As leaders we really should not simply think that we are successful because we have a low complication rate at our center or ADR is where it needs to be because the ground is shifting beneath us all the time and in order to thrive in this radically changing environment we really should put into place formal benchmarking systems which I'm going to speak about today. So while I'm just I'm not getting copies of the slides down here. So benchmarking really right now is more than just creating tables and graphs and report cards it's a strategic and business imperative. The continued downward pressure on fees and the fee for service environment itself going through transition to value. We also right now for several years depending upon one's geographic area there are bundled payment programs and alternative payment models as well as risk contracting which make benchmarking very important. And of course ASCs face many challenges with respect to cost efficiency, where do our organizations fit in with respect to how to take advantage of population health and value based reimbursement and again dealing with what we're going to focus on also which are challenging variations in care. Now the cost curve had been bending and you know as a result of Obamacare which is seemingly slowly dissolving there was a net impact especially in governmental programs on overall cost. However for those of you who get health affairs a recent article two weeks ago actually projected that health care cost by 2025 will be about 19.6 percent of GDP and that's because of the simple sheer number of people aging out and the overall cost of care which is driven by a lot of factors. Now pay for performance programs I'm not going to spend much time certainly on the hospital based ones but these have been around a long time many of them since 2011 and have had an impact especially the hospital based ones. Now as far as the ASC quality reporting program by the way do all of you participate in that here who have ASCs and those from hospital based units the hospital outpatient quality reporting system. So these are these are reporting programs which do have real impact at the hospital level on DRG reimbursement ASC also two percent hit on reimbursement for not reporting but it's not yet pay for performance and at the physician level we know the quality payment program now which under its umbrellas the MIPS program and APMs. Reporting methods for those of you already actually participating you already know these for the MIPS program in particular which is physician payment related from CMS there are many different mechanisms to participate. So this is sort of hot off the press but there is actually an ASC facility compare tool that is now available and what I'm showing here is not not that easy to find but right now what I did here was just actually last night pulled data from the center that Dave and I are both medical directors are at and another large one in Manhattan and just I'm outlining here performance on ASC 9 and 10 which are the measures that indicate either compliance with a 10-year interval for screening exams 10 is for correct surveillance interval post polypectomy and you know it's it's very interesting but overall rates are low depending upon your geography and a lot of things are driving this now this is 2016 data we put documentation programs into place that have enhanced our compliance with these the bottom line is these are not right now pay for performance it's just pay for reporting at a hospital level this is from our hospital system and it is interesting how you can generate on hospital compare these types of graphs which again here again we're looking at intervals for screening colonoscopy and you can actually see the performance of each hospital the impact of this type of data transparency is not really clear yet but one could see a time when if these programs become pay for performance that will certainly you know drive things in the right way so if we talk about two things adoption of must-do strategies in the development of core competencies with respect to strategies for the purpose of this talk two and three on the left efficiency through productivity and financial management and integrated information systems and as far as core competencies a utilization of electronic data for performance improvement are all crucial now the value equation which all of you by now know that value is quality over cost is not really the same for all stakeholders so for physicians and employees value is really quality and service over cost while for employers who are looking for value in terms of more in the cost realm it's also the employee satisfaction with their health care and health care providers and if you take a look here this really is just to demonstrate that if you look at this in terms of a pie graph that the physicians are really caught in the middle and we you know as doctors or certainly as organizations need to be responsive to what value represents for different parties so there's obviously a new level of transparency which is improving communication accountability safety and what we're doing right now still for the most part is focusing on process measures but ultimately outcomes are where we need to go definitions of quality are always important and no matter how many times I show this slide I really never remember all the definitions but what we're going to be predominantly talking about here is measurable quality but for our patients and again for employers and for other or health care organizations appreciative quality and perceptive quality are also important and at the end of the day as I opened up with if you are you delivering quality colonoscopy if your adenoma detection rate is 30% but you have a high cancellation rate the preps are bad the employee engagement is declining you have high nurse turnover and there are errors on your specimens there are so many other things that play into what quality and safety in in a unit is and again getting back to the concept of value like beauty which is in the eye of the beholder you know for patients patients worry about different things than we worry about but we have to think about them and we have to make sure that we're honoring and addressing those issues however we have a continued reliability problem and I I like to show this slide I show it every year when I give talks like this because honestly not a lot has changed this is a demonstration of the six sigma concept with of course airline safety representing really the template for what a safe organization needs to do health care reliability if you can see is actually worse than airline baggage handling and that's still true today and it's pretty daunting the fact that it's it's very hard to move that needle so and it's not just health care organizations the the performance of physicians individually continues to be highly variable and again while this is old data CMS is value-based payment modifier which essentially was in effect until recently prior to MIPS what we want to do is move physicians in the direction of the right upper quadrant there which is high-quality low-cost care yet we see that overall the bulk of physicians are not in that category so the standard definitions of benchmarking you see here and you can read them what I want to really focus on though are types of benchmarking performance benchmarking which you see at the bottom is really what we are responsible for and I'm gonna spend the most time on which is how public private and nonprofit organizations compare themselves with each other in terms of product and service and focuses on cost technical quality service features speed reliability and other performance comparisons now what really is the purpose of all of this well to create a better awareness of ourselves and also a better awareness of them them being the best and then with the techniques and best practices which we'll be sharing is figuring out how we can catch up to the best and how we can actually be or exceed the best now what that requires is a focus on metrics now if you're an individual center without a management company the task of choosing metrics and actually figure out how to present them study them and learn from them is and can be very very difficult so you have to do is really narrow them down so in each of these categories if possible you should try to do all them but you need to pick a couple so in the financial realm looking at the staff cost per case overall cost per case operationally you can look at your staff mix certainly your room turnaround time reasons for delays and cancellations patient satisfaction which we generally will formally study through H caps or compliance studies and then clinical measures which will spend a lot of time on also so it really is part of a competitive strategy at this point because traditional performance trends are not really sufficient in competitive markets like ours and also customers expectations now with social media it's always easy to find an ASC it's easy to find a doctor online we really need to do whatever we can to differentiate ourselves from others and at the core of this is performance management I would say that most academic centers and certainly even most quality ASCs use this model for improvement from the Institute for Health Improvement which focuses on choosing something you want to study and then doing serial PDSA or Plan-Do-Study-X cycles to achieve improvement in specific areas and while at the same time you may not realize that when you're doing this what you're really trying to do is create a balanced scorecard for your center or for your organization and the center of that scorecard is the mission, and what the metrics you're studying are, and the quality improvement programs you're putting into place, are to improve things from a financial perspective, an internal process perspective, the customer, meaning our patients, and also internally, our own staff, and you also from a learning and growth perspective. Now what we've done for the last eight or nine years across our centers and hospitals is essentially created a program where we have a grid that we have created with process measures that include, you can see in the center panel, rates of procedure consent being signed, discharge orders, handoffs, and recovery. At the top, we have some of the endoscopic metrics, which include withdrawal times and sequel intubation rates for our physicians, and then infection control, such as hand washing and PPE, which is done with a sampling methodology. And all of the nurse managers and sometimes the medical directors, we get together every quarter, and we actually look at these, study them in an identified way, and we share best practices so that it's done, again, non-punitive, non-competitive, just all about making things better. Now the problem is this. Many of you may have seen this study or one like it, but there is a tremendous amount of money spent on the reporting of quality measures, and it's not just the money spent for IT systems. It's the opportunity cost, and my later talk, which will be about burnout among healthcare staff associated with the human effort that's required to really put these metrics out there and get it done. And it is a very serious burden. So how do you achieve MD buy-in? Well, it's tough, and it's tough all the time. So what you can do, depending upon your geographic setting and where other factors, try to unify individual practices under an umbrella, obviously get people to agree to be measured. You want to ensure the integrity of your data and metrics. It took us a very long time before we felt comfortable, as I'll show you later, putting out report cards for physicians on an individual basis until we were sure that our IT systems were gonna generate accurate data. Because the worst thing that can happen is even one doctor who feels as if their data was inaccurate and it turns out to be, and that will poison the well in perpetuity. Also creating dashboards, financial, operational, and clinical, and trying to empower a quality champion. And I mean someone other than the medical director. It's, I think, very important to try to create dyads or triads. It certainly gets someone who is a participating member who has an interest who you can align with, who can percolate this type of a philosophy down to the rest of the other physicians. So what you want to do is, and this will happen in a de-identified way at the beginning, demonstrate the variability in the quality of care. You will likely see improvement just based on the Hawthorne effect. And what you will see among physicians is that there is healthy competition that does develop over time. People don't want to be the lowest man on the totem pole. There will be pushback. You want to maintain transparency and open-mindedness. And again, pushing this concept, especially in the ASC setting where people hold equity, and these are financially important organizations to the individual equity holders, make it clear that quality is a strategic business imperative. So as far as best practice examples, there are platforms available from all of these organizations. How many of you are participating in GI Quick here? How many are not? Okay, so probably maybe a quarter are not. So for those who are participating, you already know a lot of this, but GI Quick is a massive, successful national registry, the largest of its kind. Its goal is to raise the bar for efficiency, effectiveness, and reliability. And the good news is it's been a qualified clinical data registry for CMS, and actually now can actually help doctors comply completely with MIPS participation. And essentially, it's a combination of a data warehouse as well as a clinical benchmarking program. This data may have changed already, but the last I had was 4,500 physicians, over seven million colonoscopies logged, with an average of greater than 30,000 per week, and over a million upper endoscopies. And there's been dramatic uptake of use of this program. Just some examples of what we've done across our healthcare system. Here you see, for adenoma detection rate, the horizontal black bar being the 25% benchmark. And this is performance over almost a year period across all of our centers. And I have to tell you, this is very impactful. When we showed this at one of our annual meetings, we did put into place some educational and remediation programs across all centers, and saw actually dramatic improvement in almost across the board. There are also multiple filters that allow you to sort of look at data in many different ways. One of the most important things is not putting data out on individual physicians if your denominator is below a certain point. So we won't generate a statistic on any physician if their number of cases is below 30 for a specific metric. Again, just a way of displaying data in the form of bar graphs by doctor. So as a best practice example, I'll show you this. And again, this gets to the point of how do you engage physicians in this process. So pick your battles carefully and remain optimistic. So start small. So what we did, this is going back three or four years, we wanted to improve the rate of 10-year interval recommendations after normal screening exams. So what we did was put out a memo describing the initiative, gave the background literature on it, sent out some nice infographics, sort of depicting what the revenue adjustment could be if we didn't participate at that time in the ASC quality reporting system. And then I gave a formal presentation at our quarterly meeting with an emphasis on aligning the society endorsed measure with MIPS and the ASCQR. And what we saw here was, in fact, a dramatic improvement. I mean, we were at a miserable, this is going back to 2013, a miserable 12% compliance with that measure and had a dramatic improvement. And I recently looked at this data again and we're now up to about 70, 75%. The other very important thing that I wanted to talk about today is the use of physician quality achievement reports, which you can think of just as report cards. And we've been issuing these across our system for about five years now. We developed this as an Excel tool, which is really individual workbooks which are per center and then individual physician data can be inserted. So what the doctors see at their quarterly meetings is this. And what you see here on the left here is the patient, is the average. We have the national benchmark in the second column and then we have the average of a given center. We do now put out our data in identified way by each doctor. And the data, of course, includes ADRs, but also what we've included is compliance with ASC9 and 10 and patient satisfaction, which is achieved by extracting the physician relevant questions from our CAHPS compliance survey. And this is just an example of the actual individual report card that each physician gets at the end of the quarter. And I would tell you that we have seen improvements almost across the board in everything from ADR to sequel intubation rates and even patient satisfaction. What are the pitfalls? Well, if there's a lack of leadership attention, meaning you can initiate a program like this, get it into place, but if you think it's gonna be sustainable, you will be wrong. You have to pay constant attention to these types of initiatives. They're high touch activities. The rollout, you wanna make sure is not that rocky. It always is gonna be a little bit rocky. And like I said, insufficient follow-up. So if you look at the framework of sorts of initiatives with regard to benchmarking, what you really generally wanna do, and this is, I think, a nice way of looking at it with the disruptiveness to the practice on the vertical axis and the impact on the goal on the horizontal axis. Generally, you wanna start with priority two, which is small, easy wins. So what I just showed you with improving compliance with a 10-year screening interval. The last thing I wanna speak to, because our time is running out, is using a benchmarking survey for operations. So the ASGE has an excellent real-time platform that looks at over 100 metrics. You can look at clinical labor, patient and procedure volumes, revenue and expenses. It's got a very intuitive interface. And these are sort of the things that you can look at. You can look at your center's performance on things, for instance, like scope repair, as a percentile in terms of all the other participants. It gives you the opportunity to see where you stand in relation to other centers, both regionally and nationally. And also gives you a chance to look at your key performance indicators across different units. So just as an example here, you can see that you have a device cost per encounter, unit A, which certainly far exceeds the other units. That would allow unit A to really look at, hey, drill down, what are we doing differently than everybody else? And just as another final example, this is, for instance, a center that leased scopes at a very high cost of repairs, essentially used a benchmarking survey to then drill down and look at, hey, are there individual scopes causing the problem? Are, you know, do we have a, is there like a, I'm a lemon in the bunch. But at the end of the day, this particular program allows you really to assess in a very detailed way what is driving costs that exceed other centers doing the same thing. So in summary, systems that measure quality and benchmark are robust and allow you to show off your quality. You should embrace these concepts of quality which equate to value, not volume. And again, hammer away that benchmarking is really a strategic business imperative if you're to succeed in this world of evolving alternative payment models. Thank you.

benchmarking

healthcare industry

changing environment

strategic imperative

ambulatory surgery centers

cost efficiency