The Medicare Beneficiary Quality Improvement Project (MBQIP)

Monthly Performance Improvement CallApril 16, 2015

Amber Theel, Executive Director Patient Safety

Susan Rivera-Lee, WSHA Consultant MBQIP

MBQIP - Goal

• Improve the quality of care provided in critical access hospitals (CAHs).

• Data comparison with like organizations.

• Demonstrating value by providing cost efficient, quality care is the future of health care reimbursement. MBQIP takes a proactive approach to ensure CAHs are well-prepared to meet future quality requirements.

1 – 4th Q 2014 1 Q 2015 – 3 Q 2015 4 Q 2015Inpatient

(Phase 1)

• PN-3b: Blood Cultures Performed in

the ED Prior ABX

• PN-6b: Initial ABX Selection for CAP

• HF-1: Discharge Instructions

• HF-2: Evaluation of LVS Function

• HF-3: ACEI or ARB for LVSD

PN-6b: Initial ABX Selection for CAP

HF-2: Evaluation of LVS Function

• IMM-2: Influenza Immunization

Outpatient

(Phase 2)

• OP-1: Median Time to Fibrinolysis -ED

• OP-2: Fibrinolytic Therapy Received

Within 30 Minutes of Arrival in the

Emergency Department

• OP-3: Median Time to Transfer to

another Facility for Acute Coronary

Intervention in the ED

• OP-4: Aspirin at Arrival in ED

• OP-5: Median Time to ECG in the ED

• OP-6: Timing of ABX Prophylaxis

• OP-7: Prophylactic ABX Selection

HCAHPS

• OP-1: Median Time to Fibrinolysis -ED

• OP-2: Fibrinolytic Therapy Received

Within 30 Minutes of Arrival in ED

• OP-3: Median Time to Transfer to

another Facility for Acute Coronary

Intervention in the ED

• OP-4: Aspirin at Arrival in ED

• OP-5: Median Time to ECG in the ED

HCAHPS

• OP-1: Median Time to Fibrinolysis -ED

• OP-2: Fibrinolytic Therapy Received

Within 30 Minutes of Arrival in ED

• OP-3: Median Time to Transfer to

another Facility for Acute Coronary

Intervention in the ED

• OP-5: Median Time to ECG in the ED

• OP-20: Door to diagnostic evaluation by a qualified medical professional

• OP-21: Median time to pain management for long bone fracture

• OP-22: Patient left without being seen

• OP-27 HCP /: Influenza vaccination

coverage among healthcare personnel

HCAHPS

ED Transfer

Comm.

(Phase 3)

• EDTC-1: Admin. Communication

• EDTC-2: Patient Information

• EDTC-3: Vital Signs

• EDTC-4: Medication Information

• EDTC-5: Provider generated information

• EDTC-6: Nurse generated information

• EDTC-7: Procedures and Tests

• EDTC-1: Admin. Communication

• EDTC-2: Patient Information

• EDTC-3: Vital Signs

• EDTC-4: Medication Information

• EDTC-5: Provider generated info

• EDTC-6: Nurse generated info

• EDTC-7: Procedures and Tests

Reading Data Reports – What do I look for?

• Lack of Consistent Process

• Process May Need Adjustment

• Understanding Variation

• Variation Outside of a Limit

MBQIP – Inpatient Metrics

MBQIP – Outpatient Metrics

N/A Reports

•Data was not submitted/reported by the CAH•Data was submitted but was rejected/not accepted into

the Quality Improvement Organization (QIO) Clinical Warehouse

Zero on Reports

•Zero (0) Patients means that data was submitted and accepted to the QIO Clinical Warehouse; however, case(s) were excluded from a particular measure

AMI – Care Best Practices

ECG within 10 minutes of ED arrival

• DX the patient as early as possible.

• Promptly identify patients requiring ECG

• Nurse interview prior to registration

• Provide necessary training to registration personnel.

• Processes/protocols for rapidly acquiring ECG

• Having ECG equipment in the ED

• Specifying a location with prompt access and adequate pt privacy.

AMI – Care Best Practices

Aspirin at arrival (within 24 hrs before ED arrival or prior to transfer)

• Raise awareness among general population re: heart attack symptoms, calling 911 and taking ASA.

• Work with EMS providers to ensure standard protocol/process for giving ASA if suspected AMI.

• Establish standard protocol for chest pain to include assessment and documentation of ASA prior to ED arrival.

AMI – Care Best Practices

Fibrinolytic TX received w/in 30 minutes of ED arrival

• DX patient as early as possible (e.g. enable EMS to diagnose STEMI pts and/or notify ED of possible STEMI to initiate preparation process).

• Ensure the ED physician on duty activates the reperfusion plan according to established local guidelines/care pathways.

• Treat registration for pts with AMI similar to trauma pts with the ability to fast-track critical labs, i.e. creatinine and PT/INR.

• Store fibrinolytic agent in the ED and/or establish ability to reconstitute and administer fibrinolytic in the ED.

AMI – Care Best Practices

Time to transfer - acute coronary intervention w/in 90 min

• Diagnose the patient as early as possible.

• Work with EMS providers and regional centers to establish processes/protocols to expedite communication and transfer.

• Establish initial and backup plan for transfer or transport to a STEMI-receiving hospital.

AMI/Chest Pain – Abstraction Best Practices

• Correct identification of patient population to abstract

• most current ICD and E/M codes and criteria.

• Proper use of data elements: arrival time, transfer out time, medication administration time, initial ECG time.

• Interpret data elements: reason for delay in fibrinolytic therapy, probable cardiac chest pain, reason for no aspirin at arrival.

• Knowledge of EMR – ability to locate all the data elements.

AMI/Chest Pain – Tracking Best Practices

• Recognize “misses” or “fallouts” as you abstract (close to real-time or concurrent review)

• Actual timely reporting by nurses or physicians when “misses” or “fallouts” occur - case can be reviewed right away and corrective steps taken.

• Use of auditing/audit tools to assess compliance with measures.

Questions?