PERFORMANCE REPORTING AND

IMPROVEMENT PLAN

SUFFOLK CARE COLLABORATIVE OFFICE OF POPULATION HEALTH

STONY BROOK MEDICINE HSC, LEVEL 5, RM 058

STONY BROOK, NEW YORK 11794-8520

AUGUST 27, 2015

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TABLE OF CONTENTS PAGE #

PURPOSE 2

GOAL AND OBJECTIVES 2

SCOPE AND ORGANIZATION 3

RAPID CYCLE EVALUATION 3

PERFORMANCE REPORTING STRUCTURE 4

COLLECTION AND MONITORING OF DATA 6

COMPLIANCE & AUDIT 6

AGGREGATION AND ANALYSIS 7

PERFORMANCE IMPROVEMENT PROCESS 9

ACTION PLANNING PROCESS 10

CLINICAL PRACTICE PROTOCOLS 11

EDUCATION 12

CONFIDENTIALITY 12

ANNUAL PROGRAM EVALUATION 12

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PURPOSE

The Performance Reporting and Improvement Plan for the Suffolk Care Collaborative (SCC), known as a “Performance Provider System” or “PPS”, establishes a planned, systematic, organization-wide approach to performance reporting, performance measurement, analysis, and improvement for the health care services provided. This plan is one of several resources referenced in the SCC Reporting Plan and collectively, establishes the performance reporting program. SCC is comprised of a coalition of healthcare providers, community-based social services agencies and other organizations. The State University Hospital at Stony Brook is the lead coalition provider joined by two additional health systems, Catholic Health Services of Long Island (CHSLI) and North Shore-LIJ, each responsible for the requirements described further herein for their attributed providers and covered lives.

This plan will assist SCC in actively achieving our mission and vision of becoming a highly effective, accountable, integrated, patient-centric delivery system. As an organization, the SCC has established priorities related to the capacity to make the most of patients’ self-care abilities, improving access to community-based resources, breaking-down care silos, and reducing avoidable hospital admissions and emergency room visits. These organizational priorities will guide our performance improvement efforts and help us to achieve our strategic goals

GOAL AND OBJECTIVES

The goal of the performance reporting and improvement program is to improve the patient experience of care (quality and patient satisfaction), improve the health of the populations we serve and reduce the per capita cost of providing healthcare services, thus achieving the Triple Aim.

OBJECTIVES:

A. To design effective processes to meet the needs of our patients which are consistent with the Suffolk Care Collaborative’s mission, vision, goals and plans.

B. To define the approach to Rapid Cycle Evaluation. C. To define the reporting structure and responsibilities. D. To collect data to monitor the stability of existing processes, identify opportunities for

improvement, identify changes that will lead to improvement and sustain improvement. E. To aggregate and analyze data on an ongoing basis and to identify changes that will lead

to improved performance. F. To achieve improved performance and sustain the improvement throughout the PPS. G. To promote collaboration at all levels of the organization enabling the creation of a

culture focused on performance. H. To educate leaders and staff regarding responsibilities and effective participation in

performance improvement activities. I. To support the PPS’ transition from a fee-for-service to a value-based payment system.

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SCOPE AND ORGANIZATION

1. Board of Directors: The SCC Board of Directors is the final authority and is ultimately responsible for the Performance Reporting and Improvement Plan.

2. Clinical Committee: The Clinical Committee of the Board is accountable to the Board of Directors for the quality of care and services provided by the Suffolk Care Collaborative. The Committee identifies and prioritizes improvement opportunities and resources to accomplish performance improvement initiatives. The Committee receives, reviews and evaluates performance improvement reports identifying best practices to share across the PPS partners as well as variances that need to be addressed.

3. Performance Evaluation and Management Team: The Performance Evaluation and Management Team functions in a facilitative and consultative manner serving as the advisory workgroup to the Clinical Committee. Responsibilities of the team include: developing the performance reporting framework; defining metrics and identifying data sources; assuring data integrity; creating executive and provider specific dashboards for performance reporting; identify potential performance reporting training needs across the PPS and training strategy; develop a corrective action planning process to address variances in performance. Membership includes representation from all three health systems i.e. clinicians and professionals with experience in data informatics, quality improvement, care management and information technology. The team is supported by staff from Stony Brook University Hospital’s Information Technology and Biomedical Informatics departments who are responsible for data retrieval and analysis across the PPS as well as safeguarding protected health information (PHI).

4. SCC Central Service Organization: The SCC Central Service Organization

includes the Project Management Office (PMO), Network Development, Care Management, Finance and Compliance.

RAPID CYCLE EVALUATION

SCC’s approach to rapid cycle evaluation is supported through the organization’s structure, data collection, analysis and monitoring process and two-way flow of communication between the Board and all stakeholders. The SCC by way of the structure and processes described further herein will assure:

• Accountability for reporting results and making recommendations on actions requiring further investigation into PPS performance

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• Plan for the use of collected patient data to: o Evaluate performance of PPS partners and providers o Conduct quality assessment and improvement activities o Conduct population-based activities to improve health of the targeted population o Plan for the use of collected patient data

• Mechanism to oversee the interpretation and application of results PERFORMANCE REPORTING STRUCTURE

The organizational units responsible for reporting results and recommending actions are the SCC Performance Evaluation and Management Team and the SCC Central Service Organization. The SCC Central Service Organization is responsible for project implementation, management and evaluation for the PPS with input from the coalition health systems i.e. Catholic Health Services (CHSLI) and North Shore-LIJ. The SCC Central Service Organization PMO facilitates collective meetings with the health system’s PMOs weekly to discuss priority issues and planning needs. The Performance Evaluation and Management Team, which includes membership from all three health systems, is responsible for data collection, synthesis and interpretation of the information. Both of these organizational units work closely with the subcommittees of the Board (IT, Clinical, Finance). The Performance Evaluation and Management Team reports directly to the Clinical Committee as illustrated in Exhibit 1. The SCC Central Service Organization is represented at all three governance subcommittees to discuss important information and to receive timely feedback. This organizational unit interacts with all Project Teams and PPS coalition providers so that actionable results can be communicated to front line staff and feedback can be received. The SCC Central Service Organization will regularly brief the PAC, Executive Committees, Board and Providers on PPS performance, issues and recommendations. Accountability for the clinical and financial outcomes of specific pathways is managed at the provider, project, health system and Board level. Stakeholder Responsibility Provider The engagement and accountability requirements for coalition providers are

described in detail by provider type in the Participation Agreement. A distinction is made between “Engaged Participant” and “Knowledgeable Participant”. Engaged participants are accountable for fulfilling project and patient engagement requirements and meeting the associated performance metric goals and targets. Knowledgeable participants need to be informed of DSRIP projects and metrics.

Project Each of the 11 DSRIP projects is managed by a Project Manager. The Project

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Manager Manager has the overall responsibility for the execution of the project. The Project Manager manages day to day resources, provides project guidance and monitors and reports on the project’s metrics as defined in the Project Management Plan. As the person responsible for the execution of the project, the Project Manager is the primary communicator for the project distributing information according to the SCC Communications Management Plan.

Health System

Each health system is responsible for the providers and covered lives attributed to their health system. Responsibilities include performance reporting & monitoring, corrective action planning, project implementation and assuring data feeds are sent timely and according to the established SCC Quarterly Reporting Schedule.

SCC Board The seven Governance Committees are the sub-committees of the SCC Board of Directors. The seven Governance Committees consist of Finance; Information Technology (IT) and Biomedical Informatics (BMI); Workforce; Community Needs Assessment (CNA), Cultural Competency & Health Literacy; Compliance; Audit; and Clinical. Oversight for clinical and financial outcomes will be the responsibility of the Clinical Committee and Finance Committee.

Exhibit 1

FlowOfCommunication&ReportingOrganizationalWorkstreamProjects

SCCWeeklyMeetings

• EducationalSeminars• Website

• SynergyNewsletter• QuarterlyPACMeetings

• DSRIPinActionEmails

Governance

Committee

Commun

icationwith

DSRIP11Projects

SCCBoardofDIrectors

*Governance

CulturalCompetency&HealthLiteracyWorkgroup

WorkforceProject

Workgroup

CulturalCompetency&HealthLiteracy

•FinancialSustainability

•Budget•FundsFlow•Audit

FinancialSustainabilityWorkgroup

VBPWorkgroup

ComplianceOfficer/

Workgroup

ITSystems

ITTaskForce/ITPMO

Finance IT&BMICNA,CulturalCompetency&HealthLiteracy

Workforce Audit ComplianceClinical

Organizational

Workstream

Leads

PAC/ExecutivePAC SCCHEALTHSYSTEMPMO

SCCOfficeofPopulationHealth

PerformanceReporting

PractitionerEngagement

• PopHealthMgmt

• ClinicalIntegration

PerformanceEval&MgmtWorkgroup

PractitionerEngagementWorkgroup

PCMHCertificationWorkgroup

PopHealthMgmt

OperatingWorkgroup

Workgroups

MCO/VBP ComplianceCommunityEngagement

Workforce

*GovernanceOrganizationalWorkstreamMilestonesareapprovedbytheBoardofDirectorsDirectly

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COLLECTION AND CONTINUOUS MONITORING OF DATA The organization’s on-going collection and monitoring program covers a multitude of variables including clinical, financial, operational as well as patient satisfaction. SCC’s goal is to receive data from providers according to the SCC Quarterly Reporting Schedule to allow for rapid-cycle improvement.

Data collection activities are primarily based on the requirements for the New York Delivery System Reform Incentive Payment Program (DSRIP) and are the basis for monitoring the 11 DSRIP projects’ program progression, milestone achievement and metric results. PPS metrics that need to be defined or collected to meet DOH reporting requirements (i.e. patient engagement, medical record abstraction) will be vetted through the Performance Evaluation and Management Team and a data collection process will be developed.

The SCC Reporting Plan, which this plan is a part of, details the accountability of deliverables by defining reporting responsibility for Patient Engagement, Project Engagement and Clinical Outcomes (Domains 2-4) by Health System and Provider Types (i.e. PCP, SNF, Hospital etc.) During the onboarding process of coalition partners the participation requirements are reviewed with each partner as well as the project specific data reporting requirements and schedule.

The data collected from the coalition partners is used to monitor the stability of existing processes, identify opportunities for improvement, identify changes that lead to improvement and/or to sustain improvement and is used as the foundation for the coalition partner’s pay-for-reporting and pay-for-performance compensation model. Data will also be used at a person and population level through the care management program to enable outreach to individual beneficiaries and providers to continuously identify hot spots in need of greater resources or different interventions.

COMPLIANCE & AUDIT Partners who fail to meet the minimum data reporting requirements as specified in the SCC Reporting Plan and who may impact the PPS’ receipt of DSRIP funds will be escalated to the Clinical Committee for resolution. To assure the integrity of the data reported to SCC an audit plan has been established. The PPS will audit coalition partners’ reporting process annually and as needed. The audit is based on a random sample of medical records to assure the validity of the data reported to the SCC. Partners who fail the audit will be escalated to the Health System for resolution. At the time of the audit, partners are expected to produce documentation that validates the data reported. To ensure the security of the data transferred to and stored by SCC, the appropriate data use

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agreements will be used. AGGREGATION AND ANALYSIS OF PROCESS AND OUTCOME DATA

Decision-making throughout the PPS will be based upon data collected. Data will be aggregated and analyzed by the organization in such a way that current performance levels, patterns or trends can be identified. The organization will utilize appropriate statistical tools and techniques to analyze and display data. When appropriate, data will be trended and compared internally over time as well as to external benchmarks. Performance dashboards that include all measures of success will be created for providers, then each Project Team, then rolled-up into a specific Governance Committee (Clinical/IT/or Financial), and then to a Board level dashboard for which the PPS Board will have ultimate oversight. Areas of variation in clinical results or provider performance will initially be addressed by each Health System with support from the DSRIP Project Committee with oversight by the Clinical Committee.

Decision Support Tools Performance Logic Project Portfolio Manager (PPM) software is utilized to keep track of the 11 DSRIP plans and organizational workflows. All projects from development through the entire lifecycle are managed through the Performance Logic PPM software. Meaningful performance dashboards are generated for each project team and then reported to the appropriate Governance Committee and then to the Board. The dashboards provide a snapshot of each project’s performance with meeting engagement metrics as well as status completion of project milestones. Provider level dashboards will be created as appropriate. The Cerner HealtheIntentTM Platform will be utilized to aggregate, transform and reconcile data across the continuum of care. The Cerner platform will allow SCC to manage the population we are held accountable for, with the goal of improving outcomes and lowering costs. The Cerner platform supports SCC’s performance outcome reporting and monitoring as well as care management prioritization. Performance dashboards generated from this platform include cost, quality and utilization metrics. The same performance reporting structure to the project teams and the Board is followed here as well as including provider level performance dashboards. Until the HealtheIntent TM Platform is fully operational SCC will rely on the Salient data and tools provided by the DOH to monitor and communicate metric performance.

Performance dashboards will be generated and distributed to coalition partners. SCC will continually solicit feedback from the partners regarding the best mode for communicating performance information.

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Performance Metrics & Goals

The DSRIP metrics are grouped into four domains:

• Overall Project Progress Metrics (Domain 1) • System Transformation Projects (Domain 2) • Clinical Improvement Projects (Domain 3) • Population-wide Projects (Domain 4).

All process and outcome metrics are associated with funds flow based on either milestone completion or reaching performance goals. The metrics and standards are detailed in the SCC Metrics Matrix and the SCC DSRIP Project Management Plans.

Pay for Reporting (P4R) Measures In cases where the measure type is Pay for Reporting (P4R), SCC will receive funds for successfully reporting the measures to NYS DOH within the timeframes for each measurement year (MY). The measurement year is a 12 month period running from July 1 of the previous year to June 30th of the current year. Measures which are NYS DOH’s responsibility for reporting will be credited to SCC in P4R situations. The distribution of funds to Coalition Partners will be based on SCC collectively achieving such milestones and metrics. Pay for Performance (P4P) Measures In cases where the measure type is Pay for Performance (P4P), SCC will receive achievement value for results that meet or exceed the annual improvement target. Improvement targets are determined based on SCC’s previous annual performance in the measure and will be calculated by NYS DOH using the methodology described further herein. The distribution of funds to Coalition Partners will be based on SCC collectively achieving improvement targets.

As measures move from Pay-for-Reporting to Pay-for-Performance throughout the course of the DSRIP program, SCC will hold coalition partners accountable for meeting improvement targets as defined by the DSRIP program.

Coalition partners will be expected to reduce the gap to the goal by 10% for applicable measures. The most current measurement year (MY) result will be used to determine the gap between the result and the measure’s goal, and then 10% of that gap is added to the most current result to set the annual improvement target for the current MY (baseline for Measurement Year 1 and so on). Each subsequent year will continue to be set with an improvement target using the most recent year’s result. This will account for smaller gains in subsequent years as performance improves toward the goal or measurement ceiling. An example is provided in Exhibit 2.

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Exhibit 2

In addition, several measures are eligible for high performance payment funds. These measures relate to avoidable hospitalizations, behavioral health and cardiovascular disease.

In keeping with the standards specified in the DSRIP Measure and Specification Manual high performance will be determined through two methods:

1) Achieving a reduction in gap to goal by 20% or more in any annual measurement period for a high performance eligible measure; or

2) Meeting or exceeding the measure’s performance goal for the measurement period for a high performance eligible measure.

PERFORMANCE IMPROVEMENT PROCESS

Once opportunities for improvement are identified through data analysis, changes to the underlying system may need to be made. For quality improvement, SCC recommends coalition partners follow the Institute for Healthcare Improvement (IHI) “The Improvement Model” or another industry recognized quality improvement model (Six Sigma, etc.).

The Improvement Model consists of three fundamental questions and a Plan-Do-Study-Act cycle to test and implement changes.

Part 1 presents three fundamental questions, which can be addressed in any order:

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What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in an improvement?

Part 2 is the Plan-Do-Study-Act (PDSA) cycle to test and implement changes in real-work settings. The PDSA cycle guides the test of change to determine if the change is an improvement

THE IMPROVEMENT MODEL

ACTION PLANNING PROCESS

In keeping with the goal of achieving system-wide excellence by improving existing processes, the primary goal for SCC’s Performance Reporting and Improvement Plan will focus on examining the performance of the organization’s systems and processes and not scrutinizing individual performance. With that in mind, an action planning process has been established to identify circumstances if performance falls below the agreed-upon standard for one or more metrics (i.e. the coalition partner is said to be “in variance”). Being in variance then triggers the

Setting Aims Improvement requires setting aims. The aim should be time-specific and measurable; it should also define the specific population of patient that will be affected.

Establishing Measures Teams use quantitative measures to determine if a specific change actually leads to improvement.

Selecting Changes All improvement requires making changes, but not all changes result in improvement. Organizations therefore must identify the changes that are most likely to result in improvement.

Testing Changes The Plan-Do-Study-Act (PDSA) cycle is used for testing a change in the work setting by planning it, trying it, observing the results, and acting on what is learned.

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Action Planning process. The Clinical Committee will consider minimum (N) size when identifying variances.

For P4P and P4R metrics, each Health System with information provided from the PPS and/or DSRIP Project Committee(s) will consult with the partner and develop a corrective action plan when a metric is in variance for two consecutive quarters. The action plan should demonstrate that an analysis was done to identify possible root cause(s) driving the variance.

An action plan may include:

• Process modification, redesign, or re-engineering • Further trending of issue • Implementation of new or revised services, policies or procedures • Education • Counseling • Focused Audit • Resource Enhancement

Loop closure and re-evaluation is necessary to demonstrate that the corrective action has accomplished the desired effect. No issue will be closed until the re-evaluation process has been complete and it demonstrates a measure of performance that has been deemed acceptable by the Clinical Committee. The action plan should explain the scheduled time for re-evaluation typically, 6 months, following the implementation of the corrective action plan, and process for documenting the results of the monitoring.

Action plans will be closed and considered complete when the metric is out of variance for two consecutive quarters. In situations where performance has not improved despite action planning efforts the Clinical Committee will determine next steps and communicate their recommendations to the Board especially when it involves reconsideration of funds flow to the provider.

CLINICAL PRACTICE PROTOCOLS

SCC has committed to implement 11 DSRIP projects across the PPS coalition partners. Several DSRIP projects require developing clinical practice protocols targeting specific patient populations. The protocols are developed by project committees which are led by clinical experts in the content area. Protocols are sent to the Clinical Committee for review, revision and final endorsement. Final approval and ratification of all clinical protocols is made by the Board of Directors. The Clinical Practice Protocols will be evaluated at least annually and revised as necessary.

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EDUCATION

The educational needs for performance reporting training will be identified by the various project teams, committees, and coalition partners and will be incorporated into the overall training strategy for the PPS. All coalition partners will receive an orientation to the SCC Reporting Plan and its appendixes during the onboarding process. A baseline assessment of the performance reporting educational needs will be conducted during the onboarding process and gaps of knowledge will be addressed. SCC will identify and evaluate existing training programs across the PPS in an effort to avoid duplication of efforts. SCC will also rely on engaging industry experts in the subject matter such as The Institute for Healthcare Improvement (IHI). SCC will utilize various training methods based on the needs identified and will monitor the effectiveness of each approach.

CONFIDENTIALITY

All information generated as a result of SCC’s Performance Improvement Program is considered confidential and protected under sections 2805-j and 2805-k of the NYS Public Health Law.

Access to patient or practitioner specific information is strictly controlled with access afforded only when specific information is needed to facilitate decisions.

ANNUAL PROGRAM EVALUATION

The objectives, scope, and effectiveness of SCC’s performance reporting and improvement program will be evaluated at least annually and revised as necessary.