Quality and Transparency Within the MHS

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• Quality and Transparency Within the MHS
• Office of the Chief Medical Officer

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TMA/HA Quality
Organizational Structure
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MHS Clinical Quality ManagementInformation Flow
MHS Leadership (ASD (HA) and SGs)
Clinical Proponency Committee (DSGs)
MHS Clinical Quality Forum
Scientific Advisory Panel
Clinical Measures Steering Committee
Patient Safety Planning and Coordination Committee
Risk Management Committee
Medical Directors
HPAE Studies and Patient Satisfaction
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Recent Examples of Initiatives that have been
through or are going through the Process

• Endorsement of the implementation of the IHI
  Bundles to avoid Ventilator Associated
  Pneumonias (VAP) and Central Line Infections.
  (recently published policies)
• Endorsement of the implementation of the CDCs
  NHSN Hospital Acquired Infections monitoring
  System.
• Endorsement of uniform Quality Metrics.
• Endorsement of transparency plan.
• Endorsement of NSQIP initiative.

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Senior Medical Management Advisory CMTE
Clinical Proponency Steering CMTE
MHS Clinical Quality Forum

• Credentials and
• Privileging
• JC/AAAHC oversight

• Risk Management
• RM Committee
• DoD Dept Legal Medicine

• Credentials
• URAC/TRO oversight

• Patient Safety/PQIs
• External peer review
• PSIs (AHRQ)
• UM chart review
• Patient grievance
• Contractor QM
• TRO/URAC oversight

• Patient Safety
• PSC reporting
• Alerts/focused studies
• JC oversight of national goals
• TeamSTEPPS crew resource training

Direct Care
Network

• Prevention/Chronic Disease Measures
• Selected HEDIS measures (MHSPHP)
• DM programs (CHF, diabetes, asthma)
• Contractor QI activities
• URAC oversight

• Prevention/Chronic Disease
• Selected HEDIS measures (MHSPHP)
• Preventable Admissions
• MTF DM programs
• MTF QIAs
• JC or AAAHC oversight
• NQMP focused studies

• Inpatient Quality
• JC ORYX
• HCD website
• NQMP focused studies
• NPIC

• Inpatient Quality Measures
• CMS/HQA/JC publicly reported measures for
  network facilities
• NQMC focused studies

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Current MHS Quality Activities
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MHS Enterprise Wide Metrics
(HQA/JC ORYX)

• Acute MI
• (AMI 1) Aspirin at arrival for AMI
• (AMI 2) Aspirin at discharge for AMI
• (AMI 3) ACE-I or ARB for LVSD
• (AMI 4) Smoking cessation advice/counseling
• (AMI-5) Beta blocker at discharge
• (AMI-6) Beta blocker at arrival
• (AMI-7) Fibrinolytic medication w/I 30 min of
  arrival
• (AMI-8) Percutaneous coronary intervention within
  120 min. of arrival for AMI
• (AM1-9) Inpatient mortality (risk-adjusted)
• Heart Failure
• (CHF 1) Left ventricular function (LVF)
  assessment
• (CHF 2) Detailed Discharge Instructions
• (CHF 3) ACE-I or ARB for LVSD

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MHS Enterprise Wide Metrics
(HQA/JC ORYX)

• Pneumonia
• (PN 1) Oxygenation assessment w/i 24 hrs of
  arrival
• (PN 2) Pneumococcal vaccination status
• (PN 3) Blood cultures in ER prior to antibiotics
• (PN 4) Adult smoking cessation advice/counseling
• (PN 5) Initial antibiotic timing (4hrs)
• (PN 6) Antibiotic selection
• (PN 6) Influenza vaccination
• Pregnancy related
• (PR 1) Vaginal birth after C-section
• (PR 2) Inpatient neonatal mortality
• (PR 3) 3rd or 4th degree laceration
• Surgical Care Improvement Program
• (SCIP 1) Prophylactic antibiotics w/i 1 hr of
  surgical incision
• (SCIP 2) Prophylactic antibiotic selection
• (SCIP 3) Prophylactic antibiotics discontinued
  w/i 24 hrs of end of surgery

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MHS Enterprise-wide Metrics
(HEDIS-like measures)

• Breast Cancer Screening
• Colorectal Cancer Screening
• Cervical Cancer Screening
• Appropriate Asthma Medication
• Diabetes - HbA1C test in past year
• Diabetes HbA1C control (direct care only)
• Diabetes LDL test in past year
• Diabetes LDL control (direct care only)
• Chlamydia Screening (new)
• Follow-up from Mental Health Hospitalization
  (pending)

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Disease Management

• Uniform, high quality, cost-effective DM for
  direct AND purchased care TRICARE Prime enrollees
  
• Standard beneficiaries access MCSC DM programs
  under demonstration authority
• Targeted conditions
• CHF (implemented 1 Sept 06)
• Asthma (implemented 1 Sept 06)
• Diabetes (Implemented 1 Jun 07)
• Government determines uniform methodologies to be
  used to
• Identify potential participants
• Measure success/ formally evaluate program
• To encourage innovation, the Government is NOT
  prescribing strict program protocols (e.g., how
  often to call patients, use of technology)
• Program details provided to the Government as
  part of evaluation process
• Early evaluation low but increasing engagement
  rates

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National Perinatal
Information Center
(NPIC)

• National perinatal database for validated,
  risk-adjusted, perinatal information from U.S.
  womens and infants hospitals benchmarking infant
  and maternal outcomes, patient safety,
  utilization of services, costs and staffing data.
• 51 MTFs (all three Services) participate
• Metrics include
• Comparative C Section Rates, PSI 18 (Obstetric
  Trauma-Vaginal Delivery with Instruments), PSI 19
  (Obstetric Trauma-Vaginal Delivery without
  Instruments), PSI 20 (Obstetric Trauma-C-Section
  Delivery)
• Postpartum Readmission Rates, Obstetric Wound
  Disruption/Infection Rates
• Inborn Neonatal Mortality Rates,PSI 17 (Birth
  Injury Rates)
• MHS generally does well in rollup comparisons
  matching or exceeding outcomes in several
  categories

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DoD National
Surgical Quality Improvement
Program (NSQIP)

• Surgical Specialty Areas
• General Surgery
• Orthopedics
• Vascular Surgery
• Thoracic Surgery
• Urology
• ENT
• Neurosurgery
• Plastic Surgery
• Gynecology
• Oral Surgery

• Program Description
• Nationally recognized, outcome-based,
  risk-adjusted, and peer-controlled surgical
  quality program developed and validated by the VA
  (1994)
• National comparison of surgical morbidity and
  mortality rates
• Adopted by the American College of Surgeons
  (2004)
• Three Pilot Sites
• Walter Reed Army Medical Center, Washington, D.C.
• Naval Medical Center, San Diego San Diego, CA
• Wilford Hall Medical Center San Antonio
• Next Steps
• Contracting with ACS NSQIP for portal access and
  civilian facility benchmarking for 16 MTFs
• IT interface to autoload MTF data
• Data use agreement with VA NSQIP to allow DoD/VA
  comparison
• Formation of DoD NSQIP Executive Cmte

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Tri-Service Perinatal Education Program

• Formulated by Tri-Service perinatal clinical
  experts
• PSP to enable tools for Tri-service training
• Fetal heart monitoring training
• Perinatal and neonatal nursing education
• Contract source selection to be completed by 30
  Sep 07 with roll-out beginning in FY08
• Perinatal training tools will
• Begin to establish standardized Tri-Service
  perinatal training expectations
• Align perinatal training with research proven to
  enhance patient safety
• Create similar expectations across the direct
  care system

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Patient Safety Division

• Created in 2002 in response to the National
  Defense Authorization Act (NDAA) 2001, which
  required
• DoD Patient Safety Program within HA/TMA
• A Patient Safety program at each Military
  Treatment Facility (MTF)
• Ensures a consistent approach throughout the
  direct care system
• Standardized policies and uniform training
• Sharing of lessons learned and innovative
  initiatives

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Patient Safety Center

• Established 2001 at Armed Forces Institute of
  Pathology
• Repository for MHS patient safety data collection
  analysis
• Develop execute action plans addressing
  patterns of patient care errors, review
  integrate processes for reducing errors
• Coordinate, promote perform research using
  registry data

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TeamSTEPPS

• TeamSTEPPS is an evidence-based teamwork system
  aimed at optimizing patient outcomes by improving
  communication and other teamwork skills among
  health care professionals.

• Research
• Team Resource Centers
• Army Trauma Training Center
• National Capital Area Medical Simulation Center
• Andersen Simulation Center-Madigan AMC
• AF Center for Sustainment of Trauma Readiness
  Skills
• LD Longitudinal Study
• NAVAIR Teamwork Analysis Tools

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TeamSTEPPS

• Adopted and promoted to civilian institutions by
  AHRQ

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Center for Education and Research
in Patient Safety (CERPS)

• Provides educational materials, tools, training
  and resources necessary to improve the safety and
  quality of health care delivery within the MHS
• Focus
• Facilitation of education and training necessary
  to develop a culture of patient safety assisting
  MTFs to meet accreditation requirements related
  to patient safety
• Incorporating and disseminating best practices
• Evaluating outcome measures for patient safety
• educational programs and interventions
• Highlights
• Trained over 1,400 MHS Staff in FY07
• Collaboratively rolled-out a comprehensive PSP
  website
• Conducted three Clinical Microsystem pilots

http//dodpatientsafety.usuhs.mil/
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Hospital Acquired
Infection Reporting

• What DoD Has
• Continued collection of process-focused measures
• Three unidentifiable MTFs reporting to CDC / NHSN
  national database (MTF access only)
• Services report nosocomial event numbers in PS
  Center Monthly Summary Reports (only one is
  pathogen-specific)
• Three NSQIP pilot sites reporting outcomes data
• Two self-registered NSQIP sites reporting
  outcomes data (MTF access only)
• Initial efforts to use the AHRQ Quality
  Indicators
• Pending results of NQMP-SAP Special Study of 2
  AHRQ PSIs
• Initial efforts to collect VAP CLI data at
  Service level for possible IHI participation

• National Healthcare Safety Network (NHSN)
• Established in 2005 to integrate and supersede 3
  legacy surveillance systems at the CDC
• National Nosocomial Infection Surveillance (NNIS)
  System, Dialysis Surveillance Network (DSN),
  National Surveillance of Healthcare Workers
  (NaSH)
• NHSN facilities voluntarily report HAI data for
  aggregation into a national database for the
  following reasons
• Estimation of the magnitude of HAI
• Discovery of HAI trends
• Facilitation of inter and intra-hospital
  comparisons with risk-adjusted data
• Analysis methods that permits timely recognition
  of PS problems and prompt intervention with
  appropriate measures
• Proposal for MTFs to participate in CDC National
  Healthcare Safety Network (success is being
  staffed through the TRICARE Quality Forum,
  Clinical Proponency Steering Committee and
  ultimately the SMMAC

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Purchased Care Safety/Quality Reporting

• Potential Quality Issues (PQIs) and Serious
  Reportable Events (SREs) are through MCSC Quality
  Committee under TRO/URAC/NQMC oversight
• Sources include grievances, UM/DCP chart review,
  and NQMC reviews
• MCSCs request records, determine severity and may
  request corrective action plans, institute
  provider monitoring, or take credentialing action
• SREs are reported by TROs to HA as recognized
• Opportunity exists to create a central tracking
  process with the Patient Safety Center similar to
  that for the Direct Care system that will
  identify contributing factors, actions taken, and
  completion/outcome of corrective action
• Quality event data treated as Title 10 Section
  1102 protected data not for release or disclosure
• Consider the feasibility of adopting CMS policy
  does not reimburse for care resulting in
  NQF-defined Serious Reportable Events

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Taking MHS Quality to the Next Level
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• Transparency Within the MHS
• (Brief Update)

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Executive Order Promoting Quality and Efficient
Health Care in Federal Government Administered
or Sponsored Health Care Programs
It is the purpose of this order to ensure that
health care programs administered or sponsored by
the Federal Government promote quality and
efficient delivery of health care through the use
of health information technology, transparency
regarding health care quality and price, and
better incentives for program beneficiaries,
enrollees, and providers. It is the further
purpose of this order to make relevant
information available to these beneficiaries,
enrollees, and providers in a readily useable
manner and in collaboration with similar
initiatives in the private sector and non-Federal
public sector.
22 August 2006
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Key Points

• The MHS monitors and uses nationally recognized,
  validated quality measures
• Some DoD aggregate statistical data, and some MTF
  level aggregate statistical data is currently
  available to the public
• Aggregate DoD statistical data in the annual MHS
  RTC on Clinical Quality
• MTF JC quality (ORYX) measures/patient safety
  goals on the JC Quality Check website
• Release of MHS quality assurance data is governed
  by
• Title 10 1102
• Event level data can not be released
• Aggregate statistical data may be released by DoD
  if it meets OMB guidelines and does not identify
  individual patients or individual providers.

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MHS Enterprise Wide Metrics

• Beta-Blocker at d/c for AMI (AMI 5)
• Beta-Blocker at arrival for AMI (AMI 6)
• Percutaneous coronary intervention within 120
  mins. of arrival for AMI (AMI 8a)
• CHF - Detailed Discharge Instructions (HF 1)
• CHF Left ventricular function (LVF) assessment
  (HF 2)
• CHF ACEI/ARB for LVSD (HF 3)
• PN -Pneumococcal vaccination status (PNE 2)
• PN- Antibiotic timing (PNE 5)
• Neonatal mortality (PR 1)
• SIP Timing of antibiotics for surgical patients
  (SIP 1,3)

• Selected HEDIS
• Breast Cancer Screening
• Colorectal Cancer Screening
• Cervical Cancer Screening
• Asthma - Appropriate
• Medications
• Diabetes - HbA1c Test
• Diabetes - HbA1c in Control
• Diabetes Patient - LDL Test
• Diabetes Patient - LDL lt 100 mg/dL

• JC ORYX
• Aspirin at arrival for AMI (AMI 1)
• Aspirin at d/c for AMI (AMI 2)

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TITLE 10 U.S.C. 1102. confidentiality of
medical quality assurance records
a) Confidentiality of Records. Medical quality
assurance records created by or for the
Department of Defense as part of a medical
quality assurance program are confidential and
privileged. Such records may not be disclosed to
any person or entity, except as provided in
subsection (c). Includes our QA, RM, PS and
Peer Review Programs.
(d) Disclosure for Certain Purposes. (1) Nothing
in this section shall be construed as authorizing
or requiring the withholding from any person or
entity aggregate statistical information
regarding the results of Department of Defense
medical quality assurance programs. (j)
Definitions. (1) The term medical quality
assurance program means any activity carried out
by or for the Department of Defense to assess
the quality of medical care
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AGGREGATE STATISTICAL DATA

• Aggregate statistical data is stripped of
  personal identifiers and is numerical in nature
  to protect the privacy of the patient and
  providers involved.
• Use of aggregate statistical data allows the
  release of information to be consistent with
  requirements of both the Privacy Act and HIPAA as
  well as the OMB requirements on the use of
  federal agency statistical information.
• Recommended threshold for the denominator is gt 3
  persons in whatever class or category is involved

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Way Forward

• Title 10 1102 permits release of aggregate
  statistical data issue HA policy letter for
  clarification
• JC ORYX data for direct care hospitals and most
  network hospitals is on the JC Quality Check
  Website and linked to the TMA website
• TMA proposes that MTF level HEDIS-like quality
  measures be posted on the TMA/HA website as soon
  as web presentation can be designed and tested
  (estimate 6 months)
• Short term goal to also post Purchased Care HEDIS
  measures (aggregated regionally) on the TMA
  website in 2008.
• VA and Indian Health Service both plan to release
  similar quality measures down to the facility
  level over the next several months