Inova Fairfax Hospital Karin Cox, RN, MSN, Quality Consultant:

Inova Fairfax Hospital Karin Cox, RN, MSN, Quality Consultant: Critical Care & Neurosciences Services 1

Inova Fairfax Campus 833 licensed beds 2 million square feet 36 Off-site properties 7,000 employees Quality Staff of 13.5 Outcomes Staff of 16 2

What we will cover History of Quality Efforts in Healthcare What is an Ideal Healthcare System Role of the Quality Consultant Quality at Inova Fairfax Hospital 3

The Quality Professional’s Perspective Do the Right Thing Right, the First Time Continuous Process Improvement Timeliness Reliability Efficacy Availability Affordability Standardization Freedom from Deficiencies Customer Satisfaction 4

Quality from the Patient’s Perspective Keep me safe Heal me Be nice to me In that order! Safety quality satisfaction Excellent Care 5

Measuring Quality: Romeo and Juliet I do remember an apothecary,-And hereabouts he dwells,--which late I noted In tatter'd weeds, with overwhelming brows, Culling of simples; meagre were his looks, Sharp misery had worn him to the bones: And in his needy shop a tortoise hung, An alligator stuff'd, and other skins Of ill-shaped fishes; and about his shelves A beggarly account of empty boxes, Green earthen pots, bladders and musty seeds, Remnants of packthread and old cakes of roses, Were thinly scatter'd, to make up a show. 6

History of Quality: Florence Nightingale Went to Scutari Hospital with 38 nurses 3,000 – 4,000 soldiers Deplorable conditions 43% mortality Set up kitchens, laundry, basic sanitation, nursing Mortality dropped to 3% Nightingale Fund allowed independent endowment of St. Thomas School of Nursing 8

Florence Nightingale as statistician 9

Foundation of Process Improvement Set Standards Measure 10

Voluntary Standards Formed 1913 – American College of Surgeons founded 1917 – Minimal Standards for Hospital – five – Physicians had to be graduates of School of Medicine – Physicians had to apply for Medical Staff privileges – Organized Medical Staff had to meet at least annually to review quality of care – Medical Record – Hospital services supervised by a qualified person 11

Voluntary Standards Formed 1913 – American College of Surgeons founded 1917 – Minimal Standards for Hospital – five – Physicians had to be graduates of School of Medicine – Physicians had to apply for Medical Staff privileges – Organized Medical Staff had to meet at least annually to review quality of care – Medical Record – Hospital services supervised by a qualified person 1918 – First inspection – Only 89 out of 692 hospitals met standards 12

Pressure to Change: Standards Evolve 1950s A time of change – Number of standards increases – 3,200 hospitals achieve standards – American College of Physicians, American Hospital Association, American Medical Association, Canadian Medical Association form the Joint Commission on Accreditation of Hospitals 1965 Congress passes Social Security and “deems” that hospitals accredited by JCAH are able to participate in Medicare 1970s Expansion and Segmentation – Nurses, Hospital Administrators, Dentists – Required submission of remediation plans 13

Pressure to Change: Standards Evolve (TJC) Develop Standards for Different Types of Organizations – Hospitals – Behavioral Health – Ambulatory Care – Home Care – Critical Access (Rural) Hospitals – International Develop Disease Specific Standards (as of 2002) – Stroke – Cystic Fibrosis – Renal Disease 14

Standards Proliferated in Many Areas Rights and Ethics Provision of Care Medication Management Infection Control Performance Improvement Environment of Care Leadership Medical Staff Nursing Human Resources 15

International Comparison of Spending on Health, 1980–2004 Average spending on health per capita ( US PPP) 7000 6000 United States Germany Canada France Australia United Kingdom 5000 Total expenditures on health as percent of GDP 16 14 12 10 4000 8 3000 6 2000 1000 0 4 2 United States Germany Canada France Australia United Kingdom 0 Data: OECD Health Data 2005 and 2006. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 16 16

Wake Up Call in Public and Private Sectors Fee for Service – Rewarded utilization – No incentives for quality – Discount in exchange for volume Prospective Payment – Public Sector – DRG (Diagnosis Related Groups) Prospective Payment – Private Sector – HMO’s – Capitation 17

Standards Evolve Joint Commission 1980s “Agenda for Change” – Response to Criticism – First “Public” members – Outcome Measurements: Core Measures 1987 - 2001 – Sentinel Events 18

Different Approaches TJC – Primary Processes of care, continuum, communication, continuous improvement – Secondary Inspection, deficiencies CMS – Primary Inspection, deficiencies – Secondary Processes of care, continuum, communication, continuous improvement 19

Was it enough? We created standards We measured to these standards 20

To Err is Human Published 2000 by Institute of Medicine Adverse events occur in 2.9 to 3.7 % of hospitalizations 33.6 million hospitalizations per year in United States 44,000 to 98,000 adverse events per year Adverse events result in death 6.6 to 13.6 % Death due to medical errors as 8th leading cause of death 21

Responding to IOM Reduction in Federal reimbursement by 2% for not submitting data on Core Measures: How often a hospital adheres to evidence based clinical practice for heart attack, heart failure, pneumonia, surgery (2003) Transparency: Public website to display Core Measures results (2005) www.hospitalcompare.hhs.gov Reduction in Federal reimbursement by 2% for not submitting HCAHPS patient satisfaction data (2007) 22

National Events 23

24

Components of an “Ideal” Health Care System 1. 2. 3. 4. 5. 6. Long, healthy, productive lives Quality Access Efficiency Equity Capacity to innovate and improve 25

Mortality Amenable to Health Care Mortality from causes considered amenable to health care is deaths before age 75 that are potentially preventable with timely and appropriate medical care Deaths per 100,000 population* International variation, 1998 150 100 75 92 88 88 88 81 84 97 97 99 106 107 109 109 State variation, 2002 129 130 132 115 115 134 119 110 103 84 90 50 Fr an ce Ja pa n Sp a Sw in ed en It Au a ly st ra Ca l ia na No da Ne r th wa y er la nd s G re G ece er m an y A Ne us w t Ze ria al De an d Un n ite m a rk d St at es Fi nl an Un I ite re d l d Ki and ng d Po o m r tu ga l 0 U.S. avg 10th 25th Med- 75th ian 90th Percentiles * Countries’ age-standardized death rates, ages 0–74; includes ischemic heart disease. See Technical Appendix for list of conditions considered amenable to health care in the analysis. Data: International estimates—World Health Organization, WHO mortality database (Nolte and McKee 2003); State estimates—K. Hempstead, Rutgers University using Nolte and McKee methodology. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 26

Medical, Medication, and Lab Errors Among Sicker Adults, 2005 Percent reporting medical mistake, medication error, or lab error in past two years International comparison 60 United States, by race/ethnicity, income, and insurance status 49 34 30 22 23 UK GER 25 27 AUS 33 36 35 31 30 24 0 NZ 34 CAN US White Black Hispanic Above average income Below average income Insured Uninsured UK United Kingdom; GER Germany; NZ New Zealand; AUS Australia; CAN Canada; US United States. Data: Analysis of 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults; Schoen et al. 2005a. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 27

Went to ER for Condition That Could Have Been Treated by Regular Doctor, Among Sicker Adults, 2005 Percent of adults who went to ER in past two years for condition that could have been treated by regular doctor if available United States, by race/ethnicity, income, and insurance status International comparison 50 41 36 29 26 25 21 24 23 23 20 15 12 6 9 0 GER NZ UK AUS CAN US White Black Hispanic Above average income Below average income Insured Uninsured GER Germany; NZ New Zealand; UK United Kingdom; AUS Australia; CAN Canada; US United States. Data: Analysis of 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults; Schoen et al. 2005a. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 28

Percentage of National Health Expenditures Spent on Health Administration and Insurance, 2003 Net costs of health administration and health insurance as percent of national health expenditures 8 7.3 5.6 6 4.0 4 2 4.1 4.2 4.8 3.3 1.9 2.1 2.1 2.6 0 ce n a Fr d an l n Fi a an p Ja da a n Ca ite n U d K om d g in b he t Ne ds n rl a a tri s Au l ia c nd a a r l st er u z t A i Sw y s te * an a m St er d G ite n U 2002 b 1999 c 2001 * Includes claims administration, underwriting, marketing, profits, and other administrative costs; based on premiums minus claims expenses for private insurance. Data: OECD Health Data 2005. a Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 29

National Health Expenditures Invested in Research and Spent on Public Health Activities Compared with Administration and Insurance Costs, 2000 and 2004 Dollars (in billions) Percent of national health expenditures 2000 150 2004 136.7 8 2000 2004 7.3 6.0 6 100 81.2 4 3.2 56.1 50 39.0 43.4 2 25.6 0 1.9 3.0 2.1 0 Investment in research Government public health activities Administration and insurance costs Investment in research Government public health activities Administration and insurance costs Data: CMS Office of the Actuary, National Health Statistics Group; and U.S. Dept. of Commerce, Bureau of Economic Analysis and U.S. Bureau of the Census (Smith et al. 2006). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 30

Scorecard-Related Publications Cathy Schoen, Karen Davis, Sabrina K. H. How, and Stephen C. Schoenbaum, “U.S. Health System Performance: A National Scorecard,” Health Affairs Web Exclusive (Sept. 20, 2006):w457–w475. Available online at: http://content.healthaffairs.org/cgi/reprint/25/5/w457 Commonwealth Fund Publications: – Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Results from a National Scorecard on U.S. Health System Performance (Sept. 2006). – Cathy Schoen and Sabrina K. H. How, National Scorecard on U.S. Health System Performance: Technical Report (Sept. 2006). – Cathy Schoen and Sabrina K. H. How, National Scorecard on U.S. Health System Performance: Complete Chartpack and Chartpack Technical Appendix (Sept. 2006). These Fund publications are available for free download on The Commonwealth Fund’s Web site at www.cmwf.org. 3131

Where are we now with Quality: Financial Accountability 1987 - 2002: Hospitals were required to collect data and report on standardized – or “core” – performance measures. Failure to report results in reduced reimbursement. Core Measures – Acute Myocardial Infarction (AMI) – Heart Failure – Pneumonia – Surgical Care – Asthma 32

Where are we now with Quality: Financial Accountability 2008: Reduced reimbursement for HACs Hospital Acquired Conditions – Specific types of Infections – Injury during hospitalization (fall, burn) – Retained foreign body – Skin breakdown stage III or IV – Wrong surgery – Blood transfusion mis-match “Never” events 33

Where are we going? Pressure on Federal Government to act Many different stakeholders – Providers – Payors (Government, Private) – Regulators – Suppliers – Patients/Families Recognition of the cost of poor quality Leverage use of technology 34

Percent of Adults Ages 18–64 Uninsured by State 1999–2000 2004–2005 NH NH ME VT WA ND MT ID NY WI SD MI WY PA IA NE NV CA IL CO KS MO OH IN WV VA KY NM OK ID AL IL CO KS MO OH IN WV VA KY AZ LA NM OK DE MD DC SC AR MS TX NJ RI CT NC TN GA AL GA LA FL AK PA IA NV CA MA MI NE UT ME NY WI SD WY DE MD DC NH MN OR SC AR MS TX NJ RI CT NC TN AZ MA VT ND MT MN OR UT WA FL AK HI 23% or more 19%–22.9% HI 14%–18.9% Less than 14% Data: Two-year averages 1999–2000 and 2004–2005 from the Census Bureau’s March 2000, 2001 and 2005, 2006 Current Population Surveys. Estimates by the Employee Benefit Research Institute. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 35

Federal CMS (Medicare/Medicaid) 36

Quality from the Patient’s Perspective Keep me safe Heal me Be nice to me In that order! Safety quality satisfaction Excellent Care 37

Role of Quality Consultant Safety Performance Improvement Regulatory Readiness Peer Review 38

Role of Quality Consultant - Safety Safety Huddle – weekly / daily message Safety Coach program Safety phone Red rules DNU abbreviations HAM SALAD 39

Role of Quality Consultant - Safety Rapid Response Team (RRT) Environment of Care Tours Safety Culture Survey Medication Safety Oversight Committee Site visits from one Inova facility to another 40

Role of Quality Consultant - Safety Tubing Mis-connection project Safety Fair Data analysis for trends Data mining and display Root cause analysis Board and Administrative Ownership is KEY 41

Role of Quality Consultant – Performance Improvement LEAN PDCA: Plan – Do – Check - Act Collaborative Learning Communities – 100K Lives Campaign, Sepsis, Flow, Organ Donation Team Facilitation Bundle Compliance Teams Clinical Effectiveness Teams 42

Role of Quality Consultant – Peer Review Care Science, Crimson Initiative Mortality, Morbidity Indicator Development Case Finding, Screening, Investigation Chart preparation, Data entry, Minutes Ongoing Professional Practice Evaluation (OPPE) Focused Professional Practice Evaluation (new) Focused Review Credentialing Report 43

Role of Quality Consultant – Regulatory Readiness Federal - CMS (Medicare and Medicaid) can survey announced or unannounced. State - State surveys hospitals every two years with 48 hours notice; can also survey or investigate complaints unannounced County - Fire Marshall can survey unannounced The Joint Commission – Starting in 2006, TJC surveys became unannounced. Survey every three years; also conduct random unannounced surveys. Other - There are a variety of other regulatory bodies that also conduct surveys - CARF, NRC, CAP, etc. 44

Role of Quality Consultant – Regulatory Readiness Periodic Performance Reports (PPR) Strategic Surveillance System (S3) Outcomes Data: Core Measures, SCIP, Vermont – Oxford, NDNQI Complaint Investigations Mock Surveys (Dress rehearsal) Gap analysis 45

Role of Quality Consultant – Challenges Paper Records Changing regulatory environment “Blue” Rules Competing Priorities Integrating new technology New Stakeholders Demanding populations Ethical issues – End of Life Leadership “buy in” 46

Why is Quality Important to Inova Fairfax Hospital? Our Mission: To improve the health of the diverse community that we serve, through excellence in patient care, education and research Our Vision: To be the best healthcare system in the world Our Core Values: – Caring for and about people – Innovation – Community responsibility 47

Inova Fairfax Accomplishments Health Grades One of the top 50 hospitals in the United States for the 2nd consecutive year. Ranked Best in Virginia for Cardiology Services for two years in a row (2009-2010) Ranked Best in Virginia for Treatment of Stroke for three years in a row (2008-2010) Recipient of HealthGrades' Stroke Care Excellence Award for five years in a row (2006-2010) Ranked Best in Virginia for GI Medical Treatment for two years in a row (2009-2010) Recipient of HealthGrades' Gastrointestinal Care Excellence Award for six years in a row (2005-2010) 48

Inova Fairfax Accomplishments American Nurses Credentialing Center – Magnet Status since 1997 – First Magnet Hospital in DC region, – One of 102 nationally US News and World Report – Top 50 hospitals for GYN, Urology, Heart and Heart Surgery 49

Inova Fairfax Accomplishments Health and Human Services – Medal of Honor for Organ Donation Joint Commission Disease Specific Certification – Primary Stroke Center – VAD (Ventricular Assist Device) – Transplant American College of Surgeons – Level 1 Regional Trauma Center Working Mother Magazine – Top 100 Employers 50

www.hospitalcompare.hhs.gov 51

Data prepared for: INOVA FAIRFAX HOSPITAL HOSPITAL COMPARE - HCAHPS September 2009 release Your Hospital Score Av era ge 25th PCT L Med ian 75th PCT L Total N YES, patients would definitely recommend the hospital 70% 68 % 61% 68% 75% 3,76 5 YES, patients would probably recommend the hospital 25% 26 % 21% 26% 32% 3,76 5 NO, patients would not recommend the hospital (they probably would not or definitely would not recommend it) 5% 6% 3% 5% 7% 3,76 5 HCAHPS - Discharges from January 2008 to December 2008 Would patients recommend the hospital to friends and family? Number of Completed Surveys National 300 or More

Quality from the Patient’s Perspective Keep me safe Heal me Be nice to me In that order! Safety quality satisfaction Excellent Care 53

Questions 54