Best Practices to Improve Your Hospital Outpatient Quality Reporting March 20, 2013
Announcements This program has been approved for 1.0 continuing education unit (CEU) given by Continuing Education (CE) Provider #50-747 by the following boards: o Florida Board of Nursing o Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling o Florida Board of Nursing Home Administrators o Florida Council of Dietetics o Florida Board of Pharmacy Please send your name, state, license number, and profession to theron@fmqai.com following the program. o Professionals that are licensed by approved Florida Boards will have their CE credit submitted to CE Broker. o Professionals licensed in other states will receive a Certificate of Completion to submit to their Boards. 3/20/2013 2
Upcoming Report Dates The next clinical data submission deadline is May 1, 2013, for Q4 (October December) 2012 encounters. Population and sampling data is also due on May 1, 2013, for the same encounter period. The structural (web-based) measure reporting period begins on July 1, 2013 and extends through November 1, 2013. 3/20/2013 3
Learning Objectives At the conclusion of this presentation, attendees should be able to: List best practices for data reporting to the Hospital Outpatient Quality Reporting (OQR) Program Cite lessons learned for data reporting to the Hospital OQR Program 3/20/2013 4
Disclaimer Any software or products mentioned by todays speakers are not endorsed or recommended by the Hospital OQR Program, or the Centers for Medicare & Medicaid Service (CMS). Opinions expressed are opinions of the individual presenters and not CMS or any of its contractors. 3/20/2013 5
Faculty Levi Stone, BS, MN, CNO Odessa Regional Medical Center, Texas Jan Oertel, RN, BSN; Zahirah Habassi, RN, BS St. Anthony s Hospital, Franciscan Health Systems, Washington Erin Berry, RN; Bill Warren, ST, RN; Tom Downes, BS, MS North Arkansas Regional Medical Center, Arkansas 3/20/2013 6
Hospital OQR Program: Best Practices and Lessons Learned Levi Stone, RN, MSN Chief Nursing Officer 3/20/2013 7
Odessa Regional Medical Center (ORMC) Vision Statement Our commitment is to be the regional market leader in healthcare by providing passionate clinical services in a friendly and caring environment. 3/20/2013 8
Outpatient Services Designated Level IV Trauma Emergency Department (ED) Accredited Chest Pain Center Certified Primary Stroke Center Diverse outpatient surgical services Outpatient Core Measures impacted o o o o o o OP-AMI OP-CP OP-ED OP-PM OP-STK OP-Surgical 3/20/2013 9
Hospital Outpatient Quality Reporting Program ORMC has participated in Hospital Outpatient Quality Reporting since inception Committed to process to ensure o Quality o Better Outcomes o Cost Effective Care 3/20/2013 10
CART Tool Vendor vs. CART Tool? Abstraction through support from o Truven Health Analytics Care Discovery o QualityNet 3/20/2013 11
Information Gathering QualityNet Provides ORMC Tools Resources Updates Useful Information for data submission/public reporting 3/20/2013 12
Streamlining Greatest Success Updated Daily Report o Provided by abstractors to patient care units o Shared with staff, directors, and administration to alert/remind team of necessary items required to meet objectives o Ensures we remain diligent and provide additional resources as necessary 3/20/2013 13
Electronic Medical Record Throughout Facility McKesson o HED o HEO Emergency Department o Coral o Switching to MedHost by August 2013 3/20/2013 14
Accurate Abstracting Keys to Success Knowledgeable abstractors Concurrent chart reviews Use your resources often Communication Engaged/committed team Know the rules!!! 3/20/2013 15
Continual Improvement Best achieved through Evidence-Based Practices Best Practices Patient-centric care Data sharing 3/20/2013 16
Lessons Learned Words to live by: Every opportunity should be exercised to provide abstractors the education and training to succeed. They are key to your organization s quality initiatives. To afford the best possible outcomes, abstractors with the knowledge base to support clinical staff will yield the greatest impact to your facility. 3/20/2013 17
For Additional Information Levi Stone, RN, MSN Chief Nursing Officer lstone@iasishealthcare.com Sue Faulkner, RN Director, Case Management sfaulkner@iasishealthcare.com 3/20/2013 18
Hospital Outpatient Quality Reporting: OP-20 Data Abstraction St. Anthony s Hospital 3/20/2013 19
St. Anthony s Hospital Presenters Jan Oertel, RN, BSN Clinical Data Abstractor, Clinical Effectiveness Department Zahirah Habassi, RN, BS Clinical Data Abstractor, Clinical Effectiveness Department 3/20/2013 20
OP-20 Learning Objectives At the conclusion of this presentation attendees should be able to: Define OP-20 Acknowledge the certainty and unavoidability of electronic medical records (EMR) Identify education and abstraction process for OP-20 Recognize lessons learned and potential pitfalls to avoid 3/20/2013 21
OP-20 Door to diagnostic evaluation by a Qualified Medical Professional Time in minutes from ED arrival to provider contact for patients discharged from the Emergency Department 3/20/2013 22
Franciscan Health System St. Anthony s Hospital is part of Franciscan Health System, one of the largest private employers in the South Puget Sound region of Washington state with five hospitals, dozens of medical clinics, and other specialty care facilities. Location: Gig Harbor, Washington Opened: March 2009 Licensed beds: 80 3/20/2013 23
Electronic Medical Records One hospital of five uses an EMR o o In use for approximately 2.5 years Meditech All other facilities use partial EMR and scan paper records into electronically viewable charts o Cerner and Docuware Those four hospitals will convert to EPIC in June of 2013 o o Training will begin in April for all staff Abstraction from EPIC will begin in August 3/20/2013 24
Essential Steps for Appropriate Documentation Regional Monthly Education Focused Meetings Core Measure Nurses: RNs Introduce new measures to all providers Just in time education at bedside Promote and support evidence based practices Communicate performance improvement opportunities Process Improvement Project Managers: RNs Assist clinical teams to identify and implement process improvement projects Provide support, expertise, and guidance to management level work teams 3/20/2013 25
Essential Steps for Appropriate Abstractors: RNs o o o o Documentation, cont. Pull data from patient charts and insert it into Truven/Premier for submission to The Joint Commission and CMS Produce reports addressing variances Identify data trends Report at monthly meetings Progress of education and documentation currently in place Expert Assignments o Each abstractor has been assigned a specific population to follow regarding specification updates, education and reporting 3/20/2013 26
Essential Steps for Appropriate Documentation, cont. Twice a year, Expert Teams consisting of Abstractors and Process Improvement Project Managers meet to: Review the changes that will occur for the upcoming guideline publication Examine release notes for specification manual updates and/or changes Research Specific Measurement Information Inspect the Data Dictionary for changes 3/20/2013 27
Essential Steps for Appropriate Documentation, cont. Process Improvement Project Managers and Core Measure Nurses educate staff regarding the upcoming changes and required documentation Conduct on-site meetings to report to physicians, nurses, and management Provide education at the bedside Publish articles in network newsletters 3/20/2013 28
Abstraction Process Abstractors: RNs Rotating Assignments Seven of the eleven abstractors are generalists, working off-site The Heart Center Team and Stroke Team are specialists Ongoing internal consultations for abstraction consistency Weekly huddles Huddle notes posted to a computer shared space Questions submitted to Q-Net for clarification Whole chart re-abstractions to verify accuracy 3/20/2013 29
Variance Process Variance = Failed measure Upon discovery of a variance the original abstractor sends information to a peer requesting a second eyes review Quarterly a careful review of all variances is completed Variance report is published 3/20/2013 30
Lessons Learned/Potential Pitfalls Provide adequate time for training Obtain consensus among abstractors for locations of documented times in chart o Include all locations o Information sources are measured against specs manual requirements Take chart at face value o Not allowing experience or knowledge of clinical environment to obscure data 3/20/2013 31
For Additional Information Pauline Fraser, RN, BS, CPHQ o Manager, Clinical Effectiveness Phone: 253.552.5790 E-mail: paulinefraser@fhshealth.org Jan Oertel, RN, BSN o Clinical Data Abstractor Phone: 253.552.5788 E-mail: janoertel@fhshealth.org Zahirah Habassi, RN, BS o Clinical Data Abstractor Phone: 253.552.5787 E-Mail: zahirahhabassi@fhshealth.org 3/20/2013 32
North Arkansas Regional Medical Center Emergency Department Quality Reporting Erin Berry, RN 3/20/2013 33
North Arkansas Regional Medical Center - ED Quality Reporting 10 bed Emergency Department (ED) 4 bed acute care extension Approximately 2,000 ED visits per month Growth >20% prior year 3/20/2013 34
Electronic Medical Record Meditech 5.64, with upgrade in sights Fully integrated system ED records flows to inpatient Templates designed within our organization to fit 3/20/2013 35
Success in Meeting Measures Take it to the user Educate staff on goals and measures Brainstorm with frontline staff Develop ideas to improve the process Stay patient focused 3/20/2013 36
Making It Fit Changes made in the documentation system to ease the flow of capturing the information for the clinical staff Built chest pain assessment Addition of documentation Flow determined by the frontline staff so that it made sense 3/20/2013 37
Making It Fit, cont. Example: Blood culture collection prior to antibiotic 3/20/2013 38
Education Key to success Discuss on an individual basis Take time to discuss at every monthly staff meeting Engage the frontline staff Post screen shots for department to view on new documentation and methods 3/20/2013 39
Lessons Learned Stay patient focused Lead by example Compliance follows with o Education o Keeping the patient the focus o Going above and beyond for the patients we serve 3/20/2013 40
For Additional Information Erin Berry, RN Emergency Department North Arkansas Regional Medical Center erin.berry@narmc.com 3/20/2013 41
North Arkansas Regional Medical Center Imaging Services Tom Downes, BS, MS Director of Imaging Services 3/20/2013 42
Resources Meditech EMR and McKesson PACS o Fully integrated click on the camera icon next to an imaging order and full PACS will auto-launch o Physicians also have this capability in their offices Participated in Hospital Outpatient Quality Reporting Program from the beginning o Webinars o Educated hospital staff and physicians 3/20/2013 43
Make It Routine Mammographers routine: Run a daily report through the RIS portion of Meditech for the previous day s mammograms This report automatically prints letters for the patient and referring physician with relation to the BIRADS rating in the radiologist s report The results of the mammogram are logged for tracking whether follow-up was recommended or not These letters are mailed in the morning of the next working day after the mammogram was performed 3/20/2013 44
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Policy Controls Conservative use of IV contrast materials o January 2002 policy requires patients to have normal BUN/creatinine lab levels before use of IV contrast Primarily using GFR >45 Radiologists consult with ordering provider if they feel contrast is not necessary to obtain a good diagnostic exam Providing quality exams without the risk of adverse reactions to contrast media and saving supplies 3/20/2013 47
Education Improves Performance Educate, educate, educate More information improves performance of all 3/20/2013 48
For Additional Information Tom Downes, BS, MS Director of Imaging Services, NARMC North Arkansas Regional Medical Center Tom.Downes@narmc.com 3/20/2013 49
North Arkansas Regional Medical Center Operating Room Bill Warren, RN Operating Room Manager 3/20/2013 50
Hospital-based Outpatient and Inpatient Surgery Urology, GYN, General, Orthopedics, ENT, Spine 3/20/2013 51
Tools Vendor American Data Network Electronic Medical Record Meditech CMS 3/20/2013 52
Process Antibiotic regimen selection list EMR queries Pre-review Letters to physicians, managers, and administration 3/20/2013 53
For Additional Information Bill Warren, RN Operating Room Manager North Arkansas Regional Medical Center 870-414-4022 bill.warren@narmc.com 3/20/2013 54
We Will Now Open the Phone Lines for Q&A Odessa Regional Medical Center, Texas Levi Stone, BS, MN, CNO St. Anthony s Hospital, Franciscan Health Systems, Washington Jan Oertel, RN, BSN; Zahirah Habassi, RN, BS North Arkansas Regional Medical Center, AR Erin Berry, RN; Bill Warren, ST, RN; Tom Downes, BS, MS 3/20/2013 55
Thank You! Please contact the Hospital OQR Support Contractor if you have questions Submit questions online through the Question & Answer Tool: Hospitals-Outpatient Question/Answer OR Call the Hospital OQR Support Contractor at 866-800- 8756 For CEU credit, please send your name, state, license number, and profession to theron@fmqai.com following the program. This material was prepared by FMQAI, the Support Center for the Hospital Outpatient Quality Reporting program, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). The contents presented do not necessarily reflect CMS policy. FL-10SOW-2013FS4T11-3-680 3/20/2013 56