Improving Quality of Care for Medicare Beneficiaries. Review Types. Linking Case Review to Quality Improvement

Transcription

1 AnnualRepor t QI O CaseRevi ew I nf or mat i on Augus t1,2012-j ul y31,2013 FMQAI TheMedi car eqi Of orfl or i da

2 Improving Quality of Care for Medicare Beneficiaries FMQAI is Florida s federally designated Medicare Quality Improvement Organization (QIO), under contract with the Centers for Medicare & Medicaid Services. The QIO program is an integral part of the U.S. Department of Health and Human Services National Quality Strategy and is focused on the three aims of better patient care, better individual and population health, and lower healthcare costs through improvement. FMQAI protects beneficiaries by reviewing quality complaints and applying what we learn to help providers implement quality improvement processes, focused on the way providers deliver health care. To support our patient-centered approach, FMQAI is authorized by the Medicare Program to review medical care provided to beneficiaries to determine whether it meets medically acceptable standards of care, is medically necessary, and is delivered in the most appropriate setting. Review Types Under our current improvement efforts with Medicare, FMQAI carries out a number of activities related to Medicare case review. FMQAI conducts statutorily mandated review activities, including the following: Reviewing the quality of care provided to beneficiaries (quality of care reviews) Reviewing requests for service termination and/or discharge (notices of non-coverage) Reviewing CMS-selected cases for appropriate admission status and higher-weighted diagnosis related group assignment (coding validations, utilization). Reviewing potential Emergency Medical Treatment and Active Labor Act (EMTALA) violations (antidumping cases) Linking Case Review to Quality Improvement FMQAI links case review activities to improvements in the delivery of care by developing quality improvement activities focused on system-wide changes. FMQAI uses data from case review activities to identify problems related to the quality of care and to design quality improvement activities to help providers correct these problems. FMQAI works with patients, providers, and practitioners across organizational, cultural, and geographic boundaries to spread rapid, large-scale change, directed at improving the quality of health care that Medicare beneficiaries receive.

3 I. Total # of Reviews The total number of reviews the Quality Improvement Organization (QIO) performed in CRIS by the associated review type. Review Type # of Reviews Percent of Reviews (%) Coding Validation (120 - HWDRG) 2, % Coding Validation (All Other Selection Reasons) % Quality of Care Review (101 through Beneficiary Complaint) 1, % Quality of Care Review (All Other Selection Reasons) % Immediate Advocacy % Utilization (158 - FI/MAC Referral for Readmission Review) % Utilization (All Other Selection Reasons) 3, % Notice of Non-coverage (105 through Admission and Preadmission) % Notice of Non-coverage (118 - BIPA) 2, % Notice of Non-coverage (117 - Grijalva) 1, % Notice of Non-coverage (121 through 124 -Weichardt) 2, % Notice of Non-coverage (111 - Request for QIO Concurrence) % EMTALA 5-Day % EMTALA 60-Day % Total 14,304 II. Top 10 Principal Medical Diagnoses The top 10 principal medical diagnoses for inpatient claims billed for Medicare beneficiaries. Percent of Top 10 Medical Diagnoses # of Beneficiaries Beneficiaries (%) 1. V5789 Rehabilitation Procedure NEC* 25, % Pneumonia, Organism NOS 24, % Septicemia NOS 24, % Urinary Tract Infection NOS** 20, % Acute Kidney Failure NOS 18, % Atrial Fibrillation 18, % Obstructive Chronic Bronchitis with (Acute) Exacerbation 17, % Coronary Atherosclerosis, Native Vessel 16, % Localized Osteoarthritis NOS-Lower Leg 13, % Subendocardial Infarction, Initial 13, % Total 192, % *NEC- Not Elsewhere Classified; **NOS Not Otherwise Specified Page 1 of 11

4 III. Provider Reviews Geographics The count and percent by rural vs. urban geographical locations for Health Service Providers (HSPs) associated with a completed QIO review. Geographical Area # of Providers Percent of Providers (%) Rural % Urban % Unknown % Total % IV. Provider Reviews Settings The count and percent by setting for Health Service Providers (HSPs) associated with a completed QIO review. Setting # of Providers Percent of Providers (%) 0 - Acute Care Unit of an Inpatient Facility % 1 - Distinct Psychiatric Facility % 2 - Distinct Rehabilitation Facility % 3 - Distinct Skilled Nursing Facility % 5 - Clinic % 6 - Distinct Dialysis Center Facility % 7 - Dialysis Center Unit of Inpatient Facility % 8 - Independent-Based RHC % 9 - Provider-Based RHC % C - Free-Standing Ambulatory Surgery Center % G - End Stage Renal Disease Unit % H - Home Health Agency % N - Critical Access Hospital % O - Setting does not fit into any other existing setting code % Q - Long-Term Care Facility % R - Hospice % S - Psychiatric Unit of an Inpatient Facility % T - Rehabilitation Unit of an Inpatient Facility % U - Swing Bed Hospital Designation for Short-Term, Long-Term Care, and Rehabilitation Hospitals % Y - Federally Qualified Health Centers % Z - Swing Bed Designation for Critical Access Hospitals % Other % Total % Page 2 of 11

5 A. Quality of Care Concerns Confirmed The number of concerns by Quality of Care PRAF Category Code and the number that were confirmed at highest level of review for completed quality of care reviews. # of Concerns # of Concerns Confirmed Percent Confirmed Concerns (%) Quality of Care ( C Category) PRAF Category Codes C01 - Apparently did not obtain pertinent history and/or findings from examination % C02 - Apparently did not make appropriate diagnoses and/or assessments % C03 - Apparently did not establish and/or develop an appropriate treatment plan for a defined problem or diagnosis, which prompted this episode of care [excludes laboratory and/or imaging (see C06 or C09) and procedures (see C07 or C08) and consultations (see C13 and C14)] % C04 - Apparently did not carry out an established plan in a competent and/or timely fashion % C05 - Apparently did not appropriately assess and/or act on changes in clinical/other status results % C06 - Apparently did not appropriately assess and/or act on laboratory tests or imaging study results % C07 - Apparently did not establish adequate clinical justification for a procedure, which carries patient risk and was performed % C08 - Apparently did not perform a procedure that was indicated (other than lab and imaging, see C09) % C09 - Apparently did not obtain appropriate laboratory tests and/or imaging studies % C10 - Apparently did not develop and initiate appropriate discharge, follow-up, and/or rehabilitation plans % C11 - Apparently did not demonstrate that the patient was ready for discharge % C12 - Apparently did not provide appropriate personnel and/or resources % C13 - Apparently did not order appropriate specialty consultation % C14 - Apparently specialty consultation process was not completed in a timely manner % C15 - Apparently did not effectively coordinate across disciplines % C16 - Apparently did not ensure a safe environment (medication errors, falls, pressure ulcers, transfusion reactions, nosocomial infection) % C17 - Apparently did not order/follow evidence-based practices % C18 - Apparently did not provide medical record documentation that impacts patient care % C99 - Other quality concern not elsewhere classified % Total 1, % Page 3 of 11

6 B. Serious Reportable Events on Quality of Care Reviews The number of Quality Improvement Activities (QIAs) initiated (initial activity date within the reporting period) for all quality of care reviews with confirmed concerns; the number and percent of those QIAs that are associated with quality of care concerns that fell into the category of Serious Reportable Events. # of QIAs Initiated # of QIAs Initiated for Serious Reportable Events Percent of QIAs Initiated for Serious Reportable Events (%) % C. Confirmed Quality of Care Concerns with Associated Interventions The number of Initial Quality Improvement Activities initiated, by activity type, for reviews with one or more confirmed Quality of Care concerns; the percent of total activities that each comprises. # of Interventions (QIAs) With this Initial Quality Improvement Activity Percent of Interventions (QIAs) with this Initial Quality Improvement Activity Initial Quality Improvement Activity 1 - Send educational/alternative approach letter % 2 - Perform intensified review Require continuing education % 4 - Request/review policy/procedure % 5 - Request development of QIP % 6 - Accept provider-initiated QIP % 7 - Conduct informal meeting or teleconference % 8 - Refer to licensing board Initiate sanction activity % 10 - Other % Total % Page 4 of 11

7 D. Discharge/Service Termination The discharge location of beneficiaries linked to discharge/service termination reviews for Selection Reasons 111 (Request for QIO Concurrence) and (Weichardt Selection Reasons). Note: Data represent discharge/service termination reviews from 8/1/2012 4/30/2013. A shortened data time frame is necessary to allow for maturity of claims data, which is the source of Discharge Status for these cases. Discharge Status # of Beneficiaries Percent of Beneficiaries (%) 01 - Discharged to home or self care (routine discharge) % 02 - Discharged/transferred to another short-term general hospital for inpatient care % 03 - Discharged/transferred to skilled nursing facility (SNF) % 04 - Discharged/transferred to intermediate care facility (ICF) % 05 - Discharged/transferred to another type of institution (including distinct parts) % 06 - Discharged/transferred to home under care of organized home health service organization % 07 - Left against medical advice or discontinued care % 09 - Admitted as an inpatient to this hospital % 20 - Expired (or did not recover Christian Science patient) % 21 - Discharged/transferred to court/law enforcement % 30 - Still a patient % 40 - Expired at home (hospice claims only) % 41 - Expired in a medical facility (e.g. hospital, SNF, ICF or free-standing hospice) % 42 - Expired - place unknown (hospice claims only) % 43 - Discharged/transferred to a Federal hospital % 50 - Hospice - home % 51 - Hospice - medical facility % 61 - Discharged/transferred within this institution to a hospital-based Medicare-approved swing bed % 62 - Discharged/transferred to an inpatient rehabilitation facility including distinct part units of a hospital % 63 - Discharged/transferred to a long-term care hospital % 64 - Discharged/transferred to a nursing facility certified under Medicaid but not under Medicare % 65 - Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital % 66 - Discharged/transferred to a Critical Access Hospital % 70 - Discharged/transferred to another type of healthcare institution not defined elsewhere in code list % Other % Total % Page 5 of 11

8 E. Beneficiary Demographics The number of beneficiaries for whom a case review activity was started, by demographic category, and the percent of beneficiaries each category represents. Demographics # of Beneficiaries Percent of Beneficiaries (%) Sex/Gender Female 6, % Male 4, % Unknown % Total 10, % Race Asian % Black 1, % Hispanic % North American Native % Other % Unknown % White 8, % Total 10, % F. Quality of Care Reviews and Concerns by Intervention Type For a QIA started within the reporting period for the current year s report, a short description of the type of intervention(s)/qia(s) employed for three diverse or different quality categories (C1-99). Description 1 Type of Intervention for Quality Category C <1-99> Confirmed Concern for Quality Category C 04 (Apparently did not carry out an established plan in a competent and/or timely fashion). During the QIO medical record review for a beneficiary complaint, it was discovered that the beneficiary was admitted to a skilled nursing facility (SNF) for rehabilitation after bilateral knee replacement surgery. The beneficiary had an order for a continuous passive motion (CPM) machine for each knee. The patient had one working CPM machine and one CPM machine that did not work. The CPM machine that did not work was not replaced, and the patient did not receive the proper treatment for that knee replacement, which resulted in the family signing the patient out and taking her to another acute care facility. QI Action Taken The provider conducted a root cause analysis (RCA), which identified that there was a failure by the staff to report the non-working CPM machine; a knowledge deficit regarding availability of equipment, operating instructions, and troubleshooting measures; and policy restrictions regarding implementation of the CPM machine. The CPM policy and procedure needed to be revised, regarding who could initiate treatment with a CPM machine, to include nursing. Equipment needed to be checked to ensure that it was in working order. Through the technical assistance provided by the QIO, the provider updated its policy and procedure regarding CPM machines to allow trained registered nurse (RN) staff members to implement the treatment if the physical therapist was not available. Staff education, regarding the policy changes and the importance of initiating CPM treatments in a timely fashion, was conducted. Staff education was also provided on proper initiation of CPM machines and troubleshooting measures. All Page 6 of 11

9 CPM machines were inspected by the plant operations department for proper function, and nonfunctioning machines were repaired or replaced. All charts with physician orders for CPM machines were audited and reported to the QIO quarterly, educational in-services were provided throughout the process for reinforcement, and a goal of 100 percent compliance was achieved at having the CPM machine initiated within 24 hours of the receipt of the order. The success of this project was reported to the administrator, quality department, and the director. The process has been adopted by their sister facilities. They will continue to perform random chart checks to ensure compliance. Description 2 Type of Intervention for Quality Category C <1-99> Confirmed Concern for Quality Category C 11 (Apparently did not demonstrate that the patient was ready for discharge). During the QIO medical record review for a beneficiary complaint, it was discovered that the beneficiary was accidently discharged by the emergency department (ED) nurse. The patient was discharged from the ED and given the discharge instructions and prescription for another patient. The ED staff realized the error and contacted the patient to return to the facility, but the family chose to go to another ED for treatment. QI Action Taken The provider conducted a root cause analysis (RCA), which identified that the patient was discharged in error by the ED nurse, who failed to verify the patient s identity via hospital policy. The nurse should have verified the patient s name and date of birth with her armband prior to discharge. The patient did not receive appropriate discharge instructions and was given the instructions for another patient. The provider had a policy and procedure in place to verify at least two patient identifiers prior to discharge, but this policy was not followed. The type of activity requested was an intervention and improvement plan (IIP). Through the technical assistance of the QIO, the staff was re-educated regarding the national patient safety goals to check at least two patient identifiers at all times when providing care. A random sample of 50 charts per month was audited to ensure that there was an order written by the physician for discharge and that the patient received the correct discharge instructions and prescriptions. The results of the audits were submitted to the QIO quarterly, educational in-services were provided throughout the process as well as direct observation, and a goal of 100 percent compliance was achieved. The success of this project was communicated to the provider s quality council on a quarterly basis, shared with its free-standing ED, and implemented. Leadership rounding and random chart audits will continue to ensure patient safety with 100 percent compliance to this process. Description 3 Type of Intervention for Quality Category C <1-99> Confirmed concern for Quality Category C 16 (Apparently did not ensure a safe environment [medication errors, falls, pressure ulcers, transfusion reactions, nosocomial infection]). During the QIO medical record review for a beneficiary complaint, it was discovered that the beneficiary acquired a decubitus ulcer while in the facility, and the nursing staff did not notify the physician of the change in the patient s skin condition. QI Action Taken The provider conducted a root cause analysis (RCA), which identified that there was also a facility-wide lack of assessment and documentation of skin. The Braden Scale was not consistently being used. The Page 7 of 11

10 facility also concluded there was a lack of documentation to substantiate that the physician was notified of changes in skin condition. It had a policy and procedure in place but realized that it needed to be updated to be more comprehensive. The electronic medical record (EMR) also needed to be upgraded, as it did not adequately contain documentation of the skin care assessment. An intervention and improvement plan (IIP) was requested, and through the technical assistance provided by the QIO, the facility updated its policy to include that the Braden Score would be documented on admission, skin/wound assessments would be completed each shift, and the physician would be notified within one hour of skin breakdown. The facility instituted a new tool in the EMR to reflect the changes in the policy and appropriate skin assessment. The facility also added a communication tool on its Kardex. Educational tools were used to reinforce the changes and to reiterate the necessity of informing the physician of any changes and the need to document those in the medical record. A random sample of 50 charts per month was audited and reported to the QIO quarterly, educational in-services were provided throughout the process, and 97 percent compliance has been obtained. The provider worked collaboratively with nursing leadership, the quality department, the computerized physician order entry (CPOE) staff, and the IT department to achieve its success. It has implemented a continuous educational component, which is now part of the annual skills fair required by all staff caring for patients. Additionally, nursing leadership and the quality department will continue random chart audits to ensure 100 percent compliance on all nursing units. Example from Description 3: How Interventions Were Determined/Best Practices Every confirmed quality of care concern is evaluated on an individual basis for several factors prior to assigning it to a category for the type of quality improvement initiative (QII) that needs to be performed. All information is reviewed, including the beneficiary complaint, the nurse analyst information sent to the peer reviewer (including supporting evidence), the peer reviewer s comments, the outcome for the beneficiary, the response that is sent from the provider/practitioner, and any supporting documentation of updated processes, policies and procedures and/or education. After reviewing all information, the quality improvement team collaborates to decide the severity of the concern, involving the medical director as needed. In Description 3 above, the provider identified the need to document skin assessments and the need to communicate changes in skin condition to the physician in a timely manner. The provider took many steps to accomplish this task, based on evidence-based guidelines and protocols for prevention of pressure ulcers. Evidence shows that a good prevention plan includes a risk assessment with a standardized tool, such as the Braden Scale, on admission, reassessment intervals whenever the patient s condition changes or every 48 hours in the acute care setting, documentation of risk scores, and implementation of prevention strategies. By ongoing monitoring of the effectiveness of the prevention interventions implemented and monitoring by the healing progress of existing pressure ulcers, the facility anticipates that pressure ulcers will be reduced. If the skin assessment reveals new breakdown, it is important to use a standardized assessment tool to document category or stage and to notify the physician as soon as possible to obtain treatment orders. This facility was able to obtain best practice through collaboration with its IT department to develop a new skin assessment tool and a way to transfer this information onto a Kardex for improved communication and ongoing staff education. Reference: National Guideline Clearinghouse prevention of pressure ulcers Page 8 of 11

11 G. Evidence Used in Decision-Making For Medical Necessity/Utilization Review and Appeals, the most common types of evidence/standards of care criteria used to support review analysts assessments and peer reviewers decisions; a brief statement of rationale for how the specific evidence/standards of care were chosen. For Quality of Care, the most common types of evidence/standards of care criteria used to support review analysts assessments and peer reviewers decisions. Review Type Quality of Care Medical Necessity / Utilization Review Diagnostic Categories Evidence/ Standards of Care Used Rationale for Evidence/ Standard of Care Selected Pneumonia CMS Core Measures; McKesson s Measures have been developed, InterQual Reference Library; tested, and accepted by various UpToDate authorities. References found within McKesson s tool have been peer reviewed and published; UpToDate is well recognized and utilized in FL. Heart Failure As noted above As noted above Acute As noted above As noted above Myocardial Infarction Pressure Ulcers As noted above and National As noted above Guideline Clearinghouse prevention of pressure ulcers Urinary Tract As noted above As noted above Infection Sepsis As noted above As noted above Adverse Drug Beers Criteria for Potentially As noted above Events Inappropriate Medication Use in Older Adults. Falls Hospital Specifications Manual; As noted above National Guideline Clearinghouse Prevention of falls (acute care); CMS Core Measures; McKesson s InterQual Reference Library; UpToDate Patient Trauma AHRQ Patient Safety Indicators As noted above Surgical As noted above Complications Hospital Specifications Manual; CMS Core Measures; McKesson s InterQual Reference Library; UpToDate McKesson s InterQual Reference Library McKesson s tool has been established for many years in FL; references found within McKesson s tool have been peer reviewed and published; UpToDate is well recognized and utilized in FL. Page 9 of 11

12 Review Type Appeals Diagnostic Categories Evidence/ Standards of Care Used McKesson s InterQual Reference Library; National Coverage Determinations (NCDs) Rationale for Evidence/ Standard of Care Selected McKesson s tool has been established for many years in FL and is reliable in screening for inpatient criteria; NCDs are established by the Medicare Program. Brief examples/case studies, where case review was linked to another Aim of the QIO contract, for example, readmissions, pressure ulcers, adverse drug events, etc.; the evidence-based criteria used to support review decisions on those cases and what influenced the selection of that criteria: Example/Case Study 1: In collaboration with the C.7 Aim team, it was identified that a healthcare facility had increased CLABSI rates. The case review team was requested to conduct medical record reviews in an effort to assist in determining causative factors. The focused quality of care retrospective case review included 15 selected patient records from one healthcare facility. The reviews were completed by a nurse Review Analyst, utilizing an extraction tool developed specific to CLABSI and also included a brief summary of the case. FMQAI conducted a total of 15 Medicare beneficiary case reviews. The physician reviewers were provided the Medicare beneficiary records, the NHSN/CDC CLABSI Guidelines, and a CLABSI review tool from each case. Based on the results of the 15 case reviews conducted, it appeared that the facility did not consistently comply with the NHSN/CDC CLABSI guidelines, which may have contributed to the increased number of central line intravascular catheter-related infections. In collaboration with CMS and the C.7 Aim team, Tier 2 Quality Improvement activities were initiated with ongoing data monitoring to ensure compliance. The hospital has implemented many of the improvement activities throughout its intensive care units, thus implementing system-wide changes. Example 2 (C.7 Aim) and Example 3 (C.8 Aim): The Improve Individual Patient Care Aim (C.7) and Integrate Care for Populations and Communities Aim (C.8) teams are readily accessible and provide information to the quality of care case review team for a variety of clinical settings. As such, when a complaint is received and areas are identified, such as healthcare-associated infections (HAIs), healthcareacquired conditions (HACs), adverse drug events (ADEs), or care transitions (CTs) the C.7 and C.8 Aim teams are contacted for additional information and/or consult. The C.7 and C.8 Aim teams provide their expertise and their knowledge of the provider, such as the use of restraints and the rates of pressure ulcers. This information was utilized as reference material for the complaint review and standard of care. This fosters a collaborative relationship not only for the quality of care case review team and the C.7 and C.8 Aim teams but also for providers. This type of cross-collaboration demonstrates boundarilessness under FMQAI s 10 th SOW. Page 10 of 11

13 H. Effectiveness of QIAs 10 th SOW C.6 BFCC Deliverable B.4 Narrative Analysis: Quality improvement initiatives/interventions/activities are important tools to be utilized by both Quality Improvement Organizations (QIOs) and healthcare providers/practitioners to evaluate current patient care practices and/or processes and to determine what improvements can be made that will impact the greatest portion of the patient population. While the data may be limited to only those that are found in the CRIS application, they demonstrate the effort to support systematic improvements to processes, which in turn should improve care provided to all patients, regardless of the payor source. Many confirmed quality concerns resulted in a system-wide improvement activity. These activities ranged from process improvement plans with designed milestones and measureable achievements, up to and including formal Corrective Action Plans, as required by reviews with concerns identified as gross and flagrant or substantial numbers of violations. All system-wide improvement activities require healthcare providers/practitioners to engage in specific process steps including, but not limited to, conducting a root cause analysis, formulating and submitting an improvement plan, collaborating with the QIO to finalize the improvement plan, and monitoring progress toward achieving and sustaining improvement goals through the review and submission of data. Examples of such system-wide improvement activities are found in section F. Recommendations: The collaboration and information gleaned through the activities noted above can be utilized to augment the statewide aggregate data used by many of FMQAI s Aim teams. While the initial or index review may have identified one Medicare beneficiary, it may represent a snapshot of the processes in place at a particular time and may provide significant insight for the other Aim teams. Case review data should be used to supplement the data currently utilized by the other Aim teams, strengthening their improvement efforts and activities. Please refer to Section G, Case Study 1, for an example of FMQAI s boundarilessness across 10 th SOW Aims. This material was prepared by FMQAI, the Medicare Quality Improvement Organization for Florida, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the Department of Health and Human Services (HHS). The contents presented do not necessarily reflect CMS policy. FL-10SOW-2013FLC Page 11 of 11