Program Selection Criteria for Blue Distinction Centers for Spine Surgery and Blue Distinction Centers for Knee and Hip Replacement

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1 Program Selection Criteria for Blue Distinction Centers for Spine Surgery and Blue Distinction Centers for Knee and Hip Replacement Blue Distinction Centers are part of a national designation program that recognizes hospitals that demonstrate expertise in delivering quality specialty care safely and effectively. Building on this foundation of recognizing quality specialty care, we are expanding the program to add another level of designation, Blue Distinction Centers+. To earn this designation, hospitals must meet the same quality criteria as Blue Distinction Centers, but go an extra step to demonstrate they do so efficiently. The basics of each designation are as follows: Blue Distinction Centers: Meets quality-focused criteria that emphasize patient safety and outcomes. Blue Distinction Centers+: Meets the same quality-focused criteria that emphasize patient safety and outcomes, as well as cost of care measures. Guiding principles for the selection process were developed through a balanced set of quality, cost and access considerations, to provide consumers with meaningful differentiation in value for those specialty care facilities that are designated as Blue Distinction Centers (BDC) and Blue Distinction Centers+ (BDC+), including: Quality Establish a nationally consistent and continually evolving approach to evaluating quality and safety, by incorporating quality measures with meaningful impact, including delivery system features and specific quality outcomes to which all can aspire. Cost Establish a nationally consistent, equitable, and objective approach for selecting Blue Distinction Centers that address market and consumer demand for cost savings and affordable healthcare. Access Consider consumer access to Blue Distinction Centers, while achieving the program s overall goal of providing differentiated performance on quality and cost of care. A detailed RFI Survey and healthcare claims information were used to evaluate and identify facilities that met each designation s selection criteria. To be eligible for the Blue Distinction Centers or Blue Distinction Centers+ designation, a facility must meet the minimum thresholds for that specialty area, defined by the following evaluation components: Blue Distinction Centers Quality Decision based on information provided by a facility in the RFI Survey Business Decision based on information provided by local Blue Plans Facility/Provider Participation Status, in the local Blue Plan s BlueCard PPO Network Local Blue Plan Criteria, if applicable. 1

2 Blue Distinction Centers+ Quality Decision based on information provided by a facility in the RFI Survey Business Decision based on information provided by local Blue Plans Facility/Provider Participation Status, in the local Blue Plan s BlueCard PPO Network Local Blue Plan Criteria, if applicable Cost of Care, based on healthcare claims information using NCCT methodology The following information provides a detailed explanation of methodologies and program selection criteria used in the evaluation process. QUALITY SELECTION CRITERIA Blue Distinction Centers seeks to establish a nationally consistent and continually evolving approach to evaluating quality and safety, by incorporating quality measures with meaningful impact, including delivery system features and specific quality outcomes to which all can aspire. Facilities were evaluated on quality components that were developed with thoughtful input from the medical community, through a process that included: A review of the medical literature. Input from expert panels and medical organizations. A review of national quality and safety initiatives. A thorough analysis of past RFI survey information. Input from quality measurement experts. Metric Categories: General and Program Specific. Quality evaluation components reflect the following aspects of care provided by a facility: General Safety and Quality Metrics Address facility-wide safety, quality and patient experience, which apply generally to both Blue Distinction s Spine Surgery and Knee/Hip programs. Program Specific Metrics Address delivery system features and outcomes related to the facility s own spine surgery and/or knee and hip replacement program(s), which apply specifically to Blue Distinction Centers Spine Surgery or Knee/Hip programs. Metric Types: Required, Informational, and Scored. Evaluation metrics for the quality scoring methodology were established, using both input from the medical community and empirical analysis of applicant responses. Three Metric Types were used to evaluate quality under the General Safety and Quality Metrics and Program Specific Metrics Required Metrics, Informational Metrics, and Scored Metrics: Required Metrics Absolute requirements that a facility must meet to be considered for that particular Blue Distinction Centers designation. 2

3 Informational Metrics Responses that were not used to evaluate facilities for that particular Blue Distinction Centers designation, but were collected to capture important clinical and facility information. Scored Metrics Scored Metrics examine one of the following Quality Dimensions: o Structure Availability of key clinical services, including diagnostic, medical and multidisciplinary services and features. o Process Adherence to evidence-based (or clinically based) care processes, as well as a demonstrated focus on quality improvement and patient safety. o Outcomes Patient outcomes, including complication rates and length of stay. Each Scored Metric has a Metric Specific Threshold that the applicant facility must meet to receive the point(s) assigned to that metric. Metric Specific Thresholds were set based on the following guidelines: Yes/No Questions A Yes response is required to meet the threshold and receive the assigned point(s). Numeric/Percentage Questions Most thresholds were created at one standard deviation worse than the mean performance of all applicant facilities. The facility s response must meet the threshold to receive the assigned point(s). Checkbox Questions Thresholds were created based on applicant response distribution, to differentiate performance into lower- versus higher- performing groups. The facility s response must meet the threshold to receive the assigned point(s). If a facility failed to provide a response to a particular Scored Metric, the threshold was considered unmet and the facility did not receive any points for that metric. To complete the quality evaluation successfully, a facility must meet all Required Metrics plus minimum thresholds for Scored Metrics in each of six (6) Metric Categories: three for General Quality and Safety Metrics Category and three for Program Specific Metrics Category. Table 1 below summarizes the minimum number of Scored Metrics that a facility must meet in all Metric Categories for the Spine Surgery and Knee/Hip programs, respectively: 3

4 Table 1 METRIC CATEGORY General Quality and Safety Knee and Hip Replacement Spine Surgery MINIMUM NUMBER OF SCORED METRICS Structure 4 of 9 Process 12 of 21 Outcomes 2 of 6 Structure 7 of 13 Process 3 of 6 Outcomes 9 of 13 Structure 4 of 13 Process 2 of 8 Outcomes 9 of 13 Quality Determination Facilities must meet all Required Metrics, and must also meet the minimum threshold of Scored Metrics in each of that Blue Distinction Centers program s Metric Categories, as summarized in Table 2, to be considered for Blue Distinction Centers designation. Quality is key: only those facilities that first meet the Quality Threshold of Blue Distinction Centers nationally established, objective quality measures will be considered for designation as a Blue Distinction Center. To be eligible for designation as a Blue Distinction Center, a facility must ultimately satisfy both the quality and cost of care criteria. BUSINESS SELECTION CRITERIA The business selection criteria consist of three components Facility Participation, Provider (Physician Specialists) Participation and Cost of Care. To be considered eligible for Blue Distinction Centers designation, the facility must meet all requirements in the sections below. Facility and Provider (Physician Specialists) Participation Facility Participation All facilities are required to be participating providers in the local Blue Plan s BlueCard Preferred Provider Organization (PPO) Network. Provider (Physician Specialists) Participation All Physician Specialists whom the facility identified on its RFI survey response as those who performed spine surgery and/or knee and hip replacements at that facility are required to be participating providers in the local Blue Plan s BlueCard PPO Network; any de minimis exception to this criterion will be considered on an individual case basis through a nationally consistent appeal process. 4

5 An individual Blue Plan, at its own independent discretion, may establish and apply local business requirements consistently to all facilities within its service area as additional selection criteria for eligibility in a Blue Distinction Centers for Specialty Care program for facilities located within its Service Area. Cost of Care Selection Criteria The process of incorporating cost of care measures into the selection criteria was designed to establish a nationally consistent, equitable, and objective approach for selecting Blue Distinction Centers+ that address market and consumer demand for cost savings and affordable healthcare. The following components were evaluated to determine if a facility met the cost of care selection criteria: Cost Data Source Each facility s cost of care was calculated using the average allowed amount for a specific set of inpatient procedures appropriate for that designation type. The average allowed amounts were derived from Blue Plans claims data through the National Consumer Cost Tool (NCCT ). NCCT is the same tool that Blue Plans use on a nationally consistent basis to inform consumers of the average allowed cost of typical cases for certain treatment categories at the facility level. If NCCT data was not available for a facility that was invited for Blue Distinction Centers consideration, then the local Blue Plan provided cost data for that facility, using the same methodology as NCCT. Professional and in-network facility claims were included, during the applicable time period and using the specific inpatient procedures applicable for that particular Blue Distinction Centers designation type. Cost estimates were developed under the NCCT methodology, using 12 months of claims data from , based on Blue negotiated arrangements for all in-network facilities in nearly every US ZIP code. Medicare, secondary claims and outliers were excluded. This provided a current cost estimate for accurate comparison across facilities nationally. The NCCT methodology calculates an average allowed cost of typical cases for certain treatment categories at the facility level. The methodology totals all costs (including facility, professional, and other related costs) incurred for each individual member between the date of admission and date of discharge. Procedure costs are removed for any case that falls more than two (2) standard deviations from the average for a given procedure type, so that the resulting facility costs are fair and representative. The average of the remaining cases represents the average cost of typical cases for certain treatment categories for each facility, called the Facility Procedure Cost. Cost data was evaluated for the following inpatient procedures: For Blue Distinction Centers for Knee and Hip Replacement, cost data for both of the following treatment categories was evaluated: Hip Replacement Primary Knee Replacement Primary For Blue Distinction Centers for Spine Surgery, cost data for at least two of the three following treatment categories was evaluated: Laminectomy Inpatient Spinal Fusion (Anterior) Inpatient Spinal Fusion (Posterior) Inpatient 5

6 NCCT methodology is designed in a way that already limits the prevalence of co-morbidities and variation in the population. NCCT methodology groups procedures using MS-DRGs, to remove cases with significant complications and co-morbidities. NCCT methodology also excludes cases that do not meet NCCT s own minimum volume threshold, emergent cases, and cases that do not meet a cost threshold of two (2) standard deviations from the average, which limits the variation in costs for the procedures. Geographic Adjustment A geographic adjustment factor was applied to the Facility Procedure Cost for each treatment category, to account for geographic cost variations in delivering care. Each facility cost figure was adjusted using the 2011 CMS Geographic Adjustment Factors (GAF), resulting in a separate adjusted facility cost figure for each treatment category. GAF is a cost adjustment methodology used by the federal government to adjust cost for payment differences to physicians under Medicare. The GAF adjustment is based on a variety of data sources used to estimate the cost of delivering care in specific geographic areas, including salary data from the US Census, HUD housing data, CMS claims data, and malpractice insurance carriers rate filings. GAF adjusts for wide cost variation within geographies by having a separate factor for each state, as well as breaking out metropolitan areas within states that have higher costs from a national perspective. These factors are reviewed and updated on a regular basis by CMS. For more information on the CMS Geographic Adjustment Factors, visit Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS html Deriving a Facility Cost Index Geographically Adjusted Facility Procedure Costs (calculated as described above for each of the specific treatment categories) were then converted into a single-figure Facility Cost Index, as follows. A Facility Procedure Cost Index was calculated for each treatment category, as the ratio of geographically Adjusted Facility Procedure Cost to the National Procedure Cost for each treatment category. The National Procedure Cost was the national median of all facilities geographically Adjusted Facility Procedure Costs for each treatment category. Figures for facilities with Extreme Facility Procedure Costs (defined as costs exceeding two [2] standard deviations in either direction from the national mean of all facilities geographically Adjusted Facility Procedure Cost for each procedure type) were capped, to limit their impact on skewing the National Procedure Cost. The facility s separate Facility Procedure Cost Indices for each treatment category for that Blue Distinction Centers program were averaged to form a single-figure Facility Cost Index. The Facility Cost Index is precise to the level. This nationally applied methodology equalizes the various treatment categories for each designation type so that they can be compared equitably, regardless of regional practice patterns. The Facility Cost Index was then used to compare the facility s costs to the National Cost Threshold to determine eligibility for that Blue Distinction Center+ program. Setting the National Cost Threshold The National Cost Threshold was set as a national benchmark, relative to the distribution of the Facility Cost Indices of a national provider population, including applicants and non-applicants, for each designation program. This threshold was determined by evaluating geographically adjusted costs at a national level, and was used to identify facilities demonstrating comparative cost efficiency that also met defined quality selection criteria and other program requirements for Blue 6

7 Distinction Centers program eligibility. Important considerations in determining the threshold included meeting marketplace expectations for episode cost savings, while accommodating members access to care National Cost Thresholds Blue Distinction Centers for Spine Surgery: 1.05 Blue Distinction Centers for Knee and Hip Replacement: 1.05 Comparing Facility Cost Index to National Cost Threshold The Facility Cost Index must be equal to or less than the National Cost Index Threshold for a facility to meet the cost of care selection criteria based on Cost Index. To be eligible for designation as a Blue Distinction Center+, a facility must ultimately satisfy the quality, business and cost of care selection criteria. The Blue Cross and Blue Shield Association may make access considerations as needed to support our members in accessing Blue Distinction Centers, while achieving the program s overall goal of providing differentiated performance on quality and, for the Blue Distinction Center+ designation, cost of care. 7

8 TABLE 2 General Quality and Safety Metrics (Applies to Both Knee and Hip Replacement and Spine Surgery Designations) METRIC CATEGORY RFI # EVALUATION COMPONENTS REQUIRED Facility Accreditation 4 The facility is fully accredited by at least one of the following national accreditation organizations*: The Joint Commission (TJC) (without provision or condition). Healthcare Facilities Accreditation Program (HFAP) of the American Osteopathic Information Association (AOIA). National Integrated Accreditation Program for Healthcare Organizations (NIAHO SM ) of Det Norske Veritas Healthcare, Inc., (DNVHC). *To enhance quality while improving Blue Members access to qualified providers, alternate Local Accreditations that are at least as stringent as any National Accreditations, above, may be offered as a Local Blue Plan Requirement; for details, contact the facility s Local Blue Plan. Surgical Safety Checklist Comprehensive Inpatient Facility 22 40, OR 40a, b, and c The facility uses a surgical safety checklist that includes a pre-procedure verification process, marking of the procedure site, and a pre-procedure time-out for all invasive procedures, and is modeled after at least one of the following national quality improvement surgical safety initiatives: 1. Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. 2. World Health Organization Surgical Safety Checklist. An example of a Comprehensive Surgical Checklist was published by the Association of perioperative Registered Nurses (AORN). Facility is a comprehensive acute care facility that offers ALL of the following services on site: Intensive care unit. Emergency room or Emergency Services that include plans or systems for onsite emergency admission of post-operative patients with 24/7 availability of onsite medical response teams. 24/7 availability of in-house emergency physician coverage. Diagnostic radiology including MRI and CT. 24/7 availability of inpatient pharmacy services (may include alternative night-time access when pharmacy is closed). Blood bank or 24/7 access to blood bank services. 24/7 availability of Clinical Laboratory Improvement Amendments (CLIA) accredited laboratory services. 8

9 METRIC CATEGORY RFI # EVALUATION COMPONENTS GENERAL STRUCTURE American Nurses Credentialing Center 5 (ANCC) Magnet Recognition The facility is currently recognized as a American Nurses Credentialing Center (ANCC) Magnet hospital. For more information on ANCC, see: Health Information Technology (HIT) 11 The facility utilizes an electronic health record (EHR) that is certified by: A health information technology certification entity (e.g., Certification Commission for Health Information Technology [CCHIT]). For a list of approved certification and testing organizations, see: 13 The facility utilizes Computerized Physician Order Entry (CPOE). Governance Board Engagement The facility is able to share patient information electronically, for clinical care purposes, with providers outside of the facility (in accordance with all privacy and security rules). The facility s governance board holds executive leadership accountable for facility performance in regards to clinical quality and patient safety, as evidenced by: Including quality and safety goals in the performance review process. Linking compensation to performance on clinical quality and safety goals. Pharmacy Leadership 26 The facility has a policy for mandatory reporting of medication errors to pharmacy leadership. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) defines a medication error as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use. Peri-operative Leadership 27 Peri-operative department/area leaders at the facility have an active role in administration leadership with authority for peri-operative department performance within the organization. 9

10 METRIC CATEGORY RFI # EVALUATION COMPONENTS Association of American Medical Colleges (AAMC) Principles 30 The following criterion applies only if the facility conducts clinical trials. The Association of American Medical Colleges (AAMC) Principles for Protecting Integrity In the Conduct and Reporting of Clinical Trials are accepted by the facility. For more information on these principles, see: the Association of American Medical Colleges (AAMC) website at Nursing Sensitive Measures 34 The facility tracks and reports at least five of the following nursing sensitive measures to the facility Chief Executive Officer (CEO) (or equivalent) or participates in the National Database for Nursing Quality Indicators (NDNQI): Patient Falls: All documented falls with or without injury, experienced by patients on an eligible unit in a calendar month. Falls with Injury: All documented patient falls with an injury level of Minor or greater. Pressure Ulcer Prevalence. Restraint Prevalence (vest and limb). Skill Mix: Percentage of hours worked by: RN, LPN/LVN, UAP, Contract/Agency. Hours per patient day worked by RN, LPN, and UAP. Practice Environment Scale-Nursing Work Index (job satisfaction). Voluntary turnover for RN, APN, LPN, UAP. GENERAL PROCESS 10

11 METRIC CATEGORY RFI # EVALUATION COMPONENTS Patient Safety Training & Education Care Transitions Ventilator Associated Pneumonia (VAP) The facility provides training and education to all employees on patient safety that is consistent with the recommendations in National Quality Forum Safe Practice #3 (Teamwork Training and Skill Building). For more information on patient safety training and education, see: The facility s physician credentialing requirements include patient safety training and education that are consistent with the recommendations in National Quality Forum Safe Practice #3 (Teamwork Training and Skill Building). For more information on patient safety training and education, see: The facility has a formal method to measure and continuously improve transitions of care for patients discharged or transferred to another healthcare setting, which includes at least four of the following transition of care practices: Preparation for discharge occurring, with documentation, throughout the hospitalization. Reliable information flow from the primary care physician or referring caregiver on admission, to the hospital caregivers, and back to the primary care physician after discharge, using standardized communication methods. Completion of discharge plan and discharge summaries before patient discharge. Patient/family perception of coordination of discharge processes. For more information about care transitions, see: (Safe Practice #15: Discharge Systems) The facility tracks all-cause hospital readmissions and has a performance improvement plan in place to prevent avoidable hospital readmissions. The facility takes actions to monitor medication reconciliation; collects data, and incorporates data into a quality improvement process, with attention given to transition points in care (admission, transfer, discharge). For more information on medication reconciliation, see National Quality Forum Safe Practice 17: The facility takes actions to measure, monitor, and prevent Ventilator Associated Pneumonia (VAP), by implementing evidence-based interventions similar to those outlined in the National Quality Forum Safe Practices (Safe Practice #23). 11

12 METRIC CATEGORY RFI # EVALUATION COMPONENTS Central-Line Associated Bloodstream Infection (CLABSI) Surgical Site Infection (SSI) The facility takes actions hospital-wide to measure, monitor (including reporting data on a quarterly basis as a part of the facility s quality improvement process) and prevent Central Line Associated Bloodstream Infections (CLABSI) by implementing evidence-based interventions similar to those outlined in the National Quality Forum Safe Practices (Safe Practice #21). The facility takes actions to measure, monitor, and prevent Surgical Site Infection (SSI), by implementing evidence-based interventions similar to those outlined in the National Quality Forum Safe Practices (Safe Practice #22). Sepsis Management 19 The facility takes action to improve or maintain high levels of achievement for sepsis survival rates, by utilizing evidence-based sepsis protocols (e.g., Sepsis Resuscitation Bundles and Sepsis Management Bundles developed as part of the Surviving Sepsis Campaign). Multidisciplinary Rounds (MDR) in the Intensive Care Unit (ICU) Governance Board Engagement For more information about sepsis management, see: or The facility s intensive care unit(s) (ICUs) have established processes/procedures for conducting multidisciplinary rounds (MDR), which include (at least) the following: Who is involved? What is discussed? Where MDR take place? When MDR occur? How are MDR incorporated into physicians daily patient care rounds? The Institute for Healthcare Improvement (IHI) has additional resources for implementing Multidisciplinary Rounds, see: The facility s governance board dedicates at least 25 percent of its meeting time to quality, patient safety, performance measurement and improvement issues. For more information on engaging hospital boards in quality and patient safety, visit the Institute for Healthcare Improvement s (IHI) website at Pharmacy Leadership 25 Pharmacy leaders have an active role in administration leadership, with authority for medication management systems performance across the organization. For more information, see: National Quality Forum Safe Practice #18: Pharmacist Leadership Structures and Systems: 12

13 METRIC CATEGORY RFI # EVALUATION COMPONENTS Conflict of Interest (COI) Disclosure Surgical Care Improvement Project (SCIP) Patient Experience Quality Improvement a-c 37a- b 42 The facility has a formal conflict of interest (COI) policy on financial relationships with pharmaceutical companies or device manufacturers, which includes documented disclosure requirements for individuals including those who conduct research and provide education, those who provide clinical care, and senior institutional officials. The facility reports publicly on COI disclosures on financial relationships with pharmaceutical companies or device manufacturers made by all individuals (including those who conduct research and provide education, those who provide clinical care, and senior institutional officials). The facility has a written policy or process for selecting implantable devices to be used at the institution. The facility reports its Surgical Care Improvement Project (SCIP) results on the Hospital Compare website relating to prophylactic antibiotic use. INF-1 is >95% INF-2 is >95% INF-3 is >93% The facility reports its Surgical Care Improvement Project (SCIP) results on the Hospital Compare website relating to venous thromboembolism prophylaxis. VTE-1 is >91% VTE-2 is >89% The facility has implemented an intervention in a medical or surgical clinical area that improved patient satisfaction/experience score(s), on at least one patient satisfaction/experience measure, by no less than two percent, and provides a description of an intervention in a medical or surgical clinical area that improved patient satisfaction/experience score(s) that includes the clinical area in which the intervention was implemented, what intervention was implemented, and pre- and postintervention data that show the percentage of improvement. GENERAL OUTCOMES Central Line Associated Bloodstream Infection (CLABSI) 38 The facility reports the number of Central Line Associated Blood Stream Infections (CLABSI) and the number of central line days for each type of intensive care unit (ICU) provided at the facility for combined calendar years 2009 and 2010 with an Overall CLABSI Standardized Infection Ratio (SIR) of <

14 METRIC CATEGORY RFI # EVALUATION COMPONENTS Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) INFORMATIONAL Health Information Technology (HIT) Catheter Associated Urinary Tract Infections (CAUTI) 41a The facility reports its Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results on the Hospital Compare website. Nurses Always communicated well: >70% Physicians Always communicated well: >74% Always received help as soon as they wanted: >55% Pain Always well controlled: >64% Staff Always explained about medication before giving it to them: >54% The facility utilizes an electronic health record (EHR) that is certified by: An authorized Testing and Certification Body (ONC-ATCB) compliant with the requirements for measuring meaningful use objectives under the Centers for Medicare and Medicaid Services EHR Incentive Program Final Rules. For a list of approved certification and testing organizations, see: The facility takes actions to measure, monitor, and prevent Catheter Associated Urinary Tract Infections (CAUTI), by implementing evidencebased interventions similar to those outlined in the National Quality Forum Safe Practices (Safe Practice #25). Sepsis Management 20 The facility tracks sepsis survival data and incorporates data results in a quality improvement process. Patient Family Advisory Council (PFAC) Engagement with Patient Safety & Quality Improvement Organization 28 29, 29a The facility has a Patient Family Advisory Council (PFAC) or engages patients/families as advisors at the highest levels of the organization. The facility is engaged with national, regional, or local collaborative organization(s) focused on patient safety and quality improvement and that possess the following characteristics: Instruction for the collection and evaluation of specific quality indicators and/or process improvement. Encourage best practice sharing. Provide educational activities for participating facilities to promote quality improvement. An example of a collaborative organization that focuses on patient safety and quality improvement that offers this level of engagement is the Institute for Healthcare Improvement (IHI). 14

15 METRIC CATEGORY RFI # EVALUATION COMPONENTS Engagement with Patient Safety & Quality Improvement Organization 29b The facility engages in national, local, or regional collaborative organization(s) activities focused on patient safety and quality improvement in (at least) the following ways: Collects and evaluates quality indicator data and/or implements and evaluates quality improvement process as instructed by the collaborative organization(s). Utilizes these quality indicator data outcomes and/or audit of quality process to develop changes in the facility s quality improvement program. Participates in the sharing of best practices. Participates in educational activities provided by the collaborative organization(s), as appropriate. The facility reports publicly on The Leapfrog Group s website on at least one of the following initiatives, by participating in the Leapfrog Group Quality and Safety Hospital Survey: Leapfrog 35 Computerized Physician Order Entry (CPOE). Evidence-Based Hospital Referral (EBHR). Common Acute Conditions (CAC). ICU Physician Staffing (IPS). Leapfrog Safe Practices Score (SPS). Hospital-Acquired Conditions. Managing Serious Errors. NQF Safe Practices. Smooth Patient Scheduling (SPSC). Patient Experience of Care. For more information on Leapfrog, see: Surgical Care Improvement Project (SCIP) The facility reports its Surgical Care Improvement Project (SCIP) results on the Hospital Compare website relating to prophylactic antibiotic use. The facility reports its Surgical Care Improvement Project (SCIP) results on the Hospital Compare website relating to venous thromboembolism prophylaxis. 15

16 METRIC CATEGORY RFI # EVALUATION COMPONENTS The facility has a policy(s) that address communication and supportive care for patients/families in the intensive care unit (ICU), which includes (at least) the following: Intensive Care Unit (ICU) Communication 39 Identification and documentation of a proxy decision-maker. Documentation of advanced directives. Documentation of cardiopulmonary resuscitation (CPR) status. Pain assessment and documentation. Dyspnea assessment and documentation. Documentation of provision of written educational materials to patient/family. Scheduling of family meeting (including discussion of patient prognosis and patient goals). Evaluation and documentation of need for spiritual care. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) 41 The facility reports its Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results on the Hospital Compare website. Patient Experience Quality Improvement 42a The facility provides a description of an intervention in a medical or surgical clinical area that improved patient satisfaction/experience score(s) including the clinical area in which the intervention was implemented, what intervention was implemented, and pre- and postintervention data that show the percentage of improvement. 16

17 Knee and Hip Replacement Metrics TYPE/ CATEGORY KNEE/HIP REQUIRED RFI # Facility Volume 67 EVALUATION COMPONENTS Total joint replacement case volume performed at the applicant facility must be at least 250 procedures in adult patients at least 18 years of age during the period from 7/1/2010-6/30/2011. Facility Primary Total Knee Outcomes Analysis Facility Primary Total Hip Outcomes Analysis The program must report outcomes data on a minimum of 50 consecutive Primary Total Knee Replacement procedures that meet the Patient Population for Analysis criteria defined in the RFI survey. (Up to two years of cases may be included.) The program must report outcomes data on a minimum of 50 consecutive Primary Total Hip Replacement procedures that meet the Patient Population for Analysis criteria defined in the RFI survey. (Up to two years of cases may be included.) KNEE/HIP STRUCTURE Formal Program Structure 44 The facility has a formal joint replacement program structure with ALL of the following characteristics: Program has committed leadership including both clinical and administrative leaders. Program leadership shares a unified vision and goals regarding collaboration of a multidisciplinary team and mutual accountability for delivering patient-centered care. Program has established written policies, procedures and guidelines that provide care coordination during inpatient episodes of care. Program has processes to monitor adherence of written policies, procedures and guidelines. Dedicated Unit 45 The facility has a dedicated floor (or unit) that is utilized for providing care to the majority (at least 75 percent) of knee and hip replacement patients treated in the program in order to enhance use of care pathways and subspecialty care for patients. Multidisciplinary Care Team 46 The program s core multidisciplinary care team includes representation from ALL of the following disciplines/departments for routine episodes of care: Anesthesiology. Nursing. Physical Therapy/ Occupational Therapy. Dedicated case managers who act as care coordinators for complex patients. 17

18 TYPE/ CATEGORY Guidelines and/or Protocols Guidelines and/or Protocols RFI # EVALUATION COMPONENTS The program has established written guidelines and/or protocols in at least four of the following areas that are evidence-based (as available) for the care of knee and hip replacement patients at this facility: Infection prevention. Acute pain management in peri-operative surgical patients. Assessment and treatment of physical therapy/rehabilitative needs in post-operative care. Thromboprophylaxis during the peri-operative period and after discharge (as appropriate). Blood management guideline to prepare patients for surgery and to guide when to transfuse blood, if needed, with a goal to minimize blood use. Implant guideline to guide selection of implants for each patient, as appropriate, based on factors such as age, activity level, and other patient selection needs. Cement guideline for surgeon and nursing personnel to properly mix and use bone cement with a goal to reduce cement errors and optimize cement usage. The program performs audits to monitor compliance and effectiveness in at least three or more of the following guidelines and/or protocols: Infection prevention. Acute pain management in peri-operative surgical patients. Assessment and treatment of physical therapy/rehabilitative needs in post-operative care. Thromboprophylaxis during the peri-operative period and after discharge (as appropriate). Blood management guideline to prepare patients for surgery and to guide when to transfuse blood, if needed, with a goal to minimize blood use. Implant guideline to guide selection of implants for each patient, as appropriate, based on factors such as age, activity level, and other patient selection needs. Cement guideline for surgeon and nursing personnel to properly mix and use bone cement with a goal to reduce cement errors and optimize cement usage. 18

19 TYPE/ CATEGORY Multidisciplinary Clinical Pathways Data Management and Patient Tracking Continuous Quality Improvement (CQI) and Data Management Continuous Quality Improvement (CQI) and Data Management Surgeon Certification and Training RFI # EVALUATION COMPONENTS The program uses multidisciplinary clinical pathways (also known as critical pathways or care pathways ) for the care of knee and hip replacement patients and the program's multidisciplinary clinical pathways must have at least six of the following components: Are utilized routinely for all patients as clinically appropriate. Define treatment goals. Outline sequence and timing of interventions. Describe active participation of a multi-disciplinary team. Describe coordination of care for discharge, patient education, and other patient needs. Address the full continuum of care across inpatient and outpatient settings. Generate standardized pre- and post-operative order sets. Require specific physician orders to deviate from the pathway/standing order protocol. Are placed in the medical record or part of the electronic medical record for daily use by all care providers. Are developed with consultation of appropriate resources such as clinical guidelines and national standards. The program has an established registry or database to collect, track, and internally report outcomes data on all knee and hip replacements performed at the facility. The program has a formal Continuous Quality Improvement (CQI) program in place for knee and hip replacement services that includes the following: Collection of quality indicator data. Analysis of collected data with identification of issues. Development of improvement goals to implement changes. At least two of the following components is included in the program s CQI process for collection, tracking, and reporting of outcome data. Complications during the episode of care. Reoperations that occur within 12 months. Revisions where both the primary and revision were done at your facility. Patient satisfaction/experience specific to knee and hip replacement patients. At least 86% of the program's surgeons on the knee and hip replacement team are Board Certified (or in the process of becoming Board Certified) in Orthopedic Surgery by the American Board of Medical Specialties, the American Osteopathic Board of Surgery, or the Royal College of Physicians and Surgeons. At least 34% of the program s surgeons on the knee and hip replacement team participate in American Board of Medical Specialties (ABMS) Maintenance of Certification (MOC), Royal College of Physicians and Surgeons of Canada MOC or American Osteopathic Association (AOA) Osteopathic Continuous Certification (OCC) programs. 19

20 TYPE/ CATEGORY Surgeon Volume KNEE/HIP PROCESS RFI # EVALUATION COMPONENTS At least 21% of the program s active surgeons performed at least 50 total joint replacements in the most recent 12 months. Total volume can combine all total knee and/or hip replacement procedures, including both primary and revision procedures done at the applicant facility. At least 44% of the program s active surgeons performed at least 25 total joint replacements in the most recent 12 months. Total volume may combine all total knee and/or hip replacement procedures, including both primary and revision procedures done at the applicant facility as well as at other facilities. Transitions of Care 52 Patient Selection 53 At least one of the following communication processes is supported by the program to manage transition of care upon discharge of a patient from the facility. The program s licensed clinician (e.g., NP, PA, MD) personally speaks with the Primary Care Physician (PCP) or a licensed clinician (e.g., NP, PA, MD) working with the PCP. Program communicates with the PCP and ensures that the operation note and discharge note are made available upon discharge. The program has written patient selection criteria that are applied to all adult patients being considered for knee and hip replacement surgery. Shared Decision Making (SDM) 54 The program employs "Shared Decision Making" (SDM) processes as defined below: SDM does not refer simply to the process of obtaining informed consent. Rather, SDM refers specifically to a process of decision-making about treatment options that includes: A discussion between the patient and a health care professional regarding options circumstances and preferences. A patient-centered shared decision-making aid (e.g., booklet, video). Patient decision aids are tools that help people become involved in decision making by providing information about the options and outcomes and by clarifying personal values. They are designed to complement, rather than replace, counseling from a health care professional. Patient Education 55 The program provides one or more of the following pre-operative patient education activities: Educational group session or class. Interactive electronic media program. Materials provided to the patient (print, video). Written questionnaire completed by the patient. 20

21 TYPE/ CATEGORY Continuous Quality Improvement (CQI) and Data Management Functional Assessments RFI # EVALUATION COMPONENTS The CQI program has a protocol in place for patient follow-up (as described below) in the first year post-operatively. Patient follow-up protocol, at minimum, should include obtaining patient outcome data/status information. Such information may be obtained either in-person or through phone follow - up with the patient or their current care provider. The program routinely uses a nationally recognized functional assessment tool (e.g., stair-stepping, distance walked unaided, Harris Hip Score, Knee Society Score, etc.) to evaluate knee and hip replacement patients both preoperatively and post-operatively. KNEE/HIP OUTCOMES 69b A re-operation rate within 90 days after surgery due to peri-prosthetic Infection <1.0%. Primary Total Knee Replacement Complication Rates 69c A re-operation rate within 90 days after surgery on the same joint due to mechanical complications (excluding closed-reductions) <0.7%. 69d An unplanned re-admission rate within 30 days after discharge <5.7%. 69e A venous thromboembolism (VTE) rate within 30 days after surgery <1.9%. 69f A surgical site infection rate within 30 days after surgery <1.4%. Length of Stay (LOS) 69g 70b The average length of stay (LOS) in days for Primary Total Knee Replacement patients < 3.9 days. A re-operation rate within 90 days after surgery due to peri-prosthetic Infection <1.4%. Primary Total Hip Replacement Complication Rates 70c A re-operation rate within 90 days after surgery on the same joint due to mechanical complications (excluding closed-reductions) <1.7%. 70d An unplanned re-admission rate within 30 days after discharge <6.7%. 70e A venous thromboembolism (VTE) rate within 30 days after surgery <1.3%. 70f A surgical site infection rate within 30 days after surgery <2.0%. Length of Stay (LOS) Knee/Hip Outcomes 70g 71 The average length of stay (LOS) in days for Primary Total Hip Replacement patients < 4.2 days. At least 37% of patients who were admitted from home and treated at the program from 7/1/2010 6/30/2011 were discharged directly back to home. 21

22 TYPE/ CATEGORY INFORMATIONAL RFI # Duration 43 EVALUATION COMPONENTS The program has been performing knee and hip replacement surgery continuously for at least 12 uninterrupted months immediately preceding completion of this RFI. Multidisciplinary Care Team Shared Decision Making (SDM) Data Management and Patient Tracking Surgeon Certification and Training Facility Volume Facility Primary Total Knee Outcomes Analysis Primary Total Hip Replacement Complication Rates Functional Assessments a-b a-d, 68 69a 70a 73, 74 75, 76, 77, 78 The facility provides availability of comprehensive consultation services on site (e.g., Cardiology, Pulmonology, General Surgery, Internal Medicine, Psychiatry/Psychology, Pain Management, Critical Care, Physiatry/Physical Medicine/Rehabilitation, Endocrinology, Nephrology, Infectious Disease, Neurology, Interventional Radiology, Nutrition, and Social Services). The program s knee and hip replacement team conducts multidisciplinary team meetings or multidisciplinary case management conferences on a regular basis (at least monthly). The program employs "Shared Decision Making" (SDM) processes and solicits patient feedback about their SDM process and uses a formal tool and/or process to conduct SDM. The program submits data in order to track knee and hip replacements to at least one of the following national or multi-center registries or databases: American Joint Replacement Registry (AJRR). National Surgical Quality Improvement Program (NSQIP). University HealthSystem Consortium (UHC). Premier Clinical Advisor. Program provides the names of all surgeons who are actively performing knee and hip replacement surgery at the facility along with the surgeon's Type 1 National Provider Identifier (NPI) number. Case volume performed at the applicant facility is reported for all patients at least 18 years of age during the period from 7/1/2010 6/30/2011 for the following: Total Hip Replacement Revision Hip Replacement Total Knee Replacement Revision Knee Replacement Rates of Primary Total Knee Replacement patients who experienced the following complications: A re-operation within 90 days after surgery due to any reason. Rates of Primary Total Hip Replacement patients who experienced the following complications: A re-operation within 90 days after surgery due to any reason. Percent of the program's knee and hip replacement patients that have undergone both pre- and post-operative functional assessments at 6 and 12 months after surgery Primary Total Knee and Primary Total Hip Replacement patients who underwent pre-and post-operative functional assessments demonstrated clinical success at 6 and 12 months after surgery. 22

23 TYPE/ CATEGORY RFI # 79 EVALUATION COMPONENTS The following functional assessment tool(s) are used by the program. Harris Hip Score (HHS) Knee Society Score (KSS) Health Survey Short Form-36 Health Survey Short Form-12 Western Ontario and McMaster Osteoarthritis Index (WOMAC) Distance walked unaided Stair-stepping Other 23

24 Spine Surgery Metrics TYPE/CATEGORY RFI # EVALUATION COMPONENTS SPINE REQUIRED Surgeon Certification and Training 104 There are at least 2 surgeons who are actively performing spine surgery at the facility. Facility Volume 108 Total spine surgery case volume performed at the applicant facility must be at least 100 procedures during the period from 7/1/2010-6/30/2011. Facility 1 or 2 Level Primary Posterior Lumbar Fusion + Decompression Outcomes Analysis Facility Single Level Primary Anterior Cervical Fusion Outcomes Analysis SPINE STRUCTURE Formal Program Structure The program must report outcomes data on a minimum of 50 consecutive 1 or 2 Level Primary Posterior Lumbar Fusion + Decompression procedures that meet the Patient Population for Analysis criteria defined in the RFI survey. (Up to two years of cases may be included.) The program must report outcomes data on a minimum of 50 consecutive Single Level Primary Anterior Cervical Fusion procedures that meet the Patient Population for Analysis criteria defined in the RFI survey. (Up to two years of cases may be included.) The facility has a formal spine surgery program structure with ALL of the following characteristics: Program has committed leadership, including both clinical and administrative leaders. Program leadership shares a unified vision and goals regarding collaboration of a multidisciplinary team and mutual accountability for delivering patient-centered care. Program has established written policies, procedures and guidelines that provide care coordination during inpatient episodes of care. Program has processes to monitor adherence of written policies, procedures and guidelines. Dedicated Unit 82 The facility has a dedicated floor (or unit) that is utilized for providing care to the majority (at least 75 percent) of spine surgery patients treated in the program in order to enhance use of care pathways and subspecialty care for patients. 24