Kathleen Geier, RN, BS, CPHIMS

Kathleen Geier is the director of clinical and regulatory performance at HealthEast Care System in St. Paul, MN. She leads the strategic planning and oversight of government-required pay-for-performance and commercial payor clinical and regulatory performance measures. She is also a member of the Minnesota Statewide Quality Reporting and Measurement Committee for 2014-2016.

HealthEast Care System is a community-focused, nonprofit healthcare organization that includes one long-term acute-care hospital (126 staffed beds), three short-term acute-care hospitals (500+ staffed beds), outpatient services, clinics, home care, hospice, and medical transportation. We have 7,300 employees, 1,200 volunteers, and 1,500 physicians on staff.

HealthEast has continued to discuss and define a global or organizational approach to measuring flawless care across the system. The discussions have now turned to what this number means and how we can determine if we are making improvements as we continue to create and refine the Flawless Care Measure and Scorecard.

Creating the Flawless Care Scorecard

In developing the Scorecard we used a quality measure matrix that included all regulatory, joint commission, and commercial pay-for-performance indicators to identify measures that could be included.

Each measure must have been reported during our 2015 fiscal year so we would have a baseline against which we could compare and calculate.

We also created an easy, familiar way for leaders to enter their monthly results and data. We chose to go with Excel, with the ultimate goal to use this as a database and put the filtering and re-calculating in Epic via WebI.

The Scorecard can be filtered by:

  •  Entity;
  •  Strategy deployment team;
  •  Pillar leader clinical quality;
  •  Data entry; and
  •  Measures

The Flawless Care Score then is recalculated based on the filters.

Challenges with The Flawless Care Scorecard

The biggest challenge was the need to measure performance across:

  • Multiple dimensions (structure, process, and outcome)
  • Multiple levels (business unity, entity, organization, and population)
  • Multiple clinical areas

Also, we asked ourselves, how do we get the Flawless Care Score to change with the many needs to report this number at varying levels of the organization?

Getting everyone to enter their data in a timely manner, without having to “chase” them for the data, was crucial. 

Measures such as readmission and infection rates can lag several weeks behind before we can get a final Flawless Care Score for the month.

The Flawless Care Score is a moving result based on who has entered data and for how many months. This is one of the reasons we needed to be able to break the data out by months, as well as compile a YTD report.

Flawless Care Score

This Flawless Care Scorecard made its debut at the Acute Care Clinical Quality Council and the HealthEast Board. The Scorecard is dynamic, meaning that every time a new result is added, the YTD number changes, not only causing confusion, but making it difficult to report/display the result to various audiences. The questions of what this number means and whether it is actually a meaningful number continue to be asked.  

The Flawless Care Score is made up of 60-plus measures that have been condensed to one number to monitor and measure the delivery of flawless care. Below is an example of the data, along with the formulas used to calculate the numbers.

We have added the ability to filter various columns and have the score recalculate based on the filter. The formula is subtotal = (1,BK3:BK67). The BK3:BK67 references the column of numbers included in the sort. If you choose not to sort and recalculate the score, it is an average of all the scores in the score column.

Example of The Flawless Care Scorecard

This is a very small example of what the Flawless Care Scorecard look like; it includes many hidden columns to make it printable. Work is being done in our reporting and analytics department to recreate the scorecard and have it accessable via Epic using WebI and to allow for greater access throughout HealthEast.

Learning

Understanding what the flawless care measures mean continues to be a major point of conversation and confusion. Moving to flawless care is a journey that does not have an end point. It has been really difficult for some analysts and reporting staff to wrap their heads around one measure, because we always wanted it to be statistically significant and to be able to tell if what we are seeing is normal variation or whether we really did make an improvement. The most basic question is the most important question: What does this number mean and how do we know if we are improving?  

Next Steps

We will continue our journey in uncharted waters, and it’s going to be rough going this next fiscal year as we continue to increase our understanding and refine our processes and reporting methodology.

Critical for sustainability is to start the discussion around how to create a flawless measure at the individual patient level and how to be able to report it by using data captured in the patient medical record.

About the Author

Kathleen Geier is the director of clinical and regulatory performance at HealthEast Care System in St. Paul, Minn. She leads the strategic planning and oversight of government-required pay-for-performance and commercial payor clinical and regulatory performance measures. She is also a member of the Minnesota Statewide Quality Reporting and Measurement Committee for 2014-2016.

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Tuesday, 22 September 2015 21:54

Defining the Flawless Care Measure

HealthEast Care System is a community-focused, nonprofit healthcare organization that includes one long-term acute-care hospital (126 staffed beds), three short-term acute-care hospitals (500-plus staffed beds), outpatient services, clinics, home care, hospice, and medical transportation. We have 7,300 employees, 1,200 volunteers, and 1,500 physicians on staff.

HealthEast has continued to discuss and define a global or organizational approach to measuring flawless care across the system. Initially, there were some heated, passionate discussions regarding how to measure, what to measure, and how to make this a meaningful, actionable initiative. The following is what was defined and agreed upon as a result of those many discussions across HealthEast.

Thinking about Flawless Care

Specifically, we determined that flawless care should:

Help us to identify the greatest opportunities;

Inspire and continuously move the organization toward a common distant goal;

Measure areas of performance at the entity, business unit, and organizational levels via a balanced scorecard to calculate the overall organization flawless care score; and

Reduce readmissions, which are a type of flaw, and included to continue and expand the good work done over the past few years. The way we measure improvement will be different, so no one measure will dominate the results.

The Concept Of Flawless Care Aligns With:

The lean concept of seeking perfection and minimizing defects;

Our obligation to ensure that patients avoid harm;

Transparency and a culture of quality and safety; and

The need to measure performance across:

    • Multiple dimensions (structure, process, and outcome)
    • Multiple levels (business unity, entity, organization, and population)
    • Multiple clinical areas
    • Care that is episodic and longitudinal

Flawless Care Measure Principals

Define a flaw:

    • Structure or process: Standard not met
    • Outcome: Not optimal

Improvement goal and aggregate should be defined for each area.

This should include measures of patient care, but also patient harm and organizational and system characteristics (reliability, culture, and learning).


 

Work should be prioritized based on Pareto analysis:

    • Continue to make all measures visible to the frontline on the improvement board.
    • Focus work only on the most important or critical flaws.               

     

Use pertinent data by adding or removing measures selectively balanced against the burden of collection and reporting.

2016 Flawless Care Targets

First Quarter

    • Define metrics for all areas using current measures being reported to make selections.

Second Quarter

    • Refine metrics, process and scorecards.

Third and Fourth Quarters

    • Continue to work on selected measures using A3 Lean Methodology to improve results.

Year-End Goal: 2-Percent Improvement Over Prior Year

Learning

Moving to flawless care is a journey that does not have an end point. Not everyone will share the same viewpoint, but you still need to come to a consensus. It has been really difficult for analysts and reporting staff to wrap their heads around some measures, because we always want it to be statistically significant and to be able to tell if what we are seeing is normal variation or an actual improvement.  

Next Steps

We are in uncharted waters, and it’s going to be rough going these next few months as we continue to refine our processes and reporting methodology. Some key pieces of advice:

Create a scorecard for all leaders to enter their results, which will create the one flawless care number.

Start a discussion regarding how to create a flawless measure at the individual patient metrics, and be able to report it by using data captured in the patient medical record for 2017, starting with a couple measures.

The next article will continue to take you on the HealthEast journey and share our successes and our struggles as we continue our work on reporting and creating a scorecard to measure and monitor flawless care to improve patient outcomes, satisfaction, and our value-based purchasing results.

About the Author

Kathleen Geier is the director of clinical and regulatory performance at HealthEast Care System in St. Paul, MN. She leads the strategic planning and oversight of government-required pay-for-performance and commercial payor clinical and regulatory performance measures.  She is also a member of the Minnesota Statewide Quality Reporting and Measurement Committee for 2014-2016.

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k geierHealthEast Care System is a community-focused, nonprofit healthcare organization that includes one long-term acute-care hospital (126 staffed beds), three short-term acute-care hospitals (500+ staffed beds), outpatient services, clinics, home care, hospice, and medical transportation. We have 7,300 employees, 1,200 volunteers, and 1,500 physicians on staff.

HealthEast is continuing its journey to address and define value-based purchasing (VBP). The past year we have been discussing a more global approach to VBP and what that might look like. We have been “trying out” the idea and methodology to report a flawless care measure to see how it would work in tandem with our VBP measures. 

To create the numerator we are using the following VBP and non-VBP measures, and we further qualified it by applying it only to the short-term acute-care hospitals:

  • CMS OFI’s: PC-01 Elective Delivery Between 37-39 Weeks Gestation Completed and IMM-2 Influenza Immunization
  • Readmissions
  • Number of falls
  • Number of reportable pressure ulcers
  • Hospital-acquired infections

The denominator is the number of short-term acute-care inpatient admissions.

After scrutinizing results and tracking them for several months, we realized that the number was only repeatable, and we struggled with making it both meaningful and actionable. We enlisted the help of one of our value-based improvement (VBI) advisors to help us try to understand the data and make it actionable. The VBI advisor broke out each measure and created control charts only to encounter measures for which the “n” was so small you couldn’t graph it (and we did not know how to react to the results). 

Identified Barriers and Issues with Current Flawless Care Measure 

  • The greatest takeaway from this was that the readmission portion of the numerator definition was numerically dominating the other measures directly impacting the flawless care result. The results were being driven by one measure rather than all five measures.
  • Another issue we battled was the timeliness of the data, particularly with the readmissions and hospital-acquired infections. There is required time that needs to lapse before the readmissions and hospital-acquired infections can be counted. For example, readmissions need to run out 30 days to capture data properly.
  • There were no national benchmarks, so we compared our data against our previous data and determined the percentage of improvement over last year, not knowing if this was meaningful.
  • Capturing of the data to create the flawless care measure was done completely manually, cobbling multiple reporting systems together to calculate a monthly number.

The identified issues led back to this question: how could this be measured at the patient level of point of care? The journey has us looking more closely at what measures we currently are capturing and reporting that would make sense to include in our flawless care measure. We now have come full circle and are asking this question: what really is “flawless care,” and how do we measure for results that are repeatable, meaningful, and actionable?

The idea of identifying one number to define flawless care has evolved into a larger group of measures that define a flawless care scorecard. This will be pretty straightforward and easy to create. The challenge lies in identifying that number and making it meaningful.

The measures included in the flawless care scorecard could drive prioritization of our work around VBP using the value-based improvement methodology discussed in my first article: Value Based Purchasing; A3 Lean Methodology Being Leveraged to Improve Results.

Next Steps

Discussions will continue to occur as we create the HealthEast flawless care measure definition – again, to identify what is not only meaningful, but actionable. 

Future articles will continue to take you on the HealthEast journey, and we will share our progress and our struggles as we work towards defining flawless care and improving our VBP results.

About the Author

Kathleen Geier is the director of clinical and regulatory performance at Health East Care System in St. Paul, Minn. She leads the strategic planning and oversight of government-required pay-for-performance and commercial payor clinical and regulatory performance measures. She is also a member of the Minnesota Statewide Quality Reporting and Measurement Committee for 2014-2016.

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k geierHealthEast Care System is a community-focused, nonprofit healthcare organization that includes one long-term, acute-care hospital (126 staffed beds), three short-term, acute-care hospitals (500-plus staffed beds), outpatient services, clinics, home care, hospice, and medical transportation. We have 7,300 employees, 1,200 volunteers, and 1,500 physicians on staff.

A few years ago HealthEast created the "value equation" when value-based purchasing and value-based improvement came together, merging the quality and business processes:

table equation

This equation led us to look at new ways to foster improvement and create a value-based improvement culture by changing our approach – specifically, by using A3 Lean Methodology. A3 Lean Methodology leverages layered planning to link strategic goals with a strategy plan to identify what needs to be done to achieve those goals. A3 projects are time-based, focused initiatives that also link to the strategy plan.