Go for the Gold. Incorporating Regulatory Issues into the Quality Management Process. June 9 11, 2008 Starr Pass Resort Tucson, Arizona
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1 Go for the Gold June 9 11, 2008 Starr Pass Resort Tucson, Arizona Incorporating Regulatory Issues into the Quality Management Process Recent regulatory changes have impacted the traditional hospital Quality Management processes. Come to this session to learn how you can utilize the MIDAS+ Quality Management Modules to meet the following new requirements: Definitions of Harm, Physician Core Competencies, Joint Commission Safety Taxonomy, and Major Complications Not Present on Admission. Presented by: Barbara Craig Regional Consultant, ACS MIDAS+
2 Post-Symposium Availability Shortly after the conclusion of this year s Symposium, some General Session and all Breakout Session presentations will be available for downloading by licensed MIDAS+ clients from our Clients Only Web site. The presentations will be available online in PDF format. Copies of presentations in native PowerPoint format are not generally available. Copyright 2008 MidasPlus, Inc. All Rights Reserved. Contact us at: ACS Healthcare Solutions MIDAS North Pantano Road, Suite 200 Tucson, Arizona (520) (800) Visit our Web site at: MIDAS+, the MIDAS+ logo, DataVision, ReporTrack, Seeker, and SmarTrack are trademarks of MidasPlus, Inc. The ACS logo is a registered trademark of ACS, Inc. Third party trademarks, trade names, product names, and logos may be the trademarks or registered trademarks of their respective owners.
3 Incorporating Regulatory Issues into the Quality Management Process UPDATING YOUR QM MODULE TO REFLECT CURRENT ISSUES Barbara Craig, RN, MPH, CPHQ Regional Consultant ACS-MIDAS+ OBJECTIVES Attendees will be able to see the integration points between the MIDAS+ Quality Management Modules and current regulatory and safety issues. Attendees will learn how to update their Quality Management tables to facilitate reporting for Performance Improvement and to meet regulatory requirements Tucson, Arizona June
4 This session will cover review of the Quality Management Event and Quality Review Modules, looking at integration of the following concepts into MIDAS+ Definitions of Harm Sentinel Events Major Complications Not Present on Admission Core Process Measure Competencies National Patient Safety Guidelines Joint Commission Core Competencies UPDATING QUALITY EVENTS Data regarding Quality event types can be stored in multiple places in MIDAS+. Many of these events will need to go through the Peer Review Process, or be trended. Remember that MIDAS+ Worklists rules allow Quality Management staff to recognize issues from other modules, allowing for a type of electronic case finding Those who participate in Clinical Integration have other electronic case finding options 2 Tucson, Arizona June 2008
5 Issues that may need to be followed by Peer Review or QI Trending include: Major complications NPA WL from DAB coded data Compliance with Core Measures from Core Focus Medical records issues from MRQA Sentinel Events from Risk Major healthcare acquired infections from IC Major Behavioral Issues from Risk or Pt Relations SENTINEL EVENTS Event has resulted in an unanticipated death or permanent loss of function unrelated to the natural course of illness or underlying condition Suicide of any pt receiving care, treatment, and services in a staffed around the clock care setting or within 72 hours of discharge Unanticipated death of a full term infant Surgery on the wrong patient or wrong body part Unintended retention of a foreign object in a patient after surgery or other procedure Severe neonatal hyperbilirubinemia (30mg/dl) Prolonged fluoroscopy with cumulative dose >1500 rads to a single field or any delivery of radiotherapy to the wrong body region or >25% above the planned radiotherapy dose. Tucson, Arizona June
6 CORE PROCESS MEASURES COMPETENCIES FAILURE TO FOLLOW CORE PROCESS MEASURE FOR: PNEUMONIA ACUTE MI HEART FAILURE PREGNANCY CONDITIONS SURGICAL INFECTION PREVENTION NATIONAL PATIENT SAFETY GUIDELINES NPSG 2 Improve Effectiveness of communication between caregivers 2B Use of Do Not Use Abbreviations 2E Failure to effectively communication patient s care, treatment, services, condition, recent or anticipated changes Can include legibility issues 4 Tucson, Arizona June 2008
7 NATIONAL PATIENT SAFETY GUIDELINES NPSG 3 Improve Safety of Using Medications 3E Reduce the Risk of Harm Associated with use of Anticoagulant therapy (Applicable 1/1/2009) For patients being started on Warfarin, baseline INR is available, for all pts. on Warfarin, current INR is used to modify and adjust treatment Organization has a policy governing baseline and ongoing tests that are required for Heparin and Low Molecular weight heparin therapies. (not following policy for Heparin) NATIONAL PATIENT SAFETY GUIDELINES NPSG 7 Reduce the Risk of Healthcare Acquired Infections 7A Failure to follow WHO or CDC Guidelines for Hand washing Tucson, Arizona June
8 NATIONAL PATIENT SAFETY GUIDELINES NPSG 16 Recognition and response to changes in a Patient s Condition 16A Failure to comply with Urgent Response Policy NATIONAL PATIENT SAFETY GUIDELINES NPSG Universal Protocol Steps taken to eliminate Wrong Site, Wrong Procedure, Wrong Person Surgery Failure to follow Time Out procedures (whether or not there was a patient event) 6 Tucson, Arizona June 2008
9 { { { Clinical Data Integration Remember that Clinical Data Integration will help to automate your Performance Improvement efforts Data is interfaced from Pharmacy and Lab Worklist Rules are built to identify irregularities and electronically refer cases that need follow up Tucson, Arizona June
10 Peer Review vs. Trends The degree of patient harm should not be the sole determining factor in whether or not a case is sent for Peer Review. When it comes to the NPSG s, each case may be considered potentially harmful. Other issues (such as Core Measures) may be trended as determined by the Medical Staff. 8 Tucson, Arizona June 2008
11 UPDATING THE OUTCOMES DICTIONARY Include Major Complications (NPA) Acute MI Pneumonia You can use coded data as the source CHF of case finding for these issues. Sepsis Ischemic Stroke Acute Renal Failure Pulmonary Embolus DVT Include Other Problematic Complications Decubitus Ulcers Central Line Sepsis Transfusion Reactions Mediastinitis following Cardiac Surgery UTI UPDATING SIGNIFICANCE CODES JC Severity Index (2008): 5. Catastrophic 4. Critical 3. Major 2. Minor Negligible CALNOC: 1. No effect or minimal effect 2. Mild or minor effect 3. Moderate effect 4. Major/Severe effect 5. Death Or Degree of Harm JC 2005 Impact Terminology I. No harm and no undetectable harm II. No detectable Harm III. Mild Temporary Harm IV. Mild Permanent Harm V. Moderate Temporary Harm VI. Moderate Permanent Harm VII. Severe Temporary Harm VIII. Severe Permanent Harm IX. Profound Mental Harm Tucson, Arizona June
12 DEGREE OF HARM The proposed rules for the Patient Safety and Quality Improvement Act of 2005 will define how patient incidents are to be categorized related to severity. Due out later this summer, the regulations should drive changes to your Significance dictionaries. AHRQ, WHO and the NQF are involved currently in field testing terms. Likely terms will be simplified. Those currently in testing include:» CATASTROHPIC»MAJOR» MODERATE»MINOR DEGREE OF HARM Bottom Line Any changes you make to your significance dictionaries prior to release of this legislation likely will need to change. At the present time, make sure that the terms you currently use will be able to be mapped into more generic terms. ** See Federal Register February 12, 2008 S.544 Patient Safety and Quality Improvement Act of 2005 regarding the creation of Patient Safety Organizations 10 Tucson, Arizona June 2008
13 UPDATING STANDARD OF CARE There are many different schematics. The most common are listed below. Whichever variation you incorporate, please be certain that the Medical Staff have approved the terms used. Met Not Met Met with need for Education Met with need for improved documentation Met Opportunity for Improvement OFI regarding documentation Not Met Excellent Care Appropriate Care Controversial Care Inappropriate Care UPDATING THE MAJOR ISSUES DICTIONARY The Major Issues dictionary becomes the appropriate field for classifying events that have been through the Peer Review Process into one of the 6 Joint Commission Core Competencies. While most of those events will fall under the Patient Care umbrella, others will fall into other categories. Tucson, Arizona June
14 JOINT COMMISSION 6 CORE COMPETENCIES Use as Major Issues Credentialing MS 4.10 Patient Care Medical/Clinical Knowledge Practice-based learning and improvement Interpersonal and Communication Skills Professionalism Systems-based Practice JOINT COMMISSION 6 CORE COMPETENCIES Patient Care: Procedural Complications Failure to rescue (failure to respond) Surgical Site Infections Birth injuries Many Risk Events Major systemic complications (Renal Failure, DVT) Issues with Moderate Sedation 12 Tucson, Arizona June 2008
15 JOINT COMMISSION 6 CORE COMPETENCIES Medical/Clinical Knowledge: Use of appropriate medications (including anticoagulants) Use of Blood and Blood Products Tissue and Diagnosis discrepancies Radiology discrepancies Missed diagnoses JOINT COMMISSION 6 CORE COMPETENCIES Practice-based learning and improvement Core Measure issues Issues with supervision of house staff Practice varies from recommendations by professional organizations, evidenced-based guidelines Tucson, Arizona June
16 JOINT COMMISSION 6 CORE COMPETENCIES Interpersonal and Communication Skills: Patient Complaints Staff Complaints Behavioral Issues JOINT COMMISSION 6 CORE COMPETENCIES Professionalism: Rules Infractions Issues with Do Not Use abbreviations Legibility Failure to visit patient daily Medical Records violations HIPAA violations 14 Tucson, Arizona June 2008
17 JOINT COMMISSION 6 CORE COMPETENCIES Systems-Based Practice: Failure to follow time out procedures Inappropriate levels of care Readmission secondary to premature discharge Inappropriate use of restraints Dictionary #530 Tucson, Arizona June
18 Make Sure to Update Reports and Profiles PHYSICIAN PROFILES Surgeon/Proceduralist 16 Tucson, Arizona June 2008
19 PHYSICIAN PROFILES Medicine/Family Medicine/Hospitalist (sent to Excel) PHYSICIAN PROFILES Emergency Room Physician Tucson, Arizona June
20 PHYSICIAN PROFILES Obstetrician Take A Look At Your QM Process Make sure that you have incorporated new concepts and terminology into your dictionaries Make sure that the Medical Staff has approved all changes Make sure that your Quality Reports, Trend Reports, and Physician Profiles reflect the new terms Thank you! Questions? Discussion? 18 Tucson, Arizona June 2008
21 NOTES Tucson, Arizona June 2008
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