medicare beneficiary quality improvement...
TRANSCRIPT
Medicare Beneficiary Quality Improvement Project
March 11, 2015 - Chillicothe, Mo.
1
Welcome and MBQIP Overview
2
Introductions
Dana Downing, B.S., MBA, CPHQ
Jim Mikes, ScD, MPH
Melissa VanDyne, B.S.
CAHs
name and electronic medical record
*Half Sheet on Table
3
Agenda
Welcome and MBQIP Overview
FLEX Grant Update
Emergency Department Transfer Communication Video
MBQIP Resources
MBQIP in Practice
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Quality Reporting in Critical Access Hospitals
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Why report?
Although you may be submitting data to other sources, Hospital Compare is a tool that all other types of hospitals are required to report into and is, therefore, a source of information that lawmakers use when making funding decisions.
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CAH Reporting
Compared to all other CAHs nationally, Missouri’s reporting rates were:
LOWER for inpatient measures
LOWER for outpatient measures
LOWER for HCAHPS
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State Rankings
Among the 45 states participating in the Flex program, Missouri’s CAHs rank
39th for inpatient measure reporting
41st in outpatient measure reporting
35th for HCAHPS reporting
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HIDI Analytic Advantage® Reports
Login to Analytic Advantage
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How Do I Read My Report?
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How Do I Read My Report?
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How Can I Use My Report?
Identification of gaps
What is consistent and what is not?
Communication
staff meetings
patient safety teams
core measure teams
process improvement teams
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Roundtable
How do you use your data reports?
What are your barriers to reporting?
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Inpatient Quality Reporting
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Percent Missouri CAHs Reporting
16
87%
13%
As of 1st Quarter 2014
Reporting
Not Reporting
IQR Performance
Measure Description MO Average National Average
HF-1 Discharge Instructions 77% 82%
HF-2 Evaluation of LVS Function
78% 89%
HF-3 ACEI or ARB for LVSD 80% 90%
PN-3b Blood Cultures in E.D. Prior to Initial Abx
97% 94%
PN-6 Initial Abx Selection 87% 89%
17
2015 Voluntary Measures
Heart Failure
HF-1: Discharge Instructions
HF-3: ACEI or ARB for LVSD
Pneumonia
PN-3b: Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital
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Specifications Manual 4.4a Changes
HF Data Elements Deleted
Discharge instructions address:
– Activity
– Diet
– Follow-up
– Medications
– Symptoms worsening
– Weight monitoring
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Outpatient Quality Reporting
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Percent Missouri CAHs Reporting
21
42% 58%
As of 1st Quarter 2014
Reporting
Not Reporting
OQR Performance
Measure Description MO Average National Average
OP-1 Median Time to Fibrinolysis 52 Minutes 31 Minutes
OP-2 Fibrinolytic Therapy within 30 Minutes of ED Arrival
33% 50%
OP-3b Median Time to Transfer for Acute Coronary Intervention
60 Minutes 71 Minutes
OP-4 Aspirin at Arrival 94% 96%
OP-5 Median Time to ECG 8 Minutes 8 Minutes
OP-6 Timing of Abx Prophylaxis 100% 94%
OP-7 Prophylactic Abx Selection 96% 94%
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2015 Retired Measures
Surgical Care
OP-6: Timing of Antibiotic Prophylaxis
OP-7: Prophylactic Antibiotic Selection for Surgical Patients
23
Specifications Manual 8.0a Changes
All related to the removal of the surgical measures
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Emergency Department Transfer Communications
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EDTC Measures
EDTC-1: Administrative Communication
EDTC-2: Patient Information
EDTC-3: Vital Signs
EDTC-4: Medication Information
EDTC-5: Physician or Practitioner Generated Information
EDTC-6: Nurse Generated Information
EDTC-7: Procedures and Tests
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EDTC-1: Administrative Communication
Nurse to Nurse Communication
Physician to Physician Communication
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EDTC-2: Patient Information
Patient Name
Patient Address
Patient Age
Patient Gender
Patient Contact Information
Patient Insurance Information
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EDTC-3: Vital Signs
Pulse
Respiratory Rate
Blood Pressure
Oxygen Saturation
Temperature
Neurological Assessment
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EDTC-4: Medication Information
Medication Given in ED
Allergies/Reactions
Medication History
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EDTC-5: Physician or Practitioner Generated Information
History and Physical
Reason for Transfer/Plan of Care
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EDTC-6: Nurse Generated Information
Nursing Notes
Sensory Status
Catheters/IV
Immobilizations
Respiratory Support
Oral Restrictions
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EDTC-7: Procedures and Tests
Tests/Procedures Performed
Tests/Procedures Results
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Data Collection Tool
Disregard tool distributed in January
Stratis Health Data Collection Tool
http://www.stratishealth.org/providers/ED_Transfer.html
Tool, manual, FAQs, instructions
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Random Sampling
Each patient has equal chance of being in sample
The likelihood of bias is reduced
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HIDI Reports
After a few data points
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Hospital Consumer Assessment of Healthcare
Providers and Systems
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Delay In Reporting
Change in the HCAHPS contractor- working out a new contract
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Data Submission Dates F
Y1
4 F
lex
Gra
nt
Yea
r
CMS Reporting
Quarter
Inpatient Outpatient HCAHPS EDTC
Submit Electronically
Submit
Spreadsheet
4Q14 (Oct 1-Dec 31) May 15, 2015 May 1, 2015 Apr 1, 2015 Jan 20, 2015
1Q15 (Jan 1- Mar 31) Aug 15, 2015 Aug 1, 2015 Jul 1, 2015 Apr 20, 2015
2Q15 (Apr 1- June 30) Nov 15, 2015 Nov 1, 2015 Oct 7, 2015 Jul 20, 2015
3Q15 (Jul 1- Sept 30) Feb 15, 2016 Feb 1, 2016 TBD, Jan 2016 Oct 20, 2015
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Hospital Compare Release Dates
Hospital Compare Releases for Calendar Year 2015
Release Anticipated Release Date Anticipated Preview Dates
April April 16, 2015 December 31, 2014 through January 29, 2015
July July 16, 2015 April 3, 2015 through May 2, 2015
October October 8, 2015 July 2, 2015 through August 2, 2015
December December 10, 2015 September 15, 2015 through October 14, 2015
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Questions?
41
?
What is the FLEX Program?
Melissa VanDyne
Rural Health Manager
MO Department of Health & Senior Services
Office of Primary Care and Rural Health
The Medicare Rural Hospital Flexibility (FLEX) Program was authorized by Section 4201 of the Balanced Budget Act of 1997 (BBA), Public Law 105-33.
FLEX’s Purpose
To provide support for Critical Access Hospitals (CAHs) for quality improvement, quality reporting, performance improvements, and benchmarking; aiding in designating facilities as CAHs; and the provision of rural Emergency Management Systems (EMS).
New FLEX Program Areas
Quality Improvement (required)
Financial and Operational Improvement (required)
Population Health Management and EMS Integration (optional)
Designation of CAHs in the State
Integration of Innovative Health Care Models (optional)
QI-4 Quality Domains
Patient Safety
Patient Engagement
Care Transitions
Outpatient
Patient Safety
HCP/OP-27: Influenza vaccination coverage among healthcare personnel
Imm-2: Influenza immunization
Patient Engagement
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)- 32 questions in length
Patient Engagement (cont) Nine Key Topics
Communication with doctors
Communication with nurses
Responsiveness of hospital staff
Pain management
Communication about medicine
Discharge information
Cleanliness of hospital environment
Quietness of hospital environment
Transition of care
Patient Engagement continued
Survey includes four (4) screener questions and seven (7) demographic items
Care Transitions
Emergency Department Transfer Communication
EDTC-1: Administrative communication
(2 data elements)
EDTC-2: Patient information (6 data elements)
EDTC-3: Vital signs (6 data elements)
Care Transitions (cont)
Emergency Department Transfer Communication
EDTC-4: Medication information (3 data elements)
EDTC-5: Physician or practitioner generated information (6 data elements)
EDTC-7: Procedures and tests (2 data elements)
Outpatient
OP-1: Median time to fibrinolysis
OP-2: Fibrinolytic therapy received within 30 minutes
OP-3: Median time to transfer to another facility for acute coronary intervention
OP-5: Median time to ECG
Outpatient (cont)
OP-20: Door to diagnostic evaluation by a qualified medial professional
OP-21: Median time to pain management for long bone fracture
OP-22: Patient left without being seen
Additional Improvement Activities
There are additional areas of quality improvement activities a cohort of hospitals could work on, if, all the hospitals in that cohort have met and are reporting on the required measures
Patient Safety-Additional Activity
Healthcare Acquired Infections:
o CLABSI
o CAUTI
o CDI
o MRSA
Patient Safety-Additional Activity
Stroke
Stroke 1
Stroke 8
Proportion of patients hospitalized
with Stroke-potentially avoidable complications
OP-23
Patient Safety-Additional Activities
VTE
VTE-1
VTE-2
VTE-3
Perinatal Care
PC-01
Surgery/Surgical Care
OP-25
Patient Safety-Additional Activities
Pneumonia-proportion of patients hospitalized with Pneumonia-potentially avoidable complications
Falls-potential measurement around
Falls with injury
Patient fall rate
Screening for future fall risk
Patient Safety-Additional Activities
ADE-Potential Measurement around:
Opioids
Glycemic Control
Anticoagulant Therapy
Reducing Readmissions
Patient Safety Culture Survey
Care Transitions-Additional Activity
Discharge Planning
Medication Reconciliation
Outpatient-Additional Activity
ED Throughput
ED-1
ED-2
OP-18
Contact Information
Melissa VanDyne
Missouri Department of Health and Senior Services
Office of Primary Care and Rural Health
912 Wildwood
Jefferson City, MO 65102-0570
(573) 526-9687
FAX: (573) 522-8146
Emergency Department Transfer Communication Video
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EDTC ORHP Video Link
https://www.ruralcenter.org/sites/default/files/mbqip/hospital-reporting-ed-transfer-comm.ppsx
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MBQIP Resources
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Staffing
Dana Downing, MBQIP Facilitator.
573\893-3700, ext. 1314
Melissa VanDyne, FLEX Grant Coordinator. 573\526-9687
Jim Mikes, Rural Advocacy and Regulation. 573\893-3700, ext. 1393
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State
Quality Works® https://qualityworks.quantros.com
Missouri Hospital Association website, MBQIP section
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National
QualityNet website
CART tool
National Rural Health Resource Center
Public Reporting CMS http://www.healthcare.gov/compare/
Hospital Outpatient Quality Reporting Program Hospital Quality Initiative Information https://www.cms.hhs.gov
Public Reporting CMS https://data.cms.gov
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ListServes
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Upcoming MBQIP Education
State Meeting
Tuesday, July 28
Fall Regional Meetings
Thursday, October 1–– Springfield
Friday, October 9 –– Chillicothe
Tuesday, October 13 –– Festus
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Upcoming Quality Education
What’s Up Wednesday Webinars
Quality Transparency Webinars Tuesday, April 7 and Tuesday, April 21
Clinical Quality Regional Meetings Tuesday, April 14 –– St. Louis
Wednesday, April 15 –– Cape Girardeau
Friday, April 17 –– Macon
Wednesday, April 22 –– Independence
Friday, April 24 –– Springfield
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MBQIP In Practice
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Next Steps
Report your data!!
Sign up for a Listserv
Network with peers
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Questions?
Dana Downing
Director of Quality Program Development
Missouri Hospital Association
573\893-3700, ext. 1314
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Carroll County Memorial Hospital
Mindie Stovall LPN, CPHQ
Director of Quality and Clinic Nurse Staff
About Myself… • Graduated from Saline County Career Center with
my LPN in 2007 • Began Working for CCMH in July 2007 • I worked on the Medical Surgical Unit for 5 years • April of 2012 I took the position as Quality
Coordinator • In May 2014 I accepted the position of Clinic
Nurse Director • In November of 2014 I took my CPHQ Exam…and
PASSED!!
The Journey Continues….
My personal life consist of 2 daughters that are my life and a wonderful husband who
completes us!
Carroll County Memorial Hospital • We currently have 3 physicians and 4 mid-level
providers • We are a 25 bed facility • We have an Outpatient Clinic that currently
treats patients in the following specialties: • Cardiology • Podiatry • Pulmonology • Urology • Orthopedic • Surgery • GI • Wound Clinic • OBGYN • Oncology
• Currently expanding our facility with a 43,000 square foot, 3 story addition for Outpatient Clinic, Same Day Surgery, and Physician Office Space
• 19,989 Outpatient Visits • 235 Inpatients • 3,353 ER Visits • 3,350 Home Health Visits • 28,881 Rehab Therapy
Visits
A Glance at Our Services for FY 2013-2014
Core Measure Reporting
I personally have been reporting Core Measures since I became Quality Coordinator in 2012. CCMH has been submitting Inpatient Core Measure data since approximately 2004. In 2010 Outpatient Measures were added for submission.
Benefits of MBQIP
• Improve best practice • Improve outcomes • Decrease cost • Assist in making sure that
the patient gets the right care every time
Engagement…
Where to Start
• CEO • Providers- (Relate
to $$) • Nursing Staff • Ancillary
Departments
• Daily Interdisciplinary Team Meetings followed by rounding to patient rooms
• Implementation of Bedside Reporting • Education to all providers in Medical Staff
and notes above computers • Mandatory training for all nurses on Core
Measures • Cerner Core Measure Order Sets • Daily check-off sheets for all inpatients • Monitoring with re-education as needed • Monthly staff meetings
Some of Our Secrets to Success
Best Practices • 100% CEO support!!! • Interdisciplinary Team Meeting every morning
for discussion of patient needs, plan of care, and Core Measure indicators
• Education to all providers, including nurses, regarding Core Measure importance and what it means for CCMH
• Charting/QM orders in the EHR to assist with indicators
• Core Measure Checklist placed outside patient rooms
• Discharge Planner/Case Management discharges all patients to assure that discharge instructions are clear and accurate according to patient diagnosis
• Small laminated cards/notes placed at provider workstations for easy access to Core Measure indicators
• Medical Staff monthly meeting. Review and present Core Measure results and give updates as needed.
Core Measure Checklist
EHR Assistance Cerner Order Screen- Placing the QM order in Cerner reassures that all indicators are clearly stated for providers to view
Quality Measure Indicators for Nurses and providers- This screen is viewable on the patient summaries tab. Providers can order from this screen and nurses can document from this screen to meet all Core Measure indicators
