In an article posted by Managed Healthcare Executive on August 14, Vizient’s David Levine, MD, FACEP, vice president of advanced analytics and informatics, provided an overview of CMS’ rating methodology and the resulting issues it creates for hospitals and consumers who are hoping to find a source of truth about the quality of care at our nation’s hospitals.
“We applaud CMS’ efforts to improve quality and transparency, but we are concerned that the quality measures CMS is currently using don’t account for the high-acuity patients that are seen by many of our members – especially at academic medical centers (AMCs) and safety net hospitals,” said Levine. “CMS’ measures don’t fully account for the socioeconomic status of patients. Additionally, the data they are using is one to two years old, so in many cases it doesn’t reflect changes that have improved the quality of care at a facility.”
While the methodology isn’t perfect, there are three main takeaways from Vizient’s analysis of the April and July Star Rating preview reports from 41 AMCs and 87 community hospitals. This insight can be immediately used to begin to make changes to processes that will positively influence future ratings. Additionally, Vizient offers performance improvement collaboratives that are specifically focused on the areas that were identified.
1. Reducing readmissions. Readmission, one of the seven measure groups used to calculate the hospital summary scores, was identified and validated by the Vizient Clinical Data Base™ (CDB) as a key area for improvement. Strategies that have been successful in addressing this issue include completing a readmission risk assessment for patients seen at your facility. The assessment is guided by an analysis to identify a patient cohort of frequently readmitted patients (more than three unplanned admissions per year) for the hospital. A suggested course of action would be to develop specific care plans that are accessible to providers, especially the emergency department (ED). Designated staff would then be called prior to admission to verify medical necessity.
In addition to identifying the specific patients who are frequently readmitted, clinicians should identify the conditions most common for readmission and implement a strategy to proactively manage where possible. The identification should begin at admission and be reassessed throughout the stay. At-risk patients need to be discharged to the appropriate level of care and have close follow-up. They may also need assistance obtaining transportation and/or medication.
As part of assessing your organization’s internal processes that have the potential to impact readmissions, consider the following questions:
- Are the majority of readmissions surgical or medical?
- What are the primary diagnoses and associated comorbidities?
- If patients are readmitted within seven days, is it because they did not have adequate follow up or were they discharged without adequate support?
- Do the patients have access to medication?
Hospitals with a lower Star Rating should look carefully at what is impacting their readmission rates and implement improvement plans to address deficiencies. Vizient currently has a Frequently Admitted Patients Benchmarking Study set to begin in October. It is open to new participants through Oct. 3. Click here for more information.
2. Emergency department throughput. Within the Timeliness of Care measure group, another area for opportunity identified in the analysis of CMS scores and validated by Vizient data was ED throughput. Start by assessing the following areas where throughput issues are likely to occur:
- Output. Moving admitted patients from the ED to inpatient beds (including the ICU), will free up both staff and beds in the ED. Focus on ensuring that the right patients are in the ICU. Determine if patients are held in the ICU because there is not adequate monitoring or staffing on the inpatient floors
- Discharge planning. Have processes in place that include discharge planning at the point of admission. Floor discharges should occur early in the day to allow for patients to transfer out of the ICU early. Consider having dedicated staff to process discharges during peak times.
- Input. Patients should not spend excess time in triage and registration if there are open beds. If there is an open bed, registration should be done at the bedside. For the actual ED, are there adequate services for the less-acute patients who tend to wait the longest? Fast tracks for peak volume evening hours lead to better care and greater satisfaction for all.
- Urgent care. Utilizing urgent care with expanded hours that meet peak flow helps free up the ED. With longer waits, use protocols to obtain labs and/or x-rays from triage so when the patient is seen in the treatment area part of the work up is already completed, leading to a quicker disposition.
Vizient currently has an Emergency Department Throughput Benchmarking Study open. For more information, contact Marilyn Sherrill.
3. Patient experience. An analysis of the CMS data, coupled with validation from Vizient data, identified patient experience as a third opportunity for improvement. A crucial element for improving this metric is effective communication between patient, family and caregivers. Keeping both patient and family informed of the care plan early in the admission process helps set expectations and minimizes surprises at the time of discharge.
Communication between caregivers can best be accomplished through multidisciplinary rounding, which provides a patient-centered model of care and is a valuable tool in improving patient safety, quality and experience. Rounding provides an opportunity for the entire patient care team to get on the same page and helps keep everyone focused on ensuring a safe and timely discharge. If multidisciplinary rounding isn’t possible, then nurse rounding should take place at the bedside, when communication can occur with patient and family present.
Finally, communication is critical for keeping all staff involved in understanding patient satisfaction goals. Data should be built into KPIs for the unit as part of shared goals and updates should be shared by unit leadership. The status of KPIs should be posted prominently so all caregivers can track the progress. Staff should also be encouraged to share these goals with their patients, inviting them to provide input, further opening the lines of communication.
“Developing a performance-oriented culture within your organization will help guide improvement efforts,” said Levine. “It can positively influence future Star Ratings and improve the overall delivery of care.”