FMQAI

1. FMQAI Introduction to National Hospital Quality Measures or Core Measures

2. FMQAI FMQAI is a private non-profit organization under contract with Centers for Medicare & Medicaid Services (CMS) Congress established the QIO program to analyze and remedy widespread shortcomings in the healthcare system by improving the efficiency, effectiveness, economy, quality and safety of Medicare services Collaborate with health care providers in a variety of settings to improve the quality care for Medicare beneficiaries

3. FMQAI FMQAI was formally known as Florida Medical Quality Assurance, Inc. and before that was referred to as the Florida Peer Review Organization. QIO’s have 3 year contracts known Statement of Work or SoW. Presently in the 8th SoW

4. The Measures/Core Measures CMS (Centers for Medicare and Medicaid Services) calls them Hospital Quality Measures. JC (Joint Commission /Jayco/JCAHO) calls them Core Measures. Both were aligned 3 years ago and are almost exactly the same

5. Measures Based on large scale scientific studies with proven efficacy Scientific studies have been incorporated into guidelines developed by professional organizations Consensus of national expert panel for each measure Proven to be measurable and reliable Measures of the quality of care Focus on clinical processes: all patients, without contraindications, should be considered candidates for therapies

6. Measures Topics focus on health problems most common to the Medicare population Effective interventions have been shown to reduce disability and save lives Based on national data, many Medicare patients do not receive important therapies known to decrease morbidity and mortality

7. Measures 10 measures for Appropriate Care Measure (ACM) are designated by an asterisk*. The ACM is a composite measure that captures whether or not a patient received all the care he or she was eligible to receive based on ten-measures  (5 AMI, 2 HF, and 3 PNE). The ACM score is a measure of how often the hospital “gets it right” and focuses on providing “the right care for every person every time.”

8. The AMI Measures Acute Myocardial Infarction AMI 1 Aspirin w/in 24 hours of arrival* The early use of aspirin in patients with acute myocardial infarction results in a significant reduction in adverse events and subsequent mortality AMI-2 Aspirin at discharge.* Studies have demonstrated that aspirin can reduce this risk by 20% (Antiplatelet Trialists' Collaboration, 1994)

9. The AMI Measures AMI-3 ACEI or ARB for LVSD* ACEI therapy reduces mortality and morbidity in patients with left ventricular systolic dysfunction (LVSD) after AMI (Flather, 2000; Pfeffer, 1992; Torp-Peterson, 1999; and Yusuf, 2000). Recent clinical trials have also established ARB therapy as an acceptable alternative to ACEI, especially in patients with heart failure and/or LVSD who are ACEI intolerant (Granger, 2003 and Pfeffer, 2003)

10. The AMI Measures AMI- 4 Smoking Cessation Counseling Smoking cessation reduces mortality and morbidity in all populations. Patients who receive even brief smoking-cessation advice from their care providers are more likely to quit

11. The AMI Measures AMI-5 Beta Blocker at discharge* The use of beta blockers for patients who have suffered an acute myocardial infarction can reduce mortality and morbidity. Studies have demonstrated that the use of beta blockers is associated with about a 20% reduction in this risk (Yusuf, 1985 and Yusuf, 1988)

12. The AMI Measures AMI-6 Beta Blocker at arrival* The early use of beta blockers in patients with acute myocardial infarction reduces mortality and morbidity (ISIS-1, 1986; Goldstein, 1996; and MIAMI, 1985) and has demonstrated effectiveness in a wide range of AMI patients (Krumholz, 1998)

13. The AMI Measures AMI-7 Median time to fibrinolysis AMI-7a Thrombolytic Agent received within 30 minutes of arrival Time to fibrinolytic therapy is a strong predictor of outcome in patients with an acute myocardial infarction. Nearly 2 lives per 1000 patients are lost per hour of delay (Fibrinolytic Therapy Trialists' Collaborative Group, 1994)

14. The AMI Measures AMI-8 Median time to PCI AMI-8a PCI received within 90 minutes of patient arrival The early use of primary angioplasty in patients with acute myocardial infarction who present with ST-segment elevation or LBBB results in a significant reduction in mortality and morbidity. The earlier primary coronary intervention is provided, the more effective it is (Brodie, 1998 and DeLuca, 2004)

17. The Heart Failure Measures (Congestive)Heart Failure HF –1 Discharge Instructions Heart failure patients discharged home with written instructions or educational material given to patient or caregiver at discharge or during the hospital stay addressing all of the following: 1)activity level, 2)diet, 3)a written list of discharge medications, 4)follow-up appointment, 5)weight monitoring, and 6)what to do if symptoms worsen

18. 3) More on the written list of discharge medications The list MUST match another list in the record. Terms like “resume home meds” are unacceptable Drug doses and times are not required but desirable Use of the reconciliation record is acceptable IF it matches another list OR there is no other list. If the reconciliation record is used, it MUST BE filled out totally (everything checked or circled or however you do it)

19. The Heart Failure Measures HF-2 LVF assessment* Appropriate selection of medications to reduce morbidity and mortality in heart failure requires the identification of patients with impaired left ventricular systolic function

20. The Heart Failure Measures HF-3 ACEI or ARB for LVSD* ACEI therapy reduces mortality and morbidity in patients with heart failure and left ventricular systolic dysfunction (The SOLVD Investigators, 1991 and CONSENSUS Trial Study Group, 1987) and are effective in a wide range of patients (Masoudi, 2004). Recent clinical trials have also established ARB therapy as an acceptable alternative to ACEI, especially in patients who are ACEI intolerant (Granger, 2003 and Pfeffer, 2003)

21. The Heart Failure Measures HF-4 Smoking Cessation/counseling Smoking cessation reduces mortality and morbidity in all populations. Patients who receive even brief smoking-cessation advice from their care providers are more likely to quit

26. The Pneumonia Measures Community Acquired Pneumonia PN-1 O2 assessment w/in 24 hrs of arrival* Inadequate oxygen in the arterial blood (hypoxemia) is common in severe pneumonia and is a known mortality risk factor PN-2 Pneumococcal vaccination* Pneumococcal vaccination is indicated for persons 65 years of age and older, because it is up to 75% effective in preventing pneumococcal bacteremia and meningitis

27. The Measures PN-3a Blood cultures performed w/in 24 hours prior to or after admission to the ICU Published pneumonia treatment guidelines from ATS/IDSA recommend performance of blood cultures for all inpatients with severe pneumonia to optimize therapy. Improved survival has been associated with optimal therapy. In addition, the yield of clinically useful information is greater if the culture is collected before antibiotics are administered

28. The Pneumonia Measures 3b- Blood culture preformed in the ED before the initial antibiotic Published pneumonia treatment guidelines recommend performance of blood cultures for all inpatients to optimize therapy

29. The Pneumonia Measures PN-4 Smoking Cessation/counseling Smoking cessation reduces mortality and morbidity in all populations. Patients who receive even brief smoking-cessation advice from their care providers are more likely to quit

30. The Pneumonia Measures PN-5a – 8 hours PN-5b Initial antibiotic received within 4 hours of arrival* PN-5c - 6 hours (5a and 5b MAY eventually be changed to just 5c) There is growing clinical evidence of an association between timely inpatient administration of antibiotics and improved outcome among pneumonia patients

31. The Pneumonia Measures PN-6 Initial antibiotic selection for CAP PN 6a ICU patient PN 6b Non- ICU patient The current North American antibiotic guidelines for Community-Acquired Pneumonia in immunocompetent patients are from the Centers for Disease Control and Prevention (CDC), the Infectious Diseases Society of America (IDSA), the Canadian Infectious Disease Society / Canadian Thoracic Society (CIDS/CTS), and the American Thoracic Society (ATS)

32. The Pneumonia Measures PN 7 Influenza Vaccination Pneumonia patients age 50 years and older, hospitalized during October, November, December, January, or February who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated. Influenza vaccination is indicated for people age 50 years and older, because it is highly effective in preventing influenza-related pneumonia, hospitalization, and death. Vaccine coverage in the United States is suboptimal. Screening and vaccination of inpatients is recommended, but hospitalization is an underutilized opportunity to provide vaccination to adults.

34. The SCIP Measures Surgical Care Improvement Project (SCIP) SCIP- Inf 1Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision. The risk of infection increased progressively with greater time intervals between administration and skin incision.

35. The SCIP Measures SCIP-Inf 2 Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure). A goal of prophylaxis with antibiotics is to use an agent that is safe, cost-effective, and has a spectrum of action that covers most of the probable intraoperative contaminants for the operation.

36. The SCIP Measures SCIP-Inf 3: Prophylactic antibiotic discontinued within 24 hours after surgery A goal of prophylaxis with antibiotics is to provide benefit to the patient with as little risk as possible. It is important to maintain therapeutic serum and tissue levels throughout the operation. Intra-operative re-dosing may be needed for long operations. However, administration of antibiotics for more than a few hours after the incision is closed offers no additional benefit to the surgical patient. Prolonged administration does increase the risk of Clostridium difficile infection and the development of antimicrobial resistant pathogens

37. The SCIP Measures SCIP-Inf 4: Controlled perioperative serum glucose (Less than 200 mg/dL) among major cardiac surgery patients Hyperglycemia has been associated with increased in-hospital morbidity and mortality for multiple medical and surgical conditions.

38. The SCIP Measures SCIP-Inf 6: Appropriate hair removal Studies show that shaving causes multiple skin abrasions that later may become infected. SCIP-Inf 7: Perioperative normothermia among colorectal surgical patients Core temperatures outside the normal range pose a risk in all patients undergoing surgery.

39. The SCIP Measures SCIP-Card-2 Surgery Patients on Beta Blocker Therapy Prior to Admission Who Received a Beta Blocker During the Perioperative Period. In patients at risk of cardiovascular complications in a variety of medical conditions, beta blockers have shown to reduce that risk.

40. The SCIP Measures SCIP-VTE-1 Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered. There are over 30 million surgeries performed in the United States each year. Despite the evidence that VTE is one of the most common postoperative complications and prophylaxis is the most effective strategy to reduce morbidity and mortality, it is often underused.

41. The SCIP Measures SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery The frequency of venous thromboembolism (VTE), that includes deep vein thrombosis and pulmonary embolism, is related to the type and duration of surgery, patient risk factors, duration and extent of postoperative immobilization, and use or nonuse of prophylaxis

44. Public Reporting Recommendation: Transparency is necessary “…system should make available to patients and their families information that enables them to make informed decisions when selecting a health plan, hospital, or clinical practice, or when choosing among alternative treatments…” “…should include information describing the system’s performance on safety, evidence-based practice, and patient satisfaction.”

45. CMS Special StudyHigh Performers Special Study Nine High-Leverage Change Ideas (Drive high performance and further divide HPs and NHPs) Directly engaged leadership and executives in QI activities Delineate QI responsibilities for implementation and priority setting at leadership level (CEO) Communicate QI results to physicians Communicate all CMS core measure results to entity responsible for setting QI priorities

46. CMS Special StudyHigh Performers Special Study (Drive high performance and further divide HPs and NHPs) Implement automated triggers and reminder systems Implement rapid response techniques and technologies Document and discuss guiding principles reflecting values of clinical excellence Formally adopt a QI culture model (I.e., Baldridge, Studer) Set targets at no less than 90 percent regardless of benchmarks

47. Which National Quality Measures are Impacted by Nurses? Maybe we should ask: Which ones aren’t?

48. FMQAI Gladys Worlds, MS, CPHQ Project Director, Hospital Quality Improvement813-865-3531 Mark S. Michelman, MD, MBA Clinical Director 813-865-3540

49. FMQAI Marie Hall, RN (SCIP) Robin Kish, RN, MBA (Data/Validation) Israel (Butch) Miller, RN, MA(AMI/HF/ACM) Rebecca Ure, RN, MEd (Pneum/CAH) Project Coordinators 813-354-91111 This material was prepared by FMQAI under contract with the Centers for Medicare & Medicaid Services (CMS). The contents presented do not necessarily reflect CMS policy FL20071CF1C012510447