Impacting Quality Initiatives through Documentation Improvement. Fran Jurcak, MSN, RN, CCDS Vice President of Clinical Innovation Iodine Software
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1 Impacting Quality Initiatives through Documentation Improvement Fran Jurcak, MSN, RN, CCDS Vice President of Clinical Innovation Iodine Software
2 Objectives The learner will be able to: Articulate the goals of the CMS Quality Initiative Verbalize the differences between different quality programs Identify patient safety indicators included in PSI 90 Recognize common inclusions and exclusions for different PSI s
3 Goal of CMS Quality Initiative Quality measures are tools that help us measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide highquality health care and/or that relate to one or more quality goals for health care. These goals include: effective, safe, efficient, patient-centered, equitable, and timely care.
4 Present on Admission (POA) & Hospital Acquired Conditions (HACs) 1999 report found HACs caused by medical errors, are a leading cause of morbidity and mortality in the United States. In 2005 Congress authorized CMS to adjust Medicare IPPS hospital payments to encourage the prevention of these conditions. In 2007 CMS announced that it will curtail payments to hospitals for specific conditions that a patient acquires while an inpatient and that can be reasonably prevented by following established evidence-based guidelines.
5 Affordable Care Act 2010 New and enhanced quality initiatives New push toward outcome measures Long-awaited move from pay-to-report to pay-to-perform Incremental increase in financial risk over several years More important than ever to understand and leverage these quality and reimbursement policies
6 2016 Quality Strategy Better Care: Improve the overall quality of care by making health care more person centered, reliable, accessible, and safe. Smarter Spending: Reduce the cost of quality health care for individuals, families, employers, government, and communities. Healthier People, Healthier Communities: Improve the health of Americans by supporting proven interventions to address behavioral, social, and environmental determinants of health, and deliver higherquality care.
7 2016 Quality Strategy Goal 1: Make care safer by reducing harm caused in the delivery of care. Goal 2: Strengthen person and family engagement as partners in their care. Goal 3: Promote effective communication and coordination of care. Goal 4: Promote effective prevention and treatment of chronic disease. Goal 5: Work with communities to promote best practices of healthy living. Goal 6: Make care affordable.
8 Hospital Inpatient Quality Reporting (IQR) 2012 As announced in the IPPS FY 2012 Final Rule, CMS used eight of the 10 HACs for the Hospital Inpatient Quality Reporting (IQR) Program. CMS has been publicly reporting on these eight HAC measures successfully on the Hospital Compare Web site since September Foreign object retained after surgery Air embolism Blood incompatibility Stage III and IV pressure ulcers Falls and trauma Catheter associated UTI Vascular catheter associated infection Manifestations of poor glycemic control
9 Hospital Inpatient Quality Reporting (IQR) 2013 In 2013, CMS started to finalize a proposal to remove 8 HAC measures, 3 AHRQ Inpatient Quality Indicator (IQI) measures, and 5 AHRQ Patient Safety Indicator (PSI) measures from the Hospital IQR Program measure set. Goal is to reduce redundancy among the measures in the program. 2 of the 8 HAC measures address HAIs which are addressed by other measures currently in the Hospital IQR Program. These 2 HAI measures are the NQF endorsed CAUTI and CLABSI measures collected via the CDC s NHSN system. An additional 3 of the 8 HAC measures address similar topics (pressure ulcers, air embolism, and manifestations of poor glycemic control) to patient safety indicators that are included in the NQF-endorsed AHRQ PSI composite that is also included in the Hospital IQR Program
10 Hospital Inpatient Quality Reporting (IQR) FY 2015 The New Hospital-Acquired Condition (HAC) Reduction Program IS IN ADDITION TO The Current Hospital-Acquired Conditions Program Starting with October 1, 2014 Discharges, and affecting FY 2015 Payment Adjustment, CMS will Implement The Hospital-Acquired Condition (HAC) Reduction Program Mandated by the Affordable Care Act CMS will reduce payments by 1% for hospitals that rank among the lowest-performing 25% of hospitals
11 HAC Reduction Program FY 2015 Measures will be based on the following 2 domains: Domain One: Composite PSI#90 Pressure ulcer rate Iatrogenic pneumothorax rate Central venous catheter related blood stream infection rate Postoperative Hip Fracture Rate Postoperative Pulmonary Embolism or Deep Vein Thrombosis Rate Postoperative Sepsis Rate Wound Dehiscence Rate Accidental Puncture and Laceration Domain Two: Two Healthcare-Associated Infection Measures Central Line-Associated Blood Stream Infection Catheter-Associated Urinary Tract Infection
12 HAC Reduction Program FY 2016 FY 2017 Additional Measures Affecting Domain 2 Only FY 2016 Surgical Site Infection (Colon Surgery and Abdominal Hysterectomy) FY 2017 MRSA C Diff
13 The Key to Preventing Over Reporting of HACs A diagnosis is POA If the physician includes present on admission in the documentation If the condition was diagnosed during the admission, but was clearly present on admission. E.g., chronic conditions and cancers If the diagnosis was possible, probable, rule out, suspected, or a differential on admission and was confirmed at discharge If the condition developed during an outpatient encounter, such as emergency room, physician office, outpatient surgery or observation If the signs and symptoms of the condition were clearly present on admission, listed later in the record as a diagnosis with a POA clarified
14 Bundled Payment Models December 2016 Episode Payment Model (EPM) Goals Reward quality over quantity of care Incentive payment for improved patient care for certain episodes of care Encourage collaboration between physicians/providers and hospitals Avoid complications Prevent readmissions Increase speed of recovery Reduce cost of care
15 Episode Payment Models (EPM) December 2016 Selected geographic areas (98) Urban counties with population of >50,000 Retrospective review begins July 1, 2017 October 1, 2017 Includes hospitalization and 90 post hospital discharge Bundled payment for hospital and physician/provider Models Acute myocardial infarction (AMI) model Coronary artery bypass graft (CABG) model Surgical hip and femur fracture treatment (SHFFT) model Cardiac rehabilitation (CR) incentive payment model
16 Rewarding Quality Care Value-Based Purchasing Defined: Incentive payment based upon performance on key metrics Funded by withholding $$ from participating hospitals DRG payments Supports goals of the Affordable Care Act Allows Medicare to be a prudent purchaser of healthcare services instead of passive payer Designed to minimize payment for patient who had been harmed during an inpatient stay Designed to minimize payment for patients readmitted for the same condition (30-day window)
17 VBP Timeline 100% 90% 25% 20% 25% 20% 25% 80% 70% 60% 50% 40% 30% 20% 10% 0% 25% 30% 30% 25% 40% 25% 30% 25% 45% 25% 25% 20% 25% 10% 5% Process of Care Experience of Care Outcomes of Care Efficiency of Care Safety
18 VBP Funded by reducing participating hospitals base FY 2017 operating MS-DRG payments by 2% Any leftover funds are redistributed to hospitals based on their Total Performance Score Individual hospital reimbursement depends on the range and distribution of all eligible/participating hospitals TPS scores for a FY. Hospitals may earn back a value-based incentive payment percentage that is less than, equal to, or more than the applicable reduction for that FY
19 Total Performance Score Domain Clinical care domain comprised of process and outcomes Clinical process AMI-7a: Heart attack patients given fibrinolytic medication within 30 minutes of arrival IMM-2: Patients assessed and given influenza vaccination PC-01: Percent of mothers whose deliveries were scheduled too early (1-2 weeks early), when a scheduled delivery was not medically necessary Outcomes Acute myocardial infarction (AMI) 30-day mortality rate Heart failure (HF) 30-day mortality rate Pneumonia (PN) 30-day mortality rate Percentage of score 25 Patient- and caregiver centered experience of care/ care coordination 25 Safety 20 Efficiency and cost reduction 25
20 Patient Safety Indicators - PSI
21 AHRQuality Indicators The Patient Safety Indicators are part of a set of software modules of the Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QIs) developed by the University of California, San Francisco Stanford University Evidence-based Practice Center and the University of California, Davis under a contract with AHRQ. The Patient Safety Indicators were originally released in 2003.
22 What are Patient Safety Indicators? The Patient Safety Indicators (PSIs) are a set of indicators providing information hospital complications and adverse events following surgeries, procedures, and childbirth. The PSIs were developed after a comprehensive literature review, analysis of ICD-9-CM codes, review by a clinician panel, implementation of risk adjustment, and empirical analyses.
23 How are Patient Safety Indicators used? The PSIs can be used to help hospitals identify potential adverse events that might need further study; provide the opportunity to assess the incidence of adverse events and in hospital complications using administrative data found in the typical discharge record; include indicators for complications occurring in hospital that may represent patient safety events; and, indicators also have area level analogs designed to detect patient safety events on a regional level.
24 AHRQ indicators Can be used to help hospitals and health care organizations assess, monitor, track, and improve the safety of inpatient care. Can be used for comparative public reporting and pay-for-performance initiatives. Can identify potentially avoidable complications that result from a patient s exposure to the health care system. Include hospital-level indicators to detect potential safety problems that occur during a patient s hospital stay. Include area-level indicators for potentially preventable adverse events that occur during a hospital stay to help assess total incidence within a region. Are publicly available at no charge to the user. Include risk adjustment where appropriate
25 Patient Safety Indicators 02 Death rate in low-mortality DRG s 03 Pressure ulcer rate 04 Death rate among surgical inpatient with serious treatable conditions 05 Retained surgical item or unretrieved device fragment count 06 Iatrogenic pneumothorax rate 07 Central venous catheter-related blood stream infection rate 08 In hospital fall with hip fracture rate 09 Perioperative hemorrhage or hematoma rate 10 Postoperative acute kidney injury requiring dialysis 11 Postoperative respiratory failure rate 12 Perioperative pulmonary embolism or DVT rate 13 Postoperative sepsis rate 14 Postoperative wound dehiscence rate 15 Unrecognized abdominopelvic accidental puncture/laceration rate 16 Transfusion reaction count 17 Birth trauma rate injury to neonate 18 Obstetric trauma rate vaginal delivery with instrument 19 Obstetric trauma rate vaginal delivery without instrument 21 Retained surgical item or unretrieved device fragment rate 22 Iatrogenic pneumothorax rate 23 Central venous catheter-related blood stream infection rate 24 Post operative wound dehiscence rate 25 Accidental puncture or laceration rate 26 Transfusion reaction rate 27 Perioperative hemorrhage or hematoma rate
26 PSI-90 The composite provides an overview of hospital-level quality as it relates to a set of potentially preventable hospital-related events associated with harmful outcomes for patients (AHRQ, 2017) PSI 03 Pressure Ulcer Rate PSI 06 Iatrogenic Pneumothorax Rate PSI 08 In-Hospital Fall With Hip Fracture Rate PSI 09 Perioperative Hemorrhage or Hematoma Rate PSI 10 Postoperative Acute Kidney Injury Rate PSI 11 Postoperative Respiratory Failure Rate PSI 12 Perioperative Pulmonary Embolism (PE) or Deep Vein Thrombosis (DVT) Rate PSI 13 Postoperative Sepsis Rate PSI 14 Postoperative Wound Dehiscence Rate PSI 15 Unrecognized Abdominopelvic Accidental Puncture/Laceration Rate
27 Examples
28 PSI 03 Pressure Ulcer Rate Numerator Any secondary ICD-10-CM diagnosis codes for pressure ulcer and any secondary ICD-10-CM diagnosis codes for pressure ulcer stage III or IV (or unstageable) List of included pressure ulcer codes provided Denominator Surgical or medical discharges, for patients ages 18 years and older
29 PSI 03 Pressure Ulcer Rate Exclusions with length of stay of less than 3 days with a principal ICD-10-CM diagnosis code for pressure ulcer with any secondary ICD-10-CM diagnosis codes for pressure ulcer stage III or IV (or unstageable, see above) present on admission with any-listed ICD-10-CM diagnosis codes for hemiplegia, paraplegia, or quadriplegia with any-listed ICD-10-CM diagnosis codes for spina bifida or anoxic brain damage with any-listed ICD-10-PCS procedure codes for debridement or pedicle graft before or on the same day as the major operating room procedure (surgical cases only) with any-listed ICD-10-PCS procedure codes for debridement or pedicle graft as the only major operating room procedure (surgical cases only) transfer from a hospital (different acute care facility) transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF) transfer from another health care facility with a principal or any secondary ICD-10-CM diagnosis codes present on admission for major skin disorders MDC 14 (pregnancy, childbirth, and puerperium)
30 Example of National Benchmark
31 PSI 07 - Central Venous Catheter-related Blood Stream Infection Rate Numerator Any secondary ICD-10-CM diagnosis codes for selected infections T80211A Bloodstream infection due to central venous catheter, initial encounter Denominator Surgical and medical discharges, for patients ages 18 years and older or MDC 14
32 PSI 07 - Central Venous Catheter-related Blood Stream Infection Rate Exclusions with a principal ICD-10-CM diagnosis code (or secondary diagnosis present on admission) for selected infections (as defined by the numerator, see above) with length of stay less than 2 days with any-listed ICD-10-CM diagnosis codes for cancer with any-listed ICD-10-CM diagnosis codes or any-listed ICD-10-PCS procedure codes for immunocompromised state
33 Example of National Benchmark
34 Monitoring PSI s Trends over Time Patient type
35 CDI Implications
36 Documentation Issues Principal diagnosis selection impacts PSI reporting Present on admission is key for many PSI s Clear documentation of POA status necessary POA reminders: No required timeframe as to when a provider must identify or document a condition Conditions documented as possible, probable, suspected, or rule out at the time of discharge Conditions documented as impending or threatened at the time of discharge Source: ICD-10-CM Official Guidelines for Coding and Reporting FY, pg 110
37 Specific Documentation Issues Pressure ulcer Accuracy of staging is critical Stage 3, 4 and unstageable are excluded Patients with certain known conditions that are at high risk for developing pressure ulcers are excluded Hemiplegia, paraplegia, quadriplegia, spina bifida, anoxic brain damage, debridements that occur before or same day as operating procedure Iatrogenic pneumothorax J95811 Postprocedural pneumothorax Known conditions that exclude the patient Pleural effusion Thoracic surgery, lung biopsy, diaphragmatic repair, cardiac procedures
38 Specific Documentation Issues CLABSI T80211A Bloodstream infection due to central venous catheter, initial encounter Conditions that exclude the patient: Cancer diagnoses Immunocompromised state Hospital fall with hip fracture Includes ALL hip fractures due to an inpatient fall Principal diagnoses that exclude the patient: Seizures, syncope, stroke or occlusion of arteries, coma, cardiac arrest, poisoning, trauma, delirium and other psychoses, anoxic brain injury, metastatic cancer, lymphoid malignancy, bone malignancy, self-inflicted injury
39 Specific Documentation Issues Perioperative hemorrhage or hematoma Perioperative hemorrhage or hematoma cases involving a procedure to treat the hemorrhage or hematoma If principal diagnosis or secondary but POA patient is excluded If primary procedure is for treatment of perioperative hemorrhage or hematoma patient is excluded Conditions that exclude the patient Coagulation disorders Post-operative AKI requiring dialysis Conditions that exclude patient if principal diagnosis AKI, cardiac arrest, shock, UTI, CKD Dialysis occurs before or same day as surgical event
40 Specific Documentation Issues Post op respiratory failure Patients included: Documented as post-op On vent greater than 96 hours or less than 96 hours but occurs 2 or more days after surgery Reintubation Elective surgeries Patient excluded if: Principal diagnosis of acute respiratory failure, neuromuscular disorders, degenerative neurological disorders, MDC 4, MDC 5 Primary procedure is tracheostomy or this occurs before the first OR procedure Procedure is for lung cancer, esophageal resection, laryngeal or pharyngeal, nose, mouth, pharynx or facial surgery
41 Specific Documentation Issues Perioperative PE or DVT Includes all surgical cases Excludes isolated calf vein DVT which are clinically insignificant Excluded if POA, ECMO or acute brain or spinal injury POA Post-op sepsis Elective surgeries only Excluded if POA or other infection POA Post-op wound dehiscence Includes abdominal wall only Requires reclosure Excluded if reclosure occurs on or before the day of the first abdominopelvic surgery Excluded in immunocompromised condition or less than 2 day LOS
42 Specific Documentation Issues Accidental puncture or laceration Abdominal or pelvic surgery that requires a second abdominopelvic procedure >= 1 day of first abdominopelvic procedure Excludes if POA
43 Key Points CDI Specialists should: Know which PSI s can be impacted by accurate documentation Support accurate documentation of POA status for all conditions Be aware of inclusion and exclusions Clarify conditions or outcomes that do not meet inclusions or exclusions Look for true adverse affects or outcomes of care and ensure that these are documented correctly
44 Questions?
45 References CMS Quality Strategy, CMS ublic%2fpage%2fqnettier3&cid= fact-sheets-items/ html
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