Welcome to Healthcare Quality Week

INSERT Name of Organization

2

We’re Celebrating!

• Healthcare Quality Management Professionals

• Healthcare Quality achievements in our organization

• And we’re raising awareness about how important quality is in everyday practice

It’s all part of Healthcare Quality Week sponsored by NAHQ

Who is NAHQ?

National Association for Healthcare Quality

National Association for Healthcare Quality• Leading organization for professionals working in healthcare quality

management (6000 members)− Members work in hospitals, day surgery centers, large clinics, nursing

homes and other sites

What do they do? National Association for Healthcare Quality

• Promotes, supports, educates, and advocates for Healthcare Quality professionals and their career field

• Serves as a leading national voice on the topic of Quality in Healthcare• Publishes Journal for Healthcare Quality• Offers Certified Professional in Healthcare Quality Credential (8000+

CPHQs)− More than 8,000 professionals have earned the CPHQ

• Hosts leading quality educational events, such as webinars and the National Quality Summit

Let’s talk about quality here—what do you think is the biggest improvement? Slide for speakers insert quality achievements at their

institutions

That’s great input. And it’s important. Because the regulatory landscape is shifting-and it requires change.

THE STATE OF HEALTHCARE QUALITYLet’s talk about how we got here.

It started with a report…

Institute of Medicine “To Err Is Human,”1999• Estimated that medical errors cause as many as 100,000 preventable

deaths a year• Recommended healthcare organizations create and maintain strong

safety cultures• “Safety should be an explicit organizational goal that is demonstrated

by strong leadership on the part of clinicians, executives and governing bodies.”

Followed by a national movement and all the attendant research, examination, and exploration that was required to start fixing the issue

Which resulted in…

In 2012, NAHQ issued a Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems

It offered recommendations for best practices to enhance quality and improve safety.• “Without a strong safety culture, frontline providers and

management may fail to identify a concerning pattern of performance or a single event or may hesitate to report them.”

−Susan Goodwin, past president, NAHQ (2012)

The recommendations weren’t just good practice. They were good business.

The Safety Culture Imperative

Focus on accountability and expectations Encourage and protect reporting of quality and safety

concerns Ensure transparent and accurate data collection and

reporting Respond effectively to patient concerns Foster teamwork and communication

So where has all this work taken us?

Since the IOM Report…

U.S. Centers For Disease Control tracks national progress on infection control• 44 percent decrease in central-line associated bloodstream

infections (2008-2012)• 20 percent decrease in infections related to 10 common

surgical procedures (2008-2012)• 4 percent decrease in MRSA (2011-2012)• 2 percent decrease in hospital-onset C. diff infections

(2011-2012)

And here at our facility…

Speakers can show quality improvement statistics at their institutions here.

But there is much left to be done

Much to do… CDC: 99,000 deaths from healthcare-associated

infections in 2012 In 2012, Los Angeles Times reported a new national

report card (Leapfrog Group) showing:• 47 percent of 2,652 hospitals graded received a C or

below, including many big name institutions Agency for Healthcare Research and Quality (AHRQ)

• Safety gains from health information technology have largely failed to materialize

Locally, our goals include…

Speakers can cite goals and objectives for enhancing quality and patient safety at their institutions

What do the regulators require us to do?

Healthcare Reform and Quality

Enactment of Affordable Care Act 2010 put healthcare quality management center stage

To survive providers must transform from a focus on patient volume to value-based care

Organizations must compete in a new system • Rewards quality of care provided, rather than the

number of procedures performed

And most significantly, providers will now be paid based on quality

Quality-based Payments

Medicare and other payers now scrutinize quality of care levels

Poor performance penalized• Reimbursements are lowered for excessive

readmissions• High rates of healthcare-associated infections will be

penalized in 2015

And there are new types of healthcare organizations

Accountable Care Organizations

Physicians agree to adhere to outcomes goals Cost savings shared with physicians Emphasis on population-based care

• Wellness and prevention Goal is to reduce expensive ED visits and hospital

admissions—to provide the right care at the right time

So it’s clear that ACA has brought about change

Quality is now a major factor in our business model Financial incentives are driving change

• Payers shifting to quality-based reimbursements Medicare and Medicaid now determine good performance

• Assess clinical outcomes• Check patient evaluation surveys• Financial incentives have heightened the importance of

healthcare quality management

5And that means there are five things we must do…

Build and maintain strong safety cultures to continuously:• Improve quality of care • Optimize patient safety 1

Establish accountability for integrity of quality and safety programs 2

Create systems to continuously improve 3

Report quality and safety data accurately 4

Remove barriers to success5

Those are big goals. Let’s talk about how we can get there.

How Our Quality Management Team Can Help

We’ll show you what is required.• Ensure the organization meets or exceeds quality and safety

standards set by−Affordable Care Act−Accrediting bodies −Major insurers

We’ll ensure comprehensive, transparent and accurate reporting of information

And we’ll help ensure rapid and effective responses to quality and patient safety concerns

How do we do that?

Lead continuous improvement initiatives Monitor clinical processes and patient outcomes Report quality concerns and possible safety risks Collect and analyze quality and safety data

We also…

Ensure process management• We conduct audits

−Check documentation against standards of Joint Commission and other entities

• Practice risk management−Actions to identify, evaluate and reduce risk of injury to

patients and staff• And most importantly, we provide assistance and training

−Help staff make improvements and understand compliance needs

How do we improve the practice of Quality?

Integrate new, evidence-based practices Assure compliance with quality standards of accreditation

organizations• Such as CMS, Joint Commission, DNV and public reporting

entities Promote supportive safety culture

It’s really important stuff. So let’s talk about our goals.

Our Quality Goals at _________

Cite quality healthcare quality management/patient safety goals at your institution

Here’s what we’ve achieved so far…

Cite and describe quality management achievements in your organization

Here are the folks who have helped lead the quality charge.

Meet our Team

Introduce your healthcare quality management team members and describe their roles and responsibilities

Cite team members contact information

Now you know us. How can we work with you?

Thoughts for the Future

Here the presenters can suggest specific areas for potential collaborations appropriate for their institutions

Thank You!