PDF - IQM Initiative Qualitätsmedizin

Quality indicators generated from
routine documentation.
(G-IQI German Inpatient Quality Indicators)
Peter C. Scriba, München
Thomas Mansky, Berlin
W 9: Healthcare Financing
EHFG European Health Forum Gastein
Hofgastein , October 7, 2011
Players who need estimation of quality
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Doctors, Nurses a.o.: Demonstration of competence
Health Insurances : Selective Contracting
Pay for Performance P4P
Patients
: Patient needs,
Appropriateness
Hospital owner
: Competition for quality
QS- und QM-Profis : Basis for their existence
Research
: Health Services Research
Government
: Warranty for adequacy of service
Estimations by all players are subject to bias.
Competition of methods is therefore
scientifically essential.
Methods for Estimation of Quality
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Quality Reports
BQS-Quality Reports
Registries
Patient Safety Indicator (PSI)
Critical Incidence Reporting (CIRS)
Publication
P4P Payment for Quality P4Q
QSR and G-IQI
Considerable differences:
Documentation, resistance to manipulation,
„ scope“, evidence for efficacy and effectiveness
What do we want ?
1.
Internal feedback to doctors

2.
Public reporting



3.
peer pressure for improvement (itit‘‘s not nice to be the last on the
list)
information to referring physicians (informed decision making
making))
information to patients (free choice
choice!)
!)
Managed improvement


4.
Problem: how to reach the ‚bad
bad‘‘ ?
Identification of subpar providers (‚black sheep
sheep‘‘)
targeted improvement using audits
P4P - or better - P4Q, future development

Requirements for 2 to 4: measures should be highly restistant
against manipulation and stabile in courts (among others
others))
Mansky
Methods
G-IQI: Inpatient Quality Indicators –
private initiative (Helios group and others):
Based on use of administrative hospital data





no additional ressource consumption, checked data
evaluation restricted to coded information (coding
systems can however be extended)
similar to AHRQ methods (IQI, PSI), but much more
detailed
outcome oriented
good manipulation resistance (all charged
complications are evaluated)
Targets for indicators derived from
1. Data of Statistisches Bundesamtes,
Statistics of Hospital Diagnoses 2009
2. Medical Specialists Groups (Helios)
3. Federal Means of SQG 2009
4. Literature on Routine Data
5. Cleveland Clinic, Heart & Vascular Institutes,
Outcome 2009
6. The Society of Thoracic Surgeons 200
IQM-Indicators
Recent Results
Zielwert
IQM-Ergebnis
5
8 von 17 Kli niken er r eichen Ziel
Quellen der Benchmark-Zielwerte
9 Kliniken er r eichen Ziel nicht
5 Cleveland Clinic, Heart and Vascular Institute, Outcomes 2009
6 The Society of Thoracic Surgeons 2009
Quelle: www.initiativ e-qualitaetsmedizin.de
Better than Federal Average
Recent Results (2010)
SMR
Ziel
Berechnung: Beobachtete Sterblichkeit / Erwartete Sterblichkeit
SMR < 1 (überdurchschnittlich gutes Ergebnis im Vergleich zum Bund)
Krankenhaussterblichkeit
Fälle
IQM 10
Bund
Herzinfarkt
SMR 09
SMR 10
22.334
9,0%
10,7%
0,98
0,87
Herzinsuffizienz
38.285
7,6%
9,8%
0,92
0,81
Schlaganfall
30.418
9,6%
9,6%
1,07
1,03
Hirninfarkt
24.231
6,6%
7,4%
0,99
0,93
Lungenentzündung
27.655
8,6%
10,7%
0,92
0,86
Neu: COPD
16.885
4,4%
4,6%
1,00
0,97
Schenkelhalsfraktur
7.109
4,9%
5,6%
0,95
0,89
Neu: Petrochantäre Fraktur
6.309
4,8%
5,2%
0,98
0,92
Entwicklung
Quelle: www.initiative-qualitaetsmedizin.de
Wichtiger - Schwachstellen werden sichtbar
More important: Hospitals may realize
where they should improve
71 x Target „better than Federal Average“ reached
36 x Improvement possible ?
Quelle: Interne Gruppenauswertung 2010
2,00
1,80
1,60
1,40
1,20
1,00
0,80
0,60
0,40
0,20
0,00
SMR bei Herzinsuffizienz
Internal Optimization I

Indicator with relatively frequent
Mortality e.g. - Pneumonia
1. eigenen
Durchschnittswert
anschauen und mit
Zielwert vergleichen
2. wenn der Wert über dem
Referenzwert liegt, dann
Einzelfälle untersuchen
(Aktenanalyse) und
Behandlungsablauf
verbessern
3. Fortführung bis
Zielwert erreicht
Methods 2
AOK – insurer (+private Helios hospital group)
QSR initiative:
Evaluation of long term insurance data
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no additional ressource consumption, data is already
there
almost 100% follow up
late outcome becomes measurable (mortality,
revisions etc.)
very high manipulation resistance
Beispiel Herzinsuffizienz 2004
90-Tage Sterblichkeit liegt um 9% unter Bundesdurchschnitt
Th.Mansky, damals Helios, mit AOK, WidO, Feisa
Beispiel Herzinsuffizienz
Th.Mansky
Herzinsuffizienz HELIOS 2004
Th.Mansky
% remaining implants
Example QSR – long term outcome:
replacement rate after initial hip replacement
170,000 AOK patients with hip implant
480,000 follow-up years
Günther Heller, AOK, KH-Report 2011
years after implant
IQM: Voluntary Membership
Members have to aggree upon three basic principles:

Quality management on the basis of Routine Data

Transparancy, i.e. publication of results on
hospital level

Active Quality management by Peer Review
Mitglieder, Stand: 22.8.11
freigemeinnützig, öffentlich, privat,
universitär
Development:
Participating Hospitals, Patients
teilnehmende Krankenhäuser
stationäre Behandlungsfälle
2,70 Mio.
155
Anteil IQM
(D): 13%
(A): 15%
84
2008
1,36 Mio.
Sep 2011
2008
Sep 2011
?
IQM-Trägergruppen
Who is IQM
IQMTrägergruppe Kliniken Stimmrechte %
kommunal
23
23
16%
freigemeinnützig
33
29
21%
privat
55
62
44%
universitär
8
23
16%
international
2
4
3%
121
141
100
Summe
Who is IQM ?
Mitgliederstruktur
IQM-Kliniken - KH aller Versorgungsstufen
Anzahl Kliniken
60
53
50
42
40
30
20
15
10
5
0
bis zu
250
<250
bis <750
zu 750
bis<1.250
zu 1.250
Betten
>>1.250
1.250
Austria: Internal reporting with
audits
 Austria introduced G-IQI
this year for
internal feedback and identification of
subpar performing hospitals
 Evaluation of all hospitals by federal
ministry of health
 Subpar hospitals are chosen for external
audit
 Public
reporting may follow later
Switzerland: Public reporting
 The ministry
of health of Switzerland uses
the G-IQI indicators for public reporting
 Last year voluntary reporting, ~ 50% of the
hospitals participating
 This year obligatory reporting for all Swiss
hospitals
Inpatient Quality Indicators
USA
Germany
Switzerland
Austria
Transparency
intern (regelmäßig hauseigene Auswertungen, IQMGruppenauswertungen)
 Qualität als gemeinsame Aufgabe im Krankenhaus

Qualität abteilungs- und berufsgruppenübergreifend
verbessern
extern (jährliche Ergebnisveröffentlichung)

signalisiert Bereitschaft zur Verbesserung

schafft Vertrauen

motiviert

Orientierung für Patienten und Einweiser
IQM - Quality 2010
Targets and recent results online
Quelle: www.initiative-qualitaetsmedizin.de
Peer Review
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Interpretation of possible mistakes and of their
causes
Analysis of outlayer cases
 Learn from mistakes
 Collegue to collegue suggestions
 Open culture for handling mistakes
6 years of very positive experience at Helios
External spreading of the procedure as supported
by German Medical Association (BÄK)
Ärztliches Peer Review
Kollegiale Hilfe zur Selbsthilfe
IQM-Peers: Bereits 132 Chefärzte trägerübergreifend im Einsatz
Peer Review – Fallstudie
Hauptdiagnose Herzinsuffizienz, Todesfälle
Peer Review Verfahren
Optimierungspotential
identifizieren
gefundene Probleme:
Verbesserungen
umsetzen
umgesetzte Massnahmen:
+ interdisziplinäre M&M Konferenzen
- Verlegung auf ITS zu spät
- mangelhafte Dokumentation + wöchentliche Kurzweiterbildungen
- Diagnose Sepsis vernachlässigt+ bessere Dokumentation (Stempel)
- fehlerhafte Kodierung
+ Aufbau Kodierabteilung
Evaluation: Results 2011
Improvement is possible !
German Medical Association (BÄK)
P4Q – impact problem
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Consider:
 Hospital contracts with an insurance having 10%
patient share
 for a certain disease affecting 3 % of all patients
 P4Q contract with 4% quality dependent payments
Total P4Q-share of hospital turnover:
10 % x 3 % x 4 % = up to 0.012 % of budget affected
THIS IS NO INCENTIVE FOR THE CEO !
A partial, small P4Q contract will have no influence on
hospital behaviour (>>> THINK BIG !)
Failure of some P4Q programs may be related to
approaches, which were too small from the beginning
Conclusion
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Public reporting of IQI becomes more and more
common
Audits for identified problems are a useful
additional approach
P4Q approaches must have sufficient impact on
the budget, otherwise they cannot work
Methods are rapidly developing and we are
learning
Qualitätsmessung: Fazit
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Only what is coded can become routine data.
Therefore, other methods have to be used for
further questions (PSI, Registries etc.).
QSR und IQM represent valuable extensions of
existing QM.
Results of quality estimations depend on
methods.
Therefore, scientific comparison of results from
different players is wanted (Erkenntnistheorie).
Competition and outcome research are
necessary !
Vielen Dank für Ihre
Aufmerksamkeit !