National Patient Safety Goals & Quality Measures CY 2017 General Clinical Orientation 2017 January
National Patient Safety Goals 1. Identify Patients Correctly 2. Improve Staff Communication 3. Use Medications Safely 4. Use Alarms Safely 5. Prevent Infection 6. Identify Patient Safety Risks 7. Prevent Mistakes in Surgery
Identify Patients Correctly» Use at least two patient identifiers (Policy S-8)» Eliminate transfusion errors related to patient misidentification (Policy M-96)
Improve Staff Communication» Improve effectiveness of communication among caregivers: SBAR (Policy M-128)» Report critical results of tests and diagnostic procedures on a timely basis: Readback
Use Medications Safely: (Policy M-55)» The 5 Rights of Medication Administration» Medication Reconciliation» Label all medications, medication containers & other solutions on & off a sterile field in perioperative settings
Reduce Patient Harm From Anticoagulation Therapy» Warfarin, Heparin, and Low Molecular Weight Heparin» Protocols, monitoring, dietary interactions» Staff and Patient/Family education
Use Alarms Safely» Ensure alarms are heard and responded to timely (Policy M-143)
Reduce the Risk of Health Care Associated Infections» Use proven guidelines to prevent infections that are difficult to treat» Use proven guidelines to prevent infection of the blood from central lines (CLABSI)» Use proven guidelines to prevent infection after surgery
Reduce the Risk of Health Care Associated Infections» Use proven guidelines to prevent infections of the urinary tract caused by catheters (CAUTI)
What is the Best Way of Reducing the Risk of Health Care Associated Infections?
Identify Patient Safety Risks» Identify Patients at Risk for Suicide (Policy M-47)
Prevent Mistakes in Surgery» Prevent Wrong Site, Wrong Procedure and Wrong Person Surgery» Conduct a Pre-procedure Verification Process (Policy M-123)» Mark the Procedure Site» Perform a Time-Out Before the Procedure
How to Call a CODE» Adult: Code Blue, Dial 77777» Pediatric: Code White, Dial 55555» Outside the Hospital: Dial 911» Rapid Response: Dial 77888» Answer All questions from the Operator» Give Detailed Information: Unit/Dept & Room Number
Code Policy References» Inpatient- Policy M-35» Outpatient- Policy M-127» Visitors- Policy S-5
What are Quality Measures?» Medical information from patient records converted into a rate or percentage that shows how well hospitals care for their patients in certain categories.» Each measure is an evidence-based, scientifically-researched standard of care which has been shown to result in improved clinical outcomes.
Development of Quality Measures is Based on Following Criteria:» High impact disease (cost, morbidity, mortality, quality of life)» Guidelines that provide best practices that can be measured» Gaps in care (opportunities for improvement)
CMS Quality Reporting Programs Hospital Inpatient Quality Reporting Program Hospital Outpatient Quality Reporting Value-Based Purchasing Program Hospital Readmission Reduction Program Hospital Acquired Conditions Reduction Program
Inpatient Quality Reporting» Examples of these measures include: Venous Thromboembolism; Stroke» Inpatient Quality Reporting Metrics do not directly impact hospital reimbursement» Hospital results are posted on Hospital Compare Website
Outpatient Quality Reporting» ED Measures» Colonoscopy» Hospital Outpatient Surgery Volume
How Quality Measures Impact Reimbursement» Pay for Performance» Quality Measure data submitted this year impact our reimbursement for 2018
Value Based Purchasing (VBP)» Quality incentive program that requires hospitals to contribute a percentage of their Medicare reimbursement into a pool» Hospitals have the opportunity to earn back their full contribution and the potential of earning additional monies based on their national performance ranking» Current withholding rate FY 2018 is 2.00% of Medicare base rate
Care Transition Measure Added to VBP on FY 2018» During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left.» When I left the hospital, I had a good understanding of the things I was responsible for in managing my health» When I left the hospital I clearly understood the purpose for taking each of my medications
Hospital Readmission Reduction Program» Reduces payments to hospitals with excess readmissions» Readmission defined as an admission to acute care hospital within 30 days of discharge from the same or another acute care hospital» Unlike Value Based Purchasing (VBP) Program this is a reimbursement penalty program. Penalty reduction in Medicare payment is 3% of base rate.
Hospital Readmission Program FY 2018 Readmission Rates Acute MI 30 Day Readmission Rate Heart Failure 30 Day Readmission Rate Total Hip/Knee Arthroplasty 30 Day Readmission Rate Acute Exacerbation of COPD 30 Day Readmission Rate CABG 30 Day Readmission Rate Pneumonia 30 Day Readmission Rate: cohort expanded
Hospital Acquired Condition (HAC) Program» Defined as a condition that patients acquire while receiving treatment for another condition in an acute care setting.» Hospital performance determined on hospital s total HAC score which can range from 1-10.
Hospital Acquired Condition (HAC) Program» The higher the score the poorer the hospital performance.» HAC reduction scores are being posted on the Hospital Compare website.
HAC Reduction Program FY 2018 15% 85% AHRQ PSI-90 Patient Safety Indicator Composite CDC HAI's Healthcare Acquired Conditions CDC HAI AHRQ PSI-90 CLABSI CAUTI SSI MRSA C- Diff PSI-3 Pressure Ulcer Rate PSI-6 Iatrogenic Pneumothorax Rate PSI-7 Central Venous Catheter Related Blood Stream Infection Rate PSI- 8 Post Operative Hip Fracture PSI-12 Post Operative Pulmonary Embolism or Deep Vein Thrombosis Rate PSI-13 Post Operative Sepsis PSI-14 Post Operative Wound Dehiscence PSI-15 Accidental Puncture or Laceration
This is a QUIZ
Questions?» Who created National Patient Safety Goals?» We recommend using patient name and room number to identify a patient?» What is a Code White? What phone number do you call?» Where can I look to get information on Core Measures?
Questions?» Only nursing staff need to worry about Quality Measures?» Quality Measures are published on Hospital Compare website?» Quality Measures stay the same from year to year?» Hospital Readmission Reduction Program is a reimbursement incentive program?
What else are we measured by CMS?» Complete list (matrix) will be available in the VIP page or per request Short Name Description Measure Set Domain or Setting CMS Hospital IQR Submission Methods FY 2017 Payment Determination Outpatient Quality Reporting (OQR) FY 2017 Payment (Pending Final Rule) CMS Value-Based Purchasing (VBP) Program FY 2017 Payment CMS Meaningful Use (MU) TJC (pending confirmation by TJC) TJC Accountability Measures HAC Reduction Program Hospital Readmission Program Comments AMI-1 Aspirin at arrival for acute myocardial infarction (AMI) Acute Myocardial Infarction AMI-2 Aspirin Prescribed at Discharge for AMI Acute Myocardial Infarction Voluntary ecqm MU AMI-3 ACEI or ARB for LVSD: Acute Myocardial Infarction (AMI) Patients Acute Myocardial Infarction AMI-5 Beta-blocker Prescribed at Discharge for AMI Acute Myocardial Infarction AMI-7a Fibrinolytic Therapy Received within 30 minutes of Hospital Arrival Acute Myocardial Infarction ecqm or Chart abstracted (NA) X- NA for LLUMC NA for LLUMC NA for LLUMC (Chart abstracted or ecqm) NA for LLUMC AMI-8a Primary PCI Received within 90 minutes of Hospital Arrival Acute Myocardial Infarction Voluntary ecqm MU AMI-10 Statin Prescribed at Discharge Acute Myocardial Infarction Voluntary ecqm MU ED-1 ED-2 HF-2 Median Time from ED Arrival to ED Departure for Admitted ED Patients Admit Decision Time to ED Departure Time for Admitted Patients Emergency Department Throughput Emergency Department Throughput Evaluation of Left Ventricular Systolic Heart Failure Function (LVS) ecqm or Chart abstracted ecqm or Chart abstracted MU MU ecqm or Chart abstracted ecqm or Chart abstracted HF-3 ACEI or ARB forlvsd - Heart Failure (HF) Patients Heart Failure IMM-1 Pneumococcal Immunization Prevention Immunization Suspended IMM-2 Influenza Immunization Prevention Immunization Chart abstracted VBP PC-1 Elective Delivery prior to 39 Completed Weeks of Gestation Perinatal Care ecqm or Chart abstracted VBP MU ecqm or Chart abstracted
Questions?
Policies / Regulatory Requirements» S-8 Patient Identification» M-96 Administration of Blood and Blood Components» M-128 Hand Off Report in Clinical Areas» M-55 Medication Administration and Errors» M-55.A Administration of High Risk Medications» M-143 Clinical Alarm Management» M-30 Infection Control» M-47 Patients Suspected or Determined to be a Danger to Self or Others» M-123 Universal Protocol for Patient, Procedure, and Site Verification» M-35 Code Blue/White (CPR) and Rapid Response Team (RRT) Management» M-127 Emergency Treatment and Transport of Outpatients» S-5 Incidents Involving Visitors on LLUMC Property
Regulatory» Joint Commission ~ National Patient Safety Goals» CMS Quality Reporting Programs ~ Hospital Inpatient Reporting ~ Hospital Outpatient Reporting ~ Value Based Purchasing ~ Hospital Readmission Reduction ~ Hospital Acquired Conditions Reduction» HCAHPS (Hospital Consumer Assessment of Healthcare Provider & Systems)