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Changes in Healthcare Quality Reporting Requirements. Rosalie Weakland, RN, MSN, CPHQ, FACHE Ohio Hospital Association. Objectives. Describe changes related to future healthcare acquired infections (HAI) measures and how these will be used as part of healthcare reimbursement.

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changes in healthcare quality reporting requirements

Changes in Healthcare Quality Reporting Requirements

Rosalie Weakland, RN, MSN, CPHQ, FACHE

Ohio Hospital Association

Southwest APIC Seminar

objectives
Objectives
  • Describe changes related to future healthcare acquired infections (HAI) measures and how these will be used as part of healthcare reimbursement.
  • Outline steps the ICP can take now to maximize reporting of required measures across the continuum of care

Southwest APIC Seminar

ipps quality measures
IPPS Quality Measures
  • Number of measures to be submitted to CMS
    • FY 2011 – 45 measures
    • FY 2012 – 55 measures
    • FY 2013 – 57 measures
    • FY 2014 – 59 measures
    • FY 2015 – 73 measures

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2011 and 2012
2011 and 2012
  • FY 2011 - Retirement of AHRQ composite measure for mortality among selected procedures.
  • FY 2012 – 10 new measures
    • 2 AHRQ PSI
    • 8 HAC

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fy 2012 ipps quality measures
FY 2012 IPPS Quality Measures
  • 2 AHRQ Patient Safety Indicators (PSIs):
    • Post-operative respiratory failure
    • Post-operative pulmonary embolism or deep vein thrombosis.
  • 8 Hospital-acquired conditions (HACs):
    • Foreign object retained after surgery;
    • Air embolism;
    • Blood incompatibility;
    • Pressure ulcer stages III & IV;
    • Falls and trauma;
    • Vascular catheter-associated infection;
    • Catheter-associated urinary tract infection;
    • Manifestations of poor glycemic control.

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fy 2013 ipps quality measures
FY 2013 IPPS Quality Measures

Measurement Period: January 1, 2011 - December 31, 2011

  • CDC NHSN for central line-associated blood stream infection;
  • Providing statin at discharge for patients who had an acute myocardial infarction.

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2014 ipps changes
2014 IPPS Changes
  • Total – 59 measures
  • Retire 4 measures
    • Will also exclude the same measures from 2013 VBP
  • Suspension of 4 measures
    • Will also exclude the same measures from 2013 VBP
  • Add 3 measures

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retired measures 2014
Retired Measures - 2014
  • Effective with January 1, 2012 discharges
    • AMI 4 - Adult Smoking
    • HF 4 - Adult Smoking
    • PN 4 - Adult Smoking
    • PN 5c – Timing of initial antibiotic
    • PN 2 - Pneumococcal Vaccine*
    • PN 7 - Influenza Vaccine*

* Converted to Global Immunization measure

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suspended measures 2014
Suspended Measures - 2014
  • Effective with January 1, 2012 discharges
    • AMI 1 - Aspirin on Arrival**
    • AMI 3 - ACE/ARB for LVSD**
    • AMI 5 - BB at discharge**
    • SCIP INF-6: Appropriate hair removal**

**TJC still expects hospitals to report these measures

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fy 2014 ipps quality measures
FY 2014 IPPS Quality Measures

Measurement Period: January 1, 2012 - December 31, 2012

    • CDC NHSN measures
      • surgical site infection;*
      • Catheter Associated Urinary Tract Infection
  • Global Immunization Measures
      • Global flu immunization; *
      • Global pneumonia immunization.*

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fy 2014 ipps quality measures cont
FY 2014 IPPS Quality Measures (cont)
    • Medical chart-abstracted measures:
      • ED throughput - admit decision time to ED departure time for admitted patients;*
      • ED throughput - median time from ED arrival to ED departure for admitted patients;*
  • Structure measure
    • Participation in a General Surgery Registry
  • Cost Efficiency
    • Medicare Spending per Beneficiary

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2015 ipps changes
2015 IPPS Changes
  • Total – 73 measures
  • Add 17 new measures
  • Healthcare Associated infections
    • MRSA Bacteremia
    • Clostridium Difficile
    • Healthcare Personnel Influenza Vaccination

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2015 ipps changes1
2015 IPPS Changes
  • Stroke Measure Set
    • STK – 1 VTE prophylaxis
    • STK – 2 Antithrombotic therapy for ischemic stroke
    • STK – 3 Anticoagulation therapy for Afib/flutter
    • STK – 4 Thrombolytic therapy for acute ischemic stroke
    • STK – 5 Antithrombotic therapy by end of day 2
    • STK – 6 Discharged on Statin
    • STK – 8 Stroke Education
    • STK – 10 Assessed for rehabilitation services

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2015 ipps changes2
2015 IPPS Changes
  • VTE Measure Set
    • VTE – 1 VTE prophylaxis
    • VTE – 2 ICU VTE prophylaxis
    • VTE – 3 VTE patients with anticoagulation overlap therapy
    • VTE – 4 Pts receiving un-fractionated Heparin with monitoring protocol
    • VTE – 5 VTE discharge instructions
    • VTE – 6 Incidence of potentially preventable VTE

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proposed opps measures

Proposed OPPS Measures

Final Rule to be posted by end of October

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opps quality measures
OPPS Quality Measures
  • Number of measures to be submitted to CMS
    • FY 2011 – 11 measures
    • FY 2012 – 15 measures
    • FY 2013 – 23 measures (begin collection 1/1/12)
    • FY 2014 – 32 measures (begin collection 1/1/13)
    • FY 2015 – 33 measures (begin collection 1/1/14)

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2011 opps measures
2011 OPPS Measures
  • AMI – Treated and transferred
    • OP - 1 Median time from ED arrival to fibrinolysis
    • OP – 2 Fibrinolytic therapy received within 30 minutes of arrival
    • OP – 3 Median time from ED arrival to transfer for PCI
    • OP - 4 Aspirin at arrival for patients
    • OP – 5 Median time from ED arrival to ECG
  • Surgical Care Improvement
    • OP – 6 Timing of antibiotic prophylaxis
    • OP – 7 Selection of prophylactic antibiotic
  • Imaging Efficiency
    • OP – 8 MRI lumbar spine for low back pain
    • OP – 9 Mammography follow-up rates
    • OP – 10 Abdomen CT – Use of contrast material
    • OP – 11 Thorax CT – Use of contrast material

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2012 opps measures
2012 OPPS Measures
  • Retain 11 existing measures from 2011
  • 1 new structural measure
  • 3 new claims based measures
  • Total – 15 measures

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2012 opps measures1
2012 OPPS Measures
  • HIT (Structural)
    • The ability for providers with HIT to receive laboratory data electronically directly into their qualified/certified EHR system as discrete searchable data (data Jan. 1, 2011 – June 30, 2011)
  • Imaging Efficiency (Claims based)
    • Cardiac Risk for preoperative evaluation for low risk non-cardiac surgery risk assessment
    • Simultaneous use of brain CT and sinus CT
    • Use of brain CT in the ED for atraumatic headache

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2013 opps changes
2013 OPPS Changes
  • Retain 15 measures fro CY 2012
  • Add 7 chart abstracted measures
  • Add 1 structural measure
  • Total – 23 measures

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2013 opps measures
2013 OPPS Measures

Emergency Department Efficiency

  • OP 16 – Troponin results for ED AMI/CP patients received within 60 minutes of arrival
  • OP18 – Median time from ED arrival to ED departure for discharged patients
  • OP 20 – Door to diagnostic evaluation by qualified medical professional
  • OP 21 – ED – Median time to pain management for long bone fracture
  • OP 22 - ED – Patient left before being seen

Care Coordination

  • OP 19 – Transition record with specified elements received for discharged patients

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2013 opps proposed measures
2013 OPPS Proposed Measures
  • Imaging Efficiency
    • ED – Head CT scan results for acute ischemic stroke or hemorrhagic stroke patients who received head CT scan interpretation within 45 minutes of arrival
  • Structural HIT Measure
    • OP 17 – Tracking clinical results between visits (Jan-June 2012 data reported July/Aug. 2012)

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2014 opps proposed measures
2014 OPPS Proposed Measures
  • Retain – 23 measures from CY 2013
  • 9 new measures proposed
  • Total - 32 measures

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proposed 2014 opps measures
Proposed 2014 OPPS Measures
  • OP 25 – Diabetes Hemoglobin A1c Management
  • OP 26 – Diabetes Pair: Lipid management: (LDL-C < 130; LDL-C <100)
  • OP 27 – Diabetes: Blood Pressure Management
  • OP 18 - Diabetes: Eye Exam
  • OP 29 – Diabetes: Urine protein screening
  • OP 30 – Cardiac rehabilitation patient referral from an outpatient setting

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proposed 2014 opps measures1
Proposed 2014 OPPS Measures
  • Structural Measures
    • OP 31 – Safe Surgery Checklist
    • OP 32 – Hospital Outpatient volume Data on Selected outpatient surgical procedures (cardiovascular, eye, gastrointestinaI, gentitourinary, musculoskeletal, nervous system, respiratory, skin)
  • HAI (through NHSN) (begin collection Jan. 1, 2013)
    • OP 24 – Surgical Site Infection

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2015 opps proposed measures
2015 OPPS Proposed Measures
  • Retain – 32 measures from CY 2014
  • 1 new measures proposed
  • Total - 33 measures
  • HAI (through NHSN)
    • Influenza Vaccination Coverage among healthcare personnel (begin collection Oct 2013)

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proposed asc quality measures
Proposed ASC Quality Measures
  • Number of measures to be submitted to CMS
    • FY 2014 – 8 measures
    • FY 2015 – 10 measures
    • FY 2016 – 11 measures

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2014 asc proposed measures
2014 ASC Proposed Measures
  • 8 new measures
    • 1 new NHSN measure
    • 7 new claims based measures (1/1/2012 – 12/31/2012)
  • HAI (through NHSN) (begin collection Jan. 1, 2013)
    • Surgical Site Infection

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2014 asc proposed measures1
2014 ASC Proposed Measures
  • Claims Based Measures
    • Patient Burns
    • Patient Fall
    • Wrong site, wrong side, wrong patient, wrong procedure, wrong implant
    • Hospital transfer/admission
    • Prophylactic intravenous antibiotic timing
    • ASC patient with appropriate method of hair removal
    • Selection of prophylactic antibiotic 1st or 2nd generation Cephalosporin

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2015 asc proposed measures
2015 ASC Proposed Measures
  • 2 new measures
    • 1 new structural measure
    • 1 new volume measure (1/1/2012 – 12/31/2012)
  • Total - 10 measures

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2015 asc proposed measures1
2015 ASC Proposed Measures
  • Structural measure
    • Safe surgical checklist
  • Volume measure
    • ASC volume data on selected ASC surgical procedures (eye, gastrointestinaI, gentitourinary, musculoskeletal, nervous system, skin)

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2016 asc proposed measure
2016 ASC Proposed Measure
  • 1 new measure
    • 1 new NHSN measure
  • Total - 11 measures
  • HAI (through NHSN)
    • Influenza Vaccination Coverage among healthcare personnel (begin collection Oct 2013)

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long term acute care quality measures 2014
Long Term Acute Care Quality Measures - 2014
  • 3 new measures
  • 1 new chart abstracted measure
    • Pressure Ulcer – new or worsened
  • 2 NHSN measures – (collected Oct. 2012)
    • Central line associated bloodstream infection
    • Catheter associated urinary tract infection

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inpatient rehabilitation facility quality measures 2014
Inpatient Rehabilitation Facility Quality Measures - 2014
  • 2 new measures
  • 1 new chart abstracted measure
    • Pressure ulcer - new or worsened
  • 1 new NHSN measure – (collect Oct 2012)
    • Catheter associated urinary tract infection

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cah proposed changes
CAH Proposed Changes
  • DELAYED
  • Phase 1 (Sept. 2011)
    • Reporting data
  • Phase 2 (Sept. 2012)
    • Adding Out-Patient Measures (Benchmarking IPPS Measures)
    • HCAHPS
  • Phase 3 (Sept. 2013)
    • ED Patient Transfer Communication Measure

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phase 1 reporting data
Phase 1 – Reporting Data

Pneumonia Patients:

  • Pneumococcal Vaccination
  • Initial Blood Culture Was Performed Prior to the Administration of the First Hospital Dose of Antibiotics
  • Smoking Cessation Advice / Counseling
  • Initial Antibiotic(s) within 6 Hours After Arrival
  • Most Appropriate Initial Antibiotic(s)
  • Influenza Vaccination

Heart Failure Patients:

  • Discharge Instructions
  • Evaluation of Left Ventricular Systolic Function
  • ACE Inhibitor/ARB for LVSD
  • Given Smoking Cessation Advice / Counseling

30 Day Readmissions: HF and Pneumonia

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phase 2 adding measures
Phase 2 – Adding Measures

Out-Patient Measures

  • OP-1 Median Time to Fibrinolysis (AMI)
  • OP-2 Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival (AMI)
  • OP-3 Median Time to Transfer to Another Facility for Acute Coronary Intervention (AMI)
  • OP-4 Aspirin at Arrival (AMI/CP)
  • OP-5 Median Time to ECG (AMI/CP)
  • OP-6 Prophylactic Antibiotic Initiated Within One Hour Prior to Surgical Incision (SCIP)
  • OP-7 Prophylactic Antibiotic Selection for Surgical Patients (SCIP)

HCAHPS

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phase 3 communication
Phase 3 – Communication

ED Patient Transfer Communication*

  • Pre-Transfer Communication Information
  • Patient Identification
  • Vital Signs
  • Medication-Related Information
  • Physician or Practitioner Generated Information
  • Nurse Generated Information
  • Procedures and Tests

Review of All Orders by a Pharmacist within 24 hours

  • Potential Drug-Drug Interactions; Patient Allergies/Sensitivities; Appropriate Drug/Dose/Frequency; Accuracy of order entry/ transcription; Therapeutic monitoring/recommendations; Formulary substitution

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joint commission changes
Joint Commission Changes
  • New Standard - effective Jan. 1, 2012
    • PI.02.01.03 – The hospital improves its performance on ORYX accountability measures
    • EP 1
      • The hospital achieves a composite performance rate of at least 85% on the ORYX accountability measures transmitted to the Joint Commisssion

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tjc changes
TJC Changes

Sum of total number of times the recommended intervention was provided across all accountability measures (Numerator)

Sum of total number of opportunities to provide the recommended intervention across all accountability measures (Denominator)

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tjc changes1
TJC Changes
  • Finalized June 2011
    • Requirement for Improvement if < 85%
    • RFI due within 45 days
    • RFI can be cleared anytime during the 18 months after the full survey
    • Failure to clear RFI – contingent accrediation
  • Most recent 4 quarters prior to survey
    • Jan. 2012 survey – 3 Q 2010 – end of 2nd Q 2011

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what you can do
What you can do
  • Know your numbers
  • Identify opportunities to improve
  • Start NOW
  • Don’t work in isolation
  • What are the rates across the continuum of care

Meeting/Group

questions

Questions??

Theme:

Standardization across programs

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