Time for a Cool Change Measure and Compare

Transcription

1 Time for a Cool Change Measure and BRENDA BARTKOWSKI, CMA, CCA, BS HPA M ANAGER, C LINICAL D ATA A BSTRACTION About Amphion Dedicated core measure staff Experienced leadership in healthcare technology and services All credentialed core measure abstractors Flat organizational structure Continuous improvement Service customized to meet your unique needs 2 1

2 Today s Objectives Submission to QIOs for HIQR & HVBP HIQR: Measures removed & required Benchmarks of Care dates / data via years Hospital 3 HIQR Program Measures This material was prepared by Telligen, Hospital Inpatient Quality Reporting Program Support Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. 10SoW IA HIQRP 09/ Hospital Inpatient Quality Reporting (IQR) Program Measures (Calendar Year 2014 Discharges) Hospital IQR Program Measures Required by Category FY Year Chart Abstracted Measures Survey Measures Claims Based Measures Structural Measures Total (original starter set) (original starter set) (added expanded set) (added SCIP Inf 2, VTE 1 and VTE 2) 1 (HCAHPS) 2 (added AMI and HF mortality) (added SCIP Inf 4 and SCIP Inf 6) 1 3 (added PN mortality) (added SCIP Card 2 and removed PN 1) 1 16 (added 9 AHRQ, 1 NSC, 3 readmission) 1 (added Cardiac Registry) (removed AMI 6, added SCIP Inf 9 and SCIP Inf 10) 1 14 (harmonized PSI 04 and NSC, retired IQI 90) 3 (added Stroke and Nursing 45 Registries) (add 2 AHRQ and 8 HAC) (added AMI 10 and HAI CLABSI) [removed 6 (AMI 4, HF 4, PN 2, PN 4, PN 5c, PN 7), 1 25 (added Medicare Spending per Beneficiary) 4 (added General Surgery Registry) 55 suspended 4 (AMI 1, AMI 3, AMI 5, SCIP Inf 6), added 2 ED, 2 IMM, and 2 HAI (CAUTI and SSI)] [added 18 (8 STK, 6 VTE, 3 HAI and 1 PC), removed 1 (SCIP VTE 1)] [removed 6 (HF 1, HF 3, AMI 2, AMI 10, PN 3b, SCIP Inf 10), suspended 1 (IMM 1)] 1 12 [added 2 (THA/TKA readmission and THA/TKA complication, HWR), removed 16 (8 HAC, 3 AHRQ IQI, 5 AHRQ PSI)] 1 17 [added 5 (AMI Payment, COPD Mortality, COPD Readmission, Stroke Mortality, Stroke Readmission)] (added Safe Surgery Checklist)

3 HIQR Program Measures Hospital Inpatient Quality Reporting (IQR) Program Measures (Calendar Year 2014 Discharges) Measures Requiring Abstraction and Submission by the Hospital or its Vendor Acute Myocardial Infarction (AMI)** Submission Required On Hospital Included in HVBP AMI 1 Aspirin at Arrival (1) (Data submission voluntary for CMS) (10) AMI 3 ACEI or ARB for LVSD (1) (Data submission voluntary for CMS) (10) AMI 5 Beta Blocker Prescribed at Discharge (1) (Data submission voluntary for CMS) (10) Suspended 1Q 2012 Suspended 1Q 2012 Suspended 1Q 2012 CMS/TJC No No CMS/TJC N No CMS/TJC No No AMI 7 AMI 7a Median Time to Fibrinolysis N/A TJC No No Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival (2, 12) 3Q 2006 CMS/TJC Yes FY 2013 AMI 8 AMI 8a Median Time to Primary PCI N/A TJC No No Timing of Receipt of Primary Percutaneous Coronary Intervention (PCI) (2,6,12) 3Q 2006 CMS/TJC Yes FY2013 Heart Failure (HF)** Submission Required On Hospital Included in HVBP HF 2 Evaluation of LVS Function (1) Nov 2003 Stroke (STK)** Submission Required STK 1 Venous Thromboembolism (VTE) Prophylaxis (10) 1Q 2013 STK 2 Discharged on Antithrombotic Therapy (10) 1Q 2013 STK 3 Anticoagulation Therapy for Atrial Fibrillation/Flutter (10) 1Q 2013 STK 4 Thrombolytic Therapy (10) 1Q 2013 STK 5 Antithrombotic Therapy By End of Hospital Day 2 (10) 1Q 2013 STK 6 Discharged on Statin Medication (10) 1Q 2013 STK 8 Stroke Education (10) 1Q 2013 STK 10 Assessed for Rehabilitation (10) 1Q 2013 On Hospital Included in HVBP 5 HIQR Program Measures Hospital Inpatient Quality Reporting (IQR) Program Measures (Calendar Year 2014 Discharges) Measures Requiring Abstraction and Submission by the Hospital or its Vendor Acute Myocardial Infarction (AMI)** Submission Required On Hospital Included in HVBP AMI 1 Aspirin at Arrival (1) (Data submission voluntary for CMS) (10) AMI 3 ACEI or ARB for LVSD (1) (Data submission voluntary for CMS) (10) AMI 5 Beta Blocker Prescribed at Discharge (1) (Data submission voluntary for CMS) (10) Suspended 1Q 2012 Suspended 1Q 2012 Suspended 1Q 2012 CMS/TJC No No CMS/TJC N No CMS/TJC No No AMI 7 AMI 7a Median Time to Fibrinolysis N/A TJC No No Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival (2, 12) 3Q 2006 CMS/TJC Yes FY 2013 AMI 8 AMI 8a Median Time to Primary PCI N/A TJC No No Timing of Receipt of Primary Percutaneous Coronary Intervention (PCI) (2,6,12) 3Q 2006 CMS/TJC Yes FY2013 Heart Failure (HF)** Submission Required On Hospital Included in HVBP HF 2 Evaluation of LVS Function (1) Nov 2003 Stroke (STK)** Submission Required STK 1 Venous Thromboembolism (VTE) Prophylaxis (10) 1Q 2013 STK 2 Discharged on Antithrombotic Therapy (10) 1Q 2013 STK 3 Anticoagulation Therapy for Atrial Fibrillation/Flutter (10) 1Q 2013 STK 4 Thrombolytic Therapy (10) 1Q 2013 STK 5 Antithrombotic Therapy By End of Hospital Day 2 (10) 1Q 2013 STK 6 Discharged on Statin Medication (10) 1Q 2013 STK 8 Stroke Education (10) 1Q 2013 STK 10 Assessed for Rehabilitation (10) 1Q 2013 On Hospital Included in HVBP 6 3

4 HIQR Program Measures Hospital Inpatient Quality Reporting (IQR) Program Measures (Calendar Year 2014 Discharges) Measures Requiring Abstraction and Submission by the Hospital or its Vendor (continued) Venous Thromboembolism (VTE)** Submission Required On Hospital Included in HVBP VTE 1 Venous Thromboembolism Prophylaxis (10) 1Q 2013 VTE 2 Intensive Care Unit Venous Thromboembolism Prophylaxis (10) 1Q 2013 VTE 3 Venous Thromboembolism Patients with Anticoagulation Overlap (10) 1Q 2013 VTE 4 Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count 1Q 2013 Monitoring by Protocol or Nomogram (10) VTE 5 Venous Thromboembolism Warfarin Therapy Discharge Instructions (10) 1Q 2013 VTE 6 Hospital Acquired Potentially Preventable Venous Thromboembolism (10) 1Q 2013 Pneumonia (PN)** PN 3a PN 6 PN 6a PN 6b Blood Cultures Performed Within 24 Hours Prior to or 24 Hours After Hospital Arrival for Patients Who Were Transferred or Admitted to the ICU Within 24 Hours of Hospital Arrival Initial Antibiotic Selection for Community Acquired Pneumonia (CAP) in Immunocompetent Patient (2, 12) Initial Antibiotic Selection for CAP in Immunocompetent ICU Patient Initial Antibiotic Selection for CAP in Immunocompetent Non ICU Patient Children s Asthma Care (CAC)** Submission Required On Hospital Included in HVBP N/A CMS/TJC No No 3Q 2006 CMS Yes FY 2013 N/A TJC No No N/A TJC No No Submission Required On Hospital Included in HVBP CAC 1 Relievers for Inpatient Asthma N/A TJC Yes No CAC 2 Systemic Corticosteroids for Inpatient Asthma N/A TJC Yes No CAC 3 Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver N/A TJC Yes No 7 HIQR Program Measures Hospital Inpatient Quality Reporting (IQR) Program Measures (Calendar Year 2014 Discharges) Measures Requiring Abstraction and Submission by the Hospital or its Vendor (continued) Surgical Care Improvement Project (SCIP)** (SCIP Inf 1, 2, 3, 4 are listed in VBP final rule as HAI measures) Submission Required On Hospital Included in HVBP SCIP Inf 1 Prophylactic Antibiotic Received Within One Hour Prior to Surgical 3Q 2006 CMS/TJC Yes FY 2013 Incision (2,12) SCIP Inf 2 Prophylactic Antibiotic Selection for Surgical Patients (3,12) 1Q 2007 CMS/TJC Yes FY 2013 SCIP Inf 3 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery 3Q 2006 CMC/TJC Yes FY 2013 End Time (2,12) SCIP Inf 4 Cardiac Surgery Patients With Controlled Postoperative Blood 1Q 2008 CMS/TJC Yes FY 2013 Glucose (5, 14) SCIP Inf 6 Surgery Patients with Appropriate Hair Removal (5) Suspended CMS/TJC No No (Data submission voluntary for CMS) (10) 1Q 2012 SCIP Inf 9 Urinary Catheter Removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero (8,13) 1Q 2010 CMS/TJC Yes FY 2014 SCIP Card 2 Surgery Patients on Beta Blocker Therapy Prior to Arrival Who 1Q 2009 CMS/TJC Yes FY 2013 received a Beta Blocker During the Perioperative Period (6,12) SCIP VTE 2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 1Q 2007 CMT/TJC Yes FY 2013 Hours After Surgery (3,12) Included in Emergency Department (ED)** Submission On Hospital HVBP (Listed in the Rule as Emergency Department Throughput ) Required ED 1a Median Time from ED Arrival to ED Departure for Admitted ED Patients 1Q 2012 CMS/TJC No No Overall Rate Median Time ED 1b from ED Arrival to ED Departure for Admitted ED Patients 1Q 2012 Reporting Measure (9,10) Median Time from Ed Arrival ED 1c to ED Departure for Admitted ED Patients 1Q 2012 CMS/TJC No No Observation Patients Median Time from ED ED 1d Arrival to ED Departure for Admitted ED Patients 1Q 2012 CMS/TJC No No Psychiatric/Mental Health Patients ED 2a Admit Decision Time to ED Departure Time for Admitted Patients Overall 1Q 2012 CMS/TJC No No Rate Admit ED 2b Decision Time to ED departure Time for Admitted Patients 1Q 2012 Reporting Measure (9,10) Admit Decision Time to ED ED 2c Departure Time for Admitted Patients 1Q 2012 CMS/TJC No No Psychiatric/Mental Health Patients 8 4

5 HIQR Program Measures Hospital Inpatient Quality Reporting (IQR) Program Measures (Calendar Year 2014 Discharges) Measures Requiring Abstraction and Submission by the Hospital or its Vendor (continued) Immunization (IMM)** Submission Required On Hospital Included in HVBP (Listed in the rule as Prevention: Global Immunization Measures ) IMM 1a Pneumococcal Immunization Overall Rate (9,10,14) Suspended 1Q 2014 IMM 1b Pneumococcal Immunization Age 65 and older Suspended 1Q 2014 CMS/TJC No No IMM 1c Pneumococcal Immunization High Risk Populations (Age 5 through 64 Suspended years) 1Q 2014 CMS/TJC No No IMM 2 Influenza Immunization (9,10,14) 1Q 2012 CMS/TJC Yes FY 2016 SUB 1 Alcohol Use Screening N/A TJC No No SUB 2 Alcohol Use Brief Intervention Provided or Offered N/A TJC No No SUB 2a Alcohol Use Brief Intervention N/A TJC No No SUB 3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge N/A TJC No No SUB 3a Alcohol and Other Drug Use Disorder Treatment at Discharge N/A TJC No No SUB 4 Alcohol and Drug Use: Assessing Status after Discharge N/A TJC No No PC 01 Elective Delivery Prior to 39 Completed Weeks Gestation: Percentage of Babies Electively l Delivered Dli dpi Prior to 39 Completed dweeks Gestation ti (11) 1Q HOQR Program Measures Hospital OQR Quality Measures and Timelines for CY 2015 and Subsequent Payment Determinations Cardiac Care (Acute Myocardial Infarction and Chest Pain) Implementation* OP 1: Median Time to Fibrinolysis 2008 OP 2: Fibrinolytic Therapy Received Within 30 Minutes 2008 OP 3: Median Time to Transfer to Another Facility for Acute coronary Intervention 2008 OP 4: Aspirin i at Arrival 2008 OP 5: Median Time to ECG 2008 ED Throughput Implementation* OP 18: Median Time from ED Arrival to ED Departure for Discharged ED Patients 2012 OP 19: Transition Record with Specified Elements Received by Discharged Patients OP 20: Door to Diagnostic Evaluation by a Qualified Medical Professional 2012 OP 22: ED Patient Left Without Being Seen 2012 Pain Management Implementation* OP 21: Median Time to Pain Management for Long Bone Fracture 2012 Stroke Implementation* OP 23: ED Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke who Received Head CT or MRI Scan Interpretation Within 45 minutes of Arrival 2012 Surgical Care Implementation* OP 6: Timing of Antibiotic Prophylaxis 2008 OP 7: Prophylactic Antibiotic Selection for Surgical Patients 2008 OP 29: Endoscopy/Polyp Surveillance: Appropriate follow up interval for normal colonoscopy in average risk patients OP 30: Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps Avoidance of Inappropriate Use

6 HOSPITAL COMPARE 11 Hospital 12 6

7 Hospital What is it? 4000 Medicarecertified hospitals quality of care to improve Distribute objective, easy tounderstand data 13 Hospital Relative Sites Physician Nursing Home Home Health Dialysis Facility ectcookiesupport=1 ml DetectCookieSupport=1 ml?aspxautodetectcookiesupport=1 14 7

8 Hospital Timely & Effective OP 3b OP 5 OP 2 OP 4 AMI 7a AMI 8a AMI 2 AMI Hospital Timely & Effective HF 1 HF 2 HF 3 PN 3b PN 6 OP 6 OP 7 SCIP Inf 1a 16 8

9 Hospital Timely & Effective SCIP Inf 4 SCIP Inf 9 SCIP Inf 3a SCIP VTE 2 SCIP CARD 2 SCIP Inf 10 SCIP Inf 2a ED 1b 17 Hospital Timely & Effective ED 2b OP 20 OP 22 OP 23 IMM 2 OP 21 OP 18b IMM 1a 18 9

10 Hospital Timely & Effective CAC 1 CAC 2 STK 1 STK 2 STK 3 STK 4 STK 5 STK 6 19 Hospital Timely & Effective STK 8 STK 10 VTE 1 VTE 2 VTE 3 VTE 4 VTE 5 VTE 6 PC

11 Hospital Data Sources To QIO via CART heart attack HF PN SCIP STK VTE PC TJC children s asthma 21 Hospital NEW IPFQR HBIPS 2 HBIPS 3 HBIPS 6 & 7 Next Level of Care STK VTE Hip/Knee Replacement Complications Readmission Heart Attack HF PN Hip & Knee Replacements Hospital wide Readmissions 22 11

12 BENCHMARKS of CARE 23 ABC Methodology Achievable Benchmarks of Care Methodology Performance of top facilities Best inclass providers Encourage performance improvement 24 12

13 Determination of Benchmarks Provider median times (in 90 th minutes) rank order Percentile Benchmark Rate Top 10% Sample Rate 100% Eligible Sample 25 Benchmark Comparison 2012 & 2013 THIRD QUARTER 2012 Performance Measure Name Benchmark AMI 1: Aspirin at Arrival ,740 11, , ,200 3,053 AMI 2: Aspirin Prescribed at Discharge ,539 10, , ,069 2,930 AMI 3: ACEI or ARB for LVSD ,904 1, ,341 17,754 2,194 AMI 5: Beta Blocker Prescribed at Discharge ,355 10, , ,055 2,892 AMI 7a: Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival AMI 8a: Primary PCI Received Within 90 Minutes of Hospital larrival ,557 1, ,257 14,974 1,570 AMI 10: Statin Prescribed at Discharge ,341 10, , ,617 2,

14 Benchmark Comparison 2012 & 2013 THIRD QUARTER 2013 *The benchmarks reported here are unrelated to the 90 th percentiles that are published on Hospital for individual measures. Performance Measure Name Benchmark AMI 1: Aspirin at Arrival ,571 11, , ,081 2,934 AMI 2: Aspirin Prescribed at ,549 10, , ,503 2,860 Discharge AMI 3: ACEI or ARB for LVSD ,795 1, ,975 17,317 2,129 AMI 5: Beta Blocker Prescribed at Discharge ,098 10, ,422 99,302 2,792 AMI 7a: Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival AMI 8a: Primary PCI Received Within 90 Minutes of Hospital larrival AMI 10: Statin Prescribed at Discharge ,571 1, ,856 15,453 1, ,204 10, , ,571 2, Benchmark Comparison 2012 & 2013 THIRD QUARTER 2013 Performance Measure Benchmark Name HF 1: Discharge Instructions ,836 13, , ,690 3,966 HF 2: Evaluation of LVS Function ,825 16, , ,952 4,065 HF 3: ACEI or ARB for LVSD ,189 5, ,870 50,402 3,515 THIRD QUARTER 2012 Performance Measure Benchmark Name HF 1: Discharge Instructions ,777 13, , ,622 3,988 HF 2: Evaluation of LVS Function ,869 16, , ,875 4,094 HF 3: ACEI or ARB for LVSD ,152 5, ,775 50,471 3,

15 Benchmark Comparison 2012 & 2013 THIRD QUARTER 2013 Performance Measure Benchmark Name IMM 1a: Pneumococcal Immunization Overall ,971 47, , ,312 3,739 Rate IMM 2: Influenza Immunization** NA NA NA NA NA NA NA NA THIRD QUARTER 2012 Performance Measure Benchmark Name IMM 1a: Pneumococcal Immunization Overall Rate IMM 2: Influenza Immunization** ,223 49, , ,660 3,690 NA NA NA NA NA NA NA NA 29 Benchmark Comparison 2012 & 2013 THIRD QUARTER 2012 Performance Measure Name PN 3a: Blood Cultures Performed Within 24 Hours Prior to or 24 Hours After Hospital Arrival for Patients Who Were Transferred or Admitted to the ICU Within 24 Hours of Hospital Arrival PN 3b: Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital PN 6: Initial Antibiotic Selection for CAP in Immunocompetent Patient Benchmark ,443 2, ,026 23,546 3, ,134 11, , ,960 3, ,750 6, ,008 66,299 4,

16 Benchmark Comparison 2012 & 2013 THIRD QUARTER 2013 Performance Measure Name PN 3a: Blood Cultures Performed Within 24 Hours Prior to or 24 Hours After Hospital Arrival for Patients Who Were Transferred or Admitted to the ICU Within 24 Hours of Hospital Arrival PN 3b: Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital PN 6: Initial Antibiotic Selection for CAP in Immunocompetent Patient Benchmark ,396 2, ,388 23,833 2, ,031 11, , ,180 3, ,495 6, ,044 63,872 4,070 Education Documentation Awareness 31 Benchmark Comparison 2012 & 2013 THIRD QUARTER 2012 Performance Measure Name SCIP Inf 1: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision SCIP Inf 2: Prophylactic Antibiotic Selection for Surgical Patients SCIP Inf 3: Prophylactic Antibiotics Discontinued within 24 Hours After Surgery End Time SCIP Inf 4: Cardiac Surgery Patients With Controlled 6 AM Postoperative Blood Glucose SCIP Inf 6: Surgery Patients with Appropriate Hair Removal SCIP Inf 9: Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero SCIP Inf 10: Inf Surgery Patients with Perioperative Temperature Management SCIP CARD 2: Surgery Patients on Beta Blocker Therapy Prior to Arrival Who Received a Beta Blocker During the Perioperative Period SCIP VTE 2: Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis within 24 Hours Prior to Surgery to 24 Hours After Surgery Benchmark ,478 25, , ,377 3, ,203 25, , ,853 3, ,552 24, , ,186 3, ,113 4, ,452 40,883 1, ,032 37, , ,577 3, ,913 19, , ,422 3, ,443 33, , ,147 3, ,470 11, , ,201 3, ,446 27, , ,274 3,

17 Benchmark Comparison 2012 & 2013 THIRD QUARTER 2013 Performance Measure Name SCIP Inf 1: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision SCIP Inf 2: Prophylactic Antibiotic Selection for Surgical Patients SCIP Inf 3: Prophylactic Antibiotics Discontinued within 24 Hours After Surgery End Time SCIP Inf 4: Cardiac Surgery Patients With Controlled 6 AM Postoperative Blood Glucose SCIP Inf 6: Surgery Patients with Appropriate Hair Removal SCIP Inf 9: Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero SCIP Inf 10: Inf Surgery Patients with Perioperative Temperature Management SCIP CARD 2: Surgery Patients on Beta Blocker Therapy Prior to Arrival Who Received a Beta Blocker During the Perioperative Period SCIP VTE 2: Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis within 24 Hours Prior to Surgery to 24 Hours After Surgery Benchmark ,448 25, , ,367 3, ,082 25, , ,929 3, ,784 24, , ,788 3, ,242 4, ,919 41,150 1, ,291 36, , ,343 3, ,685 19, , ,090 3, ,141 33, , ,452 3, ,932 11, , ,275 3, ,955 26, , ,938 3, Benchmark Comparison 2012 & 2013 THIRD QUARTER 2013 Performance Measure Name ED 1b: Median Time from ED Arrival to ED Departure for Admitted ED Patients Reporting Measure ED 2b: Admit Decision Time to ED Departure Time for Admitted Patients Reporting Measure Top Tenth Percentile Median Time Media Time (minutes) (No. of ) (No. of Patients) Pti t) (minutes) , , , ,391 THIRD QUARTER 2012 Performance Measure Name Qtr Top Tenth Percentile (minutes) Qtr Median Time (minutes) Qtr Top Tenth Percentile (minutes) Qtr Median Time (minutes) Qtr Qtr Top Tenth Median Percentile (minutes) Time (minutes) Qtr Top Tenth Percentile (minutes) Qtr Median Time (minutes) Qtr Top Tenth Percentile (minutes) Qtr Median Time (minutes) ED 1b: Median Time from ED Arrival to ED Departure for Admitted ED Patients Reporting Measure ED 2b: Admit Decision Time to ED Departure Time for Admitted Patients Reporting Measure

18 Benchmark Comparison 2012 & 2013 THIRD QUARTER 2012 Performance Measure Name OP 2: Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival Benchmark , OP 4: Aspirin at Arrival ,993 2, ,432 29,452 2,741 OP 6: Timing of Antibiotic Prophylaxis ,552 17, , ,019 3,100 OP 7: Prophylactic Antibiotic Selection for Surgical Patients ,389 17, , ,084 3,093 OP 23: Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrrhagic Stroke Patients who Received Head CT or MRI Scan Interpretation Within 45 Minutes of ED Arrival ,393 7,127 2, Benchmark Comparison 2012 & 2013 THIRD QUARTER 2013 Performance Measure Name OP 2: Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival Benchmark , OP 4: Aspirin at Arrival ,211 3, ,473 29,459 2,819 OP 6: Timing of Antibiotic Prophylaxis ,512 18, , ,180 3,111 OP 7: Prophylactic Antibiotic Selection for Surgical Patients ,921 18, , ,244 3,097 OP 23: Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrrhagic Stroke Patients who Received Head CT or MRI Scan Interpretation Within 45 Minutes of ED Arrival ,067 6,825 2,

19 COMPARING INPATIENT and OUTPATIENT 37 Comparing IP and OP HIQR Proposed Rule CMS 1607 P Federal Register, Vol. 79, No. 94 Participation in systematic dbase for cardiac surgery HIQR Program p

20 Comparing IP and OP HIQR AMI 8a HF2 SCIP 1,2,3,4,9, CARD1 VTE2 STK 2,3,5,10 VTE 4 Participation in systematic dbase for cardiac surgery Severe Sepsis & Septic Shock Mgmt Bundle Episode of care payment measures for PN & HF Sepsis reduction bundle Hearing screening Readmissions for CABG & vascular access Home mgmt plan of care doc Mortality for CABG 39 Comparing IP and OP HIQR FY2015 IPPS Proposed rule published 5/19/14 Final rule expected 8/1/ /pdf/ pdf Fee for Service Payment/AcuteInpatientPPS/FY2015 IPPS Proposed Rule Home Page.html 40 20

21 Comparing IP and OP HOQR OP 19 ED OP 24 Cardiac Rehab 41 Comparing IP and OP HOQR CY2015 OPPS Proposed rule available now OQR Program: pages Participation in systematic dbase for cardiac surgery OFRData/ _PI.pdf Federal Register 7/14/14: pages /pdf/ pdf 42 21

22 What s Next Hospital April 2015 Results 7/1/13 6/30/14 Participation in systematic dbase for cardiac surgery Benchmarks Comparison Possibly August 2014 Reports Q Q Thank You! Brenda.Bartkowski@amphionmedical.com x1631 Drew.Fuhrman@amphionmedical.com x