Highmark Blue Cross Blue Shield-Changing Incentives to Promote Better Care

QualityBLUE Hospital Quality Performance Program

Preventing Hospital Infections, Improving Surgical Care & Advancing Stroke and Cardiac Event Care  

The QualityBLUE Hospital Pay for Performance Program aims to improve patient care and safety across Highmark's hospital networks through participation in a number of innovative initiatives, including:

• MRSA and Central Line-Associated Blood Stream Infection Prevention;
• Surgical Care Improvement Project:  Surgical Site Infection Reduction and Venous Thromboembolism Prevention;
• Get With The Guidelines Stroke and Cardiac Care.
• Reduction of Clostridium difficile and Catheter Associated Urinary Tract Infections;
• Implementation of medical technology to improve clinical quality or patient safety

The program aligns with industry standards and guidelines, as well as evidence-based medicine to improve member outcomes and drive to the provision of defect-free care provided by participating hospitals.

Healthcare Associated Infections

Seeking to prevent, reduce and eliminate the incidence of hospital-acquired and central line-associated bloodstream infections, Highmark Blue Cross Blue Shield QualityBLUE Hospital Pay for Performance Program incorporates indicators to reduce the incidence of healthcare associated infections.  The QualityBLUE program began in 2001 and today includes participation from 30 facilities in Pennsylvania.

Central Line-Association Bloodstream (CLAB) Infection Prevention:  80 Percent Fewer Infections than National Average

Central lines are used to deliver medication and nutrition to critically ill patients, whose condition makes them particularly prone to bloodstream infections resulting from bacteria introduced through the lines.

The QualityBLUE program is delivering results:

• The nationwide average for central line associated bloodstream infections in an intensive care setting is 5 incidents per 1,000 line days.  Through adherence to clinical performance measures, the participating Highmark hospitals were able to reduce the rate to an average of 1 infection per 1,000 line days.  A 2007 study found that in 2005, the average charge for a patient with a hospital-acquired infection was $185,260 while the average expense for a patient without a hospital-acquired infection was $31,389.  The decreased rate of infection in QualityBLUE hospitals saved a projected $33 million in treatment expenses in 2007 compared to charges expected at the national average. More importantly, when compared to the national average, the QualityBLUE hospitals saved over 300 lives.
• After the first year of program participation, new QualityBLUE hospital participants were able to reduce the rate of central line-associated bloodstream infections to less than 1 per 1,000 line days, and with continued efforts to improve the provision of care, the participating hospitals strive to reach the goal of zero central line-associated bloodstream infections.

Methicillin-Resistant Staphylococcus aureus (MRSA) Infection Prevention

The Centers for Disease Control and Prevention estimate that nearly 90,000 deaths occur annually as a result of hospital-acquired infections; while hundreds of thousands more patients endure extended inpatient stays.  Commonly associated with hospital-acquired infections, the Methicillin Resistant Staphylococcus aureus (MRSA) bacteria occurs frequently among patients undergoing invasive medical procedures or who have weakened immune systems, causing serious and potentially life-threatening infections.

In order to prevent and reduce the number of hospital-acquired infections, QualityBLUE hospital participants implemented active surveillance testing with the goal to:

• Screen hospital admissions to determine if a patient is a carrier of MRSA;
• When identified, implement barrier precautions to reduce the likelihood of spreading the infection;
• Use dedicated equipment for carriers of MRSA;
• Adhere to strict hand hygiene practices;
• Wear protective clothing at all times around the patient.

Each step is designed to minimize the likelihood of transmission of the MRSA to other patients.  Hospital performance is judged by comparing the number of patients with MRSA at admission against the total number of patients who acquired MRSA while hospitalized as a result of breaks in infection control procedures.

Surgical Care Improvement Project

The Surgical Care Improvement Project (SCIP) is a quality partnership of organizations nationwide committed to reducing postoperative complications and improving the safety of surgical care.  Two programs are operated through the initiative; the first is designed to reduce surgical site infections, while the second aims to minimize the incidence of deep vein thrombosis and pulmonary embolism.

Surgical Site Infection Program

The program seeks to reduce the likelihood of surgical site infections through adherence to five performance measures:

• The administration of preoperative antibiotics an hour before incision;
• The administration of proper antibiotics;
• The discontinuation of prophylactic antibiotics within 24 hours following surgery;
• The maintenance of postoperative normothermia (normal body temperature);
• Appropriate methods for surgical site hair removal

Hospitals report compliance with these performance measures in addition to the number of adverse events of a surgical site infection that develop in their patient population.  

Results

Compliance with the administration of antibiotics prior to the surgical incision is critical to reduce the potential for the development of surgical site infections.  The sixteen participating QualityBLUE hospitals who chose this indicator each scored well-above the state and national average by the end of the first year.  Collectively, the QualityBLUE participants averaged nearly 93 percent compliance with the preoperative antibiotic administration, compared to a state and national average of 78 percent compliance.

The postoperative discontinuation of antibiotics within 24 hours is vital to prevent the emergence of antibiotic-resistant bacteria in the hospital environment.  The emphasis on staff education, development of new policies and procedures and the use of peer reporting with this clinical measure helped to improve compliance rates across all 16 participating QualityBLUE hospitals.  Each of the QualityBLUE hospitals concluded the program year with compliance rates greater than the state and national averages, ranging from 75 percent to 100 percent adherence across the participant spectrum.

• Surgical Care Improvement prevention of deep vein thrombosis and pulmonary emboli

The program seeks to reduce the likelihood of a patient developing a deep vein thombosis or pulmonary emboli through adherence to two performance measures:

• Reporting the percentage of patients whose doctor orders prevention for deep vein thrombosis and pulmonary emboli
• Reporting the percentage of patients who actually receive this prevention within 24 hours prior to surgery to 24 hours following surgery.

Hospitals report on these 2 performance measures and also report to the QualityBLUE program the number of patients who develop a pulmonary embolism or a deep vein thrombosis.

Get with the Guidelines – Stroke and Cardiovascular Event Prevention

The Get with the Guidelines (GWTG) program is a hospital-based initiative launched by the American Heart Association designed to focus on "defect-free care" and risk modification counseling, ensuring patients receive appropriate medications on admission, during hospitalization and at discharge in order to prevent stroke and cardiovascular events.  Through the program, Highmark QualityBLUE partner hospitals seek to educate physicians, clinical staff, families and the community at-large on prevention and the importance of adhering to evidence-based medical practices to treat stroke and coronary artery disease.  Hospitals choosing to participate in either program have the opportunity to compare performance on clinical benchmarks with state and national-level averages, as well as with the performance of other QualityBLUE program care centers.

Get with the Guidelines Stroke Program:  An 11 Percent Increase in Compliance for Defect free care

Through the Get with the Guidelines stroke initiative, the American Heart Association helps to close the gap between recommended and actual treatment of patients.  The program tracks the number of stroke patients who have received all clinical interventions appropriate for their condition as part of the effort to provide defect-free care and thereby reduce the severity of damage done.

Participating hospitals used seven clinical stroke performance measures:

• Administration of Lytic within 3 hours of symptom onset;
• Deep-vein thrombosis (DVT) prophylaxis administered by second hospital day;
• Antithrombotics ordered within 48 hours of admission;
• Administration of lipid lowering therapy upon discharge (LDL-DC);
• Administration of antithrombotic medication upon discharge;
• Administration of anticoagulation in patients with atrial fibrillation upon discharge;
• Provision of smoking cessation information upon discharge.

With some of the clinical measures reliant on the intervention in the early stages of stroke onset, the need to educate the consumer on the signs and symptoms of stroke and the critical need to proceed to a local emergency department is of critical importance.

Results

Following the first year of involvement in the program, participating QualityBLUE hospitals saw their rates of compliance in the administration of all clinical measures for defect free care increase from 70 percent to 81 percent.  Additionally, the QualityBLUE hospital participants improved quarterly on three specific clinical stroke performance measures – risk of developing a blood clot, lowering fat content in the blood and offering smoking cessation advice to smokers – resulting in compliance rates near or above 90 percent by the end of the year.

Get with the Guidelines Coronary Artery Disease Program:  Outperforming the Competition with Follow-Up Cardiac Care, Daily Aspirin Regimen, & Smoking Cessation Programs

The American Heart Association reports that 13 million Americans suffer from coronary artery disease, costing an estimated $130 billion each year.  The GWTG coronary artery disease program seeks to address the gap between recommended and actual treatment received by patients admitted to hospitals with coronary artery disease and heart failure with performance measures advocating the use of clinically-proven care measures.

Following the first year of program participation, QualityBLUE hospitals outperformed all other Pennsylvania hospitals through the measurement period:

• QualityBLUE hospitals provided defect-free, comprehensive care to 93 percent of all coronary artery disease and heart failure patients.
• At QualityBLUE hospitals, 99 percent of all patient discharges were prescribed a daily aspirin routine, a critical component of preventing future cardiac events.  In comparison, the Pennsylvania state average is just 88 percent among participating hospitals.

QualityBLUE hospitals reported a dramatic jump in smoking cessation advice upon patient discharge.  Another reflection of best-practice adherence in the program, QualityBLUE hospitals improved 21 percent to a 98 percent compliance rate by year's end.

For more information, contact:

Denise R. Hughes
Media and Communication Consultant
Highmark, Incorporated
Denise.Hughes@highmark.com