Making Quality Reporting and Improvement Everyone s Responsibility

Transcription

1 Making Quality Reporting and Improvement Everyone s Responsibility October 16, 2013 Announcements November 1, 2013, is the next deadline for Clinical Data and Population and Sampling Data submission from Q (April June). The submission period for web-based measures is currently open until November 1, 2013 (please submit early to avoid any problems). The next Hospital Compare preview period will be open November December for Q2 Q and Q1 2013, for display in January /16/ Announcements The CDAC is expected to mail requests for Q (April June) validation records on approximately November 30, The CY 2014 OPPS/ASC Final Rule is expected to be displayed on November 1, /16/

2 Continuing Education Credit This program has been approved for 1.0 continuing education hour given by CE Provider # for the following professions: Florida Board of Nursing Florida Board of Clinical Social Work, Marriage and Family Therapy, and Mental Health Counseling Florida Board of Nursing Home Administrators Florida Council of Dietetics Florida Board of Pharmacy 10/16/ Continuing Education Credit Please fill out the survey you will receive after the webinar, and follow instructions from there to register at the Learning Management Center and obtain your CE Certificate of Completion. Professionals that are licensed by approved Florida Boards will have their CE credit submitted to CE Broker. Professionals licensed in other states will receive a Certificate of Completion to submit to their Boards. 10/16/ Save the Date Upcoming Hospital OQR Program educational webinars: November 20 CY 2014 Final Rule January Hospital OQR Specifications Manual Revisions February 19 Hospital OQR Program Validation Analysis Q Q /16/

3 Learning Objectives At the conclusion of the program, attendees will be able to: Identify policies, procedures, and tools used to assist Hospital OQR staff in meeting hospital outpatient quality reporting and improvement goals; Discuss how a Quality Improvement Organization (QIO) can assist hospitals in meeting outpatient measures. 10/16/ Hahnemann University Hospital Philadelphia, Pennsylvania Tracy Swartz, RN, BSN, CEN Director of Emergency Services Hahnemann University Hospital Tertiary care institution with a large percentage of beds dedicated to intensive care 496 bed academic medical center 303 telemetry monitored beds Level I Regional Resource Trauma Center 32 bed emergency department Annual volume of 48,000 visits per year 10/16/

4 Q Q Improvements OP-18b: Median Time from ED Arrival to ED Departure for Discharged ED Patients 172 minutes decreased to 126 minutes OP-20: Door to Diagnostic Evaluation by a Qualified Medical Professional 40 minutes decreased to 32 minutes 10/16/ Scope, Focus, and Approach Direct observations and data analysis of operational, clinical, and financial data were evaluated to develop recommendations. ED front, middle, and end process reviewed Patient access registration process Staffing ED staff development Ancillary services lab and imaging Admission process bed management Patient throughput inpatient discharge process Case management 10/16/ Workflow Analysis Key findings: Patient access registration times exceed recommended standards Registration process is delaying patient evaluation by triage nurse Fragmented arrival process and triage; pull til full implemented Both lab and imaging turnaround too long Waiting for physician approval delays expediting patient care 10/16/

5 Workflow Analysis Key findings: Admission process to request inpatient bed is excessive and has too many steps Opportunity for improvement exists in front, middle, and back end throughput processes in the ED Length of Stay for both ED admits and discharges exceed Tenet and national average benchmarks Late afternoon inpatient discharges has reduced the ED s ability to maintain operations 10/16/ Outcome Hahnemann University Hospital Outcome Analysis ED Visits by Disposition Source: Hahnemann MedHost Data 10/16/ OP-18b: Median Time from ED Arrival to ED Departure for Discharged ED Patients 172 minutes decreased to 126 minutes ED/Medicine task force developed Lab and radiology process flow reviewed and opportunities to improve identified Fast Track pull til full implemented Level 3 patients permitted to be seen in Fast Track when needed Flow Coordinator position developed 10/16/

6 OP-20: Door to Diagnostic Evaluation by a Qualified Medical Professional 40 minutes decreased to 32 minutes Pull til full triage as a process not a location New greeter position patients bypass registration and go directly to greeter or triage nurse Triage process changed from a one-at-a-time to multiple patients at a time Registration process streamlined Bedside registration 10/16/ Flow Coordinator Rounds each shift with Attendings Rounds with Charge RN Attends AM Bed Meetings Updates Shift Director Communicates with Triage/Admitting Team Monitors waiting room Calls Admissions with admissions Communicates with primary RN bed situation Monitors transport times of patients Notifies clerks of pending admissions Updates patients of admission/bed status 10/16/ Contact Information For additional information, please contact: Tracy Swartz, RN, BSN, CEN Emergency Department Nursing Director Hahnemann University Hospital tracy.swartz@tenethealth.com 10/16/

7 Bon Secours Community Hospital Port Jervis, New York Katie Adams, BSPA, RN, Director of Performance Improvement and Tobie Westward Milone, BSN, RN Quality Improvement Coordinator Bon Secours Community Hospital Shares resources as one of three area hospitals in the Bon Secours Charity Health System 137 beds for acute care, medical/surgical treatment, long-term-care, behavioral services 10/16/ Q Q Improvements OP-1: Median Time to Fibrinolysis OP-2: Fibrinolytic Therapy Received Within 30 Minutes OP-4: Aspirin at Arrival OP-5: Median Time to ECG OP-6: Timing of Antibiotic Prophylaxis 10/16/

8 A Picture is Worth a Thousand Words 10/16/ In-House Education Orientation What and why Posters, handouts, badges Post-monthly patient summaries Review Specifications Manual Data Dictionary Monthly communications Medical/Surgical staff meetings 10/16/ Track Communications CMS Support Contractor QIO 10/16/

9 IPRO Data Checklist 10/16/ IPRO Hospital OQR Checklist 10/16/ IPRO Outpatient Data Submission Outreach 10/16/

10 Using CART for QualityNet 10/16/ IPRO Quality Reporting Calendar 10/16/ IPRO Newsletter 10/16/

11 IPRO Hospital OQR Education 10/16/ Contact Information For additional information, please contact: Kate Adams, BSPA, RN Director of Performance Improvement Bon Secours Community Hospital Bon Secours Charity Health System 10/16/ Palo Verde Hospital Blythe, California Kimberlee Duncan, RN, MSN, MHCA, CPHQ Quality Assurance/Risk Management 11

12 Palo Verde Hospital Licensed for 51 patient beds 4 intensive care 6 perinatal 41 medical-surgical Quality Hotline promoted for patients 10/16/ Q Q Improvements OP-3b: Median Time to Transfer to Another Facility for Acute Coronary Intervention 242 minutes decreased to 74 minutes OP-4: Aspirin at Arrival 52.6% increased to 82.9% OP-5: Median Time to ECG 13.5 minutes decreased to 8.5 minutes OP-6: Timing of Antibiotic Prophylaxis 100% 10/16/ Commitment to Quality Aim to make a good first impression of the hospital in the ED Updated quality plan Timely, efficient, high quality care Streamline patient flow Modified fast-track Bedside registration 10/16/

13 Electronic Health Records (EHRs) EHR upgrade benefits: User friendly Times captured more accurately Patient information reports readily available, making corrections easier to manage 10/16/ Q Q Improvements OP-7: Prophylactic Antibiotic Selection for Surgical Patients 100% OP-18b: Median Time from ED Arrival to ED Departure for Discharged ED Patients 165 minutes decreased to 100 minutes OP-20: Door to Diagnostic Evaluation by a Qualified Medical Professional 33 minutes decreased to 17 minutes 10/16/ Answer questions Abstraction assistance Reminders Memos Webinars QIO Assistance 10/16/

14 Contact Information For additional information, please contact: Kimberlee Duncan, RN, MSN, MHCA, CPHQ Quality Assurance/Risk Management Palo Verde Hospital 10/16/ Mercy Hospital of Folsom Folsom, California Margaret Thompson, RN, MSN, CPHQ Director of Quality 10/16/ Mercy Hospital of Folsom Dignity Health System Share best practices 10/16/

15 Q Q Improvements OP-1: Median Time to Fibrinolysis OP-2: Fibrinolytic Therapy Received Within 30 Minutes OP-3b: Median Time to Transfer to Another Facility for Acute Coronary Intervention OP-4: Aspirin at Arrival OP-5: Median Time to ECG OP-6: Timing of Antibiotic Prophylaxis OP-7: Prophylactic Antibiotic Selection for Surgical Patients 10/16/ Outpatient Quality Reporting Improvement Methodologies Implement concurrent review of all patients potentially in core measure population. Quality RN reviews every admit Monday Friday. Notify Nursing by 8:00 a.m. to review indicators and implementation. 10/16/ OP-5: Median Time to ECG Made a priority by ED Director two years ago Purchased additional machines to be readily available 10/16/

16 OP-7: Antibiotic Selection O.R. hard stop for antibiotic selection/timing review Antibiotic administration held until the patient is in pre-op holding No longer begun on the nursing units 10/16/ Future Improvement Strategy OP-2: Fibrinolytic Therapy Received Within 30 Minutes 10/16/ Contact Information For additional information, please contact: Margaret Thompson, RN, MSN, CPHQ Director of Quality Mercy Hospital of Folsom 10/16/

17 Jackson Hospital Marianna, Florida Nichole Ussery, RN, BSN, LHRM Quality Director Jackson Hospital 100 bed community healthcare system 30+ physicians 10/16/ Q Q Improvements OP-3b: Median Time to Transfer to Another Facility for Acute Coronary Intervention 161 minutes decreased to 120 minutes OP-5: Median Time to ECG 18 minutes decreased to 9 minutes OP-6: Timing of Antibiotic Prophylaxis 57.1% increased to 86.4% OP-7: Prophylactic Antibiotic Selection for Surgical Patients 75.9% increased to 100% 10/16/

18 Everyone is responsible! 10/16/ Outpatient Quality Reporting Improvement Step 1 Core Measures Team and Director Surgical Committee QI Committee Develop core measure policies Meet to discuss pitfalls and issues Identify corrective measures Develop tools 10/16/ Outpatient Quality Reporting Improvement Step 2 Mandatory Education Include CNAs and Ward Clerks Anyone who touches charts Encourage questions to make correct choices 10/16/

19 Outpatient Quality Reporting Improvement Step 3 Specification sheets for each measure Helpful tips on backside List drug indications Signature lines state who did what 10/16/ Core Measures Concurrent Review 10/16/ Outpatient Quality Reporting Improvement Step 4 All levels of staff are accountable Daily follow-up Failure Reports Refusal to act is documented Peer Review Process Justified Unjustified Referrals A chance to improve performance 10/16/

20 Contact Information For additional information, please contact: Nichole Ussery, RN, BSN, LHRM Quality Director Jackson Hospital 10/16/ We Will Now Open the Phone Lines for Q&A This program is approved for a 1.0 continuing education hour. Please fill out the survey you will receive after the webinar, and follow instructions from there to register at the Learning Management Center and obtain your CE Certificate of Completion. Professionals that are licensed by approved Florida Boards will have their CE credit submitted to a CE Broker. Professionals licensed in other states will receive a Certificate of Completion to submit to their Boards. 10/16/ Thank You! Please contact the Hospital OQR Support Contractor if you have questions: Submit questions online through the Question & Answer Tool: Hospitals-Outpatient Question/Answer; or Call the Hospital OQR Support Contractor at This material was prepared by FMQAI, the Support Center for the Hospital Outpatient Quality Reporting program, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). The contents presented do not necessarily reflect CMS policy. FL-10SOW-2013FS4T /16/