The Medicare Beneficiary Quality Improvement Project (MBQIP) Monthly Performance Improvement Call

Transcription

1 The Medicare Beneficiary Quality Improvement Project (MBQIP) Monthly Performance Improvement Call April 16, 2015 Amber Theel, Executive Director Patient Safety Susan Rivera-Lee, WSHA Consultant MBQIP

2 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.

3 Inpatient (Phase 1) Outpatient (Phase 2) ED Transfer Comm. (Phase 3) 1 4 th Q Q Q Q 2015 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 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 PN-6b: Initial ABX Selection for CAP HF-2: Evaluation of LVS Function 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 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 IMM-2: Influenza Immunization 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 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

4 Reading Data Reports What do I look for? Lack of Consistent Process Process May Need Adjustment Understanding Variation Variation Outside of a Limit

5 MBQIP Inpatient Metrics

6 MBQIP Outpatient Metrics

7 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

8 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

9 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.

10 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.

11 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.

12 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.

13 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.

14 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.

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16 Questions?