, Sponsored by Fortney Pete Stark (D-CA), Introduced 07/20/04. 5.S. 2698, Sponsored by Charles E. Grassley (R-IA), Introduced 07/20/04.

10 U.S. News & World Report November 8, 2004 How to Be a Smart Patient Modern Healthcare November 1, 2004 Patient Safety Proves Elusive Wall Street Journal November 5, 2004 FDA Plans Major Review of Procedures Modern Healthcare November 1, 2004 Rurals May Lose in Quality Quest Institute of Medicine November 1, 2004 Quality Through Collaboration: The Future of Rural Health Care

12 Modern Physician November 15, 2004 Quality Group Calls Meeting on Establishing Benchmarks Kaiser Family Foundation, AHRQ, Harvard School of Public Health November 17, 2004 Five Years After IOM Report, Half of Consumers Worry About Safety of Health Care New England Journal of Medicine November 11, 2004 Improving Patient Safety – Five Years after the IOM Report Wall Street Journal November 17, 2004 Hospitals Make Fewer Errors, But all Short on Safety Goals Leapfrog Group November 16, 2004 Survey Results Published

18 © 2004 TMIT 18 The Facts: Where are we? Facts Regarding Personal Adverse Event Experience: 4 out of 10 consumers experienced harm or death. More than 1 out of 3 physicians have a family member who experienced harm or death. Little progress since first IOM Report in 1999. Source: Blendon RJ, DesRoches CM, et al. Views of Practicing Physicians and the Public on Medical Errors. NEJM 2002;347:1933-40.

19 © 2004 TMIT 19 Physician and Consumers Family Experience: Breakdown of Adverse Events 42% 35% 24% 28% 13% 10% 5% 7% Physicians Public Total Serious Health Consequences Minor Health Consequences No Health Consequences Source: Blendon RJ, DesRoches CM, et al. Views of Practicing Physicians and the Public on Medical Errors. NEJM 2002;347:1933-40.

20 © 2004 TMIT 20 Significant loss of time at work, school, or other important life activities 17% 12% 16% 11% 12% 8% 11% 6% 10% 7% Severe pain Temporary disability Long-term disability Death Physicians Public Physician and Consumers Family Experience: Breakdown of Adverse Events with “Serious Consequences” Source: Blendon RJ, DesRoches CM, et al. Views of Practicing Physicians and the Public on Medical Errors. NEJM 2002;347:1933-40.

21 © 2004 TMIT 21 The Facts: Where are we? Facts Regarding Evidence-Based Medicine: Less than 25% of care by physicians is substantiated by evidence in the literature. 1 Even when best practices are established in the literature, less than 55% of U.S. care is delivered using such best practices 2 Sources 1.Research on the delivery of medical care using hospital firms. Proceedings of a workshop. April 30 and May 1, 1990, Bethesda, MD. Med Care, 1991;29(7 Suppl):JS1-70. 2.McGlynn EA, et al. Quality of Health Care Delivered to Adults in the United States. NEJM, 2003;348(26):2635-45.

22 © 2004 TMIT 22 Facts Regarding Innovation Adoption: 17-year average adoption rate when evidence is established in the literature 1 Reimbursement single most important accelerator The Facts: Where are we? Source 1.Balas EA, Boren SA. Managing Clinical Knowledge for Health Care Improvement. Yearbook of Medical Informatics 2000: Patient-centered Systems. Stuttgart, Germany: Schattauer, 2000:65-70.

23 © 2004 TMIT 23 Original research Publication Acceptance Submission Bibliographic databases Reviews, guidelines, textbook Implementation 48% 46% 35% 50% Negative results Lack of numbers Inconsistent indexing variable 0.5 year 0.6 year 0.3 year 6-13 years 9.3 years Kumar, 1992 Poyer, 1982 Antman, 1992 Dickersin, 1987 Koren, 1989 Balas, 1995 Poynard, 1985 It takes 17 years to implement 14% of original research as evidence-based medicine

24 © 2003 TMIT Overall Perceptions 55% 44% 20042000* Percent who say they are dissatisfied with the quality of health care in this country… 4% 40% 38% 17% Gotten worse Gotten better Stayed about the same Don’t Know * Gallup Poll conducted September 11-13, 2000 with 1,008 U.S. adults. Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey on Consumers’ Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2004) Has the quality of health care in this country…

25 © 2003 TMIT Which comes closer to your view… 199620042002 27% 69% 27% 67% 36% 59% Friends and family don’t have enough knowledge and experience to provide good information about health plans The opinions of friends and family are a good source of information about health plans Employers are a good source of information about the quality of different health plans because they examine plans closely when deciding which ones to offer Employers are NOT a good source of information about the quality of health plans because their main concern is saving the company money 58% 36% 61% 29% 69% 25% Note: “Don’t know” responses not shown Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey on Consumers’ Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2004) Sources Of Information On Quality

27 © 2004 TMIT 27 Safe Practice Background “National Quality Forum Safe Practices for Better Healthcare: A Consensus Report” was developed to help standardize evidence-based safe practices of care. The Leapfrog NQF Safe Practices ‘Leap’ is using these safe practices to survey hospital performance

29 © 2004 TMIT 29 The Leapfrog NQF Safe Practices ‘Leap #4’ NQF endorsed 30 high-priority Safe Practices to be universally applied in relevant clinical care settings Includes Leapfrog’s initial 3 safe practices Leapfrog will now assess hospitals’ progress on the remaining 27 safe practices

30 © 2004 TMIT 30 Development of this New Survey Survey Tool developed by Texas Medical Institute of Technology (TMIT) 27 practices weighted according to patient safety impact, combined into a single score (1,000) Relative ranking compared to other hospitals - placed into quartiles First Public Results to be released in mid-July 2004

© 2003 TMIT Leapfrog Survey 1.0. 11.17.03 1600 CT 31 Enterprise-wide System #PracticeFinal Weighting out of 1,000 points 1Create Safety Culture263 3Ensure Adequate Nursing Workforce119 SUBTOTAL382 Enterprise-wide Process 6Verbal Order Readback36 7Standardized Abbrev./Doses17 8No Pt Care Summaries from Memory17 9Pt Care Info/Orders to all Providers84 SUBTOTAL154 TOTAL ENTERPRISE-WIDE536 Clinical Care Setting or Function Specific 5Pharmacist Active in Med Use32 10Pt Readback of Informed Consent9 11Document Resusc./End of Life/ Directives12 13Prevention of Mislabeled Radiographs16 14Wrong-site/Wrong-patient Prevention30 15Prophylactic Beta Blockers for Elective Surgery23 16Pressure Ulcer Prevention28 17DVT/VTE- Risk Assessment & Prevention27 18Anticoagulation Services39 19Aspiration Prevention24 20Central Venous Line Sepsis Prevention33 21Surgical Site Infection/AB Prophylaxis37 22Contrast-induced Renal Failure Protocol12 23Malnutrition Prevention12 24Tourniquet—Ischemia/Thrombosis Prevention9 25Hand Washing33 26Flu Vaccination for HC Workers11 27Optimize Medication Workspaces7 28Optimize Med. Storage/Pkg/Labeling22 29I.D. High Alert Medications21 30Med. Unit Dosing/Unit-of-Use Dispensing29 SUBTOTAL465 27 NQF Safe Practices Weighting Results 1,000 Points Applied to 27 Practices Weighted Individually Hospitals Nationally Ranked

© 2003 TMIT Leapfrog Survey 1.0. 11.17.03 1600 CT 32 Enterprise-wide System # PracticeFinal Weighting out of 1,000 points 1Create Safety Culture263 3Ensure Adequate Nursing Workforce119 SUBTOTAL382 Enterprise-wide Process 6Verbal Order Readback36 7Standardized Abbrev./Doses17 8No Pt Care Summaries from Memory17 9Pt Care Info/Orders to all Providers84 SUBTOTAL154 TOTAL ENTERPRISE-WIDE536 27 NQF Safe Practices Weighting Results

© 2003 TMIT Leapfrog Survey 1.0. 11.17.03 1600 CT 33 Clinical Care Setting or Function Specific 5Pharmacist Active in Med Use32 10Pt Readback of Informed Consent9 11Document Resusc./End of Life/ Directives12 13Prevention of Mislabeled Radiographs16 14Wrong-site/Wrong-patient Prevention30 15Prophylactic Beta Blockers for Elective Surgery23 16Pressure Ulcer Prevention28 17DVT/VTE- Risk Assessment & Prevention27 18Anticoagulation Services39 19Aspiration Prevention24 20Central Venous Line Sepsis Prevention33 27 NQF Safe Practices Weighting Results

© 2003 TMIT Leapfrog Survey 1.0. 11.17.03 1600 CT 34 Clinical Care Setting or Function Specific 21Surgical Site Infection/AB Prophylaxis37 22Contrast-induced Renal Failure Protocol12 23Malnutrition Prevention12 24Tourniquet—Ischemia/Thrombosis Prevention9 25Hand Washing33 26Flu Vaccination for HC Workers11 27Optimize Medication Workspaces7 28Optimize Med. Storage/Pkg/Labeling22 29I.D. High Alert Medications21 30Med. Unit Dosing/Unit-of-Use Dispensing29 SUBTOTAL465 27 NQF Safe Practices Weighting Results

© 2003 TMIT Leapfrog Survey 1.0 11.17.03 1600 CT 35 1.Compliment the NQF Safe Practices Report (May 2003): The survey, weighting system, and ranking system designs are explicitly tied to the problem areas and practices defined by the NQF report. Recognizing the challenges of tying standards, measures, or practices to a report that is written at a snapshot in time, the survey, weighting, and ranking systems take into account that new evidence and refinement of performance improvement methods are being generated all the time. Patient safety is an emerging science and is constantly evolving. Therefore, the guiding principles included focus on the excellent list of safety problems being targeted by NQF practices and apply the “4 A Framework” below. The “4 A Framework” provides real flexibility of interpretation and provides a means of providing partial credit for partial progress and partial credit for commitment to progress. Although the survey will undergo refinement through public review and optimization by our subject matter experts, the design will be kept intact in order to make the survey fair and reasonable. The goal is to neutralize the challenges of explicitly tying questions to specific language of practices that are evolving while staying well within the scope of the NQF report. 2.Partial Credit for Partial Progress: The questions were designed using a “select any that apply” response giving hospitals numerous opportunities for partial credit. Once significant public input is provided, a set of FAQs will be provided for each question to assure that respondents will have clarity regarding what will qualify for credit on a question specific basis. 3.Partial Credit for Commitment: Many of the questions provide partial credit to organizations that make substantial commitment to get started. This will help those that may be “behind the safety curve”. The intent is to provide a clear roadmap to organizations that have heretofore not prioritized safety. These questions are also intended to provide fairness in areas where patient safety issues have not been well publicized. 4.Systematic Application of 4A Framework : The 4A framework recognizes the sequential and interdependent nature of awareness of our performance opportunities, accountability of leadership, the ability to employ practices, and measurable action towards closing performance gaps. This “4A Framework” (updated from a 3 A framework published by C. Denham in 2001) was used as an organizational structure to allow systematic customization of survey questions. Awareness: Clearly, the leaders of an organization must be aware of performance problems before they can make any impact on them. The concept of THE problem or performance opportunity addresses the awareness by hospitals that there is evidence to support a common problem across all hospitals. The concept of OUR problem addresses awareness of the frequency and severity of adverse events to our patient population within our organization and recognition of the impact that practices or performance improvement methods can have on those adverse events. Awareness of THE performance opportunities and OUR performance opportunities are addressed in a relatively standardized manner in each survey question, however they were customized to each problem depending on the current state of awareness in the community. Accountability: A critical success factor to patient safety is accountability of the leadership to performance. Whether the mechanisms of personal performance reviews or performance compensation incentives are used, sustained gains in patient safety frequently do not occur without personal accountability of the leaders. This issue was addressed in a relatively standardized way throughout the survey, however the questions were fine tuned to the scope or care setting addressed by the practice. Ability: An organization may be aware of THE problem – a performance gap common to most hospitals. In fact they may be aware of OUR problem (their own) with clear evidence of frequency and severity of adverse events in their own patient population. They may even have awareness of the impact of a given practice, however if they do not invest in education or skill development and more importantly allocate real protected staff time and dollars to a given problem, the impact on safety is modest at best. Adding a patient safety responsibility to an already overloaded employee without carving out the time and providing them the necessary financial resources to make an impact sends a clear message to the organization. The “ability” related survey questions employ a graduated set of investment levels ranging from investment in education, skill development (training regarding the application of practices or performance improvement methods), dedicated HR, and dedicated line item budget allocations. Actions: Action activities were tied to the NQF cited best practices language as appropriate. Where there have been great strides in best practices, the survey questions provide latitude for activities deserving credit. A set of FAQs will be tied to each survey question that will provide guidance as to what activities may qualify for credit, especially if certain developments in patient safety have been substantiated in the literature after publication of the NQF report. Performance Improvement programs and project actions were given high emphasis, as such, these programs will require thorough literature reviews and examination of readily available practices be undertaken. Such initiatives would include but not limited to the NQF practices especially if there were new high impact actions that target the problems listed in the NQF report. Far more important than attestations of compliance to procedures, policies, and protocols are ongoing programs that have regular measurement and process improvement elements. 5.Sensitivity to use of the word “Problem”: Risk managers at hospital organizations have expressed concern over the use of the word “problem”, therefore wherever possible the term “performance opportunity” was used in the survey in place of the word “problem”. That is not to say the word problem is not used appropriately in the NQF report. It is. What Guiding Principles were used to design the 1.0 Survey Questions? 1.Compliment the NQF Safe Practices Report (May 2003): The survey, weighting system, and ranking system designs are explicitly tied to the problem areas and practices defined by the NQF report. Recognizing the challenges of tying standards, measures, or practices to a report that is written at a snapshot in time, the survey, weighting, and ranking systems take into account that new evidence and refinement of performance improvement methods are being generated all the time. Patient safety is an emerging science and is constantly evolving. The goal is to neutralize the challenges of explicitly tying questions to specific language of practices that are evolving while staying well within the scope of the NQF report.

© 2003 TMIT Leapfrog Survey 1.0 11.17.03 1600 CT 36 1.Compliment the NQF Safe Practices Report (May 2003): The survey, weighting system, and ranking system designs are explicitly tied to the problem areas and practices defined by the NQF report. Recognizing the challenges of tying standards, measures, or practices to a report that is written at a snapshot in time, the survey, weighting, and ranking systems take into account that new evidence and refinement of performance improvement methods are being generated all the time. Patient safety is an emerging science and is constantly evolving. Therefore, the guiding principles included focus on the excellent list of safety problems being targeted by NQF practices and apply the “4 A Framework” below. The “4 A Framework” provides real flexibility of interpretation and provides a means of providing partial credit for partial progress and partial credit for commitment to progress. Although the survey will undergo refinement through public review and optimization by our subject matter experts, the design will be kept intact in order to make the survey fair and reasonable. The goal is to neutralize the challenges of explicitly tying questions to specific language of practices that are evolving while staying well within the scope of the NQF report. 2.Partial Credit for Partial Progress: The questions were designed using a “select any that apply” response giving hospitals numerous opportunities for partial credit. Once significant public input is provided, a set of FAQs will be provided for each question to assure that respondents will have clarity regarding what will qualify for credit on a question specific basis. 3.Partial Credit for Commitment: Many of the questions provide partial credit to organizations that make substantial commitment to get started. This will help those that may be “behind the safety curve”. The intent is to provide a clear roadmap to organizations that have heretofore not prioritized safety. These questions are also intended to provide fairness in areas where patient safety issues have not been well publicized. 4.Systematic Application of 4A Framework : The 4A framework recognizes the sequential and interdependent nature of awareness of our performance opportunities, accountability of leadership, the ability to employ practices, and measurable action towards closing performance gaps. This “4A Framework” (updated from a 3 A framework published by C. Denham in 2001) was used as an organizational structure to allow systematic customization of survey questions. Awareness: Clearly, the leaders of an organization must be aware of performance problems before they can make any impact on them. The concept of THE problem or performance opportunity addresses the awareness by hospitals that there is evidence to support a common problem across all hospitals. The concept of OUR problem addresses awareness of the frequency and severity of adverse events to our patient population within our organization and recognition of the impact that practices or performance improvement methods can have on those adverse events. Awareness of THE performance opportunities and OUR performance opportunities are addressed in a relatively standardized manner in each survey question, however they were customized to each problem depending on the current state of awareness in the community. Accountability: A critical success factor to patient safety is accountability of the leadership to performance. Whether the mechanisms of personal performance reviews or performance compensation incentives are used, sustained gains in patient safety frequently do not occur without personal accountability of the leaders. This issue was addressed in a relatively standardized way throughout the survey, however the questions were fine tuned to the scope or care setting addressed by the practice. Ability: An organization may be aware of THE problem – a performance gap common to most hospitals. In fact they may be aware of OUR problem (their own) with clear evidence of frequency and severity of adverse events in their own patient population. They may even have awareness of the impact of a given practice, however if they do not invest in education or skill development and more importantly allocate real protected staff time and dollars to a given problem, the impact on safety is modest at best. Adding a patient safety responsibility to an already overloaded employee without carving out the time and providing them the necessary financial resources to make an impact sends a clear message to the organization. The “ability” related survey questions employ a graduated set of investment levels ranging from investment in education, skill development (training regarding the application of practices or performance improvement methods), dedicated HR, and dedicated line item budget allocations. Actions: Action activities were tied to the NQF cited best practices language as appropriate. Where there have been great strides in best practices, the survey questions provide latitude for activities deserving credit. A set of FAQs will be tied to each survey question that will provide guidance as to what activities may qualify for credit, especially if certain developments in patient safety have been substantiated in the literature after publication of the NQF report. Performance Improvement programs and project actions were given high emphasis, as such, these programs will require thorough literature reviews and examination of readily available practices be undertaken. Such initiatives would include but not limited to the NQF practices especially if there were new high impact actions that target the problems listed in the NQF report. Far more important than attestations of compliance to procedures, policies, and protocols are ongoing programs that have regular measurement and process improvement elements. 5.Sensitivity to use of the word “Problem”: Risk managers at hospital organizations have expressed concern over the use of the word “problem”, therefore wherever possible the term “performance opportunity” was used in the survey in place of the word “problem”. That is not to say the word problem is not used appropriately in the NQF report. It is. What Guiding Principles were used to design the 1.0 Survey Questions? 2.Partial Credit for Partial Progress: The questions were designed using a “select any that apply” response giving hospitals numerous opportunities for partial credit. Once significant public input is provided, a set of FAQs will be provided for each question to assure that respondents will have clarity regarding what will qualify for credit on a question specific basis. 3.Partial Credit for Commitment: Many of the questions provide partial credit to organizations that make substantial commitment to get started. This will help those that may be “behind the safety curve”. The intent is to provide a clear roadmap to organizations that have heretofore not prioritized safety. These questions are also intended to provide fairness in areas where patient safety issues have not been well publicized.

© 2003 TMIT Leapfrog Survey 1.0 11.17.03 1600 CT 37 1.Compliment the NQF Safe Practices Report (May 2003): The survey, weighting system, and ranking system designs are explicitly tied to the problem areas and practices defined by the NQF report. Recognizing the challenges of tying standards, measures, or practices to a report that is written at a snapshot in time, the survey, weighting, and ranking systems take into account that new evidence and refinement of performance improvement methods are being generated all the time. Patient safety is an emerging science and is constantly evolving. Therefore, the guiding principles included focus on the excellent list of safety problems being targeted by NQF practices and apply the “4 A Framework” below. The “4 A Framework” provides real flexibility of interpretation and provides a means of providing partial credit for partial progress and partial credit for commitment to progress. Although the survey will undergo refinement through public review and optimization by our subject matter experts, the design will be kept intact in order to make the survey fair and reasonable. The goal is to neutralize the challenges of explicitly tying questions to specific language of practices that are evolving while staying well within the scope of the NQF report. 2.Partial Credit for Partial Progress: The questions were designed using a “select any that apply” response giving hospitals numerous opportunities for partial credit. Once significant public input is provided, a set of FAQs will be provided for each question to assure that respondents will have clarity regarding what will qualify for credit on a question specific basis. 3.Partial Credit for Commitment: Many of the questions provide partial credit to organizations that make substantial commitment to get started. This will help those that may be “behind the safety curve”. The intent is to provide a clear roadmap to organizations that have heretofore not prioritized safety. These questions are also intended to provide fairness in areas where patient safety issues have not been well publicized. 4.Systematic Application of 4A Framework : The 4A framework recognizes the sequential and interdependent nature of awareness of our performance opportunities, accountability of leadership, the ability to employ practices, and measurable action towards closing performance gaps. This “4A Framework” (updated from a 3 A framework published by C. Denham in 2001) was used as an organizational structure to allow systematic customization of survey questions. Awareness: Clearly, the leaders of an organization must be aware of performance problems before they can make any impact on them. The concept of THE problem or performance opportunity addresses the awareness by hospitals that there is evidence to support a common problem across all hospitals. The concept of OUR problem addresses awareness of the frequency and severity of adverse events to our patient population within our organization and recognition of the impact that practices or performance improvement methods can have on those adverse events. Awareness of THE performance opportunities and OUR performance opportunities are addressed in a relatively standardized manner in each survey question, however they were customized to each problem depending on the current state of awareness in the community. Accountability: A critical success factor to patient safety is accountability of the leadership to performance. Whether the mechanisms of personal performance reviews or performance compensation incentives are used, sustained gains in patient safety frequently do not occur without personal accountability of the leaders. This issue was addressed in a relatively standardized way throughout the survey, however the questions were fine tuned to the scope or care setting addressed by the practice. Ability: An organization may be aware of THE problem – a performance gap common to most hospitals. In fact they may be aware of OUR problem (their own) with clear evidence of frequency and severity of adverse events in their own patient population. They may even have awareness of the impact of a given practice, however if they do not invest in education or skill development and more importantly allocate real protected staff time and dollars to a given problem, the impact on safety is modest at best. Adding a patient safety responsibility to an already overloaded employee without carving out the time and providing them the necessary financial resources to make an impact sends a clear message to the organization. The “ability” related survey questions employ a graduated set of investment levels ranging from investment in education, skill development (training regarding the application of practices or performance improvement methods), dedicated HR, and dedicated line item budget allocations. Actions: Action activities were tied to the NQF cited best practices language as appropriate. Where there have been great strides in best practices, the survey questions provide latitude for activities deserving credit. A set of FAQs will be tied to each survey question that will provide guidance as to what activities may qualify for credit, especially if certain developments in patient safety have been substantiated in the literature after publication of the NQF report. Performance Improvement programs and project actions were given high emphasis, as such, these programs will require thorough literature reviews and examination of readily available practices be undertaken. Such initiatives would include but not limited to the NQF practices especially if there were new high impact actions that target the problems listed in the NQF report. Far more important than attestations of compliance to procedures, policies, and protocols are ongoing programs that have regular measurement and process improvement elements. 5.Sensitivity to use of the word “Problem”: Risk managers at hospital organizations have expressed concern over the use of the word “problem”, therefore wherever possible the term “performance opportunity” was used in the survey in place of the word “problem”. That is not to say the word problem is not used appropriately in the NQF report. It is. What Guiding Principles were used to design the 1.0 Survey Questions? 4.Systematic Application of 4 A Framework: The 4A framework recognizes the sequential and interdependent nature of awareness of our performance opportunities, accountability of leadership, the ability to employ practices, and measurable action towards closing performance gaps. This “4A Framework” (updated from a 3 A framework published by C. Denham in 2001) was used as an organizational structure to allow systematic customization of survey questions.

© 2003 HCC Corporation 38 hccarchive\fdtncomp\communication\tools\ template\topdown.pot 38 OUR PROBLEM AWARENESS THE PROBLEM Evidence Of Education Commitment to Educate Commitment To Measure and Report To Admin Measured Events with Opportunity Report To Admin In Strategic/Ops Plan Commit To Strategic/Ops Plan ABILITY Commit to Invest in Education Commit to Invest in Skills Commit to Dedicated HR Commit to Budget Invest in Education Invest in Skills Dedicated HR Line Item Budget ACTION Commit to Performance Improvement Program Commit to Invest in Skills Commit to Clinical Functional Unit wide, Department-wide Service Line wide PI Program Commit to Enterprise-wide PI Program OR Rigorous Practice Implementation Basic Level of Practice Actions Intermediate Level of Practice Actions Enterprise-wide PI Program OR Rigorous Practice Implementation Clinical Functional Unit wide, Department-wide Service Line wide PI Program BOARD DEPT HEAD SR. EXECs CEO ACCOUNTABILITY Commitment to Dept. Head Accountability Commitment to Exec.s Accountability Commitment to CEO Accountability Commitment to Report Board The 4 A Framework provides a graduated scale of options for to Awareness, Accountability, Ability, and Action. The survey design was intended to deliver partial credit for partial progress in each of the 4 A categories. Partial credit for commitment is provided not only to help stratify the respondents but to create a Hawthorne effect: to encourage commitment through participation in the survey and recognition that a hospital organization could increase its score by making a commitment at the time of survey response. The Rural Hospital Task Force will apply the 4 A Framework to the first 3 Leapfrog Leaps. The objective is to create a fair and reasonable set of survey questions to address the unique characteristics of rural hospitals. 4 A Framework Confidential – Not to be distributed

© 2003 HCC Corporation 39 hccarchive\fdtncomp\communication\tools\ template\topdown.pot 39 OUR PROBLEM THE PROBLEM ABILITY Commit to Invest in Education Commit to Invest in Skills Commit to Dedicated HR Commit to Budget Invest in Education Invest in Skills Dedicated HR Line Item Budget ACTION Commit to Performance Improvement Program Commit to Invest in Skills Commit to Clinical Functional Unit wide, Department-wide Service Line wide PI Program Commit to Enterprise-wide PI Program OR Rigorous Practice Implementation Basic Level of Practice Actions Intermediate Level of Practice Actions Enterprise-wide PI Program OR Rigorous Practice Implementation Clinical Functional Unit wide, Department-wide Service Line wide PI Program BOARD DEPT HEAD SR. EXECs CEO ACCOUNTABILITY Commitment to Dept. Head Accountability Commitment to Exec.s Accountability Commitment to CEO Accountability Commitment to Report Board AWARENESS Evidence Of Education Commitment to Educate Commitment To Measure and Report To Admin Measured Events with Opportunity Report To Admin In Strategic/Ops Plan Commit To Strategic/Ops Plan Confidential – Not to be distributed AWARENESS Evidence Of Education Commitment to Educate Commitment To Measure and Report To Admin Measured Events with Opportunity Report To Admin In Strategic/Ops Plan Commit To Strategic/Ops Plan OUR PROBLEM THE PROBLEM

© 2003 HCC Corporation 40 hccarchive\fdtncomp\communication\tools\ template\topdown.pot 40 OUR PROBLEM THE PROBLEM ABILITY Commit to Invest in Education Commit to Invest in Skills Commit to Dedicated HR Commit to Budget Invest in Education Invest in Skills Dedicated HR Line Item Budget ACTION Commit to Performance Improvement Program Commit to Invest in Skills Commit to Clinical Functional Unit wide, Department-wide Service Line wide PI Program Commit to Enterprise-wide PI Program OR Rigorous Practice Implementation Basic Level of Practice Actions Intermediate Level of Practice Actions Enterprise-wide PI Program OR Rigorous Practice Implementation Clinical Functional Unit wide, Department-wide Service Line wide PI Program AWARENESS Evidence Of Education Commitment to Educate Commitment To Measure and Report To Admin Measured Events with Opportunity Report To Admin In Strategic/Ops Plan Commit To Strategic/Ops Plan Confidential – Not to be distributed BOARD DEPT HEAD SR. EXECs CEO Commitment to Exec.s Accountability ACCOUNTABILITY Commitment to Dept. Head Accountability Commitment to CEO Accountability Commitment to Report Board

© 2003 HCC Corporation 41 hccarchive\fdtncomp\communication\tools\ template\topdown.pot 41 OUR PROBLEM THE PROBLEM ACTION Commit to Performance Improvement Program Commit to Invest in Skills Commit to Clinical Functional Unit wide, Department-wide Service Line wide PI Program Commit to Enterprise-wide PI Program OR Rigorous Practice Implementation Basic Level of Practice Actions Intermediate Level of Practice Actions Enterprise-wide PI Program OR Rigorous Practice Implementation Clinical Functional Unit wide, Department-wide Service Line wide PI Program AWARENESS Evidence Of Education Commitment to Educate Commitment To Measure and Report To Admin Measured Events with Opportunity Report To Admin In Strategic/Ops Plan Commit To Strategic/Ops Plan Confidential – Not to be distributed ACCOUNTABILITY Commitment to Dept. Head Accountability Commitment to Exec.s Accountability Commitment to CEO Accountability Commitment to Report Board ABILITY Commit to Invest in Education Commit to Invest in Skills Commit to Dedicated HR Commit to Budget Invest in Education Invest in Skills Dedicated HR Line Item Budget

© 2003 HCC Corporation 42 hccarchive\fdtncomp\communication\tools\ template\topdown.pot 42 ABILITY Commit to Invest in Education Commit to Invest in Skills Commit to Dedicated HR Commit to Budget Invest in Education Invest in Skills Dedicated HR Line Item Budget OUR PROBLEM THE PROBLEM AWARENESS Evidence Of Education Commitment to Educate Commitment To Measure and Report To Admin Measured Events with Opportunity Report To Admin In Strategic/Ops Plan Commit To Strategic/Ops Plan Confidential – Not to be distributed ACCOUNTABILITY Commitment to Dept. Head Accountability Commitment to Exec.s Accountability Commitment to CEO Accountability Commitment to Report Board ACTION Commit to Performance Improvement Program Commit to Invest in Skills Commit to Clinical Functional Unit wide, Department-wide Service Line wide PI Program Commit to Enterprise-wide PI Program OR Rigorous Practice Implementation Basic Level of Practice Actions Intermediate Level of Practice Actions Enterprise-wide PI Program OR Rigorous Practice Implementation Clinical Functional Unit wide, Department-wide Service Line wide PI Program

45 © 2004 TMIT 45 NQF Survey Preliminary Results Overall number of survey respondents: 1,019Overall number of survey respondents: 1,019 Number of NQF Survey Respondents: 893Number of NQF Survey Respondents: 893 NQF Survey Respondent Percentage: 88%NQF Survey Respondent Percentage: 88% 75% Non Profit – 25% For Profit75% Non Profit – 25% For Profit Report to be Published 2 nd Quarter of 2005Report to be Published 2 nd Quarter of 2005 Overall number of survey respondents: 1,019Overall number of survey respondents: 1,019 Number of NQF Survey Respondents: 893Number of NQF Survey Respondents: 893 NQF Survey Respondent Percentage: 88%NQF Survey Respondent Percentage: 88% 75% Non Profit – 25% For Profit75% Non Profit – 25% For Profit Report to be Published 2 nd Quarter of 2005Report to be Published 2 nd Quarter of 2005

47 © 2004 TMIT 47 NQF Survey Preliminary Results 7 in 10 hospitals require a pharmacist to review all medication orders before medication is given to patients.7 in 10 hospitals require a pharmacist to review all medication orders before medication is given to patients. 8 in 10 hospitals have implemented procedures to avoid wrong-site surgeries8 in 10 hospitals have implemented procedures to avoid wrong-site surgeries 7 in 10 report they do not have an explicit protocol to ensure adequate nursing staff,7 in 10 report they do not have an explicit protocol to ensure adequate nursing staff, 7 in 10 do not have policy to check with patients to make sure they understand the risks of their procedures7 in 10 do not have policy to check with patients to make sure they understand the risks of their procedures 7 in 10 hospitals require a pharmacist to review all medication orders before medication is given to patients.7 in 10 hospitals require a pharmacist to review all medication orders before medication is given to patients. 8 in 10 hospitals have implemented procedures to avoid wrong-site surgeries8 in 10 hospitals have implemented procedures to avoid wrong-site surgeries 7 in 10 report they do not have an explicit protocol to ensure adequate nursing staff,7 in 10 report they do not have an explicit protocol to ensure adequate nursing staff, 7 in 10 do not have policy to check with patients to make sure they understand the risks of their procedures7 in 10 do not have policy to check with patients to make sure they understand the risks of their procedures

48 © 2004 TMIT 48 NQF Survey Preliminary Results 6 in 10 lack procedures for preventing malnutrition in patients6 in 10 lack procedures for preventing malnutrition in patients 5 in 10 report they do not have procedures in place to prevent bed sores (pressure ulcers)5 in 10 report they do not have procedures in place to prevent bed sores (pressure ulcers) 4 in 10 hospitals lack policies requiring workers to wash their hands with disinfectant before and after seeing a patient.4 in 10 hospitals lack policies requiring workers to wash their hands with disinfectant before and after seeing a patient. 6 in 10 lack procedures for preventing malnutrition in patients6 in 10 lack procedures for preventing malnutrition in patients 5 in 10 report they do not have procedures in place to prevent bed sores (pressure ulcers)5 in 10 report they do not have procedures in place to prevent bed sores (pressure ulcers) 4 in 10 hospitals lack policies requiring workers to wash their hands with disinfectant before and after seeing a patient.4 in 10 hospitals lack policies requiring workers to wash their hands with disinfectant before and after seeing a patient.

49 © 2004 TMIT 49 Are we moving the “Needle” Overall Commitment Ratio: 9.6%Overall Commitment Ratio: 9.6% For Profit Commitment slightly higherFor Profit Commitment slightly higher Commitment Ratio by Quartile:Commitment Ratio by Quartile: -Quartile 1: 7.1% -Quartile 2: 9.2% -Quartile 3: 12.4% -Quartile 4: 13.3% Overall Commitment Ratio: 9.6%Overall Commitment Ratio: 9.6% For Profit Commitment slightly higherFor Profit Commitment slightly higher Commitment Ratio by Quartile:Commitment Ratio by Quartile: -Quartile 1: 7.1% -Quartile 2: 9.2% -Quartile 3: 12.4% -Quartile 4: 13.3%

50 © 2004 TMIT 50 NQF Survey Preliminary Results Commitment Ratios for Key Safe Practices:Commitment Ratios for Key Safe Practices: - SP 1 (Create Safety Culture): 5.4% -SP 3 (Ensure Adequate Nursing Workforce): 5.4% -SP 9 (Pt Care Info/Orders to all Providers): 8.4% -SP 18 (Anticoagulation Services): 6.5% Commitment Ratios for Key Safe Practices:Commitment Ratios for Key Safe Practices: - SP 1 (Create Safety Culture): 5.4% -SP 3 (Ensure Adequate Nursing Workforce): 5.4% -SP 9 (Pt Care Info/Orders to all Providers): 8.4% -SP 18 (Anticoagulation Services): 6.5%

51 © 2004 TMIT 51 NQF Survey Preliminary Results Safe Practices with High Commitment Ratios:Safe Practices with High Commitment Ratios: -SP 15 (Prophylactic Beta Blockers for Elective Surgery): 56.5% -SP 17 (DVT/VTE - Risk Assessment & Prevention): 45.7% -SP 19 (Aspiration Prevention): 26.3% -SP 24 (Tourniquet - Ischemia/Thrombosis Prevention): 23.8% -SP 23 (Malnutrition Prevention): 21.1% Safe Practices with High Commitment Ratios:Safe Practices with High Commitment Ratios: -SP 15 (Prophylactic Beta Blockers for Elective Surgery): 56.5% -SP 17 (DVT/VTE - Risk Assessment & Prevention): 45.7% -SP 19 (Aspiration Prevention): 26.3% -SP 24 (Tourniquet - Ischemia/Thrombosis Prevention): 23.8% -SP 23 (Malnutrition Prevention): 21.1%

53 © 2003 TMIT 19% 12% 27% 15% 23% 35% 11% 22% 28% 9% 20002004 Hospitals Health Insurance Plans Doctors Percent who say they saw information in The past year comparing quality among… Percent who say they saw information On ANY of the above… Percent who say they saw quality information in the past year and used this information to make health care decisions… Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey on Consumers’ Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2004) Exposure To And Use Of Quality Information

54 © 2003 TMIT Percent of Americans who say they would prefer a… 2004 20001996 48% 46% 50% 38% 76% 20% Surgeon who has treated friends/family Surgeon that is rated higher Plan recommended by friends Plan highly rated by experts Hospital that Is familiar Hospital that is rated higher 61% 33% 62% 32% 72% 25% 45% 49% 47% 45% 52% 43% Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey on Consumers’ Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2004) Note: “Don’t know” responses not shown Relative Importance Of Quality Ratings

55 Purchaser Initiatives Founded by the Business Roundtable with support from the Robert Wood Johnson Foundation

56 Incentive & Reward Programs Growing 78 programs in Leapfrog Compendium – http://www.leapfroggroup.org/ircompendium.htm Search & sort by state, target & program structure –16 programs include Leapfrog measures –42 programs target physicians –22 programs target hospitals –6 programs target consumers Funded by Commonwealth Fund

57 Rewards Principles Top performers get increased market share through patient shift (co-pay/co-insurance differentials) and/or bonuses Other groups will get bonuses when they improve performance by moving up a group Rewards for top performers at baseline will kick in after second reporting period if they are still in the top cohort Rewards for all others will kick in after second consecutive reporting of sustained improvement or continued improvement

58 Incentives & Rewards Include Both Direct Financial Rewards and Market-Share Shift % of Contracted Payment Top Performance Bonus2.00% Improvement Bonus Cohort 3 to Cohort 21.25% Cohort 4 to Cohort 30.50% % of Contracted Payment 3.00% Hospital IncentivePatient Incentive* (Co-insurance reduction) +

62 © 2004 TMIT TMIT AssessCollectSubmitPlan Prepare Stage 1: Prepare Obtain hard copy or digital PDF version of the NQF Safe Practices for Better Health Care: A Consensus Report Print a hard copy of the Leapfrog survey and Frequently Asked Questions (FAQs) Organize Survey Submission team

63 © 2004 TMIT TMIT AssessCollectSubmit Prepare Stage 2: Plan Pull a team of “internal experts” together to help answer the survey Including: 1.Nursing 2.Pharmacy 3.Infection Control 4.Surgical Services 5.Administration Assign team member responsibilities for individual survey questions Develop Survey Submission Plan Plan

64 © 2004 TMIT TMIT AssessSubmit Prepare Stage 3: Collect Each team member collects source documents to support survey question answers Inventory source documents to each Safe Practice; establish a filing system as resource for gap analysis and future survey submissions Perform gap analysis to determine what documents are missing that need to support remaining survey questions Plan Collect

65 © 2004 TMIT TMIT Submit Prepare Stage 4: Assess Create a draft survey to determine baseline score Identify pre-submission actions that can be immediately implemented to finalize an answer to any survey questions. Identify Commitment answers to survey questions to optimize survey score Prepare potential Commitment Scenarios (see example) Plan Collect Assess

66 © 2004 TMIT TMIT Prepare Stage 5: Submit Final CEO Briefing Review baseline survey score Make decisions regarding immediate pre-submission actions Present optimized score with commitments Give recommendations for Performance Improvement Projects Plan Collect Assess Submit

67 © 2004 TMIT TMIT Prepare Stage 5: Submit (Continued) Submit to Leapfrog Web Site: www.leapfrog.medstat.com www.leapfrog.medstat.com Obtain CEO agreement to certify submission Acquire a Security Code from the Leapfrog Web Site Create Follow-up Action Plan Plan Collect Assess Submit

1 © 2004 TMIT IHI National Quality Forum Charles Denham, MD Franck Guilloteau Carol Ferguson, RN Leapfrog NQF Safe Practices Survey: A Road Map to Patient.

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1 © 2004 TMIT IHI National Quality Forum Charles Denham, MD Franck Guilloteau Carol Ferguson, RN Leapfrog NQF Safe Practices Survey: A Road Map to Patient.

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Presentation on theme: "1 © 2004 TMIT IHI National Quality Forum Charles Denham, MD Franck Guilloteau Carol Ferguson, RN Leapfrog NQF Safe Practices Survey: A Road Map to Patient."— Presentation transcript:

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