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Quality Improvement and Core Measures 101 Jill Daniels, BS Quality Project Manager, Primaris
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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.
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Greetings and Introductions
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Core Measures History
1998 • Healthcare safety
concerns • Media attention • Healthcare costs • President Clinton
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)
2001 Four Initial Core Measures Announced
• Acute Myocardial Infarction (AMI) • Heart Failure (HF) • Pneumonia (PN) • Pregnancy Related conditions (PR) –
replaced with PC in 2010
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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
Today
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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.
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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 email received from Quality Reporting Notification dated 3/26/2015.
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ANATOMY OF A CORE MEASURE
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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
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CMS VS. TJC REQUIREMENTS EFFECTIVE FOR DISCHARGES JANUARY 1, 2015 TO SEPTEMBER 30,2015
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LOCATING SPECIFICATIONS MANUALS FOR CMS AND TJC
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CMS Specifications Manual www.qualitynet.org
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CMS Specifications Manual
Current CMS Specifications Manual v4.4a for Discharges 01/01/2015-09/30/2015
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Specifications Manual for Joint Commission National Quality Measures v2015A1
https://manual.jointcommission.org
Copy and paste above link to your internet browser. Once on webpage, click current for the current specifications manual v2015A1.
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Pneumonia – That Was Then
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Pneumonia – This Is Now
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Anatomy of a Measure
Measure Set: Pneumonia Measures: PN-6 Initial Antibiotic Selection
(6a ICU Patient, 6b Non ICU Patient) Data Elements:
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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.
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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.
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= 1
Measure Algorithm PN-3b: Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital Numerator: Number of pneumonia patients whose initial ED blood culture was performed prior to the administration
of the first hospital dose of antibiotics. Denominator: Pneumonia patients 18 years of age and older who have initial blood culture collected in the ED.
Variable Key: Antibiotic Timing
Blood Culture Timing Blood Culture Collection Day
Duration of Stay Initial Antibiotic Date Initial Antibiotic Time
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.
PN-3b X
PN-3b X
PN-3b
PN-3b B
PN-3b B
PN-3b
Chest X-Ray
Comfort Measures Only
Missing
Missing
= 2, 3
= 1
= 2, 3, 4
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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
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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”
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QUALITY
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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
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Consumer
Public reporting = patients can choose best facility
2005 - Core Measure data available on Hospital Compare website for AMI, HF, PN, and SCIP
2008 - HCAHPS survey data and mortality rates added
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Consumer
2009 - Outpatient data added
2012 - CMS readmission reduction program
2013 – Hospital Value Based Purchasing (VBP) program
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www.medicare.gov/hospitalcompare
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Hospital Compare
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Hospital Compare
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Hospital Compare
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Hospital Compare
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HOSPITAL VALUE BASED PURCHASING (VBP)
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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
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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
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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
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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
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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
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Value Based Purchasing
A hospital’s performance in HVBP will be based on its performance according to the
following:
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Value Based Purchasing
Fiscal Year (FY) 2015 12 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)
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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)
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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
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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
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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
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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%
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Value Based Purchasing
FY 2016 Scoring
Domain Weight
Clinical Process of Care 10%
Patient Experience of Care 25%
Outcome 40%
Efficiency 25%
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NEXT STEPS
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Using Data to Improve Quality
Working smarter instead of harder
Electronic Medical Record (EMR)
Hardwiring success
Concurrent review – “real time”
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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)
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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
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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
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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
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Upcoming Programs
Quality Update Webinar Series May Quality Update – Peer Review
May 29, 2015 11:00 – 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 www.qhrlearninginstitute.com
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QHR Learning Institute Recordings and Videos: Come Visit Our Library
http://videos.qhr.com/
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Evaluation Reminder!
Thank you for joining us today. We value your feedback and hope that you will take a few minutes to evaluate this program so that we may continue to improve and bring you the quality educational programming you expect.
As a reminder, 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
email containing links to the online evaluation and a recording of this webinar
Upon completing the online evaluation, you will receive an email with a link to access your completion certificate.
If you have questions or need assistance, please contact [email protected].
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consult a qualified attorney for specific legal guidance.
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