Regulatory and Quality Measure Reporting Update for ASCs

Regulatory and Quality Measure Reporting Update for ASCs Paige Proffitt, RN, BSN, CASC Regional Vice President, Operations, Amsurg Cindi Skoglund, RN, BSN Associate Vice President, Clinical Services, Amsurg Learning Objectives Participants will: Discuss the current revisions to the Tennessee state regulations for ASTCs Discuss quality reporting for ambulatory surgery centers (ASCs) required by CMS Identify the current changes to the ASC quality reporting 2 1

Tennessee Standards for Ambulatory Surgical Treatment Centers (ASTCs) Chapter 1200-08-10 Standards for Ambulatory Surgical Treatment Centers Revised October 2016 http://share.tn.gov/sos/rules/1200/1200-08/1200-08- 10.20161016.pdf 3 4 Tennessee Standards for Ambulatory Surgical Treatment Centers (ASTCs) Revisions 1200-08-10-.06(11) Infection Control An Ambulatory Surgical Treatment Center shall have an annual influenza vaccination program which shall include at least: (a) The offer of influenza vaccination to all staff and independent practitioners at no cost to the person or acceptance of documented evidence of vaccination from another vaccine source or facility. The Ambulatory Surgical Treatment Center will encourage all staff and independent practitioners to obtain an influenza vaccination; (b) A signed declination statement on record from all who refuse the influenza vaccination for reasons other than medical contraindications (a sample form is available at http://tennessee.gov/health/topic/hcf-provider); 2

Tennessee Standards for Ambulatory Surgical Treatment Centers (ASTCs) Revisions 1200-08-10-.06(11) Infection Control (c) Education of all direct care employees about the following: 1. Flu vaccination, 2. Non-vaccine control measures, and 3. The diagnosis, transmission, and potential impact of influenza; (d) An annual evaluation of the influenza vaccination program and reasons for non-participation; and (e) A statement that the requirements to complete vaccinations or declination statements shall be suspended by the administrator in the event of a vaccine shortage as declared by the Commissioner or the Commissioner s designee. 5 Central Service Technician Requirements SB 1238/HB 766- This bill amends the legislation passed in 2015 that created requirements for central service technicians in health care facilities including ASCs. It outlines: 1) certification or past work experience requirement 2) continuing education requirement 6 3

Central Service Technician Requirements Certification or Past Work Experience Requirement In order to practice as a central service technician, the person must: 1(A) Successfully have passed a nationally accredited central service exam for central service technicians and holds and maintains one (1) of the following credentials: (i) A certified registered central service technician credential administered by the International Association of Healthcare Central Service Material Management (IAHCSMM); or (ii) A certified sterile processing and distribution technician credential administered by the Certification Board for Sterile Processing and Distribution, Inc (CBSPD).; or (2) Was employed or otherwise contracted for services as a central service technician in a healthcare institution before January 1, 72017 Central Service Technician Requirements Certification or Past Work Experience Requirement If the person is not certified by IAHCSMM or CBSPD or was not employed or otherwise contracted for services as a central service technician in a healthcare institution before January 1, 2017 then they must: Obtain a certified registered central service technician credential administered by IAHCSMM or CBSPD no later than two (2) years after the person's date of hire or contracting for services with a healthcare institution. 8 4

Central Service Technician Requirements Continuing Education Requirement The central service technician must complete a minimum of ten (10) hours of continuing education annually. The continuing education shall be in areas related to the functions of a central service technician. 9 **Nurses and other registered, certified, or licensed health professional under title 63 are exempted from these requirements. Surgical technologists are also exempted from the continuing education requirement. ** This is listed in the Tennessee Annotated Code, Ch 68-11-239 (Title 68 Health Chapter 11 Part 2 Regulation of Health and Related Facilities 68-11-239) **As of now, this is not be listed in the Tennessee standards 1200-08-10. ASCQR Program Measures Summary 10 5

ASCQR Program Measures Summary 11 ASCQR Program Measures Summary 12 6

ASCQR Program Measures Summary 13 ASCQR Program Measures Summary Proposed 14 7

CMS Ambulatory Surgical Center Quality Reporting Program CMS ASC Quality Reporting Program Quality Measures Specifications Manual Verify you have the latest versions 7.0 1Q18-4Q18 6.0a 1Q17-4Q17 Located @ www.qualitynet.org under ASC tab Included in this manual: Measure specifications Data collection and submission Quality Data Codes (QDCs) 15 ASC Quality Reporting Program Measures ASC-1: Patient Burn ASC-2: Patient Fall ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant ASC-4: Hospital Transfer/Admission ASC-5: Prophylactic Intravenous (IV) Antibiotic Timing Medicare Part B Fee for Service Patients Claims Based Reporting Quality Data Codes (QDCs) 16 8

ASC Quality Reporting Program Measures ASC-6: Safe Surgery Checklist Use ASC-7: ASC Facility Volume Data on Selected ASC Surgical Procedures ASC-9: Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients ASC-10: Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps-Avoidance of Inappropriate Use Web Based Reporting via QualityNet Secure Portal (www.qualitynet.org) Data collection: January 1 through December 31, 2017 Data reporting: January 1 through May 15, 2018 17 ASC Quality Reporting Program Measures ASC- 8: Influenza Vaccination Coverage among Healthcare Personnel Web Based Reporting Via Centers for Disease Control and Prevention (CDC) National Health Care Safety Network (NHSN) (www.cdc.gov/nhsn/index.html) Data collection begins with immunizations for the flu season October 1, 2017 through March 31, 2018 Deadline for data reporting for the 2017-2018 flu season is May 15, 2018. 18 9

ASC Quality Reporting Program Measures ASC-12: Facility Seven-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy Data is pulled by CMS from the Medicare Fee for Service administrative claims that were submitted by the center January 1- December 31, 2016 and subsequent years. No data submission or reporting required from the ASC Claims Detail Reports (CDR) for January 1 - December 31, 2016 were uploaded to QualityNet secure portal. Final measure calculation and public reporting of measure results from 2016 will occur in December 2017. 19 ASC Quality Reporting Program Measures ASC 13 Normothermia Outcome ASC 14 Unplanned Anterior Vitrectomy Data submitted for both of these measures are for All Patients that meet the denominator criteria. Web Based Reporting via QualityNet Secure Portal (www.qualitynet.org) Data collection: January 1 through December 31, 2018 Data reporting: January 1 through May 15, 2019 20 10

ASC 13: Normothermia Outcome Intent: To capture whether patients having surgical procedures under general or neuraxial anesthesia of 60 minutes or more in duration are normothermic within 15 minutes of arrival in PACU Numerator: Surgery patients with a body temperature equal to or greater than 96.8 Fahrenheit/36 Celsius recorded within fifteen minutes of Arrival in PACU Denominator: All patients, regardless of age, undergoing surgical procedures under general or neuraxial anesthesia of greater than or equal to 60 minutes duration 21 ASC 14: Unplanned Anterior Vitrectomy Intent :To determine the number of cataract surgery patients who have an unplanned anterior vitrectomy Numerator: All cataract surgery patients who had an unplanned anterior vitrectomy Denominator: All cataract surgery patients Numerator Exclusions: None Denominator Exclusions: None 22 11

ASC 15: Outpatient/Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) The five survey-based measures (ASC-15a-e) are collected via one survey {OAS CAHPS}: ASC-15a: About Facilities and Staff; ASC-15b: Communication About Procedure; ASC-15c: Preparation for Discharge and Recovery ASC-15d: Overall Rating of Facility; and ASC-15e: Recommendation of Facility Data collection of these measures has been delayed. 23 ASC 15: OAS CAHPS Survey Website Official OAS CAHPS website https://oascahps.org/ (This is the official website for news, training and information about the OAS CAHPS survey.) The survey has three administration methods: mail-only; telephone-only; and mixed mode (mail with telephone follow-up of nonrespondents) 24 Toll-free number: 1-866-590-7468 for questions 12

In Summary: How Your Data Is Reported Claims Based Reporting Quality Data Codes (QDCs) Patient Burn Patient Fall Wrong Site, Side, Patient, Procedure, Implant Hospital Admission/Transfer Prophylactic IV Antibiotic Timing Web Based Reporting via QualityNet Secure Portal (www.qualitynet.org) Safe Surgery Checklist Use ASC Volume of Selected Procedures for all-patients Endoscopy Surveillance: Appropriate follow-up for Normal Colonoscopy Endoscopy Surveillance: Colonoscopy Interval for History Adenomatous Polyps Normothermia Unplanned Anterior Vitrectomy 25 In Summary: How Your Data Is Reported Web Based Reporting Via Centers for Disease Control and Prevention (CDC) National Health Care Safety Network (NHSN) (www.cdc.gov/nhsn/index.html) Influenza Vaccination Coverage Among Health Care Personnel Administrative Claims Facility Seven-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy Survey Administered by CMS Approved Vendor ASC 15a-15e: Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) 26 13

ASC 6, 7, 9 & 10: Key Points To Remember Active Security Administrator to access QualityNet Secure Portal Recommended to have two security administrators if possible Sign in to QualityNet secure portal frequently (every 60 days) to keep the account active ASC 7 (volume data measure): Need to fill in all procedures listed in QualityNet even if your volume is zero 27 Key Points To Remember ASC 8 (influenza vaccination): - A user s Secure Access Management Services (SAMS) account will be deactivated if they do not log in at all within a 12 month period (1 year). You will receive an email notification. 28 14

Key Points To Remember ASC 9 and 10 (colonoscopy measures): The sample size for each measure is determined by the number of cases that meet the denominator criteria. If you do not perform endoscopy procedures you STILL need to log into www.qualitynet.org secure portal and enter zero for the numerator and denominators in both measures. 29 Key Points To Remember ASC-12: (facility seven-day risk-standardized hospital visit rate after outpatient colonoscopy) no data submission or reporting required from ASCs for ASCs performing colonoscopy, confidential reports include patient level data and will be uploaded to the QualityNet Secure Portal patient (medical record number), date of birth, date of service type of hospital visit (ED, observation, hospital) admitting facility diagnosis code of hospital visit and hospital ID 30 15

Key Points To Remember ASC 13 and 14 (Normothermia and Unplanned Anterior Vitrectomy) All patients that meet the denominator criteria If you do not perform these procedures you STILL need to log into www.qualitynet.org secure portal and enter zero for the numerator and denominator in both measures. 31 Key Points To Remember Each facility should have at least two people signed up for the QualityNet email notifications Go to www.qualitynet.org; click on ambulatory surgery center and click on email notification 32 16

2018 Medicare Hospital Outpatient Prospective Payment System (OPPS)/ASC Payment Proposed Rule Released on July 13, 2017 https://s3.amazonaws.com/publicinspection.federalregister.gov/2017-14883.pdf ASC Quality Reporting Program begins on page 515: Section XIV. Requirements for the Ambulatory Surgical Center Quality Reporting (ASCQR) Program 33 2018 Medicare Hospital Outpatient Prospective Payment System (OPPS)/ASC Payment Proposed Rule Previous measures ASC 1-14 Delay implementation of (ASC 15a-e ): OAS CAHPS Survey measures beginning with the CY 2020 payment determination (data collection 2018) Remove three measures from the ASCQR Program measure set: - ASC 5: Prophylactic Intravenous (IV) Antibiotic Timing, - ASC 6: Safe Surgery Checklist Use and, - ASC 7: Ambulatory Surgical Center Facility Volume Data on Selected Ambulatory Surgical Center Surgical Procedures. Beginning with the CY 2019 payment determination (data collection 2017) 34 17

2018 Medicare Hospital Outpatient Prospective Payment System (OPPS)/ASC Payment Proposed Rule Adopt one new measure for the CY 2021 payment determination (data collection 2019) and subsequent years: - ASC-16: Toxic Anterior Segment Syndrome (TASS) Adopt two new measures for the CY 2022 payment determination (data collection 2020) and subsequent years: - ASC-17: Hospital Visit after Orthopedic Ambulatory Surgery Procedures - ASC -18: Hospital Visit after Urology Ambulatory Surgery Procedures 35 ASC 16: Toxic Anterior Segment Syndrome (TASS) Outcome (Proposed) Intent :To capture patients having anterior segment surgery who were diagnosed with TASS postoperatively Numerator: All anterior segment surgery patients diagnosed with TASS within 2 days of surgery Denominator: All anterior segment surgery patients Numerator Exclusions: None Denominator Exclusions: None 36 18

ASC 16: Toxic Anterior Segment Syndrome (TASS) Outcome (Proposed) Definitions: Anterior segment surgery: for purposes of this measure, CPT codes 65400-66999 Toxic Anterior Segment Syndrome (TASS): an acute, sterile post-operative anterior segment inflammation that develops following anterior segment surgery Web Based Reporting via QualityNet Secure Portal (www.qualitynet.org) Data collection: January 1 through December 31, 2019 Data reporting: January 1 through May 15, 2020 37 ASC 17: Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures Data is pulled by CMS from the Medicare Fee for Service administrative claims that will be submitted by the center January 1- December 31, 2020 No data submission or reporting required from the ASC The measure outcome is all-cause, unplanned hospital visits (Emergency Department Visit, Observation Stays, Unplanned Inpatient Admission) within seven days of an orthopedic procedure performed at an ASC. Claims Detail Reports (CDR) will be uploaded to QualityNet secure portal for facility review 38 19

ASC 18: Hospital Visits after Urology Ambulatory Surgical Center Procedures Data is pulled by CMS from the Medicare Fee for Service administrative claims that will be submitted by the center January 1- December 31, 2020 No data submission or reporting required from the ASC The measure outcome is all-cause, unplanned hospital visits (Emergency Department Visit, Observation Stays, Unplanned Inpatient Admission) within seven days of an urology procedure performed at an ASC. Claims Detail Reports (CDR) will be uploaded to QualityNet secure portal for facility review 39 Websites with Additional Information ASC Quality Collaboration website (measure summary and implementation guide) http://ascquality.org/qualitymeasures.cfm Ambulatory Surgery Center Association (ASCA) website http://www.ascassociation.org QualityNet website (CMS Specifications Manual & Email Notifications) http://qualitynet.org Quality Reporting Center HSAG (CMS national support contractor) http://www.qualityreportingcenter.com/ 40 20

Questions? For ASC Quality Reporting Program Questions: Contact Health Services Advisory Group (HSAG) (formerly FMQAI) at https://cms-ocsq.custhelp.com/ or via phone (866) 800-8756 Monday through Friday, 7 a.m. to 6 p.m. Eastern Time For Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) Influenza Vaccination Questions: Contact NHSN@cdc.gov and include HPS Flu Summary-ASC in the subject line For assistance with SAMS, contact the SAMS Help Desk @ 1-877-681-2901 or samshelp@cdc.gov 41 Federal Register / Vol. 76, No. 230 / Wednesday, November 30, 2011 / Rules and Regulations. Available at http://www.gpo.gov/fdsys/pkg/fr-2011-11-30/pdf/2011-28612.pdf Federal Register / Vol. 77, No. 221 / Thursday, November 15, 2012 / Rules and Regulations. Available at http://www.gpo.gov/fdsys/pkg/fr-2012-11-15/pdf/2012-26902.pdf. Federal Register / Vol. 78, No. 237 / Tuesday, December 10, 2013/ Rules and Regulations. Available at http://www.gpo.gov/fdsys/pkg/fr-2013-12-10/pdf/2013-28737.pdf Federal Register / Vol. 79, No. 217 / Monday, November 10, 2014/ Rules and Regulations. Available at http://ww.gpo.gov/fdsys/pkg/fr-2014-11-10/pdf/2014-26146.pdf Federal register/ Vol. 80, No. 219 / Friday, November 13, 2015/ Rules and Regulations. Available at http://www.gpo.gov/fdsys/pkg/fr-2015-11-13/pdf/fr-2015-11-13.pdf Federal register/ Vol. 81, No. 219/ Monday, November 14, 2016/ Rules and Regulations. Available at https://www.gpo.gov/fdsys/pkg/fr-2016-11-14/pdf/2016-26515.pdf Federal register/ Vol. 82, No. 138/ Thursday, Thursday, July, 20 2017/ Rules and Regulations. Available at https://www.gpo.gov/fdsys/pkg/fr-2017-07-20/pdf/2017-14883.pdf ASC Quality Collaboration Implementation Guide, Version 4.0, September 2016. Available at http://ascquality.org/documents/asc-qc-implementation-guide-4.0-september-2016.pdf CMS ASC Quality Reporting Program Quality Measures Specifications Manuals, Versions 6.0.a, 7.0 Available at www.qualitynet.org QualityNet at www.qualitynet.org QualityReportingCenter at www.qualityreportingcenter.com National Healthcare Safety Network www.cdc.gov/nhsn/ Chapter 1200-08-10 Standards for Ambulatory Surgical Treatment Centers http://share.tn.gov/sos/rules/1200/1200-08/1200-08-10.20161016.pdf 42 References 21