Quality Improvement Strategies Impacting Value Based Purchasing

Several major initiatives evolved as a result of the Affordable Care Act and all will have a significant impact on quality and improving health care.  This newsletter will share information on the National Quality Strategy, the CMS Innovation Center and the Transforming Clinical Practices Initiative. 

The National Quality Strategy

Mandated by the Affordable Care Act, this strategy was developed through a collaborative and transparent process with input from a wide variety of stakeholders.  There are three overarching aims, six priorities that address the most common health concerns for Americans today and nine levers to assist stakeholders in aligning their functions to drive improvement.

The NQS provides a focus for addressing the abundance of clinical quality measures currently used in national programs.  This initiative has three broad aims:

• Better Care – improve the overall quality by making healthcare more patient-centered.
• Healthy People/Healthy Communities – improve the health of the population by supporting proven interventions that address behavioral, social and environmental determinants of health.
• Affordable Care – reduce the cost of quality healthcare.

Six priorities were developed to advance these aims:

• Making care safer by reducing harm caused by delivery of care.
• Ensuring that each person and family is engaged as partners in their care.
• Promoting effective communication and coordination of care.
• Promoting the most effective prevention and treatment practices for the leading causes of mortality.
• Working with communities to promote wide use of best practices to enable healthy living.
• Making quality care more affordable.

Improving health and health care quality can only occur if all sectors – individuals, family members, payers, providers, employers and communities make it their mission.  Members of the healthcare community can align to the National Quality Strategy by using the levers.  These levers represent core business functions, resources or actions that can be taken by the stakeholder to align with this improvement strategy.  These levers are:

• Measurement and Feedback
• Public Reporting
• Learning and Technical Assistance
• Certification, Accreditation, and Regulation
• Consumer Incentives and Benefit Designs
• Payment
• Health Information Technology
• Innovation and Diffusion
• Workforce Development

For more information check out the website www.ahrq.gov/workingforquality. This site shares examples of how the priorities have been put into action and offers a great toolkit to assist in your program development.

The CMS Innovation Center was created with the purpose of testing innovative payment and service delivery models to reduce expenditures.  This program has the following priorities:

• Testing new payment and service delivery models
• Evaluating test results and advancing best practices
• Engaging a broad range of stakeholders to develop additional models for testing

After a rigorous evaluation of the impact of a model, feedback is provided in order to foster continuous quality improvement.  The center leverages claim data to deliver actionable feedback to providers about their performance and encourages providers to use their own performance data to drive continual improvement in their outcomes.  Every service delivery or payment model developed by the Innovation Center includes a plan of action to ensure that lessons learned and best practices identified during the test can be widely disseminated, sharing the results on an ongoing basis in order to promote rapid learning.

A great website for additional information on this initiative is http://innovation.cms.gov/About/index.html.

The Transforming Clinical Practices Initiative was designed to assist clinicians in achieving large-scale health transformation and will impact practices over the next four years in sharing, adapting and further developing comprehensive quality improvement strategies. The goals are:

• Promoting broad payment and practice reform in primary care and specialty care
• Promoting care coordination between providers of services and suppliers
• Establishing community-based health teams to support chronic care management
• Promoting improved quality and reduced cost by developing a collaboration of institutions that support practice transformation.

The Department of Health and Human Services will invest $840 million over the next four years.  This will be a combination of incentives, tools and information to encourage doctors to team with their peers and others to move from volume-driven systems to value-based, patient centered, coordinated healthcare.

As you can readily see, all three of these initiatives have intertwining goals and priorities – all of which pursue the ultimate goal of improving healthcare.

Value Based Purchasing Newsletter Article Part II

                           Better Care.  Smarter Spending.  Healthier People.

Paying for Value – Not Volume!

Whether you are a patient, a provider, a health plan or a taxpayer it is in our common interest to build a healthcare delivery system that is better, smarter and healthier – a system that delivers better care; a system that spends healthcare dollars more wisely; and a system that makes our communities healthier!  We must develop and implement better ways as a country to deliver care, pay providers and distribute information.

Improving the quality and affordability of care for all Americans has always been a pillar of the Affordable Care Act, alongside expanding access to such care.  The ACA provides an opportunity to shape healthcare delivery, improve the quality of care provided and reduce overall growth of healthcare costs.  Value and care-coordination will now be rewarded, rather than volume and care duplication.  The Department of Health and Human Services has established and communicated the benchmarks and metrics that will be used for accountability and drive the attainment of goals for Value Based Purchasing.

There are actually four categories that currently outline this new structure for payments to providers:

1.     Category One – fee-for-service with NO link of payment to quality.

2.     Category Two – fee-for-service with a link of payment to quality.

3.     Category Three – alternative payment models built on fee-for-service architecture.

4.     Category Four – population-based payment.

Value-based purchasing includes payments made in categories 2 thru 4, with the goal of moving the majority of encounters to the population-based payment group.  The goal is to increase accountability for both quality and total cost of the care provided.  At the end of 2014, an estimated 20 percent of Medicare reimbursements had shifted to categories 3 and 4. 

The Department of Health and Human Services has set a goal that by the end of 2016, 30 percent of all Medicare payments will be in categories 3 and 4, and that goal increases to 50 percent by the end of 2018.  Part of this will be accomplished by utilization of alternative payments models such as the medical home, bundling payments and utilization of Accountable Care Organizations. Ultimately the goal is that by the end of 2018, 90 percent of Medicare fee-for-service payments will be in categories 2 thru 4.  In these alternative payment models, providers are accountable for the quality and cost of care for the people and populations they serve moving away from the old way of doing things which amounted to “the more you do, the more you get paid”.

Let’s expand a bit on one of the alternative models.  In the Patient Centered Medical Home model, instead of physicians working in silos, separately, care coordinators oversee all the care a patient is getting.  This means patients are more likely to get the right tests and medications rather than getting duplicated tests, procedures, etc.  These medical homes typically offer patients access to a physician or other clinicians 24/7, and some may offer extended office hours.

According to the Secretary of the Department of Health and Human Services in a statement earlier this year, she stated the progress made thus far has saved taxpayers more than $116 billion. This savings translates in the ability of organizations to reduce expenditures and reinvest those dollars in higher quality care for their employees – wellness programs, for example.

America’s healthcare system is poised to move into its next phase – a coordinated, cost-efficient and quality driven system that promotes and supports individuals and community health.

New drivers have been implemented to foster these changes and next month we will share information on The Center for Medicare and Medicaid Innovation, Transforming Clinical Practices Initiative and the National Quality Strategy. 

“A Deeper Dive: ISO 9001:2015”

It is our strong recommendation that organizations do not make changes to their quality management systems until the formal standard is released in 2015.

As a certified diver, there is probably nothing more satisfying and thrilling than seeing all of your training and preparation pay off as you gently glide through the water with harbor seals and sea lion pups frolicking and dancing around you, begging you to play.  As a father of three certified divers and being obsessively compulsive about their safety, getting to the play portion can only come after the safety portion.  I have personally sat through the training program three times when each of my sons became old enough to enter this whole new world of adventure, and therefore I feel that I have earned the right to be in charge of all the rules.  As we in the ISO family begin this brand new adventure into an uncharted world, I can’t help but make some simple connections between ISO and SCUBA.

Before each and every dive there are some safety protocols that each and every “good” diver should go through.  As a diver, you Begin With Review and Friends (BWRF).  This acronym stands for each of the safety checks that you and your buddy check out on each other’s equipment before each dive to ensure a successful dive.  “B” stands for BCD, or your Buoyancy Control Device. Does your flotation device work?  “W” stands for weights. Can you and your buddy easily remove the weights in the event of an emergency and get to the surface?  “R” stands for regulator. Does your breathing device work? No explanation needed.  “F” stands for a final once over for all the gear that will be going down with you to make sure that nothing is tangled, loose, missing, or defective.  You don’t want to get to the bottom and find out something isn’t right.

For our adventure into the deeper and uncharted waters of the ISO 9001:2015 Standard, I want to encourage you to use the same acronym but with a little twist on Begin With Review and Friends, “BWRF”.    “B” stands for Base.  What you have already put in place with your ISO 9001:2008 standard will become the base of your 2015 program.  Do not think that you have to go and start all over again.  You do not have to recreate the wheel.  You would think that this is common knowledge; however, I have already been approached by organizations to help them redo what has already been determined to be effective, efficient and compliant with both the 2008 & 2015 Standard.  In each of the coming months as we discuss how to actually begin to implement the new standard, we will always start with what 2008 has given you as a base before we begin building what 2015 is asking for.

“W” stands for “Woody is right!” Just Kidding?

“W” stands for What.  What does the new ISO 9001:2015 standard actually require?  Already, we have received questions from clients that indicate that people and organizations are beginning to read into the standard requirements that simply are not stated in the standard, but are being drawn out by interpretations.  This can result in far more complex, restrictive and overbearing management systems that in time may prove to be so cumbersome that the organization fails to realize the return on investment for their efforts.  As we journey through the ISO standard, we will take just a few statements to clarify exactly what the standard is saying and what it is not saying.  Hopefully this will keep organizations from getting too deep without enough air to support themselves.

“R” stands for Reason.  Reason will have a twofold purpose in our coming articles.  The first purpose will be an explanation as to some of the reasons why the ISO 2015 standard is requiring what they are requiring. The second and most important purpose will be a clear, concise and logical approach to achieving the requirement.  Many times organization will put in place multiple control features to ensure compliance in every possible scenario at the expense of time, resources, money and much frustration and anxiety.  ICH hopes to bring to the table implementation ideas and concepts that will help your organization fulfill the new requirements without overtaxing the organization and its resources.

“F” stands for Final.  When we say final, we want to ensure that organizations do not put anything in place that is not a good business practice...that if implemented and not a final requirement of the ISO 9001:2015 Standard, would not in any way negatively impact the organization.   With that being said, the final sections of each of the following news articles will focus on where organizations can begin to implement the new standard and not be at risk of putting an unnecessary activity or process in place that is not beneficial to the organization.  We will offer suggestions for user friendly methodologies for compliance.  We will suggest multiple possibilities as to where the organization can use systems that are already in place for compliance.  We will recommend best practices that have been identified across the country in the healthcare industry.  We will do our very best to make this transition to the new standard as painless as possible. And as always, we will be there to lend a helping hand or be a sounding board for any of your questions.

Who’s ready to Dive Deeper?  Next month we cover Management Review and Risk Control.

In over my head and loving it,

“W”

   

"I Love Improvement"

It is our strong recommendation that organizations do not make changes to their quality management systems until the formal standard is released in 2015.  

                           

Do you remember your first computer, your first CD player Walkman, your first boom box, your first cassette player, your first eight track player...should I stop? Change and improvement has a funny way of being quite enjoyable when someone else is doing the work for us, but when it is us that needs to change and improve, it might be a different story. I was giving some guidance to a client just yesterday and from memory rattled of not only the ISO clause down to the letter, but also recited the requirement. Yes, I am an ISO GEEK! I laughed to myself and thought how quickly that is going to change, and I will once again be right back where I was the last time the standard made a major revision. I will be in the same boat with everyone else learning a brand new standard and trying to improve how I communicate the requirements of the standard to my customers. As I think about it though, I am not sure that I would have much respect for a standard that requires continual improvement if the writers did not practice what they preach. Remember when dad would say, "Do as I say, not as I do???" Yeah, that meant a lot. When the ISO 9001:1994 transformed into the ISO 9001:2000, it set the quality management system world on its ear. Everyone was running around as if the sky was falling trying to figure it out. You know what? 15 years later, ISO still stands. I can't really recall what the big deal was, and do you know what else? I don't know how we ever managed without the improvement that the new standard brought. So here we are again, and all I can say is hold on, the ride is going to be fantastic.

Section Ten of the ISO 9001:2015 is all about improvement; improvement from known issues or improvement from potential issues - all in an effort to meet customer requirements and enhance their satisfaction. This improvement can be implemented at the system, process or service line levels.

Section 10.2 Nonconformity and corrective action starts with the known issues. Let's clean house before we try to improve. For the first time, nonconformity has become a single term in the ISO standard. There is no longer segregation between nonconforming product, nonconforming service, customer complaint, internal audit finding, process performance failure or system failures. When bad things happen, we are going to correct them and deal appropriately with the consequences. Next, we are going to ask ourselves if this nonconformity is severe enough that it warrants further investigation to ensure that it does not recur. If it is of a magnitude that could jeopardize the organization, processes or customer then we are going to find out what the true cause of the nonconformity is. We are going to ask ourselves if this same situation has or could occur elsewhere in the organization. We are going to implement applications of control to prevent the nonconformity from recurring anywhere. If need be we might even have to change our quality management system. Never forget that ISO 9001 is okay with making mistakes, but is never okay with repeating them.

Section 10.3, the final chapter or epilogue, brings us to Continual Improvement. It is as if the ISO 9001:2015 standard is saying, "Look we've given you everything you need to make your organization the very best. Now get to it."  

4.1 We understand our Context

                                  Internal and External Risk and Opportunities

4.2 We understand our Interested Parties

                  

                                  External Expectations Risk and Opportunities

5 Leadership is on board

                                        

                                  Supporting, Empowering, and Leading

6.1 We have developed a plan

                                   

                                  Risk and Opportunity is planned

6.2 Actions are taken to address issues                      

                                  Risk & Opportunity is addressed & mitigated

6.3 We plan for change                                              

                                  Change is part of our everyday focus

8.7 Nonconformities are controlled                           

                                  We contain what mistakes we encounter

9.1.2 We know what our customers think                  

                                  We react accordingly to stay ahead

9.1.3 We know what processes are weak                  

                                  We focus our attention there

9.1.3 We know the impact of suppliers

                       

                                  We work together to mitigate risk

9.2 We know where our QMS is weak                       

                                  We change the way we do business

9.3 Management drives us to be better                     

                                  Supplying resources, support, and guidance

10.2 We will make mistakes                                        

                                 Only Once!

All through the standard, the common thread of continual improvement can be identified. Sometimes I wonder if this section should have been the first section of the new revision?

ISO 9001:2015 Geeks Unite!

Woody  

P.S. Watch for "A Deeper Dive into ISO" coming in March!!!

by Woody, the ISO Wizard