Patient Safety

 

Mercy Health Plans is consistently building on its variety of resources that allow the member to be the center of health care decisions.  These efforts are aimed at improving:

1.     the quality of the health care experience,

2.     compliance with best practices (from both a member and clinician point-of-view),

3.     outcomes of health care treatment plans, and

4.     the safety of the member who accesses the health care system.

 

Mercy Health Plans embraces a culture of patient safety through its education and outreach efforts, reporting/intervention strategies, web-based tools, and telephonic support system.  Our goal is to provide the individual needing health care with the information needed to effectively participate in both the decision-making and treatment processes.  In addition, we strive to assure that information on best practices and associated outcomes are placed in the hands of the providers who facilitate effective treatment plans for our members. 

 

Our tools are meant to open up the health care process, reduce the incidence of errors, and ensure safe practices and environments are available for all members.

 

We have been bringing the patient safety message directly to our members via the Internet (articles, tools, and interactive activities), member newsletters, and supporting provider resources. 

 

Mercy Health Plans is led by a charismatic team of individuals who stress the member as the focus of our business.  Our Corporate Compliance Officer and Chief Medical Officer provide a multi-disciplined leadership in the area of patient safety (together they function as Mercy Health Plans’ patient safety officer).  These individuals lead several governing bodies within Mercy Health Plans that drive continuous quality improvement and patient safety initiatives.  These committees are the Quality Improvement Committees (Missouri and Laredo Region) and Corporate Compliance Committee.  All Mercy Health Plans’ teams are responsible for furthering the recommendations and work plans of these committees. 

 

All quality improvement programs and interventions are member focused, dependent on the application of best practice as a means of improving outcomes, and mindful of the safety implications for members. 

 

Clinical Practice Guidelines

 

Clinical improvement programs are centered on the application of best practice clinical guidelines.  Mercy Health Plans has adopted (and/or adapted) several nationally recognized clinical guidelines, including but not limited to:

·       American Diabetes Association (ADA) guideline for the management of Type II Diabetes

·       National Heart, Lung, and Institute’s  (NHLBI) Asthma Guideline

·       NHLBI’s Cholesterol Management Guideline

·       American College of Cardiology (ACC)/American Hospital Association (AHA) Congestive Heart Failure Guideline

·       American Lung Association’s Smoking Cessation Guideline

·       National Institute of Health (NIH) and ACC Coronary Artery Disease (CAD) Guidelines

·       Preventive Health Guidelines (compilation of best practice recommendations from the United States Preventive Services Task Force, various specialty organizations, the American Cancer Society, and other nationally recognized clinical organizations)

·       American College of Immunization Practices (ACIP) recommendations for coverage of immunization (adult and child)

 

Reporting, analysis, interventions (both member and provider), and re-measurement are based on these guidelines.  All guidelines are:

·       followed during the creation of care and disease management programs;

·       distributed to participating physicians (using newsletters, provider resource manual, and the Mercy Health Plans’ website); and

·       highlighted in the development/adoption of member educational information (distributed through the Mercy Health Plans’ website, member newsletters, and other individually focused mailings). 

 

Samples of provider newsletters, disease care management policies, and website resources that highlight the use and distribution of clinical practice guidelines are included with this letter. 

 

Successes (based on HEDIS 2002) in improving compliance with best practice clinical guidelines include, but are not limited to:

 

Measure	Region	2001 Results	2002 Results	2003 Results	Benchmark
Breast Cancer Screening	Eastern and Central MO	70%	72%	71%	70%
	Southwest MO	75%	76%	76%	70%
	Laredo TX	67%	71%	66%	70%
A1C Tested	Eastern and Central MO	73%	78%	76%	75%
	Southwest MO	75%	74%	77%	75%
	Laredo TX	59%	70%	75%	75%

Note:  HEDIS 2003 will be available for publication in late third quarter 2003.

 

Care and Disease Care Management Programs

 

Mercy Health Plans offers several Care and Disease Specific Care Management Programs.  A nurse care manager will contact an eligible member via telephone to discuss the availability of the program and then to assess the individual’s interest in participation, willingness to change, and goals they hope to achieve.  Initial evaluation includes a health risk assessment (can be done in writing on via the phone); identification of barriers, evaluation of goals, and development of action plans. 

 

In the Southwest Region members living with a chronic illness may be supported through disease management clinics as well as care managers.  Available clinics include The Asthma Resource Center and the Hammond Heart Institute.

 

Follow-up will be provided via the telephone; use of written correspondence and associated best-practice consistent written materials (See Attachment II for samples of disease management patient-education materials); and provision of a 24-hour nurse assist line (Mercy-on-Call or the Professionals), as well as web-based interactive tools (See the Diabetes Education Center and Asthma Wizard on the Mercy Health Plans’ website). 

 

Well-researched supplemental health information is available on the Mercy Health Plans’ Building Better Health website at http://mercy.buildingbetterhealth.com.  This website includes written and audiovisual support tools for members and their families. 

 

Depending on the nurse’s assessment of acuity, members would be offered the opportunity to receive an outreach call (or other action) every one to four weeks.  Members who are effectively accomplishing their self-established goals may be contacted less frequently.  Members who accomplish one health-related goal may move onto additional goals that they wish to work on with the care managers. Some who meet their goals will be discharged from the disease care management program; however, they are assured that they may contact the nurse at any time. 

 

Current disease care management programs, and corresponding goals, include, but are not limited to:

 

Fragile (high-risk members):  Through Mercy Health Plans’ partnership with StatusOne, a Boston-based care management company, we are able to proactively identify and assist individuals with multiple chronic conditions who are at-risk for a high-intensity acute event (i.e., hospitalization, multiple ER visits, etc.) as a result of their current care paths. 

 

Once identified (this process is completed monthly), all members are offered the options of working with a care manager in establishing goals, developing action plans, and improving their access to the right services within the health care system.  Our care management program focuses on six aims of care - 1) coordinate medical care; 2) increase self-reliance; 3) enhance daily activity and fitness; 4) strengthen interdependence with family and friends; 5) stimulate mentally activity; and 6) encourage community involvement and purpose. 

 

Through focused, patient-centered goal development and action we are able to help:

·       Decrease acuity level of individuals living with two or more chronic conditions.

·       Improve functional status of these most at-risk members

·       Decrease the individual’s reliance on acute care hospitalizations.

 

Diabetes (Targeted Care Management Outreach):  Our targeted disease management program identifies individuals living with diabetes who considered high- or moderate-risk, but who do not qualify for StatusOne intervention.  Quarterly reports, hospitalization triggers, and physician or member referral identify individuals who may benefit from this care management program.  Nurses assist individuals in focus on best practices, comply with physician-recommended treatment plans, and meet the goals they have established for themselves.  The care manager uses a variety of tools to meet the needs of the individual including telephonic and written outreach, web tools (see Diabetic Education Center), and community resources. 

 

Goals of this program include:

·       Increase the percent of members living with diabetes who receive at least two A1C tests per year.

·       Increase the percent of members living with diabetes, AND who qualify for case management, who have an A1C equal to or less than seven.

·       Decrease hospitalization of individuals living with diabetes.

 

We are currently evaluating NCQA-accredited Disease Management companies to work with in expanding this program.

 

Quality Improvement Monitors and Studies

 

Mercy Health Plans has initiated several studies that it believes will assist in us improving the safety of individuals traversing the health care system.  These include, but are not limited to:

 

·       Cholesterol Management: 

·       Radiology Use Assessments

·       Emergency Room Assessments

·       Drug Profiles

 

Physician and Hospital Quality Recognition Program

 

Mercy Health Plans’ web-based provider directory provides members with information on physicians and hospitals recognized for their commitment to quality and safety.  This directoy can be accessed at http://www.mercyhealthplans.com/doctor/default.asp.  We recognize providers dedicated to quality with the following icons:

 

The Leapfrog Groupfor Patient Safety symbol is an indicator on our website that a hospital has complied with the reporting requirements of the Leapfrog Group for Patient Safety.  We are proud to be affiliated with St. John’s Mercy Medical Center in St. Louis, the first St. Louis-based provider to report their outcomes.

 

Malcolm Baldrige Award is an indicator on our web site that the hospital or physician is affiliated with SSM Health Care, the first health care provider, ever, to win the Malcolm Baldridge Award for quality.  This provider has been able to meet the rigorous standards of the Malcolm Baldridge organization, including patient safety.

Blue Ribbon Award is an indicator assigned by Mercy Health Plans to physician groups that agree to participate and report quality improvement results via the Internet. Mercy Medical Group is the first physician group to participate.  Results (from both a clinical and service perspective) are available at www.mercyhealthplans.com/scorecard/page2.htm.  Examples of results include:

A sample search outcome page is included with this report. 

 

Member, Provider, and Other Profiling Activity

 

In the Eastern/Central Missouri and Laredo Texas regions, Mercy Health Plans monitors outcomes at member, product, provider network, and provider group levels.  This monitoring includes HEDIS-related evaluations, use-of-services evaluations, and exception reporting for best-practice access to services.  This information is distributed to physicians via newsletters and the Mercy Health Plans’ website. 

 

Physicians receive exception reports on members who have not obtained age/gender-appropriate immunizations and other preventive services.  Mercy Health Plans notifies participating physicians, in writing when a member living with diabetes and assigned to a particular physician, has not received recommended testing or services. 

 

In addition, we have begun profiling on use of services, such as emergency room (for low intensity diagnoses and services), as well as radiology (See Radiology Safety discussion later in this report).  These results are shared with provider networks and groups.  We anticipate publishing information via the Mercy Health Plans’ website in the future.  

 

Various other reports including co-morbidity reports, disease-specific stratification reports, and acute care service reports are generated on a periodic basis to assist in identifying individuals who may benefit from participation in a Mercy Health Plans’ Disease and/or Care Management program. 

 

See the discussion on physician quality recognition and required public recognition earlier in this report for more information on physician profiling.  

 

In the Southwest Missouri region, Mercy Health Plans’ provider partner, St. John’s Health System, produces physician-specific, disease-specific profiles.  These reports are distributed on a quarterly basis.  St. John’s Health System nurses and physicians contact participating physicians to assist in report analysis and identification of performance improvement opportunities. 

 

For all regions, Mercy Health Plans provides members with information available from other sources, to assist them in the decision-making process.  This includes but is not limited to:

·       2002 Missouri Consumer’s Guide to Hospital Surgery Volume

·       The Leapfrog Group website

·       Health Care Procedure Pricing (Eastern / Central Missouri Region only at this time)

 

Other Patient Safety Initiatives

 

Radiology Safety (Effective September 1, 2003)

 

On September 1, 2003, Mercy Health Plans will introduce HealthHelp’s RadConsult^© programto assist physicians in making the best decisions regarding medical imaging.  Physicians will be encouraged to seek specialty consultation prior to ordering computerized tomography (CT) and magnetic resonance (MR) procedures.  This process is not intended to obstruct or delay patient care, but rather to enhance both the care of patients and the educational process for referring physicians. 

 

The radiology consultants will provide referring physicians with “evidence-based” resources regarding the most appropriate use of CT and MR procedures.  By making the most appropriate imaging decision, physicians can improve and expedite the well being of their patients while limiting radiation risks.

 

Ionizing radiation has proven to be one of the most important diagnostic discoveries in the history of medicine. Without ionizing radiation, x-ray examinations, fluoroscopy, angiograms, and CT would not be possible. With these examination tools, a physician is able to successfully diagnose and treat patients. Unquestionably, ionizing radiation saves lives.

 

Despite the many benefits ionizing radiation provides, radiation also takes lives.  Ionizing radiation’s effect on molecules causes serious biological changes, such as cancer and genetic mutation. The more radiation a patient receives, the more likely these negative consequences will occur.  As indicated in the graph on this page, the radiation exposure for one CT exam can be as high as 10 mSv (100mSv or more for specialized CTs).  In contrast, a single, frontal-view chest x-ray provides a radiation exposure of only 0.02 mSv.  Nevertheless, CT exams are gaining popularity; physicians ordered 58 million CT exams in 2000, which represents a dramatic increase from 2.8 million CT exams in 1981.  Physicians are urged to limit ionizing-radiation exams; especially CT scans, which produce a massive dose of radiation.

 

The effect of CT on children and females is of particular concern. Children face a greater risk of cancer from exposure to ionizing radiation than adults.  However, between 1996 and 1999, a major children’s hospital increased pediatric body CT scans by 92 percent.  Recent publications, including those from the National Cancer Institutes and the Pediatric Radiology Society, highlight the risk CT scans pose to children, which may be in the range of one cancer death per 1,200 CT scans performed. Women also face an increased risk because breasts and ovaries are especially sensitive to radiation, causing cancer and genetic mutation.

 

The chart below shows the radiation (in mSV) for certain procedures.

 

 

 

 

 

 

 

 

 

 

 

 

The full effect of ionizing radiation, particularly at lower doses, continues to be somewhat controversial.  However, the principle of ALARA (As Low As Reasonably Achievable) remains the most widely accepted method for managing human exposure to ionizing radiation.   Put simply, human exposure to ionizing radiation should always be kept as low as reasonably achievable. Physicians must consider the consequences of ionizing radiation when ordering radiology exams. While imaging is an important diagnostic tool, using it without moderation proves more harmful than beneficial. Reducing the unnecessary use of all forms of ionizing radiation, especially CT in children, will result in fewer cancer deaths. 

 

Currently, there are no known biological effects from non-ionizing methods of imaging such as MR imaging.  However, indirect effects such as contrast reactions, metal object or implant related accidents, and adverse reactions to sedation can all occur in patients undergoing MR procedures. Therefore, patient exposure to all exams should be limited when possible.   

 

When in doubt, or when ordering procedures that carry a significant risk, physicians may benefit from the knowledge of experts in the field of medical imaging. 

 

Information on radiology safety will become a routine part of member newsletters and Mercy Health Plan’s website. 

 

Surgery, Patient Education, and Informed Decision-Making (In implementation)

 

Informed decision-making is one of the six principles of the Institute of Medicine’s (IOM) plan for health care quality improvement.  Mercy Health Plans’ clinical professionals believe that a proactive rather than reactive decision-making process allows individuals the best opportunity for successful outcomes by:

§        Improving the individual’s understanding of the benefits and risks of various procedures, as well as how these outcomes may affect their lives;

§        Enabling the physician to more fully understand the expectations and values of individuals considering surgery;

§        Assisting the physician in understanding how an individual’s attitude relates to treatment options and outcomes; and

§        Establishing realistic expectations about the role of surgery. 

 

Effective informed decision-making (informed consent) may sound easy, but it can be complex and problematic.  Therefore, Mercy Health Plans has partnered with Graphic Surgery, a physician-led technology company, to provide participating surgeon offices with access to a fully researched and Internet-accessible education program (Doc-Tour System^TM). 

 

The Doc-Tour System™ is a high-quality, dynamic, and interactive system that uses 3D animations to discuss surgical interventions.  This virtual tour is meant to supplement, not replace, a surgeon’s discussion with information that addresses the unique visual needs of surgical education as well as the ability to automatically document the education process.  Learn more about the Doc-Tour System™ at www.graphicsurgery.com.

 

Mercy Health Plans will provide members with access to the Doc-Tour System™ in two ways:

§        Direct Internet link through the Mercy Health Plans’ website.

§        Physician-directed access in the office setting. 

 

The Doc-Tour System^TM supports Mercy Health Plans’ commitment to patient safety.  Surgeons who wish to participate in providing physician-directed access will qualify for a quality bonus.  Eligibility criteria for participation in this program include:

§        Willingness of the surgeon to participate in the Graphic Surgery outcome reporting process.

§        Willingness of the surgeon to participate in the Mercy Health Plans’ consumer survey process.

§        Availability of office-based access to a secure confidential computer area.

§        Provision of in-office access to high-speed Internet technology.

 

More information on this program, including an informed-consent bibliography and a Frequently Asked Questions document, can be obtained by clicking on “Provider Info” at www.mercyhealthplans.com.   

 

Pharmacy Management

 

Mercy Health Plans utilizes the AdvancePCS QUANTUM Alert Drug Utilization Review system to prevent potential patient safety issues at the point-of-service.  This messaging system alerts the pharmacist to potential safety issues prior to prescription claim adjudication, allowing the pharmacist to intervene based on his/her clinical discretion.  The DUR alerts include:  drug-age, drug-drug interaction, drug-pregnancy interaction, drug-disease interaction, late refill, therapeutic duplication, drug-allergy interaction, low daily dose, high daily dose, and excessive utilization.

 

Mercy Health Plans also participates in the AdvancePCS Patient Profiling program, a quarterly retrospective Drug Utilization (DUR) program used to identify opportunities and elicit improvements in patient care based on a comprehensive analysis of a patient’s medication history.  The key features of the program are:

• Patient profiling is done using historical claims
• Patients are ranked based on quantitative and clinical risk
• High risk patient profiles are reviewed by clinical pharmacists to determine the need for interventions
• Letters are sent to the physician to address specific patient care issues.  The letters include patient-specific prescription drug profiles.

 

The goal of the program is to improve the quality of patient care by providing a structured, ongoing program that evaluates patients’ drug use patterns and communicates patient-specific utilization patterns and clinical issues to physicians.