Hospital Outpatient Department Quality Measures

National Hospital Quality Measures

Team MembersAnesthesia

Surgical ServicesLabor & DeliveryNursing Education

Electrophysiology LabUrology Department

Medical RecordsEPIC

Quality Resource ManagementCenter for Clinical Effectiveness

Confidential: For Quality Improvement Purposes Only

Surgical site infections are a major complication after surgery, resulting in considerable morbidity, mortality, and resource utilization. Proper use of antibiotics-giving the right drug

at the right time-is effective in preventing infections after surgery.

Opportunity Statement

Confidential: For Quality Improvement Purposes Only

Hospital Outpatient Quality Data Reporting Program

National Program• Progression of CMS Value-based purchasing plan.

• Program is modeled on the current quality data reporting system for inpatient services (Core Measures: Heart Failure, Pneumonia, SCIP & AMI)

• To meet requirements and receive full reimbursement for CY 2008 services, hospital must submit data for seven quality measures, if applicable.

• Failure to report data will incur a reduction in their annual payment update factor by 2%.

HOP QDRP

Confidential: For Quality Improvement Purposes Only

• Force 7: Quality Improvement• Force 11: Nurses as Teachers• Force 13: Interdisciplinary

Relationships

Forces of Magnetism

Confidential: For Quality Improvement Purposes Only

• Administer antibiotics within one hour before surgical incision

• Administer appropriate antibiotic identified for select procedures

AIM STATEMENT

Confidential: For Quality Improvement Purposes Only

•Met with specific out-patient surgical areas to introduce project and identify improvement opportunities– Lack of consistent documentation of procedure

start times– Lack of consistent documentation of antibiotic

administration– Lack of consistent documentation for use of

Vancomycin– Use of appropriate antibiotic

Department Specific Initiatives

Confidential: For Quality Improvement Purposes Only

Outpatient Surgical Care• Perioperative Care: Timing of Antibiotic Prophylaxis• Perioperative Care: Selection of Prophylactic Antibiotic

– Departments Involved: Ambulatory Surgery Center, Main OR, EP Lab, Labor/Delivery, & Urology

– Over 200 Procedure Codes– Types of Surgeries:

• Cardiac: Pacemaker revisions, battery change-outs• Vascular: grafts• Genitourinary: Transrectal prostate biopsy• Gastric biliary: peg placements, laparoscopic

appendectomy • Gynecology: Vaginal hysterectomy, synthetic

pubovaginal sling• Head and Neck: Treatment of jaw fractures

Quality Measures

Confidential: For Quality Improvement Purposes Only

Analysis: Patients received the proper prophylactic antibiotics within one hour of surgery start time 87% of the time. Knowledge deficits of project requirements and lack of proper documentation of required

elements are identified as opportunities for improvement in this new imitative. Last month’s data demonstrate improvement towards

stretch goal of 95%.

Perc

ent

National Hospital Quality MeasuresHospital Outpatient Department Quality Measures

Q2-3 2008 Antibiotic Selection

For Quality Improvement Purposes Only

70

75

80

85

90

95

100

105

Mean

UCL

Mean

LCL

Stretch goal 95%

Project begins 4/1/4008

Correct Antibiotic Selection

Confidential: For Quality Improvement Purposes Only

Perc

ent

National Hospital Quality MeasuresHospital Outpatient Department Quality Measures

Quarter 2-3 2008Antibiotics within One Hour of Surgey/Procedure

For Quality Improvement Purposes Only

50

60

70

80

90

100

110

Mean

UCL

Mean

LCL

Analysis: Patients received prophylactic antibiotics within one hour of surgery start time 79% of the time. Knowledge deficits of project

requirements and lack of proper documentation of required elements are identified as opportunities for improvement in this new imitative. Last two

months demonstrate improvement towards stretch goal of 95%.

Project begins 4/1/2008

Stretch goal: 95%

Antibiotics Within One Hour of Surgery/Procedure Start Time

Confidential: For Quality Improvement Purposes Only

• Develop physician specific reports for results

• Educate departments on initiative and opportunities for improvement

• Report to key stakeholders• Re-education of data abstractors to

changing specifications

Next Steps