Adopting Standardized Definitions The Future of Data Collection and Benchmarking in Alternate Site Infusion Must Start Now! Connie Sullivan, RPh Infusion Director, Heartland IV Care Lyons, CO
CE Credit in Four Easy Steps! 1. Scan your badge as you enter each session. 2. Carry your Evaluation Packet to every session so you can add session evaluation forms to it. 3. Track your hours on the Statement of Session Attendance Form as you go. 4. At your last session, total the hours and sign both pages of your Statement of Session Attendance Form. Keep the PINK copy for your records. Put the YELLOW and WHITE copies in your CE Envelope. Make sure an Evaluation Form is in your CE Envelope for each session you attended. Miss one? Extras are in a file near Registration. Fill out the information on the outside of the CE Packet envelope, seal it, and drop it in the box near Registration. Applying for Pharmacy CPE? If you have not yet registered for an NABP e-profile ID, please visit www.mycpemonitor.net to do so before submitting your packet. You must enter your NABP e-profile ID in order to receive CE credit this year! 3/29/2013 2
Speaker Disclosures The speaker declares no conflicts of interest or financial interest in any service or product mentioned in this program. Clinical trials and off label/investigational uses will not be discussed during this presentation. 3/29/2013 3
Objectives Review the findings of the Data Definitions Survey Review the different categories of measures that define quality List and describe infusion related outcome measures that are collected today Describe the procedures for implementing a data collection program Map out a procedure for measuring & reporting a sample quality indicator 3/29/2013 4
The Drive to Measure Quality 3/29/2013 5
2012 NHIA Data Definitions Survey Defined the following measures: Hospitalization Reason codes ER Visit ADR Interventions 3/29/2013 6
2012 NHIA Data Definitions Survey Definitions Cont. Catheter infection Status upon Discharge/ Therapy Complete Outcome of hospitalization/ ER Visit/ ADR/ Catheter Event Patient Satisfaction 3/29/2013 7
Hospitalization Definition: An unplanned stay in any acute care facility for more than 23 hours for any reason. All hospitalizations should be counted Hospitalization will be further categorized as related or unrelated to the infusion therapy being provided. 3/29/2013 8
Related Hospitalizations A hospitalization is categorized as related to the infusion therapy if it results from: A catheter event Worsening of the condition for which the infusion therapy is being received An adverse reaction or complication caused by the I.V. medication
Reasons for Hospitalization Standard categories for describing the reasons for hospitalizations related to the infusion therapy are as follows: Catheter infection Catheter event other than infection Worsening of the condition being treated with I.V. therapy Adverse Drug Reaction Infection other than catheter related Change in home environment Unknown
Outcome of Hospitalization The outcome of hospitalization will be categorized as follows: Discharged from I.V. services I.V. services continued without changes I.V. services continued with changes Death
Survey Response for Hospitalization and ER Visit Definitions 98% Agreed with definition 74% Able to report 75% Willing to report 3/29/2013 12
Time Frame for Reporting Hospitalizations Not addressed in definition survey 2 time frames to consider 30 day readmission rate post hospital DC Full I.V. episode 3/29/2013 13
Proposed Definition: Emergency Room Visit Any visit to an acute care facility for immediate treatment resulting in a stay of less than 23 hours, that occurred in an active patient for any reason. Follows same format for related and unrelated as hospitalizations 3/29/2013 14
Adverse Event World Health Organization Definition: "A response to a drug which is noxious and unintended and which occurs at doses normally used in man for prophylaxis, diagnosis, or therapy of disease or for modification of physiological function." (WHO Technical Report 498, 1972) 3/29/2013 15
WHO Classification System Serious: Any adverse event occurring that results in any of the following outcomes: Death, a life threatening adverse event, requires inpatient hospitalization or prolongation of existing hospitalization, a persistent or significant disability/incapacity, or a congenital anomaly/birth defect. Severe: An experience that requires therapeutic intervention. If hospitalization is required for treatment it becomes a serious adverse event. Moderate: An experience that is alleviated with simple therapeutic treatments. Mild: An experience that is usually transient and requires no special treatment or intervention. 3/29/2013 16
Survey Response for ADR 99 100% Agree with definition 90% Able and willing to report 63% Currently use WHO system to categorize ADRs 90% document interventions to ADRs 3/29/2013 17
Discharge Status (Therapy Complete) Applies to any patient who administered all prescribed doses at the time of discharge. Proposed Rules: Rule # 1 Patients count as having completed therapy even if there were interruptions for adverse events, hospitalizations or catheter events. Rule # 2 The designation "Therapy Complete" does not factor in progress toward specific therapy goals or continuation of oral antibiotics after cessation of IV treatment. 3/29/2013 18
Survey Response for Therapy Complete 94% Agreed with definition 80% Able to report 79% Willing to report 3/29/2013 19
Discharge Status Codes DISCHARGE STATUS CODES Total Single Site Multi Site National Death expected 66% 68% 67% 33% Death unexpected 58% 58% 67% 33% Hospitalized 82% 82% 83% 67% Transfer to alternate site/level of care (hospice, SNF, HHA/VNA) 79% 80% 75% 67% Insurance change 58% 58% 58% 67% Lack of adherence 56% 53% 75% 67% Adverse drug reaction 57% 54% 75% 67% Change in home environment/lack of caregiver 43% 41% 50% 67% Loss of IV access 47% 45% 58% 67% Other 27% 26% 33% 33% 3/29/2013 20
Patient Satisfaction More than 80% of providers responded that they ask a same or similar question on their satisfaction survey for most questions 3/29/2013 21
SATISFACTION SURVEY QUESTION SIMILAR SAME TOTAL The medications, equipment and supplies were delivered on time. 12% 79% 91% You would recommend our service to your family and friends. 13% 69% 82% The instructions were adequate to teach you or your caregiver how to give the intravenous (IV) 20% 65% 85% medications. You were satisfied with the overall experience of receiving IV therapy at home. 26% 64% 90% Instruction was adequate for whom to call if you had a problem. The response received to calls for assistance after regular business hours was satisfactory. The services provided met your needs and expectations. You were informed of the possible side effects of the medication you received. The explanation of your financial responsibilities was adequate. 20% 63% 83% 17% 63% 80% 27% 61% 88% 13% 57% 70% 19% 54% 73% 3/29/2013 22
Process Measures Outcome Measures Patient Experience Structural Measures Types of Measures 3/29/2013 23
Infusion Process Measures How well you execute on internal procedures Example: Policy: All PN patients receive a consultation from the dietitian within 72 hours of admission. Measure: % of new PN patients that received an RD assessment within 72 hours of admission 3/29/2013 24
Infusion Outcome Measure Quantifies the results of care Reflects changes in clinical status Example: % Patients who received anti infective therapy that remain infection free for 30 days post EOT % EN patients who are re admitted within 30 days of discharge from the hospital setting 3/29/2013 25
Infusion Patient Experience Measures a patient s satisfaction with the services provided Examples: Would recommend your services to family and friends Agreed the supplies and equipment provided were sufficient to meet needs 3/29/2013 26
Infusion Structural Measures Describe and measure the conditions under which the care is provided Examples: % of patients served by staff vs. contract RN % of patients by catheter type 3/29/2013 27
What NOT to include in an Externally Focused Quality Measure Program Quality measures should reflect patient care This does not include business related indicators such as: Staff turnover rates Employee training practices Length of stay Diagnosis information 3/29/2013 28
Infusion Measures Today Categorize each type of measure: 3/29/2013 29
Answer 3/29/2013 30
Steps for Measuring & Reporting on Quality Indicators Define What? Who? When? Generate the data Retrieve & Validate the data Interpret & Report the data 3/29/2013 31
What to Measure Quality indicator Patient centered Define the value of the service NHIA Data Definitions Re hospitalizations ER Visits ADR Therapy Complete Catheter Complications Patient Satisfaction 3/29/2013 32
Hospice Industry Example Hospice Pain Measure National Quality Forum (NQF) # 0209 Measures the % of patients with pain at initial assessment who report their pain was brought under control within 48 hours 3/29/2013 33
Hospice Quality Measure Cont. First quality measure for hospice All hospices required to report data from Q4, 2012 or have 2014 payments reduced No standardized data collection tool Tool developed by SHP for their customers Submission deadline is April 1, 2013 3/29/2013 34
Defining the Denominator = Who WHO should be measured? Describe the patient population eligible for the measure Hospice Example: All new hospice admissions Any patient who can self report pain Patients 18+ years old Able to communicate and understand the language of the person asking the assessment questions 3/29/2013 35
When to Measure Define the time frame for generating the data May exceed dates of service 30 day hospital re admissions IVAB Relapse rates Hospice Example: Q4 2012 data due 4/1/13 3/29/2013 36
Data sources: Generate the Data EMR Paper patient records Incident reports Specific data collection tool or worksheet Satisfaction surveys 3/29/2013 37
Hospice Pain Data Collection Tool 3/29/2013 38
Hospice Example Method Admitting RN will generate the data during the first home visit Verify eligibility Ask initial question Develop a tracking process for patients needing follow up in 48 72 hours 48 hour follow up question will be asked during a home visit or via phone call by hospice case manager 3/29/2013 39
Retrieve the Data Electronic extraction reports Identify eligible patients Patient/indicator specific data Collection of paper worksheets Review for accuracy Do the responses make sense? Missing data? Employee errors? 3/29/2013 40
Validate Compare number of reports to total patients eligible Spot audits Chart reviews Patient interviews Employee interviews Compare documentation & results from different sites/ employees 3/29/2013 41
Aggregate the Data Determine what data elements need to be counted/quantified Determine the source for each piece of data 3/29/2013 42
Good Advice Not all things that can be counted matter, and everything that matters cannot always be counted. Albert Einstein 3/29/2013 43
Hospice Measure Example Data Elements to Aggregate & the Source: # of patients (18 years or order) admitted during the measurement time frame (EMR billing system) # patients that were eligible (Worksheet) # patients that answered no to Q 1 (Worksheet) # patients that answered yes to Q 1 (Worksheet) # patients eligible for 48 hour follow up question (Manual Spreadsheet) # patients that answered no to Q 2 (Worksheet) # patients that answered yes to Q 2 (Worksheet) 3/29/2013 44
Hospice Example Cont. Denominator Calculation: # Patients with pain at initial assessment + any missing Identifies patients that must be followed for 48 hour follow up question 3/29/2013 45
Hospice Example Cont. Numerator Calculation # Patients that answered yes to the 48 hour follow up question Reported as % of patients with pain at initial assessment who report pain was under control within 48 hours. 3/29/2013 46
Figure 3. NQF #0209 Data Collection Process
Review 1. Define the measure 2. Define the population (denominator) 3. Define the time frame 4. Develop a data generation process 5. Develop a procedure for validation 6. Aggregate, Validate and Report 3/29/2013 48
Workshop Work with a partner Identify a patient centered quality measure to map Demonstration measure: 30 day hospital re admission rates 3/29/2013 49
Step 1: Identify a Quality Measure Choose from one of the following: Process Measure Structural Measure Patient Satisfaction Outcome Measure 3/29/2013 50
Step 1. Selecting a Quality Measure Is the measure Patient Care Related? Does it address one of the following areas? Symptom management Care coordination Safety Change in clinical status Satisfaction 3/29/2013 51
Example Measures % of patients re hospitalized within 30 days of hospital DC (demo) % of patients that experience an ADR % of patients achieving independence with selfadministration of I.V. therapy % of patients who complete therapy as prescribed % of patients that require a catheter de clotting procedure % of patients receiving a medication profile review within 72 hours of admission 3/29/2013 52
Step 2: Describe the Population Who is eligible to be measured? Any special characteristics that need to be considered? Site of care variations? How will the population be identified? Will you exclude any patients? Why? 3/29/2013 53
Sample Measure Population % of patients re hospitalized within 30 days of hospital DC All patients admitted to service that are discharged from the hospital setting Additional considerations? Limit to single hospital provider? Limit by therapy type? Limit by payer? Any populations that need to be excluded? 3/29/2013 54
Re hospitalization Rate Example For this example we will look at all nonhospice patients discharged from the hospital setting admitted for IVAB and nutrition support therapies Data will be aggregated by age <65 years 65 + years 3/29/2013 55
Source of Population Data Describe the source that will provide the full list of eligible patients to be measured Electronic Report Admissions Reports 30 day Re admission Rate Example: Rockpond report from CPR Plus Will identify all non hospice patients who were admitted to service from the hospital setting 3/29/2013 56
CPR Source Population Report 3/29/2013 57
Step 3. Identify the Time Frames Define the reporting time period Usually monthly or quarterly Set targets for reporting each measurement period April 1 for Q4, 2012 Consider the source and quantity of data How much time is needed to validate and aggregate? 3/29/2013 58
Step 4. Describe the Data Collection Tools Electronic fields Unique data field User defined Minimize free text Standardization is key! Worksheet tools Electronic v. Manual Minimize writing 3/29/2013 59
30 Day Re admission Example 3/29/2013 60
Data Collection Tips Aim for in the moment documentation Avoid stock piling data to enter after the fact Electronic prompts/reminders Visual reminders Employee training is KEY! 3/29/2013 61
Step 5. Aggregate the Data List the data elements to be collected Develop a tool for summarizing the data 30 Day Re admission Rates Example: # Eligible Patients Hospital DC date Therapy Type Age # Re hospitalized within 30 days 3/29/2013 62
Sample Data Aggregation Tool 3/29/2013 63
Step 6. Validate Identify methods for validation Compare reports from different sources Chart audits 30 Day Re admission Rate Example Compare Hospital Assessments to Hospitalization Progress Notes entered Review patients with billing gaps 3/29/2013 64
Step 7. Report Identify how the data will be used? QI Sales efforts Operations Benchmarking Who is the audience for your data? 3/29/2013 65
30 Day Re admission Rate Example 3/29/2013 66
Report your results Internal v. external Reporting Benefits of internal reporting Creates ownership Generates new ideas Improves quality & efficiency Identify & overcome barriers 3/29/2013 67
Audience Presentations 3/29/2013 68
Wrap Up 1. Adopt the NHIA standard definitions www.nhia.org/data 2. Get started! Identify SOMETHING you can measure NOW!! Look for data opportunities that create value for your organization 3. Evaluate data collection methods Electronic, Standardize, Minimize 4. Aggregate, Validate and Report your data 3/29/2013 69