For the past several years, physicians have participated in the Physician Quality Reporting System (PQRS) established by Medicare as a way to assess the quality of patient care and tie that to reimbursement. Beginning in 2015, a negative payment adjustment hit individuals and group practices whose quality reporting has fallen short of the mark, and those kinds of penalties will continue to be a concern in the era of increasing scrutiny on outcomes.
Some anesthesia providers have actively engaged in quality improvement efforts—not only to strengthen the bottom line but, more importantly, for the sake of their patients.
Richard Dutton, MD, says the most important reason for quality reporting is “to save lives.” Dr Dutton was chief quality officer for the Anesthesia Quality Institute (AQI) in Schaumburg, Illinois, until the end of August, when he became chief quality officer at US Anesthesia Partners, Fort Lauderdale, Florida.
“The desire to continuously improve the quality of care you deliver is what it means to be a professional,” he says.
Dr Dutton, who will continue to work with AQI, says, “Good quality aligns very nicely with good efficiency. The opposite of quality is variability; you can’t improve one without improving the other.”
Greater efficiency helps the bottom line, and Dr Dutton notes, “Efficiency and steady improvement are motivating and help with recruitment and retention of physicians.”
Creating a strong anesthesia quality program that provides these benefits and meets reporting requirements depends on strong leadership and a commitment to improvement.
As with most projects, it’s important to have a champion for an anesthesia quality improvement program, in this case an anesthesiologist. That doesn’t mean others aren’t involved.
“Quality is a team sport,” says Katherine Grichnik, MD, MS, FASE, vice president of quality and safety for MEDNAX National Medical Group, in Sunrise, Florida. “It’s really important that your anesthesia care team, your nursing care team, your surgical care team, and your hospital all get together and define what’s important to them.”
Emily Richardson, MD, chief quality officer for Encompass Medical Partners, a multispecialty practice management company in Fort Collins, Colorado, and vice chair of AQI’s practice quality improvement committee, adds that a systemwide commitment to quality and improving patient care is essential for a successful program and facilitates anesthesia provider engagement.
A positive approach is also key. “We focus on the goal of improving care, not getting people into trouble,” she says. “It’s a nonpunitive approach.”
Dr Richardson says the following elements make for a successful quality improvement program:
• multidimensional comprehensive data collection
• outcome measure analysis for reporting
• regulatory reporting
• clinical pathways
• patient satisfaction reporting
• provider education resources.
One of the first decisions is whether to keep the quality initiative solely in the hospital or anesthesia group, or to add external support.
Many anesthesia groups have turned to registries to help them with data collection and analysis now that data must meet PQRS requirements.
The Centers for Medicare & Medicaid Services (CMS) has approved qualified clinical data registries (QCDRs) that collect and submit data on behalf of physicians. CMS says “eligible professionals” (including physicians and certified registered nurse assistants) who “satisfactorily” participate in PQRS through a QCDR “may avoid the 2017 negative payment adjustment (-2.0%).”
An example of a registry is the National Anesthesia Clinical Outcomes Registry (NACOR), established in 2008. The American Society of Anesthesiologists (ASA) contracts with AQI to manage NACOR. In October, the ASA announced that ArborMetrix in Ann Arbor, Michigan, will provide technical operations, including data intake and hosting, for NACOR, with the new platform expected to be operational by June 2016. AQI will continue to manage the NACOR operations and QCDR service and support ASA members conducting clinical research.
To date, 31 million cases have been registered in NACOR. There are 47,000 participating providers, 4,700 participating facilities, and 500 anesthesia practices.
At first, NACOR concentrated on individual anesthesiologists and group practices, but it is increasingly partnering with hospitals. The challenge is that anesthesia providers practice in a variety of settings. “The average anesthesia group works in 10 different facilities,” Dr Dutton says.
Other anesthesia groups and hospitals turn to existing partners that are already providing services. For example, MEDNAX provides a robust quality improvement program for its customers.
“It’s our job to work with our hospitals, work with our healthcare providers, and work with our healthcare systems to ensure the best care possible,” Dr Grichnik says.
CMS has approved five anesthesia groups as QCDRs, including AQI and MEDNAX. AQI has approved Encompass as a QCDR-ready vendor.
Encompass Medical Partners, which manages some of its clients’ participation in NACOR, matches its approach to client needs.
“We collaborate with clients in goal alignment,” Dr Richardson says. That might mean using EQUIP, a proprietary system, or helping hospitals set up a system where they can share quality data with anesthesia groups. The goal is a comprehensive reporting platform that includes national benchmarks.
Not all anesthesia groups or hospitals turn to outside organizations to support quality efforts. Vanderbilt University Medical Center in Nashville has built a strong quality program (see related article on p 18).
A major decision is what to measure in the quality program (sidebar, below).
Indicators used in registries, hospitals, and anesthesia groups come from a variety of sources, but must include at a minimum the 2015 reporting requirements for PQRS: Report at least nine measures covering at least three National Quality Strategy domains, and report each measure for at least 50% of the providers’ patients (Medicare and non-Medicare). Of these measures, two out of nine must be outcomes measures.
AQI provides a list of anesthesia-related measures by National Quality Strategy domain at http://www.aqihq.org/files/pqrs/2015_PQRS_QCDR_MEASURES_BY_NQS_DOMAIN.pdf.
CMS has open nominations for indicators, and Dr Dutton says AQI strives to encourage CMS to establish quality measures that reflect anesthesia. “We understand what quality means in anesthesia, so we can suggest measurements that matter, that move quality along.”
For example, one of the first quality measures started several years ago was giving the preoperative antibiotic on time, but Dr Dutton notes this task would not have made the “top 20” goals of anesthesia providers. “The most important measure is whether the patient wakes up,” he says.
Ideally, indicators should go beyond what the government requires, and those from NACOR, MEDNAX, and Encompass all do so. AQI works with the National Quality Forum and harvests measures at the local level.
“We look at the registry and see what the common problems are,” Dr Dutton says. For example, it might be patients falling out of bed in the postanesthesia care unit (PACU). “Rolling data up is one way to get national-level measures that make sense,” he adds.
Dr Grichnik also monitors for trends. “If we see an uptick in something that shouldn’t happen, for example, corneal abrasions, we go back and determine why.” Indicators she has added to the required ones include reintubation rates, dental damage or loss, aspiration, and unplanned ICU or hospital admissions.
New indicators are first vetted by a committee that ensures the definitions for indicators are precise.
“It’s really important that you have a strict metric, and then you have a strict definition that goes with that,” Dr Grichnik says. Otherwise, she adds, comparisons aren’t possible. Definitions are only modified annually to promote consistency.
MEDNAX, Encompass, and NACOR all include measures of patient satisfaction. Dr Richardson says Encompass uses a survey developed by a vendor that is more specific to anesthesia than the Hospital Consumer Assessment of Healthcare Providers and Systems. The Encompass survey includes elements rated on a 1 to 5 Likert scale, such as time spent with anesthesiologist before surgery, nausea and vomiting experience, and whether patients were well prepared to ask informed questions.
NACOR patient experience indicators include:
• overall patient satisfaction by service, facility, and patient type
• rate of postoperative nausea and vomiting
• adequacy of pain management in the PACU
• patient complaints by service, facility, and patient type.
Dr Grichnik cautions against collecting too many indicators. The quality team should ask, “What are the 10 things that matter to us the most?” For her, a top 10 item is assessment of transfer of care: “Does the person accepting the responsibility for care of the patient know everything that is needed to achieve the best patient care?”
Once the top 10 items have been identified, Dr Grichnik says, “You can get a set of data that can drive both your quality assurance (are we doing the right thing?), and your quality improvement (how can we change something to improve care?).”
The best scenario is seamless data collection that doesn’t require additional staff. “Our goal from the start was to harvest exiting data so that no additional staff would be needed in the anesthesia group or hospital,” Dr Dutton says.
For example, AQI is able to extract information from the digital record that anesthesia providers send to the billing company to obtain payment.
Other possible data sources include anesthesia management systems and hospital electronic records. In some instances, AQI received data only from providers and not hospitals; in other cases, both provide data and both receive reports.
MEDNAX uses Quantum Clinical Navigation System®, a proprietary tool that includes acquisition and reporting of quality data. Anesthesia providers and nurses enter information such as pain control and assessment for postoperative nausea and vomiting.
“We’re trying to make sure we seamlessly align all of those variables,” Dr. Grichnik says. “Then at the end of the day, we have 80 to 100 different reports that we can send to our clinicians and other partners.” For example, a hospital could request a report specifically on the incidence of postoperative nausea and vomiting.
Streamlining data collection facilitates engagement and accurate data. “It’s important to build a system where the provider doesn’t have to enter the data twice, and to make data entry as easy as possible,” Dr Richardson says.
ASA members can participate in NACOR for free and may choose to share data with the hospitals they work with. Dr Dutton says AQI is starting to explore hospital-specific participation as well.
Encompass clients pay a fee for digital data collection. The anesthesia practice may have additional costs for registry participation, quality consulting and analytics, and patient satisfaction surveys.
Three payment scenarios exist at Encompass: the anesthesia group pays for EQUIP, the hospital pays, or the cost is shared.
MEDNAX provides its quality data program at no additional cost.
Dr Richardson notes that a formal QI system is “too costly, difficult, and complicated” for many private anesthesia groups to put in place, which is why she suggests tapping into hospital programs when possible.
Reports include individual results and comparison with national benchmarks. “The ability to compare shows the reports are meaningful,” Dr Richardson says.
“OR managers should know that their anesthesia department is looking at the data and acting on it,” Dr Dutton says. For example, OR leaders can learn how long a specific surgery takes. He also believes there should be greater sharing of the data collected by the OR staff and anesthesia providers.
Dr Grichnik emphasizes the team approach to quality. “We must all work together to define what’s important to measure,” she says. Dr Richardson agrees: “We need to work in terms of the whole perioperative system by collaborating with surgical staff and PACU staff to create a robust quality system.” ✥
Anesthesia Quality Institute. Introduction to NACOR. http://www.aqihq.org/files/Introduction%20to%20NACOR.pdf.http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2288837&resultClick=3.
Centers for Medicare & Medicaid Services. Qualified clinical data registry reporting. July 29, 2015. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Qualified-Clinical-Data-Registry-Reporting.html.
The Anesthesia Quality Institute (AQI) created a visual representation of what should be reported as part of a quality program.
Specifics as to what should be reported for business, process, and clinical outcome indicators can be found at http://www.aqihq.org/files/AQI%20Recommended%20Indicators%20doc%281%29.pdf.
Data in the AQI-managed National Anesthesia Clinical Outcomes Registry fall into four categories:
• Practice demographics: Describe the anesthesia group (age, training, certifications) and the environment (facilities, hospital size, inpatient-outpatient mix).
• Case-specific data in several tiers: Simple (eg, CPT code, anesthesia type, provider ID number, patient age), moderate (eg, duration of surgery, agents used), and complex (eg, output from the anesthesia information management system with vital signs, fluids, drug doses).
• Outcomes data: Basic (eg, intraoperative cancellation, mortality, major morbidities) and extended (eg, infections, prolonged length of stay, late events).
• Risk adjustment data: ICD-9 diagnostic codes, preoperative medication use, defined comorbidities, and hospital length of stay. Much of the data will come from the hospital or healthcare facility’s systems.