Protocols, Automation and the Medicare Quality Initiatives Opportunity

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Protocols, Automation and the Medicare
QualityInitiativesOpportunity!!!

• Presented byJudith Tietsort RN RRT FAARC
• Senior Clinical Consultant MediServe

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Goals of this Presentation

• Introduce the audience to the issues facing RT
  departments as relates to inappropriate therapy
  delivery
• Help the participant understand the new quality
  measures set forth by CMS,and how compliance or
  non compliance will determine reimbursement
• Help the participant realize that with the new
  CMS QIs there is a bright light at the end of
  the tunnel
• Review why automation can be an advantage to
  protocol implementation and quality

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Misallocation What is it?

• Is there misallocation inyour hospitals ?

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Misallocation

• Can occur when ordered/delivered therapy is
• Too frequent
• Not frequent enough
• Not ordered when should be
• Incorrect mode
• Unnecessary altogether

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Misallocation Summary

• Over-ordering 25 - 61
• Under-ordering 7 - 20
• Potentially 34 - 81
• of the patients being treated with
• respiratory therapy are not receiving
• maximal clinical benefit !!

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My Experience

• 17 years of auditing departments as part ofan
  implementation/update process
• 40-45 misallocated nebs (if no protocols)
• 25-30 misallocation, if protocol program in
  place
• 60-80 oxygen

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Issues Out There

• Non evidence based
• Poly pharmacy
• Stacking
• Stacking for convenience
• Productivity
• Protocol not a protocol
• No program or therapy outcomes
• Why just BD
• Are you the O2 police?
• (Do we need Registered Respiratory therapists
• to do the above?)

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Actual Therapy Audits
Costs of Misallocated Care

• 387,311
• 360,008
• 298,210
• 620,281

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Definition Protocol

• A structured approach for analyzing a clinical
  situation with Rx decisions intended to assure
  maximal quality.
• Physician ordered PROGRAM
• Physician-driven
• Patient care plans based on CPGs
• Reviewed and accepted by the Medical staff
• Allow up or down regulation of frequency
• Allow change in mode, frequency and D/C
• Allow vent adjustments/weaning
• Requires data to prove efficacy, expand, monitor
  staff

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Incentive Spirometer 4.0 INDICATIONS

• 4.1 PRESENCE OF CONDITIONS PREDISPOSING TO THE
  DEVELOPMENT OF ATALECTASIS
• 4.1.1 Upper abdominal surgery
• 4.1.2 Thoracic surgery
• 4.1.3. Surgery in patients with COPD
• 4.1.3 Major spinal back procedures

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Incentive Spirometer 9.0 ASSESSMENT OF
OUTCOME

• 9.0 ABSENCE OF OR IMPROVEMENT of SXs OF
  ATALECTASIS
• 9.1.1 Decreased respiratory rate
• 9.1.2 Resolution of fever
• 9.1.3 Normal pulse rate
• 9.1.4 Absent crackles ( rales ) etc.
• 9.1.4. Oxygen saturation within normal range
• etc

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Protocol With a Capitol P

• Allows the RCPs to
• Determine Need (indications)
• Determine mode
• Determine frequency
• Determine when therapy outcomes are met (when to
  D/C)
• Manage ventilators

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Cook Book Medicine?

• Care Paths
• Based on time-driven decisions.This is cook
  book medicine.
• Protocols
• Method driven by specific patient data.This is
  not cook book medicine.

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Why Protocols?

• Quality
• Cost
• Introduce or upgrade current procedures
• Increased patient census
• Decreased Available RT staff

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15 years later

• AARC Study
• 2003 AARC study 57 of hospitals say they do
  protocols
• 2007 study 70
• 2008 Goal help hospitals go from single
  protocols to program

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We Already Have a Program

• Are you practicing protocols with a capitol P?
• Can the therapistsInitiate, adjust, add and
  decrease modes, and D/C, without calling the
  physician (unless the pts condition worsens?)
• A protocol or A program?
• What outcome measures are used to determine
  success of your program?
• Both program and therapy outcomes
• ? percent therapy is done by protocol
• of the physicians utilize program

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Possible Reasons for low TDP implementation rate.
Managers

• Lack of management time
• Justify, develop gain support for the program
• Implementation calendar
• Develop education program
• Provide education/competency testing
• Marketing plan
• Staff buy-in
• Nursing buy-in

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RT Staff.
My assessment skills arent what they used to
be!
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RT Staff 2nd Shift..
I cant do these protocols on top of everything
else!
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Hospital Workflow Models

• Traditional
• Doctor says, therapist does
• Shared Participation
• Teams, standing orders, etc
• Protocols
• Doctor orders ASSESS and TREAT
• Therapist eval and orders

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INCLUDED IN A PROTOCOL

• FEV1 to determine appropriateness
• FEV1 all smokers (NHLEP)
• FEV1 all high risk post ops
• O2 sats / titration to d/c
• Pulmonary rehabilitation referral
• Smoking cessation referral
• Peak flow on all asthmatics
• Patient education
• When to call the doctor

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Marshall McLuhan
Our Age of Anxiety is, in great part, the result
of trying to do todays jobs with yesterdays
tools. (we have new tools, lets use them!)
Herbert Marshall McLuhan was a visionary educator
ofmass media. "The medium is the message",
perhaps his most often quoted phrase, was one of
many of his many advanced perceptions. In media,
he studied both their overriding effects on
society and their character as extensions of the
senses of the individual. He was born July 21,
1911 in Edmonton, Alberta Canada of
Scottish-Irish heritage.
First we shape our tools thereafter, they
shape us.
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Why Computerize Protocols?
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Human Limitation

• Humans Limited ability to turn
• information into decision making
• Short term memory only retains and utilize 4-7
  data points
• Less than 7 data points results in ineffective
  decision making
• The minds attention span is 5-7 minutes
• 5 minutes average duration of a mind burst
• We speak 135 words/minute
• We hear 400-800 words/minute
• No wonder the mind wanders!

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Excess Information

• Excess Information Increases the Likelihood of
  Clinical Errors
• Consider
• Clinical decision error rate of
• 1 threatens patient safety
• Clinical error rates are common (1- 50)
• Goal of computerization
• Decrease clinical error rates
• Error rate of to patient safety.

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Advantages of Computerized Protocols

• Standardizes clinical decision making
• Can be developed to generate reminders and alerts
• Boundaries
• Collects data needed to justify/ improve program
• Assures consistency among the staff
• Reports based on last imputed data
• daily QA
• triage
• Answers the question how can I be assured____

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Computer-based vs. Paper-based Protocols
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Computer-Based Protocols

• Contain much more detail than is humanly possible
  to expect paper based protocols to contain.
• Indications
• Outcomes criteria
• Patient education
• When to notify the physician
• Information that
• Allow outcomes to be studied
• Quality to be measured
• Worksheets to be developed

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Paper-based protocols

• Clinicians must use clinical judgment to fill in
  gaps in logic.
• This results in
• Variations among clinical decision makers
• and clinical procedures
• Not possible for humans, without the stimulus
  of computerization to include the detail
  necessary to treat complex clinical problems

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Protocols, Automation and Quality

• Protocols and JCAHO
• Quality Standard MM.3.10
• Assure there is a documented diagnosis,
  condition, or indication-for-use for each
  medication ordered.
• Protocols and Patient safety
• Eliminate stacking
• Stacking issue originally intended for outpatient
  care
• now it is a quality issue

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The Hospital Quality InitiativesAn albatross or
an opportunity?

• Medicare
• IHI
• JCAHO

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Medicare (CMS)

• Quality/Pay-for-Performance-Initiatives

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Medicare

• A federal health insurance program established by
  Congress in 1965
• Medicare Designed to assist
• 65 and older
• Some disabled individuals under the age of 65
• End-stage kidney disease

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The Medicare Hospital Quality Initiatives

• Goals
• Improve care provided by the nations hospitals
• Provide quality information to consumers

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Not Just Hospitals

• 2002 Nursing Homes
• 2003 Hospitals
• Physicians Doctors Offices
• Group practices (small and large)
• 2004 Kidney Dialysis Centers
• Quality-Information
• Technology project
• Disease management/Case management

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They are not in this alone!

• The Hospital Quality Alliance
• National Quality Forum (NQF)
• Joint Commission (JCAHO)
• Centers for Medicare Medicaid Services (CMS)
• National Committee for QA (NCQA)
• Agency for Health Care Research (AHCR)
• American Medical Society (AMA)
• ALF-CIO
• AARP
• others

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Background of Hospital Quality Programs

• The current model of healthcare reimbursement is
  based on
• Volume of admissions
• Number of patients enrolled
• LOS
• DX
• Fixed reimbursement with no incentive for
  quality

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DRG Reimbursement (The Rest of the Story)

• Prospective Fixed in Advance
• Depends on DX and major procedures reported at
  D/C
• In reality
• Influenced by what happens during hospitalization
• DRG plus CC
• Acquired CCs paid more
• (if hospital fixes quality issues payments are
  decreased)
• DRG plus outlier payment
• DRGs went from 475 to 538 to 745 proposed!

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Respiratory DRGs

• Major Chest Procedures Surgical
• 76 Other Resp System O.R. Procedures w CC
  Surgical
• 77 Other Resp System O.R. Procedures w/o CC
  Surgical
• 78 Pulmonary Embolism Medical
• 79 Resp Infect Inflam Age 17 w CC
  Medical
• 80 Resp Infect Inflam Age 17 w/o CC
  Medical
• 82 Respiratory Neoplasms
  Medical
• 83 Major Chest Trauma w CC
  Medical
• 84 Major Chest Trauma w/o CC Medical
• 85 Pleural Effusion w CC Medical
• 86 Pleural Effusion w/o CC Medical
• 87 Pulmonary Edema Respiratory Failure
  Medical
• 88 Chronic Obstructive Pulmonary Disease
  Medical
• 89 Simple Pneumonia, Pleurisy Age 17 w CC
  Medical
• 90 Simple Pneumonia, Pleurisy Age 17 w/o CC
  Medical

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Medicare 2003 Pay for Performance (P4P)

• Will reward () for quality not quantity
• Additional reimbursement to hospitals and
  physicians
• 2009 will not reimburse for certain issues

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The first CMS Hospital Quality Initiative program

• Three Year Project
• Launched in November 2003
• Voluntary
• A strong incentive to submit data on 10 quality
  measures starter set
• now if they do not submit data, reimbursement
  would be cut by 0.4

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3 Medical 1 Surgical Condition

• Acute MI
• Heart Failure
• Pneumonia
• Surgical Infection Prevention

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6 Measures Related to Pneumonia Care

• of Patients Given
• Pneumococcal Vaccination
• Adult Smoking Cessation Advice/Counseling
• Oxygenation Assessment
• Initial Antibiotic's within 4 Hours After Arrival
• Appropriate Initial Antibiotic's?
• Blood Culture Prior to First Antibiotic Received

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Heres the Money

• Hospitals in the top 50 reported as top
  performers
• Hospitals scoring in the top 20
• 2 bonus on total Medicare payments
• Hospitals scoring in the highest 10
• 1 bonus
• In 3rd year (2007) Hospitals not meeting
  pre-determined threshold score
• Subject to reduction in payments

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P4P Update

• Medicare first year distributed 8.85 M to 123
  top performers that showed measurable
  improvements in care
• BCBS 86 acute beds Wisconsin
• March 2004 - June 2005 Estimated saved 165.5
  million and 81,020 hospital days
• California 2003 2004 90 million to physician
  organizations for measurable outcomes

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Medicare 2007 Quality Program

• More Quality Indicators of health
• Utilization outcome quality measures
• Clinical and topic areas
• AMI
• Heart failure
• Stroke
• Pneumonia
• Cardiovascular surgeries
• Cancer surgeries

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No Payment for the Following

• To begin October 2008
• Catheter associated urinary tract infections
  (1/2 million/year occur)
• Blood stream infections from catheters
• Pressure ulcers
• Object left body after surgery
• Air embolism
• Blood incompatibility
• Falls
• Mediastinitis
• 2009 will add
• Staph- aureus septicemia
• Ventilator caused pneumonia

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Present On Admission (POA)

• 2007
• On Oct 1st - Each Hospital Began Reporting
• 2008
• On Oct 1st - Program Will Begin

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DTR 2009

• Coming Soon Non Payment for
• Preventable Hospitalizations
• Asthma
• Diabetes
• Heart failure
• COPD

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Lets Talk About Pulmonary Rehab

• Pulmonary rehab outcomes
• Prevents readmissions
• Decreased resources if admitted
• Increased QOL
• Increased knowledge of disease and how to treat
• Improved ability to exercise
• Hospitals improve bottom line
• -Increased revenue
• -Prevention of LOSS
• revenue losers
• Preventable readmissions

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Ranking of Highest Volume Diagnoses For
Re-Admitted Patients

• DRG 127- Heart failure and shock
• DRG 088- Chronic obstructive pulmonary disease
• DRG 089- Simple pneumonia and pleurisy
• DRG 014- Specific cerebrovascular disorders
• DRG 079- Respiratory infections inflammations
  
• DRG 296- Nutritional and misc. metabolic
  disorders
• Source National Claims History File

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The Top Ten DRGs By Volume

• DRG 127 (649,505)
• DRG 089
• DRG O88
• DRG 209
• DRG 116
• DRG 014
• DRG 182
• DRG 296
• DRG 174
• DRG 143 (232,282)

• Heart Failure Shock
• Simple Pneumonia Pleurisy
• COPD
• Major Joint and Limb Proc
• Cardiac Pacemaker Implant
• Cerebrovascular Disorders
• Esophagitis, Gastro etc
• Nutr and Misc. Metabolic
• GI Hemorrhage
• Chest Pain

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IHI

• Institute for Healthcare Improvement

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IHI 100,000 Lives Campaign (2003-2006)

• Reducing preventable deaths
• Ended July 2006
• Voluntary
• 3,100 Hospitals Participated
• Exceeded their Goal of
• by an estimated 122,000 lives

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IHI 100,000 Lives Campaign

• Proven Interventions
• Rapid response team (59)
• Prevention of heart attack deaths (ASA, Beta
  Blockers, Smoking Cessation) (77)
• Prevent medical errors (73)
• Preventing developing infections related to IVs
  (hand and pt skin washing) (72)
• Prevent post op infections (antibiotics in timely
  manor) (67)
• Prevent VAP (ventilator bundle) (65)

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2007 Protecting 5 Million Livesfrom HARM

• IHI estimates 15 million instances of medical
  harm/yr
• 40,000 Incidents/day
• - More than the total deaths from AIDS/year
• Dec 2006- Dec 2008
• Enlist 4,000 hospitals

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2007 IHI Protecting 5 Million Lives

• GOAL
• Protect Patients From
• Hospital acquired infections
• Adverse drug events
• Surgical errors
• Other complications

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IHIs Interventions for 5 Million

• The previous 6 interventions from 100,000 lives
• Plus
• High alert meds (anticoagulants, sedatives,
  narcotics and insulin)
• Surgical complications (THATS US)
• Pressure ulcers
• Meth resistant staph aureus infections
• Evidence based care for CHF
• Get boards on board

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Big Brother IS Watching

• We can all take a look!

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Big Brother is watching (1984)

• PROTOCOLS
• Assure Quality
• Shift by shift QA
• Demographics, Therapy, frequency, days on
  therapy, home therapy/O2 at home, BSs, last RX
  given, O2 sat, triage score,
• Enhanced therapists worksheet
• Same info as above?

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JCAHO Consumer Quality Check What can consumer
Can learn from a Quality Report?

• The accreditation decision of the health care
  organization. 
• Special Quality Awards what has the organization
  has achieved.
• National Patient Safety Goals
• In compliance with quality goals?
• National Quality Improvement Goals view the
  results of the quality measurement compliance

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www.HospitalCompare.com

• Search for a Hospital
• By NameI want to find a hospital by entering
  all/some of its name
• Hospital Name
• By ProximityI want to find all hospitals within
  a certain distance of
• City, ZIP Code
• By GeographyI want to find all hospitals within
  a
• State, County
• The information on the website has been provided
  primarily by hospitals participating in a
  national project called the Hospital Quality
  Alliance (HQA) Improving Care Through
  Information  

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Conclusions

• The new push protocols/computerization and
  quality
• Appropriate care
• Efficient use of people
• Evidence based care
• Patient safety
• Proven clinical outcomes
• Opportunities to Justify
• Computerized protocols
• Pulmonary rehab
• Check all payer PL
• Check Readmissions for COPD
• ER Asthma follow-up program
• Taking back VE proving we can affect post op
  respiratory complications

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Are you able to change ?
When youre through changing, youre
through.-- Bruce Barton
Bruce Barton (1886-1967) is considered by many to
be one of the most influential advertising men of
the 20th century.  He was not your ordinary adman
-- religious author, Congressman, founder of the
advertising agency BBDO, creator of Betty
Crocker.  The interesting, yet complicated, life
of this man illustrates the complexity of the
creative mind.  A mind that was not limited to
one endeavor, but found a way to apply similar
skills and abilities to a multitude of
opportunities.  Despite all of his other
accomplishments, he is still remembered first and
foremost as an adman.  In a fictional novel based
on BBDO, The Virgin Queene, the Bruce Barton
character named Barnham Dunn tried to explain his
success  "I knew I'd never be more than a
second-rate business man and a second-rate writer
-- so I decided to add the two things together
and be a first rate advertising man" (Fox, 1984,
p.110)
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Times Up