Shared Risk: Putting a Dollar Value on Quality and Patient...

Shared Risk: Putting a Dollar Value on Quality and Patient Experience

Presented by Howard Greenfield, MD

Principal of Enhance Healthcare

Anesthesia Value Model “Are there better anesthesia care models that will allow us to free our physicians to extend their skills to new areas and to expand the influence and scope of our specialty?” “ To set our own course for the future, we should lead the development of those new models of anesthesia care with evidence-based supervision paradigms, and assure quality as those system changes are adopted.”

Miller R, Hannenberg A: Anesthesiology’s choices for the next century. ASA Newsletter 2005; (Centennial Issue):36–7

The New Anesthesia Normal…

Compensation Alignment,

Control

Outcomes Quality

Bundled Payments

Integrated Surgical Delivery

CEO’s Top 10 Expectations of Anesthesia Groups R Stiefel, MD 2012 Anesthesia Billing Seminar

10. Help us Meet Hospital P4P Items 9. Help us be “accountable” 8. Advise on Technology 7. Cover “Out of OR” cases 6. Address Post Op Pain 5. Drive OR Efficiency 4. “Own” Pre-op Preparation 3. Reduce our Subsidy 2. Leadership, Leadership, Leadership

1. Please,please,please keep the surgeons out of

my office!!

Value of Leadership Rovenstine Lecture 2011 P. Kapur

What acute care needs of patients in the healthcare system are not being adequately met? How can anesthesiologists take the lead to do so? Do members of the anesthesiology group have leadership experience or training? Can someone be sent for business or health administration education?

How can the anesthesiology group free up a member to attend every important committee meeting of the medical staff or medical center?

Who in the anesthesiology group can step up to lead institution-wide quality and safety initiatives?

Who in the anesthesiology group is interested to take on leadership in the OR, the PACU, the preoperative screening clinic, or other directorship duties? Who is interested in leading critical care or in establishing or directing rapid response teams Can anesthesiology leadership expertise help non-OR procedural suites work more smoothly and be more productive? Are some of the anesthesiology group members maintaining general medical skills to manage the pre- and post procedure components of the patient’s entire hospital stay, i.e., able to manage the entire surgical home experience?

Anesthesia Customer Service !  Patients want to go to sleep and wake-up. Pain free with no N,V.

!  Surgeons want on time starts and OR availability so that they get back to office and see more patients.

!  Hospital administrators want productivity and efficiency without surgeon, nursing or patient complaints

!  The Operating Room staff want to work with competent, caring physicians who respect their efforts

!  Members of the anesthesia department want acknowledgement for their hard work ( and all cases to be done by 3pm!!)

Quality and Performance Agreement: Hospital and

Exclusive Anesthesia group 120 day implementation period with ability for both to modify agreement Measures can vary annually with mutual agreement Variable weight in pool 15% -20 % for each of 6 measures Defined criteria and collection source Quarterly payments based on pre-existing hospital data

Quality and Performance Agreement: Regional

Anesthesia group and Multi –Hospital system

Annual incentive bonus available 80% for quality incentives and 20% for performance incentives Explicit definitions of documentation, auditing for quality metrics Anesthesia attendance required at key meetings Clear expectations for Anesthesia Ready, Patient Seen, On-time and first case starts.

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Measure Criteria Expected Achievable Performance Yearly

Yearly Incentive Of available Bonus

Correct Antibiotic Administered

CMS Surgical Care Improvement Project (SCIP) on all surgical patients over the age of 18 years

Meet or exceeds national benchmark percentile performance

90th percentile or >=25% of available Bonus

75th percentile to 90th percentile=10% of available Bonus

<75th percentile=0% of available Bonus

On-Time Administration of Antibiotics






Administration of Beta Blocker During Perioperative Period






Antibiotic Redosing per Guidelines

Redosing of Antibiotic per ASHP recommendations

Meet or exceed 90% compliance.

90% or > compliance= 10% of available Bonus

75%-90% compliance=5% of available Bonus

<75%=0% of available Bonus

Epidural Complications to include but not limited to:

• 349: Post-dural headache

• 324: Epidural abscess

• 998.12: Epidural hematoma

Actual documented complications from insertion of epidural in DRG: 765-768, 774, 775 with an epidural charge as reported through Crimson

Perform at or better than cohort population.

349: 0.82%

998.12: 0.02%

E879.8: 0.14%

Meet or exceed reference population rate=15% of available Bonus

Less than reference population rate=0% of available Bonus

Performance Metrics 20% of POOL

Measure Criteria Expected Achievable Performance Yearly

Yearly Incentive Of available Bonus

First Case on Time Start delays associated with anesthesia provider

Surgical Dashboard Less than or equal to 2% of total first case delays

Meet or exceed goal-20% of available Bonus Less than goal- 0% of available Bonus

Turn Around Time consisting of wheels in to incision

Surgical Dashboard Meet or exceed facility specific goal

Meet or exceed facility goal-20% of available Bonus Less than facility goal- 0% of available Bonus

Satisfaction with Anesthesia – Physician Perception

Physician Perception Survey administered by MidAmerica Division

90% or greater with scoring of “Excellent or Very Good”

Greater than or equal to 75th percentile-25% of available Bonus Less than 75th percentile-0% of available Bonus

Same Day Surgery Patient Satisfaction – Anesthesia

Gallup survey for SDS Gallup 95th percentile Greater than or equal to Gallup 95th percentile-25% of available Bonus Between 75th up to 94th percentile-7% of available Bonus Less than 75th percentile- 0% of available Bonus

Attendance at Required Medical Staff/Program Meetings (Trauma and Surgical Operations) Active participation in the Trauma Program Operational Process Performance Committee/Multidisciplinary System Committee

Medical Staff Office attendance records

Based on facility and or program specific requirements

10% max payment for attending all required MS/Program meetings. Attendance less than required MS/Program meetings- 0% of available Bonus

!

Quality and Performance Agreement:

Hospital and APMC

5-10 % of annual subsidy at risk for APMC

Metrics to be mutually agreed upon both parties Hospital responsible for collection of data

Definitions and expectations explicitly defined

Satisfaction and Professionalism clause detailed

Satisfaction Surveys-Do you get paid for Action or Interaction ?

ACTION- Most anesthetics are completed safely and effectively- Patient goes to sleep and wakes up with minimal pain and PONV. INTERACTION- Patient Pre-op assessment- Pt history and clearance Clearly explain anesthetic type and procedure Answer questions from patient and family Provide post op pain relief INTERACTION- Surgeon Anesthesia provider on time arrival Pt prepared for surgery Timely movement to OR, expeditious turnover between cases Efficient and safe anesthetic. INTERACTION-Administration. No patient complaints No surgeons lining up at door Nursing not complaining about patients with inadequate pain relief.

Limitations to Patient Satisfaction Surveys !  Assessments of satisfaction with anesthesia services, contain outcomes

which may not be easily attributable to a single individual.

!  Some anesthesiologists have been reluctant to accept outcome measures for which they are only partially responsible.

!  In the future it is likely that anesthesiologists, as part of the entire perioperative team, will need to accept broader responsibility for patient outcomes.

AQI, in partnership with ASA, has received funding from the Patient Centered Outcomes Research Institute (to collect data on patient satisfaction and study methods for improvement. Anesthesia practices that report patient satisfaction data to the AQI will have the opportunity to receive free educational materials from ASA, including both CME for anesthesiologists and multi-media information for patients.

http://www.anesthesiallc.com/publications/ealerts/280-anesthesiology-and-pain-medicine-patient-satisfaction-surveys

Anesthesia Quality Institute Practices that archive their data are best positioned to take advantage of federal incentives for physician quality reporting systems and pay for performance,” said Richard P. Dutton, MD, MBA, executive director of the Anesthesia Quality Institute, in Park Ridge, Ill. “Contribution of this data ‘upward’ to a national registry allows benchmarking against national practice norms, facilitates our scientific understanding of rare adverse events, and enables comparative effectiveness research.

Business Indicators

Process Indicators

Clinical Indicators

Surgeon Satisfaction

! How does your organization propose to provide for clinical

providers to maximize their individual productivity and quality of services?

! What percentage of the providers’ income will be at-risk for meeting identified production goals.

! What percentage of the providers’ income will be at-risk for meeting identified quality goals.

Sample RFP Questions #1

Sample RFP Questions #2 ! Outline a plan for quality/performance improvement,

including committee structure, meeting schedule, and the formal program of evaluation and measurement. Will customer satisfaction surveys be used to determine level of satisfaction with patients and surgeons?

! Provide examples of surveys that are in use at other facilities

you currently provide services to. !  Specify the extent to which your organization provides the

facility with Quality Metrics. If you are using a “dashboard” please provide or specify the Quality Metrics that are used.

Sample RFP Questions #3

!  State any advanced technological abilities of your services that would be included in your services, such as computerized staff scheduling or record-keeping systems.

!  What differentiates your anesthesia services from other

vendors? ! Describe the clinical quality improvement projects the group

has worked on during the last 24 months and describe the clinical outcomes.

Can your group respond like this ??

!  Describe the clinical quality improvement projects the group has worked on during the last 24 months and describe the clinical outcomes.

. !  1. Measures were implemented to improve SCIP metrics and currently SCIP

compliance in the anesthesia department is 100%. !  2. Implemented an acute pain service in collaboration with MH administration. The

program has demonstrated excellent patient and surgeon satisfaction !  3.The use of ultrasound was implemented to improve the quality of nerve blocks and

allow for the placement of perineural catheters for post-operative pain. . !  4. MH was the first hospital in the state to implement an ambulatory perineural catheter

program and has had great success in controlling post- operative pain as evidenced by stellar Press-Ganey scores.

!  5. Dr. ZM partnered with Dr. Ortho to perform a study that showed that perineural catheters improve pain control in the short term and increase strength and range of motion in Rotator cuff repair patients at 3 months.

!  6.Currently pioneering the use of Adductor Canal catheters which improves both pain control and post-operative physical therapy after knee surgery. These catheters have allowed for earlier discharge from the hospital and thus have led to substantial savings for the hospital and improved patient satisfaction scores.

QUALITY METRICS

Powerful visual controls drive transparency

and enable hospitals and providers to

recognize trends and make fact-based

decisions.

XX delivers prompt timely corrective actions

and keeps administrators and clinicians in the

know.

Clinical data can be integrated with evidence-

based medicine to implement best practices

and improve operating procedures, including

OR efficiency and provider performance.

Gain critical insight into clinical and operational value streams.!

"#!

Sharing Risk and Demonstrating Value Kapur Anes 2012 116:758-67

!  Step up to leadership ! We must determine quality benchmarks and equal or exceed them. ! We must oversee and solve perioperative, peri-procedural, intensive

care, and pain issues throughout the health system, utilizing a cost-effective mix of providers appropriate for the severity of the cases.

! We must facilitate procedural throughput at all levels, including

critical care. ! Organizationally we must become integral to the management of all

areas where acute care and pain services are being delivered.

! We need to become the acute care go-to people, the acute care solution, for each of our clinical sites.

Shared Risk: Putting a Dollar Value on Quality and Patient...

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