Comp2 Unit7b Lecture Slides

The Culture of Healthcare
Quality Measurement and Improvement

Lecture b
This material (Comp2_Unit7b) was developed by Oregon Health and Science University, funded by the Department of Health
and Human Services, Office of the National Coordinator for Health Information Technology under Award Number
IU24OC000015.
Quality Measurement and
Improvement
Learning Objectives
Define healthcare quality and the major types of quality
measures: structural, process, and outcome measures
(Lecture a)
Describe the current state of healthcare quality in the
United States (Lecture a)
Discuss the current healthcare quality measures used in
various healthcare settings in the US, including those
required for the HITECH meaningful use program
(Lecture b)
Describe the role of information technology in measuring
and improving healthcare quality (Lecture c)
Describe the results of current healthcare quality efforts
in the US (Lecture c)
2
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Lecture b
Sampling of Current Quality Programs
and Measures
Warning: There are many sets and acronyms, and they change
constantly
We are still early in the science of quality improvement (Berwick,
2008)
Science defined in an IOM report (2006)
Many measurements in use (Damberg, 2011) but still need
improvement (Pronovost, 2011)

Many measures have been developed, reflecting various perspectives
AHRQ maintains clearinghouse www.qualitymeasures.ahrq.gov
Growing consensus that standard sets are needed for each perspective

We will view them from following perspectives
Health plans
Outpatient
Inpatient
Quality measures in HITECH Stage 1 meaningful use program
3
Lecture b
Quality Reporting for Health Plans
Called out because of historic role
Health Plan Employer Data and Information Set
(HEDIS) by NCQA provides 60 measures that
evaluate health plans, particularly health
maintenance organizations
NCQA annual reports calculate lives saved
based on outcomes from adherence
4
Lecture b
HEDIS Categories and Example
Measures
Effectiveness of care
Childhood and adult immunizations
Use of beta blockers after myocardial infarction
Screening for various types of cancer
Comprehensive diabetes care

Access/availability of care
Access to preventive health services
Availability of primary care providers
Initiation of prenatal care

Satisfaction with care
Member satisfaction surveys

Use of service
Rate trends
5
Lecture b
Reporting for Outpatient Setting
In US, major efforts led by Centers for Medicare and Medicaid
Services (CMS, www.cms.hhs.gov) in Medicare program
Physician Quality Reporting System (PQRS, formerly PQRI,
http://www.cms.hhs.gov/pqri/)
Extra 1% reimbursement for reporting on large number of
measures (194 in 2011)
Also receive 0.5% for maintenance of certification
Bonus changes to penalty starting in 2015
Electronic Prescribing (eRx) Incentive Program
(http://www.cms.gov/ERxIncentive/ )
Extra 1% reimbursement for use of e-prescribing
Bonus continues through 2013; penalty starts in 2012
These quality measures are separate from meaningful use
regulations, for which the Government Accountability Office (GAO,
2011) has criticized CMS for inconsistencies across the programs
6
Lecture b
Some example PQRS measures
Hemoglobin a1c poor control in diabetes mellitus
Percentage of patients aged 18 to 75 years with diabetes
mellitus who had most recent hemoglobin A1c greater than
9.0%

Thoracic surgery: recording of clinical stage for lung cancer
and esophageal cancer resection
Percentage of surgical patients aged 18 years and older
undergoing resection for lung or esophageal cancer who
had clinical TNM staging prior to surgery

Weight assessment and counseling for children and
adolescents
Percentage of children 2 to 18 years of age whose weight
is classified based on BMI percentile for age and gender
7
Lecture b
Reporting for inpatient setting
Hospital Quality Alliance
(HQA, www.hospitalqualityalliance.org)
Collaboration among CMS, Joint Commission, and
others to create a starter set of quality measures for
various conditions
In Hospital Compare Project, hospitals voluntarily
provide quality information that can be accessed via a
Web sitewww.hospitalcompare.hhs.gov
Consists of two programs based on reporting to CMS
Inpatient Quality Reporting (IQR) for HQA data; not
participating results in 2% Medicare reimbursement reduction
Hospital Consumer Assessment of Healthcare Providers and
Systems (HCAPHS) reporting of patient satisfaction at
hospitals
8
Lecture b
HQA Categories and Examples
Myocardial infarction
Aspirin at arrival and discharge
Inpatient mortality

Heart failure
Discharge instructions
Evaluation of left ventricular systolic function

Pneumonia
Time to blood cultures and antibiotics
Pneumococcal and influenza vaccinations

Surgical infection prevention
Prophylactic antibiotics
Prophylaxis for deep venous thrombosis

Childrens asthma care
Reliever medication while hospitalized
Home Management Plan of Care Document
9
Lecture b
Other Inpatient Quality Initiatives
National Surgical Quality Improvement Program
(NSQIP www.acsnsqip.org)
Effort of American College of Surgeons to
measure, risk-adjust, and improve quality of
surgical care
University HealthSystem Consortium (UHC
www.uhc.edu)
Quality measurements to benchmark academic
medical centers
Measured by green dots and red dots ( to 2)
10
Lecture b
Clinical Quality Measures and
Meaningful Use (Blumenthal, 2010)
One of the five healthcare goals for meaningful
use is improving quality, safety, and efficiency
One of the 15 core measures for eligible
professionals (EPs) is reporting of clinical quality
measures to CMS or the states
One of the 14 core measures for eligible
hospitals (EHs) is reporting of clinical quality
measures to CMS or the states
11
Lecture b
Specific Quality Measures in
Meaningful Use Criteria
EPs must report on
3 core measures
Can substitute alternate core measures if
denominator of any core measure is 0
3 of 38 additional measures
EHs must report on 15 measures
Reporting by attestation in 2011 and provision of
data in 2012 and beyond
CMS aims to align all quality reporting programs,
i.e., PQRI, CHIPRA, IQR, etc.
12
Lecture b
EP core/alternative quality measures
Core
Hypertension: Blood Pressure Measurement
Preventive Care and Screening Measure Pair: a)
Tobacco Use Assessment, b) Tobacco Cessation
Intervention
Adult Weight Screening and Follow-up
Alternative
Weight Assessment and Counseling for Children
and Adolescents
Preventive Care and Screening: Influenza
Immunization for Patients 50 Years Old or Older
Childhood Immunization Status

13
Lecture b
EP additional quality measures (1-12)
1. Anti-depressant medication management: (a) Effective Acute
Phase Treatment, (b)Effective Continuation Phase Treatment
2. Appropriate Testing for Children with Pharyngitis
3. Asthma Assessment
4. Asthma Pharmacologic Therapy
5. Breast Cancer Screening
6. Cervical Cancer Screening
7. Chlamydia Screening for Women
8. Colorectal Cancer Screening
9. Controlling High Blood Pressure
10. Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD
Patients with Prior Myocardial Infarction (MI)
11. Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-
Cholesterol
12. Coronary Artery Disease (CAD): Oral Antiplatelet Therapy
Prescribed for Patients with CAD
14
Lecture b
13. Diabetes: Blood Pressure Management
14. Diabetes: Eye Exam
15. Diabetes: Foot Exam
16. Diabetes: Hemoglobin A1c Control (<8.0%)
17. Diabetes: Hemoglobin A1c Poor Control
18. Diabetes: Low Density Lipoprotein (LDL) Management and Control
19. Diabetes: Urine Screening
20. Diabetic Retinopathy: Communication with the Physician Managing Ongoing
Diabetes Care
21. Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema
and Level of Severity of Retinopathy
22. Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin
Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
23. Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction
(LVSD)
24. Heart Failure (HF): Warfarin Therapy Patients with Atrial Fibrillation
25. Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: a)
Initiation, b) Engagement
15
Lecture b
26. Ischemic Vascular Disease (IVD): Blood Pressure Management
27. Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control
28. Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
29. Low Back Pain: Use of Imaging Studies
30. Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen
Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer
31. Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients
32. Pneumonia Vaccination Status for Older Adults
33. Prenatal Care: Anti-D Immune Globulin
34. Prenatal Care: Screening for Human Immunodeficiency Virus (HIV)
35. Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation
36. Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk
Prostate Cancer Patients
37. Smoking and Tobacco Use Cessation, Medical Assistance: a) Advising Smokers
and Tobacco Users to Quit, b) Discussing Smoking and Tobacco Use Cessation
Medications, c) Discussing Smoking and Tobacco Use Cessation Strategies
38. Use of Appropriate Medications for Asthma
16
Lecture b
EH quality measures
Anticoagulation overlap therapy
Emergency Department Throughput admitted patients Admission decision time to
ED departure time for admitted patients
Emergency Department Throughput admitted patients Median time from ED
arrival to ED departure for admitted patients
Incidence of potentially preventable venous thromboembolism
Intensive Care Unit venous thromboembolism prophylaxis
Ischemic or hemorrhagic stroke Antithrombotic therapy by day 2
Ischemic or hemorrhagic stroke Rehabilitation assessment
Ischemic or hemorrhagic stroke Stroke education
Ischemic stroke Anticoagulation for atrial fibrillation/flutter
Ischemic stroke Discharge on anti-thrombotics
Ischemic stroke Discharge on statins
Ischemic stroke Thrombolytic therapy for patients arriving within 2 hours of
symptom onset
Platelet monitoring on unfractionated heparin
Venous thromboembolism discharge instructions
Venous thromboembolism prophylaxis within 24 hours of arrival
17
Lecture b
Improvement
Summary Lecture b
Many different healthcare quality measures are used
in a variety of settings from health plans to inpatient
to outpatient
Health plans most commonly have quality assessed
using the HEDIS measures of NCQA
Outpatient settings most often use measures in the
PQRS program
Inpatient settings have a variety of measures, but
most commonly used are those of the HQA
One of the core meaningful use criteria for EPs and
EHs is a series of quality measures

18
Lecture b
Improvement
References Lecture b
References
Anonymous. (2006). Performance Measurement: Accelerating Improvement. Washington, DC: National
Academies Press.
Anonymous. (2011). CMS Should Address Inconsistencies in Its Two Incentive Programs That Encourage the Use
of Health Information Technology. Washington, DC: Government Accountability Office. Retrieved from
http://www.gao.gov/new.items/d11159.pdf
Berwick, D. (2008). The science of improvement. Journal of the American Medical Association, 299, 1182-1184.
Blumenthal, D., & Tavenner, M. (2010). The meaningful use regulation for electronic health records. New
England Journal of Medicine, 363, 501-504.
Damberg, C., Sorbero, M., Lovejoy, S., Lauderdale, K., Wertheimer, S., Smith, A., . . . Schnyer, C. (2011). An
Evaluation of the Use of Performance Measures in Healthcare. Santa Monica, CA: RAND Corp. Retrieved from
http://www.rand.org/pubs/technical_reports/TR1148.html
Pronovost, P., & Lilford, R. (2011). A road map for improving the performance of performance measures. Health
Affairs, 30, 569-573.

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Lecture b

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The Culture of Healthcare

Quality Measurement and Improvement

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