Performance = pay

Performance = pay

QUALITY.. THE TRUE SUSTAINABLE STRATEGY TO ENSURE VIABILITY L. Keith Granger Chair AlaHA Quality Task Force October 3, 2017 Federal quality measurement and transparency 2005 Hospital Compare is launched 2012 Value-based purchasing 2013 Readmission penalties 2015 Penalty for being in top poorest performing quartile of HACs 2015 Meaningful Use Penalties began About 9% of Medicare payments at risk Hospital Compare Website Value Based Purchasing (VBP) Readmissions Reduction Program (RRP) Hospital Acquired Conditions (HAC) Comprehensive Care for Joint Replacement (CJR) Episode Payment Model (EPM)

9/27/17 CMS announced it will not update the overall hospital quality star rating in October. IS IT PAY FOR PERFORMANCE OR PENALTY FOR FAILURE TO PERFORM ??? Do you really have a TEAM? Quality Clinical (nursing and ancillaries) Medical Staff Finance Risk, IP, Wound Care, etc. Case Management Others Impact Areas Reputation Clinical Efficiency/Outcomes Financial Security VBP --- Started with a bang

In the first year of CMSs value-based purchasing program, Alabama hospitals ranked number one in quality performance and quality improvement. As a result, Alabamas hospitals received the second largest bonus payment, $1.9M, of any state 113 percent of pool Estimates for FY2018 Alabama rank 40! Alabama estimated to lose $2.1 million ($12 million in worst case scenario on this single program) Domain weights over time 100% 90% 0.2 25% 30% 0.25

0.25 0.25 0.25 25% 0.25 0.25 0.25 0.25 25% 25% 2018 2019

80% 70% 30% 60% 30% 40% 50% 40% 0.2 70% 30% 30% 45% 20% 25% 25%

10% 20% 10% 0% 2013 2014 2015 2016 5% 2017 Clinical Care Efficiency Patient Outcomes (Clinical Care: Outcomes 2017+)

Safety Patient Experience of Care Process of Care (Clinical Care: Process 2017+) Alabama VBP Trends Statewide Performance Percentage 120.0% 113.4% 110.0% 100.0% 90.0% 80.0% 70.0% 60.0% 104.2% 105.6% 100.9% 100.9%

Domain Weighting for FY2018 VBP Patient Experience of Care25% Clinical Care25% Safety of Care25% Efficiency and Cost Reduction: 25% FFY 2018 (Based on FFY 2017 Performance) Alabama Hospitals VBP (2% of Payment) (38 Hospitals Penalized) Readmission (3% of Base) (70 Hospitals Penalized) HAC Penalty (1%) (14 Hospitals Penalized) TOTAL IN-PLAY LOSS PROJECTED $30,374,200

$2,124,900 $46,375,251 $12,642,000 $18,784,487 $1,820,300 $95,533,968 $15,587,200 Hospital Compare Update 2nd Quarter 2017 Overall Star Rating: 1-5 Stars - Q2 2016 thru Q4 2016 HCAHPS Star Rating -

Q1 2015 thru Q2 2017 HCAHPS Star Rating Breakdown by Measure - Q1 2015 thru Q2 2017 No specific reimbursement tied to Star Rating but Safety of Care Measures 6 Hospital Acquired Infection HAI Measures - Q2 2014 thru Q2 2017 for data that is complete Patient Safety PSI-90 - Q3 2013 thru Q2 2016 (* PSI not updated due to AHQA software issues) Process Measures: IMM-2, AMI-7a, PC-01 - For 2018 IMM-2 and AMI-7a will be removed along with process domain. PC-01 will go to safety domain. Safety of Care Measures CLABSI

(ICU & Select Wards HAI-1) CLABSI (ICU Only HAI-1a) CAUTI (ICU & Select Wards HAI-2) CAUTI (ICU Only HAI-2a) SSI (Colon HAI-3) SSI (Abdominal Hysterectomy HAI-4) MRSA (HAI-5) C-Diff (HAI-6) Patient Safety Indication Composite (PSI-90)

VBP Patient Outcomes Composite taken from 2 SSI categories. Clinical Care Process Measures - Patients assessed and given Influenza vaccination (IMM-2) - Fibrolytic Therapy within 30 minutes of hospital arrival (AMI7a) - Elective Delivery Prior to 39 Weeks (PC-01) Patient Experience of Care Q2 2014 Q2 2017 10 measures (technically become 9 measures): Communication with Nurses Communication with Physicians Responsiveness of Hospital Staff Pain Management Communication about Medication

Patient Rooms and Bathrooms Kept Clean Quietness Around Patient Rooms Discharge Information Overall Rating of Hospital 3 Item Care Transition Measure (CTM-3) Patient Experience (CJR & EPM) Q3 2015 thru Q2 2017 - Not the same as VBP CJR and EPM use linear mean score for each and use all Would you recommend scores. Combined on VBP Outcome of Care Measures 5 Mortality and 1 Complications Rate measures Q4 2014 Q2 2017 (where complete data is available) The 6 Patient Outcomes: 1. AMI - 30 day mortality (MORT-30-AMI) 2.

HF - 30 day mortality (MORT-30-HF) 3. PN - 30 day mortality (MORT-30-PN) 4. COPD - 30 day mortality (MORT-30-COPD) 5. CABG - 30 day mortality (MORT-30-CABG) 6. Risk Standardized Complications Rate (RSCR) - Following elective primary Total Hip (THA) and Total Knee Arthroplasty (TKA) *Q2 2016 Pneumonia Readmission expanded to include aspiration pneumonia and patient with sepsis and secondary diagnosis of pneumonia (therefore previous periods are not comparable) Readmission Measures Readmission Measure 6 measures Q4 2014 Q2 2017 1. AMI 30 day readmissions rate 2. HF 30 day readmissions rate 3.

PN 30 day readmissions rate 4. COPD 30 day readmissions rate 5. CABG 30 day readmissions rate 6. RSCR Risk Standardized Complications Rate following Total Hip and Total Knee 30 day readmissions rate *Q2 2016 Pneumonia Readmission expanded to include aspiration pneumonia and patient with sepsis and secondary diagnosis of pneumonia (therefore previous periods are not comparable) Efficiency Measure Medicare Spending per Beneficiary Q4 2013 through Q3 2016 Hospital Compare July 26, 2017 Update COMP_HIP_KNEE: Rate of complications for hip/knee replacement patients 21 4/1/2013 - 3/31/2016 Alabama Rank: 47 3.5

3 National Rate 3.02 2.8 2.5 2 1.5 1 0.5 0 DE VT NHNM OH NE WA ID FL AZ NY SC WI CA MI TN CO KS LA PA IN RI MT OR MD TX NJ ND ME KY AR SD OK MN IL MO UT VA MA GA HI NC WV MS WY IA AL AK NV CT Hospital Compare July 26, 2017 Update H_CLEAN_HSP_A_P: Patients who reported that their room and bathroom were "Always" clean

22 10/1/2015 - 9/30/2016 Alabama Rank: 32 90 80 National Rate 73 74 70 60 50 40 30

20 10 0 NE ID SD WI IA ME HI VT KS MN NH TX CO ND KY IL LA IN OH OK AR OR WY MT CT WV RI WA MI MS PA AL TN GA UT MOMA SC VA NM NC DE AK CA NY FL NJ AZ NV MD Hospital Compare July 26, 2017 Update H_COMP_1_A_P: Patients who reported that their nurses "Always" communicated well 23 10/1/2015 - 9/30/2016 Alabama Rank: 13 86 84 82 82 National Rate 80

80 78 76 74 72 70 68 66 SD NE LA ND MN ME KS NH WI IA MS IN AL OH VT RI KY HI CO TN AR NC ID PA MA OK TX MI DE IL SC MO OR MT VA CT GA WV UT WYWA AZ NJ NY NM FL AK MD CA NV Hospital Compare July 26, 2017 Update H_COMP_2_A_P: Patients who reported that their doctors "Always" communicated well 24 10/1/2015 - 9/30/2016 Alabama Rank: 3 90 86 85

National Rate 82 80 75 70 65 LA MS AL NE SD KS IA KY MN SC ID OK WI AR GA ND TN ME HI NC UT NH VT TX MO IL WV MT VA CO RI IN WY MI OH OR MA DE PA AK WANM CT CA FL NY MD AZ NJ NV Hospital Compare July 26, 2017 Update H_COMP_3_A_P: Patients who reported that they "Always" received help as soon as they wanted 25 10/1/2015 - 9/30/2016 Alabama Rank: 27 90 80

70 70 National Rate 69 60 50 40 30 20 10 0 SD ND MN NE ID KS WI MT WY LA NH ME IA OK MI OH VT HI IN AR TX CO OR KY AK MS AL IL TN DE NC PA UT WV RI SC MANMMOWA VA GA CT AZ FL NY NJ NV CA MD

Hospital Compare July 26, 2017 Update H_COMP_4_A_P: Patients who reported that their pain was "Always" well controlled 26 10/1/2015 - 9/30/2016 Alabama Rank: 6 76 74 73 72 National Rate 71 70 68 66

64 62 60 ID LA NE KS SD VT AR AL MN ME OK TX KY MS TN SC HI IA WI RI MI CO NH ND OH IN IL PA NC MA MT UT OR GA NMMO VA WY CT WV DE AZ FL WA NJ CA NY MD NV AK Hospital Compare July 26, 2017 Update 27 H_COMP_5_A_P: Patients who reported that staff "Always" explained about medicines before giving it to them 10/1/2015 - 9/30/2016 Alabama Rank: 14 72 70 68 66 67

National Rate 65 64 62 60 58 56 54 ND ME SD LA WI WY NE VT ID TX KS MN NH KY MS AR SC AL IA HI NC CO OK AK MI DE VA WA OHWV UT OR IN GA IL TN NMMA RI PA MO AZ MT CA CT NY NV FL MD NJ Hospital Compare July 26, 2017 Update H_COMP_6_Y_P: Patients who reported that YES, they were given information about what to do during their recovery at home 28 10/1/2015 - 9/30/2016

Alabama Rank: 36 92 90 88 86 National Rate 87 86 84 82 80 VT ME UT NE SD WI NH ID OH CO IA MNMA WY IN WA SC KS VA PA IL MI OR DE MO CT KY OK MT NC LA RI WV TX AZ AL TN GA NM NY MD AK HI AR CA NV FL MS ND NJ Hospital Compare July 26, 2017 Update

H_COMP_7_SA: Patients who "Strongly Agree" they understood their care when they left the hospital 29 10/1/2015 - 9/30/2016 Alabama Rank: 40 70 60 National Rate 50 50 52 40 30 20 10

0 NE LA WI KS ME IA SD MN ID HI UT VT NH ND IN CO OH KY MA OR RI WY IL TX DE WA MI AR PA SC OK MT MO CT MS NC GA VA TN AL FL NM AK AZ WV CA NY MD NJ NV Hospital Compare July 26, 2017 Update 30 H_HSP_RATING_9_10: Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest) 10/1/2015 - 9/30/2016 Alabama Rank: 24 90 80 National Rate 72 73 70 60 50

40 30 20 10 0 NE SD KS WI IA UT MN LA ID IN CO ME TX HI ND NH OH KY MI OK NC VT AR IL WAWY AL MA GA OR SC MO TN MS VA PA DE RI MT AZ CT WV CA FL NM AK NJ MD NY NV Hospital Compare July 26, 2017 Update H_QUIET_HSP_A_P: Patients who reported that the area around their room was "Always" quiet at night 31 10/1/2015 - 9/30/2016 Alabama Rank: 3 80 72 70

National Rate 63 60 50 40 30 20 10 0 LA MS AL SD TX NE KS OK AR SC GA TN MN CO KY ND IA WY WI NC ID IL MO HI MT IN UT NM MI OH VA WV ME FL AK NH MD AZ DE OR RI PA VT WA NJ NV NY CT CA MA Hospital Compare July 26, 2017 Update H_RECMND_DY: Patients who reported YES, they would definitely recommend the hospital

32 10/1/2015 - 9/30/2016 Alabama Rank: 27 90 80 National Rate 71 72 70 60 50 40 30 20

10 0 SD NE UT KS WI CO ME IA MN LA NH ID IN HI MA TX VT ND OK RI OR WA KY MT OH MI SC AL IL GA TN NC AR MO CT VA PA CA DE MS FL AK WV AZ WY NJ NV NM NY MD Hospital Compare July 26, 2017 Update HAI_3_SIR: Surgical Site Infection from colon surgery (SSI: Colon) 33 10/1/2015 - 9/30/2016 Alabama Rank: 3 2.5 2 1.5 National Rate 1 1

0.58 0.5 0 AK MT AL HI AR OR NV TN NC OH NJ MA LA WA FL PA MD TX MO MS KY OK WI CA IN SC IL ID VA CO MI GA NHWV SD CT MN UT NE NY KS AZ RI IA WYNMME ND DE VT Hospital Compare July 26, 2017 Update HAI_4_SIR: Surgical Site Infection from abdominal hysterectomy (SSI: Hysterectomy) 34 10/1/2015 - 9/30/2016 Alabama Rank: 30 3.5 3 2.5 2 1.5

National Rate 1 1 1.05 0.5 0 NH AK OK KS MT KY AR NC TX NV ID TN NJ FL MO IA WA OR WI GA IL AZ MD OH SC NY WV MI LA AL CO PA MN ND CA UT IN DE VA MA NE MS CT RI ME SD NM VT HI Hospital Compare July 26, 2017 Update 35 HAI_5_SIR: Methicillin-resistant Staphylococcus Aureus (MRSA) Blood Laboratory-identified Events (Bloodstream infections) 10/1/2015 - 9/30/2016 Alabama Rank: 42 2.5 2

1.5 1.18 National Rate 1 1 0.5 0 ID HI ME WI MN MT IA ND NE OR CO MA SD NH KS IL CT DE NV IN RI PA UT VA WANM TX OH VT NY WV NJ MO MI AR NC CA SC FL MS AZ AL MD KY WY TN OK GA LA AK Hospital Compare July 26, 2017 Update HAI_6_SIR: Clostridium difficile (C.diff.) Laboratory-identified Events (Intestinal infections) 36 10/1/2015 - 9/30/2016 Alabama Rank: 3 1.8

1.6 1.4 1.2 National Rate 1 1 0.8 0.63 0.6 0.4 0.2 0

AR HI AL MS AK KY ME NE ID NC GA NM LA MI OH IN SC MO KS IA TX TN FL SD NJ WI VA PA WAWV AZ MN OK NY NH IL CT MA WY NV RI MT ND OR CA CO MD UT DE VT Hospital Compare July 26, 2017 Update MORT_30_AMI: Acute Myocardial Infarction (AMI) 30-Day Mortality Rate 37 7/1/2013 - 6/30/2016 Alabama Rank: 48 15 14.5 14.17 14 National Rate 13.6 13.5 13 12.5

12 11.5 11 RI SD MA AK ID MT MN DE UT OH MI CO CA PA IL CT MD NY KS NJ AZ WI OR IN FL NE MONM VA NH NC SC VT ND IA LA TX KY ME WV OK WA GA TN WY HI NV AL MS AR Hospital Compare July 26, 2017 Update MORT_30_CABG: Death rate for CABG 38 7/1/2013 - 6/30/2016 Alabama Rank: 46 5 4.5 3.93 4 3.5

3.2 National Rate 3 2.5 2 1.5 1 0.5 0 SD HI VT NJ MA NY AK MD NC VA ID NHWA NE MN IL CA WI MI CT UT MT OH PA FL AZ SC IN CO DE KY TN MO IA OR LA GA TX NM KS ME WY RI ND OK AL MS NV AR WV Hospital Compare July 26, 2017 Update MORT_30_COPD: Death rate for chronic obstructive pulmonary disease (COPD) patients 39 7/1/2013 - 6/30/2016 Alabama Rank: 17 10 9

National Rate 8 8 7.99 7 6 5 4 3 2 1 0 MA CT HI OH DE NJ IL NH KY WV RI LA FL MI IN PA AL MNMO CA TX NY MS NC OK VA KS GA TN NE SD MD SC WI VT AK AZ AR IA ND NV ME NM UT CO MT WAWY OR ID Hospital Compare July 26, 2017 Update MORT_30_HF: Heart failure (HF) 30-Day Mortality Rate 40 7/1/2013 - 6/30/2016

Alabama Rank: 24 16 14 National Rate 11.9 12 12.10 10 8 6 4 2 0

DE MA NJ RI MD CA AZ OH CT WV FL NY NV VA IL PA TX GA LA MI MN NH NM AL SC OK CO NC KY TN MO SD IN HI MS WI ND KS ME AK UT WA NE IA ID MT OR AR WY VT Hospital Compare July 26, 2017 Update MORT_30_PN: Pneumonia (PN) 30-Day Mortality Rate 41 7/1/2013 - 6/30/2016 Alabama Rank: 45 18 National Rate 16.83 15.9 16 14 12

10 8 6 4 2 0 MA RI CT VT NJ ME MN OH AZ LA TX MI CO CA DE ID ND NH PA WI MOWV IL SD NY UT FL MT HI MDNM KS OK IN VA NE OR GA IA KY NV TN WA AK AL SC WY MS NC AR Hospital Compare July 26, 2017 Update MORT_30_STK: Death rate for stroke patients 42 7/1/2013 - 6/30/2016 Alabama Rank: 31 18 16

14.6 National Rate 14.96 14 12 10 8 6 4 2 0 DE NJ MA CT LA RI OH PA IL MD CA MN NY MS MO SC TX FL NH MI KY HI AZ NC VA IN OK NE ID KS AL WV GA WA SD TN AK CO ME WY WI NM AR NV IA OR MT VT ND UT

Hospital Compare July 26, 2017 Update MSPB_1: Medicare hospital spending per patient (Medicare Spending per Beneficiary) 43 1/1/2015 - 12/31/2015 Alabama Rank: 27 1.2 National Rate 0.99 1 0.98 0.8 0.6 0.4 0.2

0 HI NM OR MN ND SD MT WY AK WA IA WI ID AZ OK NC MO VA WV ME GA NY SC CO MI KY AL NE UT RI AR DE NH CA VT NV PA IL IN MS KS MA TN CT OH FL LA TX NJ Hospital Compare July 26, 2017 Update PSI_12_POSTOP_PULMEMB_DVT: Serious blood clots after surgery 44 7/1/2013 - 6/30/2015 Alabama Rank: 26 7 6 National Rate 5.31 5 4.89 4

3 2 1 0 ME AR RI IN ND WY ID MT AK SD KS DE KY IA NE HI WA UT VT TX CA OK WI MN NH AL NC AZ OR MO SC TN FL NMMA OH CO LA VA GA MS MI WV PA IL NY NV CT NJ Hospital Compare July 26, 2017 Update PSI_13_POST_SEPSIS: Blood stream infection after surgery 45 7/1/2013 - 6/30/2015 Alabama Rank: 1 11.5 11 10.5

National Rate 10.21 10 9.5 9.41 9 8.5 AL ND NC ME VT OR GA WI TN PA NH TX SC NJ AZ MN KY LA OH SD MAWV MT IA DE MOWA FL CO VA AR ID IN NM OK IL KS MS AK CA NY UT HI WY RI MI NE CT NV Hospital Compare July 26, 2017 Update PSI_14_POSTOP_DEHIS: A wound that splits17 open after surgery on the abdomen or pelvis 46 7/1/2013 - 6/30/2015 Alabama Rank: 15 3 2.5

National Rate 2.32 2.29 2 1.5 1 0.5 0 UT AR ID ME IN WV MA VT TX KS TN MO NE WA AL NJ WI CA OR FL NM IA HI NH GA SC NC OK AZ OH PA RI VA MS MN NY LA NV WY IL MI KY CT AK CO MT SD ND DE Hospital Compare July 26, 2017 Update PSI_15_ACC_LAC: Accidental cuts and tears from medical treatment 47

7/1/2013 - 6/30/2015 Alabama Rank: 23 2.5 2 National Rate 1.51.43 1.46 1 0.5 0 DE NJ WV NV VA FL MA TX IL NC KY PA MO SC TN NY OH AR VT LA MS NE AL KS CA IN GA CT HI OK CO MI ID MN RI NH NM SD WI IA OR AZ ND WY ME UT WA MT AK Hospital Compare July 26, 2017 Update PSI_3_ULCER: Pressure sores 48

7/1/2013 - 6/30/2015 Alabama Rank: 22 0.9 0.8 0.7 0.6 National Rate 0.50.48 0.42 0.4 0.3 0.2 0.1 0

VT MT ID IL UT IA IN MO GA OH NC SD AK VA CO NH WY MS SC MN OR AL NM AZ TN OK AR TX FL KS WA MI RI MA NE HI NJ ND KY CA WV WI DE PA LA NV ME NY CT Hospital Compare July 26, 2017 Update PSI_4_SURG_COMP: Deaths among Patients with Serious Treatable Complications after Surgery 49 7/1/2013 - 6/30/2015 Alabama Rank: 49 180 160 National Rate 153.04 136.48 140 120 100

80 60 40 20 0 VT MN OH SD IL MI AZ FL IA IN UT NM MT CO RI PA MO OR MA CT NC KY NE WI ME VA CA KS NH WA GA WV TN DE TX OK AR AK ID NJ NV LA SC NY WY MS ND HI AL Hospital Compare July 26, 2017 Update PSI_6_IAT_PTX: Collapsed lung due to medical treatment 50 7/1/2013 - 6/30/2015 Alabama Rank: 32 0.6 0.5 National Rate

0.41 0.41 0.4 0.3 0.2 0.1 0 VT DE VA NJ HI SD IL AR LA MI NC MA CA IN NY UT OH NH TN ME ID MS SC MN AK PA FL IA OK RI WY AL NM KY TX KS MT GA WI CT AZ CO NV WVMOWA NE OR ND Hospital Compare July 26, 2017 Update PSI_7_CVCBI: Infections from a large venous catheter 51 7/1/2013 - 6/30/2015 Alabama Rank: 5

0.25 0.2 National Rate 0.17 0.16 0.15 0.1 0.05 0 HI IN SD UT AL WAMONMMN NE IA MI OR KS CO ND WI KY TX IL CA OK OH PA NC NY VA MT MA WY MS ME NV AZ WV SC GA ID TN AR RI NH FL LA CT AK NJ VT DE Hospital Compare July 26, 2017 Update PSI_90_SAFETY: Serious complications 52

7/1/2013 - 6/30/2015 Alabama Rank: 23 1.2 1 National Rate 0.9 0.88 0.8 0.6 0.4 0.2 0 DE AR IN VT TX KY NC VA ID RI FL KS MA HI NE MO SC IA CA SD TN OH AL WV ME OK MNWY NH LA IL WI MS ND GA CO NM PA OR AZ UT MI NJ MT NV WA NY AK CT

AL Lowest Scoring Areas for Action Measure Rank Hip/Knee Complications 47th HCAHPS Patient Information for Recovery at Home 36th HCAHPS Patient Understanding Their Care Leaving Hospital 40th MRSA 42nd AMI Mortality (30 day)

48th CABG Mortality (30 day) 46th Pneumonia Mortality (30 day) 45th PSI 4 Deaths Serious Treatable Complications After Surgery 49th SSI Abdominal Hysterectomy 30th Readmissions HIP/KNEE 50th Readmissions AMI

41st AlaHA Contacts Rosemary Blackmon Margaret Borders Wesley Ashmore Do you really have a TEAM? Quality Clinical (nursing and ancillaries) Medical Staff Finance Risk, IP, Wound Care, etc. Case Management Others Questions?

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