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Medical Staff Quality Program Comprehensive program led by Medical Staff leaders to improve Evidence Based Practice 2
Regulatory Standards CMS Centers for Medicare & Medicaid Services CMS Deeming Authority DNV GL AHCA Agency for Healthcare Administration Regulates the State of Florida
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Medical Staff Quality Oversight Committee Governing Body Medical Staff Quality 5
Collegial Peer Review 6
Peer Review Process by which peers collegially assess the Quality of Medical Care provided by their colleagues. MEDICAL STAFF QUALITY
Collegial Peer Review Patient Safety Work Product (PSO) Referrals Review Committee 8
Peer Review Outcomes Issue Identification Patient Evaluation Decision Making Ordering Diagnostics Performing Diagnostics Patient Monitoring Documenting Communication 9
Performance Feedback Reports 10
Physician Performance Feedback Reports (OPPE) CMS Interpretive Guidelines 482.22(a)(1) (the hospital) must evaluate each individual practitioner s qualifications and demonstrated competencies to perform each task or activity within the applicable scope of practice or privileges for that type of practitioner for which he/she has been granted privileges. 11
Continuum of Care 12
DNV-GL Accreditation Standards Practitioner Specific Performance: SR.1 Blood Use SR.2 Prescribing of Medications SR.3 Surgical Case Review SR.4 Specific Department indicators SR.5 Sedation Adverse Events SR.6 Readmissions/Unplanned Returns to Surgery SR.7 Appropriateness of care SR.8 Utilization SR.9 Significant Deviations SR.10 Medical Record Completion SR.11 Variances / Trends 13
Performance Metrics Hospital Level Metrics Twice a year on a rolling 24 month schedule
Performance Metrics Custom Level Specialty Level 15
Focus Professional Practice Evaluation 16
Focus Review (FPPE) Monitor the Initial Competency Monitor Ongoing Performance Monitor New Procedures New Procedure New Physician Reviewed by Department Chairman Reported to Credentials Committee Reported to MEC/BOD 17
CMS REGULATORY
CMS Value Based Purchasing Domain Weighting 25% Clinical Outcomes 5% 25% Patient Experience 25% Efficiency 20% Safety Efficiency Safety Patient Experience Clinical Outcomes Process of Care 19
Value Based Purchasing Measures IMM-2: Influenza Immunization PC-01: Elective Delivery prior to 39 weeks gestation 5%
Process of Care Measures VTE Venous Thromboembolism STK Stroke PC-01 Perinatal Global IMM-2 & ED-1 Sepsis (Oct 2015) Outpatient AMI, Chest Pain, ED CAC Children s Asthma Care 5% 21
Clinical Care Outcome Measures 30 Day Mortality Rates MORT-30-AMI: Acute Myocardial Infarction MORT-30-HF: Heart Failure MORT-30-PN: Pneumonia 25%
Agency For Healthcare Research & Quality Improvement (AHRQ) PPSI-90: Patient Safety Indicators PSI-03 Pressure Ulcer Rate PSI-12 Post Op PE / DVT PSI-06 Iatrogenic Pneumothorax Rate PSI-07 CLABSI PSI-08 Post Op Hip Fracture PSI-13 Post OP Sepsis PSI-14 Post Op Dehiscence PSI-15 Accidental Puncture or Laceration 20% 23
Healthcare Associated Infections CAUTI Catheter Associated Urinary Tract Infection CLABSI Central Line Associated Blood Stream Infection SSI Colon Surgery Abdominal Hysterectomy MRSA Bacteremia Clostridium difficile Infection 20% 24
Patient Experience Of Care HCAHPS PATIENT SURVEY: 27 questions Must be TOP BOX responses Communication with Doctors Pain Management Communication about Medications Discharge Information Communication with Nurses Responsiveness of Hospital Staff Cleanliness and Quietness Overall Rating of Hospital 25% 25
Efficiency Domain MSPB-1: Medicare Spending per Beneficiary Assesses Medicare Part A&B Beneficiary Payments Spans 3 days Prior to IP Hospital Admission Through 30 Days After Discharge (Episode) Payments are Price- Standardized and Risk Adjusted Achievement Threshold Median Spending Across All Hospitals Benchmark Mean of Lowest Decile of Spending Across All Hospitals 25% 26
Medical Staff Quality Team 27