Impact of Hospital-Acquired Conditions and NQF Safe Practices
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1 TMIT National Test Bed Work Shop: Impact of Hospital-Acquired Conditions and NQF Safe Practices CEO s Meet Your Revenue Preservation Officer Your PSO Charles Denham MD September 4, TMIT 1 2
2 NQF Safe Practices for Better Healthcare: A Consensus Report 34 Safe Practices Criteria for Inclusion Specificity Benefit Evidence of Effectiveness Generalization Readiness 2008 TMIT 3 Harmonization The Quality Choir 2008 TMIT 4
3 The Patient Our Conductor 2008 TMIT 5 SP 1 Information Management & Continuity of Healthcare Assoc. Infections Condition & Site Specific Practices 2008 TMIT All Rights Reserved 6
4 Structures & s Meas, Team Training CHAPTER 2: Creating and Sustaining a of Measurement, Feedback and Interventions Teamwork Training and Team Interventions Informed Life Sustaining Information Management & Continuity of of giver BSI Donation Therapy Sx Control Media Use 7 CHAPTER 3: Informed Informed Life Sustaining of the giver Information Order and Abbreviations s Safe Adoption of Integrated Clinical s including Pharmacist Leadership Role Including: High- Alert Med. & Unit Dose Standardized Medication & Packaging of the Ventilated Patient &, Infection Surgical Site Infection Influenza Surgery Organ Donorship Pressure Ulcer DVT/VTE Gycemic Control Contrast Media-Induced Renal Failure Measurement, Feedback and Interventions Informed Life Sustaining of Teamwork Training and Team Interventions giver Information Management & Continuity of Information Order and Abbreviations s Safe Adoption of Integrated Clinical s Identification and Mitigation has modest substantive including changes CHAPTER 2: Creating and Sustaining a of Measurement, Feedback and Interventions Teamwork Training and Team Interventions Structures Meas, Team Training CHAPTER 2: Creating and Sustaining & s a Risk & Hazards of Patient Safety NEW: CHAPTER 3: Informed Informed Life Sustaining of the giver All four have been separated into individual practices and Risk harmonized with CMS HAC s. Pharmacist Leadership Role Including: High- Alert Med. & Unit Dose Standardized Medication & Packaging BSI Donation Therapy Sx Control Media Use 8 of the Ventilated Patient &, Infection Surgical Site Infection Influenza Surgery Organ Donorship Pressure Ulcer DVT/VTE Gycemic Control Contrast Media-Induced Renal Failure
5 LEADERSHIP STRUCTURES and SYSTEMS Patients and Community Values s Structures Behaviors Outcomes Leadership Structure and s Measurement, Feedback, and Improvement Team Training and Team Interventions Identification and Mitigation of Risks and Hazards NQF 30 Safe Practices 9 Structures & s Meas, Team Training CHAPTER 2: Creating and Sustaining a of Measurement, Feedback and Interventions Teamwork Training and Team Interventions CHAPTER 3: Informed Informed Life Sustaining of Informed CHAPTER 3: Informed giver & Life Sustaining of the giver Informed Life Sustaining NEW: Information Management & Continuity of of the giver Practice Information Order and Abbreviations s Safe Adoption of Integrated Clinical s including Pharmacist Leadership Role Including: High- Alert Med. & Unit Dose Standardized Medication & Packaging BSI Donation Therapy Sx Control Media Use 10 of the Ventilated Patient &, Infection Surgical Site Infection Influenza Surgery Organ Donorship Pressure Ulcer DVT/VTE Gycemic Control Contrast Media-Induced Renal Failure
6 Structures & s Meas, Team Training CHAPTER 2: Creating and Sustaining a of Measurement, Feedback and Interventions Teamwork Training and Team Interventions Informed Life Sustaining CHAPTER 4: Information Management & Continuity of NEW: of giver Nothing No Substantive BSI Donation Therapy Sx Control Media Use 11 CHAPTER 3: Informed Informed Life Sustaining of the giver Information Order and Abbreviations s Safe Adoption of Integrated Clinical s including Pharmacist Leadership Role Including: High- Alert Med. & Unit Dose Standardized Medication & Packaging of the Ventilated Patient &, Infection Surgical Site Infection Influenza Surgery Organ Donorship Pressure Ulcer DVT/VTE Gycemic Control Contrast Media-Induced Renal Failure Structures & s Meas, Team Training CHAPTER 2: Creating and Sustaining a of Measurement, Feedback and Interventions Teamwork Training and Team Interventions Informed Safe Adoption of Integrated Clinical s including Press. Ulcer s Life Sustaining Organ Donation Wrong site Sx Anticoag Therapy Glycemic Control 12 DVT/VTE Contrast Media Use of giver CHAPTER 3: Informed Informed Life Sustaining of the giver Management & Continuity of Information Order Abbreviations Information Order and Abbreviations s Safe Adoption of Integrated Clinical s including Pharmacist Leadership Role Including: High- Alert Med. & Unit Dose Standardized Medication & Packaging of the Ventilated Patient &, Infection Surgical Site Infection Influenza NEW: BSI Order Readback and Abbreviations Combined into one practice. Surgery Organ Donorship Pressure Ulcer DVT/VTE Gycemic Control Contrast Media-Induced Renal Failure
7 Structures & s Meas, Team Training CHAPTER 2: Creating and Sustaining a of Leadership Structures & s Measurement, Feedback and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Informed Life Sustaining of Informed giver Life Sustaining of the giver CHAPTER 6: Unit Dose Medications Medications, Standardized Healthcare Associated Medication Infections & Packaging, and Unit Dose Medications BSI Pharmacist Role Information Management & Continuity of High-Alert Medications Standardized Medication & Packaging NEW: Pharmacist Role is expanded and High-Alert Synched with Joint C. Information Order and Abbreviations s Safe Adoption of Integrated Clinical s including Medication Reconciliation Pharmacist Leadership Role Including: High-Alert Med. & Unit Dose Standardized Medication & Packaging of the Ventilated Patient &, Infection Surgical Site Infection Influenza Wrong Site, Wrong Procedure, Wrong Person Surgery Organ Donorship Pressure Ulcer Donation Therapy DVT/VTE Anticoagulation Therapy Gycemic Control Sx Control Media Use Contrast Media-Induced Renal Failure 13 Structures & s Meas, Team Training CHAPTER 2: Creating and Sustaining a of Leadership Structures & s Measurement, Feedback and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards Informed Life Sustaining of Work Aspiration Force and Ventilator Infection Surgical Site Medication Infection Management of giver CHAPTER 3: Informed Informed Life Sustaining of the giver CHAPTER 7: Associated Pneumonia, Information Management & Continuity of Influenza Information Order and Abbreviations s Safe Adoption of Integrated Clinical s including Medication Reconciliation Pharmacist Leadership Role Including: High-Alert Med. & Unit Dose Standardized Medication & Packaging : expanded to of the Ventilated Patient of the Ventilated Patient &, Central Venous BSI Major Updates Infection Surgical Site Infection Hand Urinary Hygiene Tract Infection Practice BSI Influenza Multi-Drug Resistant Organism Surgical Site Infections Major Updates Wrong Site, Wrong Procedure, Wrong Person Surgery Organ Donorship Pressure Ulcer Donation Therapy DVT/VTE Anticoagulation Therapy Gycemic Control Sx Control Media Use Contrast Media-Induced Renal Failure 14
8 Condition or Site Specific Practices Structures Meas, Team Training & s Evidence Based Referrals DVT/VTE Informed Life Sustaining Pressure Ulcer of giver Wrong Site, Wrong Work Procedure, Force Wrong Person Evidence Medication Based Management Referrals DISCONTINUED CHAPTER 2: Creating and Sustaining a of Leadership Structures & s Measurement, Feedback and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards CHAPTER 3: Informed Informed Life Sustaining of the giver Surgery Peri-operative Myocardial Infarct/Ischemia Prev. Information Management & Continuity of Contrast Media-Induced Renal Failure : Information Order and Abbreviations s Safe Adoption of Integrated Clinical s including Medication Reconciliation Pharmacist Leadership Role Including: High-Alert Med. & Unit Dose Standardized Medication Substantive & Packaging Update DVT/VTE Substantive Update of the Ventilated Patient &, Infection Surgical Site Infection Surgery Central V. Cath Sx Site Inf. Influenza Substantive Update BSI Influenza Peri-operative Myocardial Infarct/Ischemia - DISCONTINUED Contrast Media- Gandolinium ADDED Wrong Site, Wrong Procedure, Wrong Person Surgery Organ Donorship Pressure Ulcer Donation Therapy DVT/VTE Anticoagulation Therapy Gycemic Control Sx Control Media Use Contrast Media-Induced Renal Failure 15 Integrated Timeline Q Q Q Q Q1 Q2 Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June Committee Work Completed Work Product Public Review Voting Revisions Board Approval Appeal Period Published Report Jan, Leapfrog Survey Period April 1, Leapfrog Survey First Deadline June 30, 2007 Submission Deadline June 30 th Reporting July 15 th TMIT Research: End to End Review (MSP Research Program) Interview Design Pilot July Aug Sept Oct Nov Dec Q July Aug Sept Oct Nov Dec FAQ/Survey Update Prior to relaunch Preinterview Practice Line Up : Practice Elements Broken up into 4 Practices 2 Practices Discontinued Jan Feb Mar April May June July Aug Sept Oct Nov Dec 4 Practice combined into 1 Q Communication Practices Combined into 1 7 Practices Added CMS Hospital Settings Feedback Defined Interviews from the Patient field (ongoing) and Family Involvement Section Added Survey Re- Release Oct th Survey Design, Survey FAQ., Ranking/Scoring Release March Dev & Pilot Testing Q Q Corrections and Clarification Q Q Jan Feb Mar April May June July Aug Sept Oct Nov Dec Hospital Interviews (ongoing) Final Report: Submission Deadline June 30 th Reporting July 15 th Format Structure Preserved Lightly Edited Text of Most Practices Practices Updated References Setting Clarification using CMS Classification Measures To Be Considered (in formulation) Softcopy Document Hyperlinks Cross-walk Tables Glossary Hospital Strategic Interviews reassessment (2008) of survey & interview needs TMIT INTERNAL DOCUMENT 2007 HCC, Inc. 16
9 Crosswalk: CMS Hospital Acquired Conditions WITH NQF Safe Practices (2008) Go Into Effect October 1, 2008: CMS Hospital Acquired Conditions NQF Safe Practice Crosswalk Foreign Object Retained After Surgery SP4: ID & Mit. Risk/Hazards Air Embolism SP4: ID & Mit. Risk/Hazards Blood Incompatibility Stage III & IV Pressure Ulcers and Trauma Catheter-Associated Urinary Tract Infection Vascular Catheter-Associated Infection SSI-Mediastinitis after CABG SP4: ID & Mit. Risk/Hazards SP 27: Pressure Ulcers & SP 4: ID & Mit. Risk/Hazards SP 33: & SP 4: ID & Mit. Risk/Hazards SP 25: CA SP 21: Blood Stream Infections SP 22: SSI 17 Crosswalk: CMS Hospital Acquired Conditions WITH NQF Safe Practices (2008) MRSA Candidate Conditions Originally Considered to Go Into Effect October 1, 2008 CMS Hospital Acquired Conditions Ventilator associated Pneumonia Staph aureus septicemia NQF Safe Practice Crosswalk SP 23: of Ventilated Patient SP 21: Blood Stream Infections SP 24: & SP 4: ID & Mit. Risk/Hazards Clostridium Difficile-Associated Disease (CDI) SSI: Total knee, gastric bypass, ligation and stripping of varicose veins Legionnaire s Disease DVT/PE Glycemic Control Iatrogenic Pneumothorax Delirium SP 24: SP 22: SSI SP 4: ID & Mit. Risk/Hazards SP 28 SP 32: glycemic control & SP 4: ID & Mit. Risk/Hazards SP 4: ID & Mit. Risk/Hazards SP 4: ID & Mit. Risk/Hazards 18
10 Go To For Streaming Video, Slide Set Updates, and s Regarding Safe Practices Updates Charles Denham MD September 4, TMIT 19
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