Quality Improvement and Core Measures 101. Jill Daniels, BS Quality Project Manager, Primaris

Transcription

1 Quality Improvement and Core Measures 101 Jill Daniels, BS Quality Project Manager, Primaris

2 You can ask a question by clicking the blue? icon or speech bubble icon. 2

3 Evaluate this Session! Please help us improve our educational sessions by completing an evaluation of this program. You will have two opportunities to complete an evaluation and receive a completion certificate: At immediate conclusion of webinar Post event: within two business days of the webinar, you will receive an containing links to the online evaluation and a recording of this webinar Upon completing the online evaluation, you will receive an with a link to access your completion certificate. If you have questions or need assistance, please contact Learning_Institute@qhr.com. 3

4 Jill Daniels, BS Quality Measure Project Manager, Primaris Ms. Daniel has 10 years of experience in performance improvement and clinical quality. She currently is a Project Manager and the Educator for her department at Primaris. She has used her training in lean six-sigma and root-cause analysis to facilitate and improve processes to save healthcare organizations both time and money. She has experience with all core measures, National Cardiovascular Data Registry (NCDR) for CathPCI and ICD, the Society of Thoracic Surgery (STS) Data Registry, and has served as a team lead for the GPRO abstraction project. 4

5 Greetings and Introductions 5

6 Core Measures History 1999 Institute of Medicine (IOM) 44 98,000 preventable deaths Exceeds MVA s, Breast Cancer, and AIDS TJC solicits stakeholder input 2002 TJC and CMS align measure specifications July Begin collecting data Launch Nursing Home Quality Initiative (NH Compare) 1998 Healthcare safety concerns Media attention Healthcare costs President Clinton 2001 Four Initial Core Measures Announced Acute Myocardial Infarction (AMI) Heart Failure (HF) Pneumonia (PN) Pregnancy Related conditions (PR) replaced with PC in

7 Today Surgical Care Improvement (SCIP) (voluntary for discharges as of 1/1/15) Venous Thromboembolism (VTE) Stroke (STK) Children s Asthma Care (CAC) Immunization (IMM) Emergency Dept (ED) Hospital Based Inpatient Psychiatric Services (HBIPS) Perinatal Care (PC Moms and Infants) Outpatient (OP) Measures; ED, AMI, Chest Pain, Surgery, Pain Management, Stroke 7

8 October 2015 Adding Sepsis On 04/01/15, CMS and TJC released the National Hospital Quality Measures (NHQM) Specifications Manual, v5.0 that is effective with October 1, 2015 discharges. Included in this manual were the new specifications for the Sepsis Bundle which will be a requirement for hospitals currently being reimbursed by the Inpatient Prospective Payment System (IPPS) beginning with October 1, 2015 discharges. 8

9 Why are the New Sepsis Measures Important? CMS believes that this is an important area for measurement because mortality rates range from 16-49% for patients that are admitted with a sepsis diagnosis. Early and effective treatment of severe sepsis will help decrease mortality related to sepsis and also help decrease the costs associated with inefficient care of sepsis patients. CMS will be able to identify if care of severe sepsis and septic shock patients is improving. Material taken from received from Quality Reporting Notification dated 3/26/

10 ANATOMY OF A CORE MEASURE 10 10

11 Core Measures Core (Quality) Measures gauge how well an entity provides care to its patients Measures are based on scientific evidence (National Quality Forum NQF endorsed) and can reflect guidelines, standards of care, or practice parameters A Quality Measure converts medical information from patient records into a rate or percentage that assesses performance 11 11

12 CMS VS. TJC REQUIREMENTS EFFECTIVE FOR DISCHARGES JANUARY 1, 2015 TO SEPTEMBER 30,

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18 LOCATING SPECIFICATIONS MANUALS FOR CMS AND TJC 18 18

19 CMS Specifications Manual

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22 CMS Specifications Manual Current CMS Specifications Manual v4.4a for Discharges 01/01/ /30/

23 Specifications Manual for Joint Commission National Quality Measures v2015a1 Copy and paste above link to your internet browser. Once on webpage, click current for the current specifications manual v2015a

24 Pneumonia That Was Then 24 24

25 Pneumonia This Is Now 25 25

26 Anatomy of a Measure Measure Set: Pneumonia Measures: PN-6 Initial Antibiotic Selection (6a ICU Patient, 6b Non ICU Patient) Data Elements: 26 26

27 Who Are the patients? Patients admitted to the hospital for inpatient acute care are included in the PN Initial Patient Population and are eligible to be sampled if they have: An ICD-9-CM Principal Diagnosis Code for PN as define in Appendix A, Table 3.1, NO ICD-9-CM Other diagnosis Code of Cystic Fibrosis as defined in Appendix A, Table 3.4, a Patient Age (Admission Date minus Birthdate) grater than or equal to 18 years, and a Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days OR An ICD-9-CM Principal Diagnosis Code of Septicemia or Respiratory Failure as defined in Appendix A, Table 3.2 and Table 3.3 accompanied by an ICD-9-CM Other Diagnosis Code of PN as defined in Appendix A, Table 3.1, NO ICD-9-CM Other Diagnosis Code of Cyctis Fibrosis as defined in Appendix A, Table 3.4, a Patient Age (Admission Date minus Birthdate) greater than or equal to 18 years, and a Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days

28 What Do the Abstractors Do? Review hospital electronic medical records Understand and utilize Specifications Manuals Answer Data Element questions according to the CMS/TJC Specifications Manual Instructions Enter answers/data into a hospital-selected Vendor tool (electronic form) Perform Inter Rater Reliability within their team/peer groups for assessment of accuracy Hospital then submits data to CMS/TJC for Reporting purposes Identify outliers (those that do not meet specification manual standards) and communicates with Quality Improvement Staff to improve care

29 Measure Algorithm PN-3b: Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital Numerator: Denominator: Number of pneumonia patients whose initial ED blood culture was performed prior to the administration of the first hospital dose of antibiotics. Pneumonia patients 18 years of age and older who have initial blood culture collected in the ED. Start Run cases that are included in the PN Initial Patient Population and pass the edits defined in the Transmission Data Processing Flow: Clinical through this measure. Variable Key: Antibiotic Timing Blood Culture Timing Blood Culture Collection Day Duration of Stay Initial Antibiotic Date Initial Antibiotic Time PN-3b X Missing Chest X-Ray = 2, 3 PN-3b B = 1 PN-3b X Missing Comfort Measures Only = 1 PN-3b B = 2, 3, 4 PN-3b PN-3b 29 29

30 Measure Category Assignment/Outcomes B: Case is excluded from the denominator D: Case is in Measure population and the intent of the measure was not met (failure) E: Case is in Numerator population and the intent of the measure was met (pass) X: Data are missing that is required to calculate the measure record will be rejected when transmitted Y: UTD Value does not allow calculation of the measure 30 30

31 Specific PN Case Outcomes PN3A Blood Cultures 24 Hours Before/After Arrival ICU Patients Category assignment: B Patient has been excluded from this measure. Reason for exclusion: ICU Admission or Transfer was abstracted with the value of No PN3B Blood Culture Before First Antibiotic Category assignment: E Standard of care met. PN6A Initial Antibiotic Selection for Immunocompetent Patient ICU Category assignment: B Patient has been excluded from this measure. Reason for exclusion: ICU admission or Transfer was abstracted with the value of No PN6B Initial Antibiotic Selection for Immunocompetent Patient Non ICU Category assignment: B Patient has been excluded from this measure. Reason for exclusion: Healthcare Associated PN was abstracted with the value of Yes 31 31

32 QUALITY 32 32

33 Hospital Quality Initiative (HQI) Quality (Core) Measures Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction survey Medicare claims data: 30-day risk-standardized mortality and readmission measures Infection control measures 33 33

34 Consumer Public reporting = patients can choose best facility Core Measure data available on Hospital Compare website for AMI, HF, PN, and SCIP HCAHPS survey data and mortality rates added 34 34

35 Consumer Outpatient data added CMS readmission reduction program 2013 Hospital Value Based Purchasing (VBP) program 35 35

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37 Hospital Compare 37 37

38 Hospital Compare 38 38

39 Hospital Compare 39 39

40 Hospital Compare 40 40

41 HOSPITAL VALUE BASED PURCHASING (VBP) 41 41

42 Value Based Purchasing CMS is changing the way Medicare pays for hospital care by rewarding hospitals for delivering services of higher quality and higher value 42 42

43 Value Based Purchasing VBP Program, established by the Affordable Care Act, implements a pay-for- performance approach that accounts for the largest share of Medicare spending affecting payment for inpatient stays in approximately 3,000 hospitals across the country 43 43

44 Value Based Purchasing Purpose VBP seeks to encourage hospitals to improve the quality and safety of care that all patients receive during acute-care inpatient stays by: eliminating or reducing the occurrence of adverse events (healthcare errors resulting in patient harm) adopting evidence-based care standards and protocols that result in the best outcomes for the most patients re-engineering hospital processes that improve patients outcomes 44 44

45 Hospital Value Based Purchasing Uses 12 quality measures that hospitals already report to Medicare Measures fall under four clinical areas focused on improving care and paying for good quality care 45 45

46 Value Based Purchasing Medicare is adjusting a portion of payments to hospitals beginning in FY 2013 based on either: How well they perform on each measure compared to all hospitals, or How much they improve their own performance on each measure compared to their performance during a prior baseline period 46 46

47 Value Based Purchasing A hospital s performance in HVBP will be based on its performance according to the following: 47 47

48 Value Based Purchasing Fiscal Year (FY) Clinical Process of Care measures Eight Patient Experience of Care dimensions of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey Three 30-Day Outcome Mortality measures: Acute Myocardial Infarction (AMI) Heart Failure (HF) Pneumonia (PN) One Agency for Healthcare Research and Quality (AHRQ) Composite Measure: Patient Safety Indicator (PSI-90) One Healthcare Associated Infection: Central Line-Associated Blood Stream Infection (CLABSI) One Efficiency measure: Medicare Spending Per Beneficiary (MSPB) 48 48

49 Value Based Purchasing Fiscal Year (FY) 2016 Eight Clinical Process of Care measures Eight Patient Experience of Care dimensions (HCAHPS) Three 30-Day Outcome Mortality measures: Acute Myocardial Infarction (AMI) Heart Failure (HF) Pneumonia (PN) One Agency for Healthcare Research and Quality (AHRQ) Composite measure: Patient Safety Indicator (PSI-90) Four Healthcare Associated Infection: Central Line-Associated Blood Stream Infection (CLABSI) Catheter-Associated Urinary Tract Infection (CAUTI) Surgical Site Infection o Abdominal Hysterectomy o Colon Surgery One Efficiency measure: Medicare Spending Per Beneficiary (MSPB) 49 49

50 VBP Clinical Process of Care Domain for FY 2015 AMI-7a fibrinolytic therapy received within 30 minutes of hospital arrival AMI-8a primary PCI received within 90 minutes of hospital arrival HF-1 discharge instructions PN-3b blood cultures performed in the ED prior to initial antibiotic received in hospital PN-6 initial antibiotic selection for CAP in immunocompetent patient AMI= Acute Myocardial Infarction HF= Heart Failure PN=Pneumonia 50 50

51 VBP Clinical Process of Care Domain for FY 2015 (Continued) SCIP-Card-2: Surgery patients on a beta blocker prior to arrival that received a beta blocker during the perioperative period SCIP Inf-1: Proyphylactic 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= Surgical Care Improvement Project 51 51

52 VBP Clinical Process of Care Domain for FY 2015 (Continued) SCIP-Inf-4: Cardiac surgery patients with controlled 6am postoperative serum glucose SCIP -Inf-9: Postoperative urinary catheter removal on post operative day one or two SCIP-VTE-2: Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery SCIP=Surgical Care Improvement Project 52 52

53 Value Based Purchasing Scoring - A hospital s performance in HVBP is based on measures/dimensions for the domains per FY. The Total Performance Score (TPS) is composed of: FY 2015 Scoring Domain Weight Clinical Process of Care 20% Patient Experience of Care 30% Outcome 30% Efficiency 20% 53 53

54 Value Based Purchasing FY 2016 Scoring Domain Weight Clinical Process of Care 10% Patient Experience of Care 25% Outcome 40% Efficiency 25% 54 54

55 NEXT STEPS 55 55

56 Using Data to Improve Quality Working smarter instead of harder Electronic Medical Record (EMR) Hardwiring success Concurrent review real time 56 56

57 How Can Data Help to Improve Quality? Problem: Facility is performing poorly on the immunization measure influenza vaccination status. Patients who have not received a flu vaccination during the current flu season are slipping through the cracks, and are not getting the vaccination while in the hospital. Pneumonia and influenza are the fifth leading cause of death in older adults in the U.S. according to the Centers for Disease Control and Prevention (CDC) 57 57

58 Why Is the Flu Vaccine Important? Pneumonia and influenza are the fifth leading cause of death in older adults in the U.S. according to the Centers for Disease Control and Prevention (CDC). According to CMS, there are over 200,000 hospitalizations from influenza on the average every year, and an average of 36,000 Americans die annually due to influenza and its complications (most are 65 years and older). The best way to prevent the flu is to get vaccinated each year during the fall season 58 58

59 How Can We Keep Patients from Slipping Through the Cracks? Ensure that flu vaccine questions are a part of the initial Nursing Assessment If the patient has not received a flu vaccine during the season, and would like one, have it set up where the EMR automatically generates an order from the Nursing Assessment that orders the vaccine from the pharmacy This will not only improve Quality scores, it will also help improve quality of care and patient satisfaction 59 59

60 About Primaris Trusted healthcare advisors Work with providers to drive better health outcomes, improved patient experience, and a better bottom line Translate healthcare data into actionable quality improvement processes Create highly reliable healthcare organizations 60 60

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62 Upcoming Programs Quality Update Webinar Series May Quality Update Peer Review May 29, :00 12:00 p.m. CT Quality Classroom Programs: New Quality Director Boot Camp (May 6-8, 2015) Advanced Quality Director Forum (October 20-21, 2015) Register at

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