Medicare Beneficiary Quality Improvement Project. March 11, Chillicothe, Mo.

Transcription

1 Medicare Beneficiary Quality Improvement Project March 11, Chillicothe, Mo. 1

2 Welcome and MBQIP Overview 2

3 Introductions Dana Downing, B.S., MBA, CPHQ Jim Mikes, ScD, MPH Melissa VanDyne, B.S. CAHs name and electronic medical record *Half Sheet on Table 3

4 Agenda Welcome and MBQIP Overview FLEX Grant Update Emergency Department Transfer Communication Video MBQIP Resources MBQIP in Practice 4

5 Quality Reporting in Critical Access Hospitals 5

6 Why report? Although you may be submitting data to other sources, Hospital Compare is a tool that all other types of hospitals are required to report into and is, therefore, a source of information that lawmakers use when making funding decisions. 6

7 CAH Reporting Compared to all other CAHs nationally, Missouri s reporting rates were: LOWER for inpatient measures LOWER for outpatient measures LOWER for HCAHPS 7

8 State Rankings Among the 45 states participating in the Flex program, Missouri s CAHs rank 39 th for inpatient measure reporting 41 st in outpatient measure reporting 35 th for HCAHPS reporting 8

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10 HIDI Analytic Advantage Reports Login to Analytic Advantage 10

11 How Do I Read My Report? 11

12 How Do I Read My Report? 12

13 How Can I Use My Report? Identification of gaps What is consistent and what is not? Communication staff meetings patient safety teams core measure teams process improvement teams 13

14 Roundtable How do you use your data reports? What are your barriers to reporting? 14

15 Inpatient Quality Reporting 15

16 Percent Missouri CAHs Reporting As of 1st Quarter % 87% Reporting Not Reporting 16

17 IQR Performance Measure Description MO Average National Average HF-1 Discharge Instructions 77% 82% HF-2 Evaluation of LVS Function 78% 89% HF-3 ACEI or ARB for LVSD 80% 90% PN-3b Blood Cultures in E.D. Prior to Initial Abx 97% 94% PN-6 Initial Abx Selection 87% 89% 17

18 2015 Voluntary Measures Heart Failure HF-1: Discharge Instructions HF-3: ACEI or ARB for LVSD Pneumonia PN-3b: Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital 18

19 Specifications Manual 4.4a Changes HF Data Elements Deleted Discharge instructions address: Activity Diet Follow-up Medications Symptoms worsening Weight monitoring 19

20 Outpatient Quality Reporting 20

21 Percent Missouri CAHs Reporting As of 1 st Quarter % 42% Reporting Not Reporting 21

22 OQR Performance Measure Description MO Average National Average OP-1 Median Time to Fibrinolysis 52 Minutes 31 Minutes OP-2 Fibrinolytic Therapy within 30 Minutes of ED Arrival OP-3b Median Time to Transfer for Acute Coronary Intervention 33% 50% 60 Minutes 71 Minutes OP-4 Aspirin at Arrival 94% 96% OP-5 Median Time to ECG 8 Minutes 8 Minutes OP-6 Timing of Abx Prophylaxis 100% 94% OP-7 Prophylactic Abx Selection 96% 94% 22

23 2015 Retired Measures Surgical Care OP-6: Timing of Antibiotic Prophylaxis OP-7: Prophylactic Antibiotic Selection for Surgical Patients 23

24 Specifications Manual 8.0a Changes All related to the removal of the surgical measures 24

25 Emergency Department Transfer Communications 25

26 EDTC Measures EDTC-1: Administrative Communication EDTC-2: Patient Information EDTC-3: Vital Signs EDTC-4: Medication Information EDTC-5: Physician or Practitioner Generated Information EDTC-6: Nurse Generated Information EDTC-7: Procedures and Tests 26

27 EDTC-1: Administrative Communication Nurse to Nurse Communication Physician to Physician Communication 27

28 EDTC-2: Patient Information Patient Name Patient Address Patient Age Patient Gender Patient Contact Information Patient Insurance Information 28

29 EDTC-3: Vital Signs Pulse Respiratory Rate Blood Pressure Oxygen Saturation Temperature Neurological Assessment 29

30 EDTC-4: Medication Information Medication Given in ED Allergies/Reactions Medication History 30

31 EDTC-5: Physician or Practitioner Generated Information History and Physical Reason for Transfer/Plan of Care 31

32 EDTC-6: Nurse Generated Information Nursing Notes Sensory Status Catheters/IV Immobilizations Respiratory Support Oral Restrictions 32

33 EDTC-7: Procedures and Tests Tests/Procedures Performed Tests/Procedures Results 33

34 Data Collection Tool Disregard tool distributed in January Stratis Health Data Collection Tool nsfer.html Tool, manual, FAQs, instructions 34

35 Random Sampling Each patient has equal chance of being in sample The likelihood of bias is reduced 35

36 HIDI Reports After a few data points 36

37 Hospital Consumer Assessment of Healthcare Providers and Systems 37

38 Delay In Reporting Change in the HCAHPS contractor- working out a new contract 38

39 FY14 Flex Grant Year Data Submission Dates CMS Reporting Quarter Inpatient Outpatient HCAHPS EDTC Submit Submit Electronically Spreadsheet 4Q14 (Oct 1-Dec 31) May 15, 2015 May 1, 2015 Apr 1, 2015 Jan 20, Q15 (Jan 1- Mar 31) Aug 15, 2015 Aug 1, 2015 Jul 1, 2015 Apr 20, Q15 (Apr 1- June 30) Nov 15, 2015 Nov 1, 2015 Oct 7, 2015 Jul 20, Q15 (Jul 1- Sept 30) Feb 15, 2016 Feb 1, 2016 TBD, Jan 2016 Oct 20,

40 Hospital Compare Release Dates Hospital Compare Releases for Calendar Year 2015 Release Anticipated Release Date Anticipated Preview Dates April April 16, 2015 December 31, 2014 through January 29, 2015 July July 16, 2015 April 3, 2015 through May 2, 2015 October October 8, 2015 July 2, 2015 through August 2, 2015 December December 10, 2015 September 15, 2015 through October 14,

41 Questions?? 41

42 What is the FLEX Program? Melissa VanDyne Rural Health Manager MO Department of Health & Senior Services Office of Primary Care and Rural Health

43 The Medicare Rural Hospital Flexibility (FLEX) Program was authorized by Section 4201 of the Balanced Budget Act of 1997 (BBA), Public Law

44 FLEX s Purpose To provide support for Critical Access Hospitals (CAHs) for quality improvement, quality reporting, performance improvements, and benchmarking; aiding in designating facilities as CAHs; and the provision of rural Emergency Management Systems (EMS).

45 New FLEX Program Areas Quality Improvement (required) Financial and Operational Improvement (required) Population Health Management and EMS Integration (optional) Designation of CAHs in the State Integration of Innovative Health Care Models (optional)

46 QI-4 Quality Domains Patient Safety Patient Engagement Care Transitions Outpatient

47 Patient Safety HCP/OP-27: Influenza vaccination coverage among healthcare personnel Imm-2: Influenza immunization

48 Patient Engagement Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)- 32 questions in length

49 Patient Engagement (cont) Nine Key Topics Communication with doctors Communication with nurses Responsiveness of hospital staff Pain management Communication about medicine Discharge information Cleanliness of hospital environment Quietness of hospital environment Transition of care

50 Patient Engagement continued Survey includes four (4) screener questions and seven (7) demographic items

51 Care Transitions Emergency Department Transfer Communication EDTC-1: Administrative communication (2 data elements) EDTC-2: Patient information (6 data elements) EDTC-3: Vital signs (6 data elements)

52 Care Transitions (cont) Emergency Department Transfer Communication EDTC-4: Medication information (3 data elements) EDTC-5: Physician or practitioner generated information (6 data elements) EDTC-7: Procedures and tests (2 data elements)

53 Outpatient OP-1: Median time to fibrinolysis OP-2: Fibrinolytic therapy received within 30 minutes OP-3: Median time to transfer to another facility for acute coronary intervention OP-5: Median time to ECG

54 Outpatient (cont) OP-20: Door to diagnostic evaluation by a qualified medial professional OP-21: Median time to pain management for long bone fracture OP-22: Patient left without being seen

55 Additional Improvement Activities There are additional areas of quality improvement activities a cohort of hospitals could work on, if, all the hospitals in that cohort have met and are reporting on the required measures

56 Patient Safety-Additional Activity Healthcare Acquired Infections: o CLABSI o CAUTI o CDI o MRSA

57 Patient Safety-Additional Activity Stroke Stroke 1 Stroke 8 Proportion of patients hospitalized with Stroke-potentially avoidable complications OP-23

58 Patient Safety-Additional Activities VTE VTE-1 VTE-2 VTE-3 Perinatal Care PC-01 Surgery/Surgical Care OP-25

59 Patient Safety-Additional Activities Pneumonia-proportion of patients hospitalized with Pneumonia-potentially avoidable complications Falls-potential measurement around Falls with injury Patient fall rate Screening for future fall risk

60 Patient Safety-Additional Activities ADE-Potential Measurement around: Opioids Glycemic Control Anticoagulant Therapy Reducing Readmissions Patient Safety Culture Survey

61 Care Transitions-Additional Activity Discharge Planning Medication Reconciliation

62 Outpatient-Additional Activity ED Throughput ED-1 ED-2 OP-18

63 Contact Information Melissa VanDyne Missouri Department of Health and Senior Services Office of Primary Care and Rural Health 912 Wildwood Jefferson City, MO (573) FAX: (573)

64 Emergency Department Transfer Communication Video 64

65 EDTC ORHP Video Link qip/hospital-reporting-ed-transfer-comm.ppsx 65

66 MBQIP Resources 66

67 Staffing Dana Downing, MBQIP Facilitator. 573\ , ext Melissa VanDyne, FLEX Grant Coordinator. 573\ Jim Mikes, Rural Advocacy and Regulation. 573\ , ext

68 State Quality Works Missouri Hospital Association website, MBQIP section 68

69 National QualityNet website CART tool National Rural Health Resource Center Public Reporting CMS Hospital Outpatient Quality Reporting Program Hospital Quality Initiative Information Public Reporting CMS 69

70 ListServes 70

71 Upcoming MBQIP Education State Meeting Tuesday, July 28 Fall Regional Meetings Thursday, October 1 Springfield Friday, October 9 Chillicothe Tuesday, October 13 Festus 71

72 Upcoming Quality Education What s Up Wednesday Webinars Quality Transparency Webinars Tuesday, April 7 and Tuesday, April 21 Clinical Quality Regional Meetings Tuesday, April 14 St. Louis Wednesday, April 15 Cape Girardeau Friday, April 17 Macon Wednesday, April 22 Independence Friday, April 24 Springfield 72

73 MBQIP In Practice 73

74 Next Steps Report your data!! Sign up for a Listserv Network with peers 74

75 Questions? Dana Downing Director of Quality Program Development Missouri Hospital Association 573\ , ext

76 Carroll County Memorial Hospital Mindie Stovall LPN, CPHQ Director of Quality and Clinic Nurse Staff

77 About Myself Graduated from Saline County Career Center with my LPN in 2007 Began Working for CCMH in July 2007 I worked on the Medical Surgical Unit for 5 years April of 2012 I took the position as Quality Coordinator In May 2014 I accepted the position of Clinic Nurse Director In November of 2014 I took my CPHQ Exam and PASSED!! The Journey Continues. My personal life consist of 2 daughters that are my life and a wonderful husband who completes us!

78 Carroll County Memorial Hospital We currently have 3 physicians and 4 mid-level providers We are a 25 bed facility We have an Outpatient Clinic that currently treats patients in the following specialties: Cardiology Podiatry Pulmonology Urology Orthopedic Surgery GI Wound Clinic OBGYN Oncology

79 Currently expanding our facility with a 43,000 square foot, 3 story addition for Outpatient Clinic, Same Day Surgery, and Physician Office Space

80 A Glance at Our Services for FY ,989 Outpatient Visits 235 Inpatients 3,353 ER Visits 3,350 Home Health Visits 28,881 Rehab Therapy Visits

81 Core Measure Reporting I personally have been reporting Core Measures since I became Quality Coordinator in CCMH has been submitting Inpatient Core Measure data since approximately In 2010 Outpatient Measures were added for submission.

82 Benefits of MBQIP Improve best practice Improve outcomes Decrease cost Assist in making sure that the patient gets the right care every time

83 Engagement Where to Start CEO Providers- (Relate to $$) Nursing Staff Ancillary Departments

84 Some of Our Secrets to Success Daily Interdisciplinary Team Meetings followed by rounding to patient rooms Implementation of Bedside Reporting Education to all providers in Medical Staff and notes above computers Mandatory training for all nurses on Core Measures Cerner Core Measure Order Sets Daily check-off sheets for all inpatients Monitoring with re-education as needed Monthly staff meetings

85 Best Practices 100% CEO support!!! Interdisciplinary Team Meeting every morning for discussion of patient needs, plan of care, and Core Measure indicators Education to all providers, including nurses, regarding Core Measure importance and what it means for CCMH Charting/QM orders in the EHR to assist with indicators Core Measure Checklist placed outside patient rooms Discharge Planner/Case Management discharges all patients to assure that discharge instructions are clear and accurate according to patient diagnosis Small laminated cards/notes placed at provider workstations for easy access to Core Measure indicators Medical Staff monthly meeting. Review and present Core Measure results and give updates as needed.

86 Core Measure Checklist

87 Cerner Order Screen- Placing the QM order in Cerner reassures that all indicators are clearly stated for providers to view EHR Assistance Quality Measure Indicators for Nurses and providers- This screen is viewable on the patient summaries tab. Providers can order from this screen and nurses can document from this screen to meet all Core Measure indicators

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