PfP NJ 2.0 Pressure Ulcer Prevention Learning Action Group

Webinar #1:Quality Improvement Frameworks to Implement Evidence-

based Practices for Pressure Ulcer Prevention

June 15, 2016

Hosted by New Jersey Hospital AssociationLauren Rava, MPP

Collaborative FacultyWilliam V. Padula, PhD

Assistant Professor of Health Policy and Management Johns Hopkins Bloomberg School of Public Health

Baltimore, MD

Agenda

• Partnership for Patients-NJ 2.0 updates• Presentation: Quality Improvement

Frameworks to Implement Evidence-based Practices for Pressure Ulcer Prevention

• Q&A• Next steps

Goals• Reduce HACs 40% from 2010 baseline• Reduce preventable readmissions 20% from

2010 baseline

*It is important to note a data anomaly for the fall and falls with injury rates for first quarter 2015. The data shows a dramatic increase in rates. There are a couple of possibilities. One, 2015 was a particularly harsh winter and this could have possibly led to increase in falls due the effect with the elderly population. Or two, the data is misrepresented. We are currently investigating the issue and will update with our findings.

Project Updates

Project Updates

Project Updates

Project Updates

PfP NJ 2.0 Falls Learning Action Group Structure

• Subject-Based Presentations:– Quality Improvement Frameworks to Implement

Evidence-based Practices for Pressure Ulcer Prevention

– Pressure Ulcer Prevention in Vulnerable Elders– Reducing Pressure Ulcers from Medical Devices– Pressure Ulcers and Nutrition

Quality Improvement Frameworks to Implement Evidence-based Practices for Pressure Ulcer

Prevention

William V. Padula, PhD, MS, MScAssistant Professor

Twitter: @DrWmPadula

© 2015/2016, Johns Hopkins University. All rights reserved.

Tweet me during the presentation@DrWmPadula

#NPUAPregistry

© 2015/2016, Johns Hopkins University. All rights reserved.

Acknowledgements and Disclosures• Unrestricted grant from AHRQ (1-F32-HS023710-01) • Collaborators:

• David O. Meltzer, MD, PhD• Peter J. Pronovost, MD, PhD• Robert D. Gibbons, PhD• Adam J. Ginenskey, PhD• Mary Beth F. Makic, PhD, RN• Heidi L. Wald, MD, MSPH• Manish K. Mishra, MD, MPH• Robert J. Valuck, PhD, RPh• Donald Hedeker, PhD• Tony Ursitti• Laura Ruth Venable• Ziv Epstein

• Molnlycke Healthcare: Speakers Bureau and Consultant• Commissioner: ANCC Commission on Magnet

The Donabedian Model

Donabedian, JAMA 1988

The secret of quality is love. -Avedis Donabedian

Structure

ProcessOutcomes

Hazards of Hospitalization in the Elderly

Creditor, Ann Intern Med 1993

Framework of Implementation and Dissemination

Gonzalez et al (2012). A Framework for Training Health Professionals in Implementation and Dissemination Science, Academic Med.

Evidence-based Practices (EBPs) for Pressure Ulcer Prevention

a. Risk-assessment with Braden Scaleb. Patient repositioningc. Managing moisture and incontinenced. Monitoring nutritione. Modern support surfaces (beds, overlays)f. Continual nursing education about EBPs

• It’s a Checklist

Braden, Res Nurs Hlth 1994; Ratliff, NPUAP 2004

Economic BurdenBerwick: Eliminating Waste in U.S. Health Care

Financial Impact of Pressure Ulcers

• Most costly hospital-acquired condition– Treatment: $500-130,000– Malpractice settlements:

$Millions

• $11 billion/year in U.S.– Direct– Indirect

• Pressure Ulcers represent 0.3% of all healthcare

• $36-45 Billion spent on “failures of care delivery”

Berwick, JAMA 2012; Kuhn, Nurs Econ, 1992; Padula, Med Care 2011

• Main comparators– Do-Nothing: Inconsistent

EBPs implementation– Prevention with EBPs

• Evidence-based practices for pressure ulcer prevention are cost-effective– Invest $55/patient/day in EBPs– Cost-saving

• *If practiced consistently*

Inpatient

Deep Tissue Injury

Discharge

Pressure Ulcer

Stage I/II

DeathPressure

Ulcer Stage III/IV

No Complication

Nurse & Monitor

Acute & Chronic

Care

Surgery

Standard Care

Prevention

M

Markov Model

Stakeholders of QI• Government

– National Institutes of Health (NIH)– Agency for Healthcare Research and Quality (AHRQ)– Dept Health and Human Services (HHS)

• Payers– Centers for Medicare and Medicaid Services (CMS)– Commercial Payers

• Advocacy– Institute of Medicine (IOM)– Institute for Healthcare Improvement (IHI)– The Joint Commission (TJC), formerly the Joint Commission

on Accreditation of Healthcare Organizations (JCAHO)

IOM Reports

• To Err is Human– Human error is a natural occurrence and can lead

to adverse events– However, systematic flaws within the healthcare

environment are what lead to medical error– Systematic Improvement could reduce likelihood

of compound human error that exposes patients to harm

IOM Reports

• First, Do No Harm– Evidence-based directives

• Failure to employ indicated tests• Error in performance of operation, procedure or test• Inadequate monitoring of follow-up of preventive

treatments• “other” system failures

– Motivate health care stakeholders

IOM Reports

• Crossing the Quality Chasm– Calls for complete system redesign of U.S. Health

Care– Concept that medical errors cannot be “patched”

up with straightforward recommendations– Adjusting not only how EBPs reach the patient,

but how clinical teams reorganize to ensure that EBPs are implemented consistently [without harmful variation]

Fallout of IOM Reports

• Create Center for Patient Safety within AHRQ• A national system of mandatory and voluntary

reporting of medical error within hospitals to create provider transparency

• Regulators need to raise standards– FDA– The Joint Commission

• Healthcare organizations should create safety systems of safe, evidence-based practices

IHI Campaigns

• 100,000 Lives– Encourage hospital adoption of…

• preset goals• preset timeframe

– Garner a personal [hospital] sense of responsibility towards improving quality and patient safety

– Prevention of several hospital-acquired conditions (HACs)

• Surgical Site Infections (SSIs)• Central Line Infections (CLABSI)• Adverse Drug Events (ADEs)

IHI Campaigns

– Continue mission of 100,000 Lives– Add 5 more preventable conditions

• CAUTI, pressure ulcers, falls, etc.– An effort to move past EBPs and into patient-centered

care (PCC) to improve prevention• Over 4,000 hospitals adopted this QI campaign• HACs dropped as much as 72%

Issue with EBP -> PCC in 2006

• Providers, especially nurses at the interface of change, not adhering to EBPs– 64% of nurses read 1 or more specialty journals– 53% read a nursing journal– 20% did not read any professional journals– 0% read a journal dedicated to publication of

original research

The Joint Commission

• The regulatory body of hospital quality and performance

• Accredit payer reimbursements (e.g. CMS)• Mandate adherence to EBPs• Errors and preventable harms that occur are

recorded and noted and associated to EBP implementation failures

• Misreporting quality/performance measures can jeorpardize accreditation

CMS

• Largest single-payer in the U.S.– 46 million Medicare beneficiaries– 50 million Medicaid eligible

• Powerful stance on reimbursement policy• Has used reimbursement to influence QI

– Nonpayment for harms– Pay for performance

• Monitors quality/performance measures of health systems to deduct reimbursements

CMS Nonpayment Policy

• Spring, 2007: CMS announces nonpayment policy for hospital-acquired conditions

• October, 2008: Implementation of nonpayment policy for hospital-acquired conditions

• Present: Hospitals absorb costs for all hospital-acquired conditions– e.g. Pressure Ulcers; Falls; Ventilator-associated

Pneumonia; Catheter-associated UTI; Surgical-site Infections; MRSA; Central-line Infections; etc.2

– Theoretical redistribution of estimated $40+ billion per year3

CMS Policy Updates: P4P

• 1% payment reduction to hospitals ranking in the lowest quartile of HAC prevention

• HAC including: PSI-03 Pressure Ulcer; PSI-06 Iatrogenic Pneumothorax; PSI-07 CLABSI; PSI-08 Hip Fracture; PSI-12 Pulmonary embolism and DVT; PSI-13 Sepsis; PSI-14 Wound Dehiscence: PSI-15 Accidental puncture/laceration

• Affects all hospitals reimbursed through the inpatient prospective payment system (IPPS)

Timeline of Culture of Improving Quality

7%(Whittingon,

2004)

4.6%(Bergquist-Beringer,

2009)

4.5% (Lyder, 2012)

2-3% (Padula,

2013)?

Significant Reductions in Pressure Ulcer Incidence since mid-2000s (Stotts, 2013)

Goal is 0%(The Joint

Commission)

$5436

$6721

$8905

$1285$3469

$0$1,000$2,000$3,000$4,000$5,000$6,000$7,000$8,000$9,000

$10,000

AMI AMI + UTI AMI +Urosepsis

Reimbursement for AMI at University of Colorado Hospital, 2007

Wald, JAMA 2007

Health care has developed EBPs for many patient safety issues

UHC Hospital Rates of HAPUsAHRQ PSI-3

CMS Policy Interruption

Padula, Jt Comm J Qual Pat Saf 2015

Pressure Ulcer Prevention Protocol

Quality ImprovementDefinition

The combined and unceasing efforts of everyone – health care professionals, patients and their families, planners, administrators, educators – to make changes that lead to better patient outcomes, better systematic performance, and better professional services.

-Quality by Design

Key Terms in QI• Evidence-based Practices vs. Quality Improvement

– Evidence-based Practices• Must be implemented in order to achieve better outcomes• Guidelines that should be followed

– Quality Improvement• Tools designed to increase effective implementation of EBPs• A theoretical framework of tools and resources• Lead to systematic change for improved adherence to evidence-based practice

• Implement vs. Adopt– Implement = evidence-based practices

• Institutionalized by CMS and The Joint Commission• Measured quality indicators

– Adopt = quality improvement interventions• Establishing a culture of better care• Up to individual practitioners to develop

QI Best-practice Framework

Padula, Adv Skin Wound Care 2014)

Rationale to Study QI

• To study methods for evaluating comparative effectiveness of QI interventions

• Why HAPUs are a good case study for QI:– CMS policy incentives– High HAPU incidence– Costly condition– Quality Improvement, an IOM priority area in Comparative

Effectiveness Research: Compare the effectiveness of different quality improvement strategies in disease prevention, acute care…for diverse populations…13

Specific Aims

1. To characterize QI Interventions according to the EBP framework for U.S. hospitals

2. To determine the effectiveness of QI interventions for implementing the evidence-based HAPU prevention protocol

3. To identify effective combinations of QI interventions for a HAPU prevention strategy

Study Design• Longitudinal data analysis of hospital HAPU rates

over time• Evaluating changes in HAPU rates associated with QI

adoption, at the hospital-level• Retrospective cohort of academic medical centers

(UHC)• Analyses

– Descriptive Analysis of QI Adoption Patterns– Effect Size Analysis– Mixed-effects Poisson Regression

Data Sources• Studying hospitals between

2007-2012• University HealthSystem

Consortium (UHC)– Data pooling of 120+

academic hospitals• Inpatient/Outpatient Data• QI/Safety Outcomes

– AHRQ PSI-3– Inpatient records– Hospital-level outcomes

• Survey– Target UHC hospitals– HAPU prevention protocol– QI interventions – Response to CMS policy

Parameter UHC Clinical Data SurveyAge xGender xHospital LOS xMortality xICU Admission xCase-Mix Index xMedical/Surgical Procedures xHAPU Incidence xHospital Staffing xHAPU Prevention Protocol xContextual Influences xQuality Improvement Strategies x

AHRQ PSI-03Hospital-acquired Pressure Ulcers

• Measure CMS uses to monitor HAPU rates– Defines quality improvement as 1 case reduction per 1,000 patient admissions

per quarter

• Inclusion:– Stage III, IV, or unstageable pressure ulcer – Not present on admission (POA)– Without primary or secondary diagnosis of a pressure ulcer POA– LOS >5 days

• Exclusion– MDC 9 (skin) or MDC 14 (pregnancy and child birth)– Paralysis (hemiplegia, paraplegia, quadriplegia)– Diagnosis of spina bifida or anoxic brain damage

Sample Population, 2007-2012 (N=55)

Padula, Jt Comm J Qual Pat Saf 2015

QI Adoption in 53 UHC Hospitals

Padula et al, Medical Care 2016

Longitudinal Data Analysis• Effect Size Analysis

– Changes in HAPU rates associated with QI adoption– Unadjusted comparison of clinically meaningful QI interventions

according to CMS reduction threshold: 1 HAPU case per 1,000

• Mixed-effects Poisson Regression– Counts of HAPU rates over time, nested in Hospitals– Random intercept– Random effect: CMS nonpayment policy– Adjusted comparison of statistically significant QI interventions– Outcome Measures:

• Associations between QI interventions and HAPU counts• Empirical Bayes estimates of hospital-level rates

Padula, BMJ Qual Saf 2012

Unadjusted Effect Size Analysis

Padula, Jt CommJ Qual Pat Saf2015

Combinations of QI Interventions

QI InterventionLeadership Initiatives

Visual Tools HAPU Staging

Skin Care Nutrition

Leadership Initiatives x x x x xVisual Tools 0.0011 x x x xHAPU Staging 0.0013 0.0011 x x xSkin Care 0.0013 0.0012 0.0014 x xNutrition 0.0013 0.0012 0.0012 0.0013 x

BOLDED effect sizes indicate statistical significance at the 95% confidence-level. HAPU indicates Hospital-acquired Pressure Ulcer; QI, Quality Improvement.

Unadjusted Effect Size Analysis

• 5 QI interventions found to have clinically meaningful impact on prevention– Leadership Initiatives to present data in clinics– Visual Tools (e.g. checklists, posters)– Updates to HAPU staging protocol– Use of new skin care products or creams– Emphasis on patient nutrition

Padula, Jt Comm J Qual Pat Saf 2015

Mixed-effects Poisson Regression

• Adjusting for QI interventions

• Relative treatment effects of effective QI interventions over time

Poisson[E(Yij)] = (β0 + ui0) + β1quarterj + β2QIij + (β3 + ui1) × policyj + … + Ζij

Poisson[E(Yij)] = (β0 + ui0) + β1quarterj + β2QIij + (β3 + ui1) × policyj + …

+ β5quarterj × QIij + β6policyj × QIij + Ζij

Hedeker & Gibbons, Longitudinal Data Analysis 2006

ME Results – all QI interventions

Padula, Hospital Med 2015

ME Results - Updates to EBPsMixed-effects Poisson Regression Model

Hospital-level empirical Bayes estimates

Padula, Hospital Med 2015

EBP Updates associated with 1 HAPU case Reduction per Year = $130,000

Limitations• Fair response rate (30.5%; 55 / 180 hospitals)• Reporting bias from survey responses• Recall bias for QI interventions dating back 4-5

years• Difficult to imply all HAPU outcomes on

adoption of QI interventions• Results of QI adoption are co-linear to CMS

policy

Conclusions

• Hospital Implications– Updates to EBPs leads to improve patient outcomes– Identifies the best QI interventions to explore for HAPU prevention – Effective QI strategy to bundle with EBPs:

• Leadership: Leadership Initiatives• P&I: Visual Tools; HAPU Staging; Nutrition; Skin Care

• CMS nonpayment policy provided incentive for hospitals to prevent HAPUs

• Model framework for CER of QI and HACs– Utilize the best-practice framework: Leadership, Staff, IT, Perform &

Improve– Reapply to other areas: Falls; CAUTI; Pain management; C. Difficile

Final Thoughts• Every system is perfectly

designed to get the results it gets.– Paul Batalden, MD

Co-founder of IHI

• Any indication of a forced concept or practice upon clinicians receives pushback…– Peter Pronovost, MD, PhD

Director of Armstrong Inst.

© 2015/2016, Johns Hopkins University. All rights reserved.

References1. Creditor, Ann Intern Med 19932. NPUAP 2014 International Prevention Guidelines. www.npuap.org.3. Berwick. Eliminating Waste in the U.S. Healthcare System JAMA 20124. Kuhn, Nurs Econ, 1992; 5. PADULA, W V, MISHRA MK, MAKIC MB, SULLIVAN PW (2011 Apr). Improving the

Quality of Pressure Ulcer Care with Prevention: a cost-effectiveness analysis. Med Care 49(4): 385-392.

6. Wald, JAMA 20077. BRADEN, B, BERGSTROM N (1994). Predictive validity of Braden Scale for

pressure sore risk in a nursing 8. Qaseem, Ann Intern Med 20159. Landis, Biometrics 197710. Hedeker & Gibbons, Longitudinal Data Analysis 200611. NATIONAL PRESSURE ULCER ADVISORY PANEL (2010). Not All Pressure Ulcers

are Avoidable. J. Bank. Washington, DC, NPUAP.

© 2015/2016, Johns Hopkins University. All rights reserved.

Thank you

@DrWmPadula#NPUAPregistry

Next Steps

• Please complete survey to receive your attendance certificate

• Continue to submit data • Next webinar: July 21 - Pressure Ulcer

Prevention in Vulnerable Elders• Registration link:

https://njha.webex.com/njha/onstage/g.php?MTID=e171ce67c7465b0b0b2567b5bc15ddbbc