Welcome to this Quality Improvement for Institutions Learning Center lesson titled Engaging the Clinical Team to Develop a Quality-Centered Program. This is lesson number one of a five-lesson series authored by NCDR participant expert Sheila Nichols, who is a Clinical System Analyst, HVTI, and Strategic Operations Administrator at the Cleveland Clinic. Sheila will be sharing her expertise from an academic system perspective. NCDR participant expert Andrea Price, who is from Indiana University Health System. Andrea will be sharing her expertise from a community hospital perspective. And Michelle Hare. Lesson number one focuses on how to perform a gap analysis within your organization. I am Kate Malish, and I will be narrating the following five lessons. After reviewing this five-lesson presentation, the participant should be able to define the key components for building a culture-based quality program, illustrate processes for data analyzation, metric reporting, and issue identification, summarize quality improvement methods and tools. There will be five lessons discussing and demonstrating the key components or steps for building and or refining a quality-based program. Each lesson will discuss a key program development component, including how to perform an initial gap analysis, engage leadership to align goals and objectives, establish a core quality team, engage and expand the quality team for an improvement activity, and conduct a quality or process improvement and manage ongoing program growth. Each lesson will also provide an example from both the community and academic-based facility. Maria Price will demonstrate and discuss examples and or best practices from a community hospital aspect, and Sheila Nichols from an academic viewpoint. In lesson one, we will discuss the importance and steps to conduct an initial gap analysis. A gap analysis process allows a person or organization to compare the current state with an ideal state or goals, which highlights opportunities for improvement. This can be accomplished by talking with all the identified stakeholders, clinicians, leaders, quality team members, key nurses, and other members of the care team. This can be a simple process of meeting with each person to ask what is working well and where they may be an opportunity for improvement. Developing solutions and creating an implementation plan is part of the gap analysis, and these two steps can be performed later when you have a larger core team assembled. The goal of performing this initial analysis is to understand the overall quality program landscape so you can discuss goals and objectives with leadership. To start the gap analysis, it is often best to understand and develop a programmatic baseline. Leadership. Often more than one person fills this role, other times not. Remember, a key leader is a person who will be an owner of the program's mission and be the change agent to accomplish goals. Sometimes there are designated program or therapeutic persons with a formal leadership title who are identified leaders. There may also be an informal leader that does not really own the program's mission who will influence change within your organization. The goal is to understand who really is responsible for the mission and who is not. Those with formal leadership roles may also be able to secure needed resources for project success. Champions are members of the administrative and clinical team that will help you advance the program goals. It is vital you identify a clinically based champion. This person can be in a dyad or triad model with other champions. Obtaining input from the people with their boots on the ground is invaluable. Since you are desiring to develop or refine your quality program, it is important to understand the data collection process and reporting structure. We will discuss this more in depth in the next slide. What is your hospital or program strategic goals and how does the quality program affect these goals? Understanding the larger strategic landscape is important when you or your leader is trying to align the program goals with senior leadership. The quality program's objectives should align with the larger goals of the organization. Lastly, assessing the readiness for change is very important as well as the why for change. When organizational or programmatic readiness for change is high, members are more likely to initiate change, exert greater effort, exhibit greater persistence, and display more cooperative behavior. The result is more effective implementation of goals. This will help determine a starting point or the initial tactics. When undergoing your initial brief gap analysis, there are several key components of the data collection and reporting structure you need to understand and capture. What data is currently available? What registries does the organization participate in and who abstracts the data? How to analyze data and who reviews and analyzes the data? And what do they do with the data? Abstractor, manager, anyone. How is the data validated? Is the data meaningful and how trusted is the data you will be using with the clinical staff? It is very important to understand timing of data. When is the data available? Is there a way to decrease data collection time? What are the existing quality meetings and forums? Who leads these meetings? Is it well attended with the right care team members? Who should review data communications? It is vital to know your audience. Who needs what data and when? What is currently reported? How often and to whom? How is the data used both internally and externally for the organization? Different audiences will want different data. Consider how your data reports differ from the vice president versus the cath lab manager. VPs may be interested in the public reporting rankings and how participation improved U.S. News and World Report rankings. A cardiovascular dyad may want to know in more detail what is driving quality or process performance. In a health care system, comparative performance throughout the health care system may be of value. Providers and clinical process contributors may need outcome data to track improvement, potential compensation measures, and overall program performance. Non-clinical departments such as finance or compliance may be interested in performance for efficiency tracking and adherence to external regulatory and private payers' requirements. During this fact-finding inquiry, be aware that all of these different departments may not know what and or how other areas of the organization are using available data. The goal is to gain the information so you can work with a core team to determine what to focus on, what the priorities are, and who should participate and know what is occurring. Gaining understanding around the available clinical registry data analytic tools will be important information for the core group to use once it is established. They will use this information to understand what data is available and how to use the data to eventually drive program quality improvement. Available data tools include registry dashboards, including metrics and associated benchmarks, NCDR ACC provider-level dashboards, NCDR Registry Comparator tab, NCDR outcome reports which contain executive summary, graphs, and detail lines, public reporting, the National Quality Forum publicly reported metrics, and metric performance awards. Data points not tracked in the NCDR dashboard metrics may also be analyzed. However, these data elements may not have external benchmarks available. State or federal quality programs data reporting requirement is another important consideration. Public care procedures are the financial backbone of hospital organizations and many cardiovascular practices. Further movement away from fee-for-service payment models and toward payment for efficient high-quality care is anticipated and expected, so it is important to understand what state and national programs are using quality process data and how it is affecting reimbursement. The Centers for Medicare and Medicaid Services have established a number of quality payment programs. The VBP program, established by the Affordable Care Act, implements a pay-for-performance approach to the payment system that accounts for the largest share of Medicare spending, affecting payment for inpatient stays in approximately 3,000 hospitals across the country. The hospital VBP program is designed to promote better clinical outcomes for hospitalized patients and improve their experience of care during hospital stays. Under the hospital VBP program, Medicare adjusts a portion of payments to hospitals beginning each fiscal year based on either how well they perform on each measure compared to all hospitals or how much they improve their own performance on each measure compared to their performance during a prior baseline period. Readmissions. The Affordable Care Act authorizes Medicare to reduce payments to acute care hospitals with excess readmissions that are paid under CMS's inpatient prospective payment system. The program focuses on patients who are readmitted for select high-cost or high-volume conditions and procedures, namely heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease, hip or knee replacement, and coronary artery bypass graft surgery. The hospital readmissions reduction program is designed to improve quality of care and care transitions by incentivizing the reduction of hospital readmissions. Bundled payment models capitalize on the provider entity's need to manage a budget and ensure quality. The entity receiving the bundled payment earns a higher margin if a patient utilizes less care, but also must cover the cost of unexpected utilization and complications. The Medicare Access and CHIP Reauthorization Act, MACRA, changes how the Centers for Medicare and Medicaid Services pays physicians who provide care to Medicare beneficiaries. It ties physician compensation to quality and encourages doctors to participate in alternative value-based payment models. A portion of physician payment is tied to goals such as reduced costs and improved quality, meaning that physician incentives now more closely track imperatives faced by hospitals and health systems in their march toward value-based health care. Hospital Inpatient Rule, 2 Midnight Rule, CMS implemented a 0.2% payment reduction for inpatient stays due to an expected increase in inpatient hospital stays under the 2 Midnight Rule policy. The financial impact of these programs vary depending upon many organizational factors. It is important to understand what your hospital or corporation is focused on prioritizing. Identifying data that can help improve quality or processes that affect reimbursement is often a good place to begin or should be a prioritized improvement activity. Often the state or national quality program's impact is linked to hospital or corporate goals as well. Take time to understand your hospital-based or corporate system quality initiatives. Do they support a strategic goal? These initiatives often involve something like throughput LOS, readmission, mortality. After assessing these key areas, develop 3-5 recommendations to present to leadership. These recommendations should be high-level quality or process improvement goals along with the rationale. The recommendations you will be presenting may be more general such as improved procedural outcomes and throughput for cardiovascular interventional program versus the specific There is something to consider. If you are presenting to your immediate leader, they may need to share this information to present to their leadership. Your recommendations should correlate or impact the hospital or corporate goals. Andrea Price shares best practice from a community hospital in the Indiana University Health System. When completing a gap analysis, go through the steps to identify the root cause of the problem. Is it really the absorbed mortality? Or is it a lack of understanding the mortality metric, including the risk methodology? It was the experience of one of our community hospitals the gap was around having timely access to meaningful data. In this example, the NCDR registry data had a 4-5 month lag and the dashboards were not available as the data was not submitted on a weekly basis for the hospital. When clinical data was lacking, administrative data was being used. While administrative data may be useful to healthcare systems, the attribution issues and population cohorts are barriers to improving cardiovascular care. Clinical registries are meaningful as they are designed around cardiovascular guidelines and evidence, and if the data is put in regularly, the data is refreshed weekly. The team was on call to answer any questions on the data, including going back and validating some of the cases that had caused the physicians to question the historical registry data. Explaining how a patient was coded yes for cardiogenic shock, as well as providing an opportunity for bi-directional conversations, created trust in the data. With the insights, we worked to ensure the data collection was caught up so it could be used for data analyzation. Best practices in academic setting may be different, and Sheila Nichols shares her experience as a Clinical System Analyst, HVTI, and Strategic Operations Administrator at the Cleveland Clinic. In a large academic system, there are usually multiple internal and external stakeholders. Interests of these groups may not always align, so a gap analysis, including key stakeholders, is essential. Assess whether the hospital and academic leadership have the same vision. Assess whether employed and private practice physicians are in alignment. An example of this was the identification of low device-based therapy guideline compliance, as noted in the ICD Registry Outcomes, for some hospitals in the system. Further drill down into the data confirmed opportunities for improvement. It was noted that private practice physicians were not documenting all pertinent data elements. Most of their notes were dictated versus using the template that employed physicians used. When questioned about this, some had a dismissive attitude as though this did not pertain to them. Consequently, the next step in the gap analysis was to identify physician and program champions to gain their insight on the outcomes and opportunity recommendations, specifically around documenting evidence-based care and compliance to data accountability. All this information was gathered to analyze and formulate a recommendation to improve physician documentation and accountability for non-employed physicians with leadership. This concludes Lesson 1, Engaging the Clinical Team to Develop a Quality-Centered Program, Forming Initial Gap Analysis. Thank you for your participation.

Engaging the Clinical Team to Develop a Quality-Centered Program

lesson one

initial gap analysis

current state of the quality program

areas for improvement