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Auditor, Audit Thyself

MW Blog 7 14 2017 Sandia Crest The Needle sm

Numbers. Numbers can tell us many things, including how good or bad something is. When the numbers are low in my bank account, that’s bad. When the numbers are high, that’s good. As a member of the External Quality Review (EQR) team, numbers are part of my daily routine. As a nurse and an auditor, I’m trained to interpret different numbers. In quality review, numbers tell us about the effectiveness of an organization's objectives. In our personal lives, numbers tell us if we are meeting our own objectives or if we’re headed in the wrong direction.

 

Last year, when our staff underwent biometric screening, I had my blood drawn, just like many of my co-workers. Unlike many others, my numbers were bad. As a nurse, I know about lab results and what patients should do when the results are bad. When I saw how high my hemoglobin A1C was, I paid attention. I knew what this number meant – if I didn’t do something soon, I would soon be diabetic and need insulin, just like my parents. I needed to figure out how to do the improvement.

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Behavior Change and Duct Tape – the Stickier, the Better!

Couple walking

Adopting a new behavior, even one that is good for us, can be difficult. I belong to a gym, and I've come to observe each January with interest. That's when the resolutionists, as I affectionately call them, flood the gym for the first several weeks of the new year after making some sort of fitness resolution. The parking lot becomes crowded and exercise machines are busier than ever. (They really like the treadmills for some reason). While I hope a few new faces will stick with it and become familiar over the coming months, most of the crowd has dispersed by the early part of February and continues to taper over the following months until we're largely back to our usual routine. As I looked around the gym recently, I wondered – what would it take to retain a greater percentage of the resolutionists?

We know that individual behaviors are substantial contributors to our health outcomes, representing about 30-50 percent according to a Health Affairs Policy Brief. But how can we effectively take charge of our own health by implementing and retaining more healthy behaviors?

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As Payment Moves to Value, the Circle of Root Causes Expands

Group in conference room

Over the past 20 years at HealthInsight, I've had the opportunity to work with health care providers and organizations on root cause analysis to learn from sentinel events, patient harms and other negative, unwanted and unexpected events. Seeking to prevent future harms, we've learned that the most important answers to the question "why did this happen?" – the root causes – are often far removed in time and space from the events that occasioned the review.

Cause and effect analysis is a technique employed in root cause analysis that pushes you to consider all possible causes of a problem, rather than just the ones that are proximal and obvious. Forms of cause and effect analysis include the "5 Whys" and causal tree analysis. Analyses using these techniques produce cause-effect chains, with each identified cause itself becoming the effect of preceding causes. When learning and applying either of these analysis techniques, it's not always clear when the analysis stops, because one can always propose a preceding cause – even if you have to go back to the "big bang."

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Toward a Multistakeholder Approach to Payment Reform

Doctors

MACRA. QPP. MIPS. Value-based payment. If you feel lost in the sea of acronyms, reporting requirements and systems-level change, you aren't alone. Years of ongoing effort to transform the health care delivery system are now aligning with Medicare's commitment to paying for high-value care, and the change process seems dizzying at times.

Almost everyone agrees that the cost of health care is unsustainable and we must change the way we pay for care. Yet providers, health plans and other stakeholders face significant barriers as they strive to implement and sustain new payment models. System changes come with innumerable intricacies and nuances, including concerns about who wins and who loses. A major challenge is how to obtain and share reliable data to inform and test new models, and to reassure providers who are asked to accept accountability for improving quality while reducing cost. In the midst of these swirling changes, practices have to keep working hard to ensure high-quality care that satisfies their patients.

As I've worked in system change initiatives with multiple stakeholder groups over the years, I've noted all too often that stakeholders tend to work on addressing challenges within their individual spheres—be it a clinical practice, an organization or a network—even though adjustments in one part of the system have an impact on all others. Sustainable change depends on making all adjustments mesh effectively for all stakeholders.

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What is Return on Investment for the QIO Program?

2016 QIO Program Progress Report

Thoughts from a fiscally conservative taxpayer

I have been working for HealthInsight since 1995 and most of that time has been spent operationalizing the Medicare Quality Improvement Organization (QIO) contracts over the years. During this journey, there have been numerous times when the QIO program has been assessed by various entities to determine whether it produces value for Medicare beneficiaries, health care providers and ultimately the U.S. taxpayer who funds the program.

In the effort of being transparent, I believe any taxpayer funded program should be thoroughly reviewed to determine value to the ultimate funder. After all, the U.S. has a national debt approaching $20 trillion or about $60,000 per citizen, so all dollars need to be cherished. If the QIO program is funded in the $1 - $3 billion range—an educated guess—for this contract cycle, what is the estimated return on that investment? What impact, if any, does the QIO program have in driving change?

Being part of the QIO program for over two decades, I have sometimes struggled with my own internal debates and have been defensive when it appears the QIO program has received criticism from various entities for failing to "transform" the health care system or failing to be a cost effective program. I argue of course the QIO program is producing change and transformation. I pull out pre and post measures and data over time to show localized impact as well as community engagement levels. On the other hand, I ponder: is the QIO really a primary lever in any observed changes? Would any of these observed and measured improvements have happened without the QIO program?

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