The PHA: Where to Next?

Slide Presentation from the AHRQ 2008 Annual Conference

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On September 9, 2008, Vi Naylor made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (3.5 MB).

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Slide 1

The Partnership for Health and Accountability (PHA): Where to Next?

Vi Naylor
Executive Vice President
Georgia Hospital Association (GHA)

Slide 2

The PHA Roadmap to Success

Notes:

• GHA Board approved concept in 1999
• First meeting held February 2000
• Agency for Healthcare Research and Quality (AHRQ) grant awarded 9/25/01 and ended 1/31/05
• Partnered with Emory University
• Involved all acute care hospitals in Georgia—over 150

Slide 3

Once upon a time....

• Georgia Hospital Association established the Partnership for Health and Accountability
• Purpose:
  • To promote: Accountability, Best practices, Patient safety and To improve quality of care statewide
• Vision:
  • "Stakeholders collaboratively use data to proactively improve quality, patient safety and health, and effectively communicate results across the publics served."

Notes:

• When we look back on our purpose and vision, we certainly have achieved great strides

Slide 4

Critical Success Factors

• Long standing good relationships among partners
• Built on existing programs
• Involved all from the beginning
• Full authority for committees
• Utilized provider-driven, non-punitive public/private effort that fostered learning
• Addressed public and provider needs
• Public recognition

Notes:

• Some of the things we attribute success to are listed on this slide. You will see later that we have incorporated some of these same success factors in our next big step up. But let me just review a few quick things.

Slide 5

Addressed Public and Provider Needs

• Public:
  • Health Education and Public Reports User friendly and readable.
    • State of the Health of Georgia
    • Hospital Specific Reports: Quality Insights
• Provider:
  • Accountability for Patient Safety:
    • Sharing of Sensitive confidential data
  • Shared learning opportunities:
    • Toolkits
    • Technical Assistance

Notes:

• Addressing both public and provider needs was important. Our very initial activities were directed toward giving hospitals and communities information they could use in their health improvement programs. This aspect continues to be a strong part of our program.
• State of the Health of Georgia Reports:
  • (2000, 2002, 2004, 2006 and coming soon in 2008)
• Annual Hospital Specific Report: Insights:
  • Participation in Safety & Quality Initiatives
  • Performance Reports
• Patient Safety Week Activities (2002-2008)
• Patient Safety Award Winners (2000-2008)

Slide 6

Positive Recognition

The slide shows both a screen shot of GAHospitalQualityCheck.org's Web site and a screen shot from Emory Healthcare's Web site where it states that Emory University Hospital was named to Georgia Hospital Association's Quality Honor Roll.

Notes:

• Another critical success factor was the use of positive public recognition. This is a screen shot from our public Web site where visitors can view a myriad of information that is intended to help them make informed healthcare decisions.
• Positive recognition started in 2000 with the Quality and Patient Safety Award Winners. When CEOs saw the publicity award winners received, they started asking "why not us...? I want our hospital there next year."

Slide 7

The End Result?

• Award program with recognition from the Governor
• Public Website for consumer information
• Significant reduction in medication errors
• Improved in adherence to evidence-based guidelines
• Sentinel Event Reporting with related Safety Alerts
• Shared Learning

Notes:

• It is hard to put all that we have done in just one slide.  During the award period we addressed selected safety issues such as falls, pressure ulcers, and safe medication use as well as errors of omission related to adherence to the Centers for Medicare & Medicaid Services (CMS) measure sets
• We wrestled with public reporting, getting ours completed before others went public.  To ease the interpretation burden,, we also created a Quality Index.
• Quality and Patient Safety Awards categories grew because of the increase in applications
• Safety Alerts and Safety Forums with the development of event reporting
• Educational forums and telnets on current topics of interest
• Best Practice Summits held yearly
• Enhanced communication with our members via weekly emails on patient safety issues

Slide 8

Whew!

The slide shows an image of a man sleeping at his desk.

Notes:

• Throughout the 3 and ½ years of funding hospitals were on a non-stop cycle of annual self assessments in a variety of areas, improvement plans and quarterly reports, and participation on committees and in educational opportunities. Some think we really over- taxed the resources of the hospitals.

Slide 9

Is the Party Over?

The photograph shows a child with a safari hat lying in the grass peering through binoculars.

• The program is now institutionalized—Give us a break!

Notes:

• People were exhausted with our PHA requirements as well as and all the other external requirements from CMS, The Joint Commission, leapfrog, etc. They needed a break! And, quite frankly with funding ending, we weren't sure what was next.

Slide 10

Now What?

• GHA board agreed to fund on-going PHA initiatives
• We switched focus to the Community Side while maintaining Quality and Safety Initiatives
• Strategically sought grants

Notes:

• We needed continued funding. People were tired and anxious to do new things. Luckily, the Board saw value in the program. Also, under another external funding source we had updated our performance measurement system from the early 90s and have been able to help offset expenses through their sales.

Slide 11

Community Outreach

• Grant funding to develop a community based program in chronic care management
• Grant to develop a tobacco-free hospital campus toolkit
• Created Center for Rural Health
• Library initiative: "connected the dots" between the public and their local hospitals
• Diabetes and Venous Thromboembolism (VTE) Special Interest Groups

Notes:

• On the community side, we increased outreach through a Healthy Communities Access Program grant.
• Tobacco-free toolkit is a 100+ page document that gives samples of every kind of information a hospital might need to become tobacco-free with numerous references and methods of encouragement toward that goal.
• We provide all of the public libraries in Georgia with handouts and materials to use for bulletin boards and public display areas in their libraries. The material is free and downloadable online. This follows the national Health Observance Calendar of topics (with 3 selected areas of concentration each month). We also serve as a liaison point between libraries and hospitals in order to provide health fairs or other health related information between the two.

Slide 12

Quality and Patient Safety

• Continued Event Reporting and Safety Alerts and Safe Medication Audio Conferences
• Expanded the Quality and Patient Safety Award program
• Created the Hospital Mentor Program
• Responded to environmental forces:
  • Transparency Web site
  • Teams for Infection Prevention Success (TIPS)
• Best Practices PowerHour Plus telnets held monthly
• Added resources/toolkits

Notes:

• Along with our community outreach efforts, we began a limited redirection of the Quality and Safety program by enhancing certain aspects and adding new components.
• We have distributed over 20 safety alerts and provided an educational discussion forum to disseminate best practices. Our Safe medication telnets are based upon the problems IN the hospital and how our best practice people have solved them.
• We received since its inception, over 200 applications for the Quality and patient safety Award.
• To handle the increase in applications, we created the Josh Nahum Infection Prevention and Circle of Excellence Awards
• We developed a mentor program so that we could take our "best practice" hospitals and use the best and brightest there to aid our slower hospitals.
• As public attention increased related to price and quality transparency and healthcare associated infections, we created the transparency Web site and our TIPS program.
• Our monthly power hours include a section just for small and rural hospitals and their needs—the PowerHour is designed to give a networking forum to our members to discuss best practices and creative problem solving. It is aimed at those areas with the greatest opportunity for improvement

Slide 13

Clinical Measures

The two tables show:

• 2002 Analysis:
  • Acute myocardial infarction (AMI): AMI 1-Control Issues/AMI 5-Control Issues/AMI 7-Control Issues
  • Pneumonia (PNE): PNE 2-In Control*/PNE 3-Control Issues/PNE 5-Control Issues
  • Heart failure (HF): HF 1-Control Issues/HF 2-Control Issues/HF 3-Control Issues
• 2007 Analysis:
  • AMI: AMI 1-In Control*/AMI 5-In Control*/AMI 7-In Control*
  • PNE: PNE 2-In Control*/PNE 3-In Control*/PNE 5-In Control*
  • HF: HF 1-In Control*/HF 2-In Control*/HF 3-In Control*

• Note: *Highlighted

Slide 14

Georgia Progress Lags National Progress

The bar graph measures the percentage of PN 4, PN 2, HF 4, HF 1, AMI 4, and AMI 2 for Q3 2003 Rate, Q1 2008 Rate, and Q1 2008 Nation.

• PN 4:
  • Q3 2003 Rate: 47%
  • Q1 2008 Rate: 93%
  • Q1 2008 Nation: 95%
• PN 2:
  • Q3 2003 Rate: 29%
  • Q1 2008 Rate: 85%
  • Q1 2008 Nation: 88%
• HF 4:
  • Q3 2003 Rate: 70%
  • Q1 2008 Rate: 97%
  • Q1 2008 Nation: 97%
• HF 1:
  • Q3 2003 Rate: 53%
  • Q1 2008 Rate: 72%
  • Q1 2008 Nation: 81%
• AMI 4:
  • Q3 2003 Rate: 74%
  • Q1 2008 Rate: 99%
  • Q1 2008 Nation: 99%
• AMI 2:
  • Q3 2003 Rate: 93%
  • Q1 2008 Rate: 96%
  • Q1 2008 Nation: 97%

Notes:

• HF 4—(smoking cessation), we went from 70% to 97%
• HF 1 (discharge instructions), we went from 53% to 72%
• AMI 4 (ami smoking cessation), we went from 74% to 99%
• AMI 2 (aspirin at discharge), we went from 93% to 96%
• But we are trying to "catch" a moving goal and we are not moving fast enough to meet national goals (everyone else is improving too)

Slide 15

Our Wake-up Call

• U.S. Averages*:
  • National = 84.5%
  • Top State = 92.9%
  • Top 10th State = 88.1%
• Georgia Status:
  • Average = 81.4% *
  • Georgia Rank = 46
• Georgia Now = 87.1%
• Right care every time for targeted core measures: AMI, CHF, PN

Notes:

• When we looked at the CMS Appropriate Care Measure score, Georgia was lagging behind. We took the issue to the GHA Board who made "Moving Georgia to the Top Ten" as a major strategic priority.
• Our Center for Rural Health Board has also adopted the Top Ten Program as a strategic priority.

Slide 16

Moving Georgia to the Top Ten

• What Can Hospitals Do to Improve?
  • Participate! Participate! Participate!

Notes:

• We knew from our AHRQ Demonstration Grant that increased participation led to better results. The next slide shows the correlation between number of measure sets collected and performance.

Slide 17

Increased Participation = Better Results

The graph shows Composite Scores and Index Scores measured by Participation, Number Measure Sets times Number of Quarters, and Performance in ACM and Index. The majority of scores lie in the upper right hand quadrant of the graph.

• Participation vs. Performance

Notes:

• Showing this to "laggard" hospitals has been helpful in motivating improvement. With our Center for Rural Health, it prompted a request from those CEOs to be copied on everything was being sent to their QI staff. We have also started doing the same with other hospital CEOs.

Slide 18

Original Guiding Principles Revisited

• Accountability to the public
• Physician is responsible for medical treatment decisions*
• Physician performance should be reviewed by physician peers*
• Proactive and voluntary
• Public and private stakeholders
• Continuous improvement rather than a punitive, "name, blame, shame"*
• Provides for trust
• Resources and buy-in to support a long term commitment—with QI staff
• Repository for confidential peer review protected information*
• User-friendly feedback reports, but not for CEOs, MDs and Trustees
• Promotes best practices
• Educational
• Note: *Crucial!
• Note: Each bullet point should show a checkmark at the end

Notes:

• While we felt we were adhering to our guiding principles, we did have some flaws.We were trying too hard to not call on CEOs and physicians unless we had to because of their continued claims—too busy, call me only when absolutely necessary. "My QI staff are handling that."
• We only had limited buy-in and engagement from most CEOs and physicians and they weren't really interested in receiving the data! We found that our hospital peer review contact were not always sharing as we hoped they would. These would be things to focus on in the Top Ten Program.

Slide 19

Return to Prior Success

• Build on existing programs
• Involve all from the beginning
• Full authority to committees
• Foster collaboration and shared learning/education
• Public recognition

Notes:

• We also looked at past success factors and pulled a few to focus on for the Top Ten Program.

Slide 20

Moving to the Next Level: Top Ten Program

• Step up Trustee Education
• Communicate Board's action
• Increase physician and CEO engagement
• Invitational Conference: From Worst to First
• Create infrastructure to implement Conference recommendations
• Make Quality a standing Board agenda item.
• Increase public recognition

Notes:

• We created the Trustee Education Certification Program and have communicated the Board's adoption of Moving GA to the Top Ten as the motivator to attend the conference. We've publicly recognized those who are meeting target and invited those CEOs and their physician quality officers to be round table moderators at the conference.

Slide 21

The sample form shows "Georgia's Quality Dashboard from Q1 '07-Q4 '07" which rates the quality of CORE Measures, Georgia's Performance on Appropriate Care Measures (ACM), and Hospital Acquired Conditions as on target, mediocre, or poor.

Slide 22

Change in Reporting

The sample report for "Right Care" shows the rating for 48 hospitals in the areas of Overall ACM Composite Score; Total Patients Receiving Care for ACMs; Total Patients Eligible for ACMs; Total Patients Not Receiving ACM "Right" Care; AMI Composite Score; Total AMI Patients Not Receiving ACM "Right" Care; HF Composite Score; Total HF Patients Not Receiving ACM "Right" Care; PN Composite Score; and Total PN Patients Not ACM "Right" Care. About 17 hospitals were considered to be "On Target," with greater than 88% overall ACM rate.

Slide 23

Increasing Public Recognition

• Hospitals meeting the Joint Commission 90th percentile in one or more Appropriate Care Measure
• A name badge for the GHA shows the individual's first name bolded, full name, hospital affiliation, city and state and a red dot, yellow dot, and green dot going down along the right of the name badge.
  • Red Circle = AMI
  • Yellow Circle = Heart Failure
  • Green Circle = Pneumonia

Notes:

• To increase public recognition, we modified our name badges. The ACM data is in our membership database, updated quarterly and used on any printed name badge for any GHA event.
• We also have posters that are displayed at our meetings.

Slide 24

Quality Honor Roll

The document image entitled, "On Target: These hospitals are moving Georgia into the top 10 in the nation for Targeted Care Measures," shows a listing of Georgian hospitals.

Slide 25

Engaging Physicians and CEOs

• From Worse to First Conference:
  • Recurring Theme:
    • Incentivize acceptance and promote implementation of evidence-based practice among the hospital board, CEO, medical and hospital staffs

Notes:

• We had over 100 CEOs and physicians in attendance who engaged in roundtable discussions related to ways to move Georgia up the clinical quality ladders.
• Following the meeting, staff was charged with developing and disseminating the summary and to recommend next steps

Slide 26

Right Care Model

The diagram shows three overlapping circles: Administration, Medical Staff, and Board; where they intersect, "Right Care." Over the top of the circles is "Support; Best Practices/ASU/Education; and Tools, Resources, and Education." Under the circles is "Steering Committee; Recommended Consensus-Based 'Right Care Every Time' Strategies." To the right of the circles is "Partner Organizations; Mutually Endorsed Right Care' Strategies." To the left of the circles is "GHA Board; Mutually Endorsed 'Right Care' Strategies." Linking them all are two arrows on either side of the circles flowing in both directions.

• Interrelating Functional Roles: Supporting "Right Care Every Time"

Notes:

• To address the theme voiced at the conference, it was important to implement a model that would promote collaboration among administration, medical staff and board. This model shows the area of tension "right care" in the overlap of the circles.
• We also wanted to build on existing capacity with our Best Practices committee, Analytical Services Unit, and Education Dept. The next graphic shows the committee structure to be used.

Slide 27

Top Ten Organizational Structures

• Medical Staff:
  • Physician-Directed "Right Care"
• Board:
  • Institutional Policies and Statements Regarding "Right Care"
• Administration:
  • Executive Leadership and Resources
  • Allocation to Support "Right Care"
• These three work together to become a steering committee working on consensus building
• Use Educational Services:
  • Multi-disciplinary/ Discipline-specific
  • Distance Learning
  • Face to Face
  • Statewide/Regional
• Use Best Practices/ASU:
  • Provision of Tools/Resources
• Report to Partner Organizations
• Report to GHA Board
• Congruence on Mutually Endorsed "Right Care" Strategies

Notes:

• This structure also builds upon existing capacity with PHA providing educational services, best practices dissemination, tools and resources both from GHA and from our partner organizations.
• This chart depicts three committees each cross-populated and charged with similar tasks to reach consensus on mutually endorsed strategies. Originally the steering committee was to meet only when there was lack of agreement on issues. This has changed after the first meeting of the physician committee. The steering committee will be composed of leaders, representing physicians, hospital trustees, CEOs, executive leadership and front line staff. They will be charged with exploring and making recommendations regarding major systemic and cultural issues which negatively impact right care every time.

Slide 28

Purpose

• Work together in partnership with physicians, hospitals, trustees, and CEOs/Executive Leadership/Front line staff to determine and promote mutually endorsed reliable, systematic processes of care that support "right care every time."

Notes:

• The newly revised purpose emphasizes both partnerhip and reliable systematic processes of care. The next slides list the preliminary agenda items to be handled by each committee.

Slide 29

Physician-Directed "Right Care Every Time"

• Use of evidence-based practice to support "right care, every time"
  • Systematic reliable process of care such as Medical staff-approved order sets and nurse initiated protocols
  • Strategies to recognize and promote physicians' investment of time in developing processes for outstanding performance.
  • Identify obstacles to providing "right care every time."

Notes:

• We have over 70 physicians from close to 50 hospitals agreeing to work with us to achieve right care every time. Early advisors told us to stay away from the use of "evidence-based medicine." As we finishing appointments to the other two committees, we will draw from hospitals not yet represented. We do have all but a couple of hospitals who have the greatest number of cases not receiving right care every time.
• At the first meeting of the physician work group, members introduced the importance of evidence-based practice and systematic reliable processes of care.

Slide 30

Physician-Directed "Right Care Every Time"

• Strengthen physicians' role as the captain of the ship as related to accountability for "right care every time"
• Identify system supports such as "redundancy" and "forcing"
• Provide physician specific real-time data
• Promote the use of performance data in re-credentialing; set targets

Notes:

• Some additional objectives that will probably be added at the upcoming meeting will be the development of a physician mentor program and speakers bureau for local medical staff presentations.

Slide 31

Physician-Directed "Right Care Every Time"

• Integrate activities and recommendations in partnership with hospital trustee and executive leadership activities.
  • Promote local Top Ten infrastructure
  • Strategies for active engagement of local "voluntary" physicians
  • Provide regular Continuing Medical Education (CME) to address Top 10 strategies through "Physician Power Hour"

Notes:

• Following the first physician meeting, physicians created nine committees with many agreeing to work on more than one committee.
• The subcommittees will address topics related to decreasing variation, recognition program criteria, obstacles to right care, physician data, educational needs, systematic processes, etc.
• We have also established CME for participation in these efforts.
• Most want to meet for an hour monthly with sub committee meetings interspersed between.
• Some of the education topics suggested include: Coding, techniques for reminding or assessing deficiencies for correction before the patient is discharged, how to manage real time data, effective communication tools for physicians, human factors and reliability science, emergency barriers to perfection.

Slide 32

Trustees: Institutional Policies/Statements

• Assure visibility of the board's ultimate responsibility for evidence-based practice.
  • Include adherence to evidence-based practice in contracts.
• Reinforce physician accountability for evidence-based practice.
  • Institutional adoption of evidence-based practices
  • Performance data for re-credentialing
  • Recognition program related to evidence-based practice

Notes:

• One system support often not utilized is that of the hospital board. We are now organizing the Trustee Committee to focus on stepping up their involvement and acceptance of their ultimate accountability for quality.

Slide 33

Executive Leadership

• Facilitate evidence-based practices.
• Multi-disciplinary discussions to determine obstacles and identify supportive system functions to facilitate "right care every time."
• Employ forcing and redundancy strategies.

Slide 34

Executive Leadership

• Enhance ability for physician to participate in recommending reliable systematic processes of care.
• Concurrent monitoring for real time assessment and completion of missing elements of "right care every time."
• Physicians real-time feedback data.

Slide 35

The Future

• Our Vision—2010
  • Quarter: Q4 2010
  • GA Rank: 1
  • GA Rate: 95.5
  • National Rate: 90.2
  • Top State Rate: 95.5

Current as of January 2009

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Internet Citation:

The PHA: Where to Next?. Slide Presentation from the AHRQ 2008 Annual Conference (Text Version). January 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualmtg08/090908slides/Naylor.htm

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