Hospital Outpatient Department Quality Measures - PowerPoint PPT Presentation

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Hospital Outpatient Department Quality Measures
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Hospital Outpatient Department Quality Measures

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  1. National Hospital Quality Measures Hospital Outpatient Department Quality Measures Team Members Anesthesia Surgical Services Labor & Delivery Nursing Education Electrophysiology Lab Urology Department Medical Records EPIC Quality Resource Management Center for Clinical Effectiveness

  2. Opportunity Statement Surgical site infections are a major complication after surgery, resulting in considerable morbidity, mortality, and resource utilization. Proper use of antibiotics-giving the right drug at the right time-is effective in preventing infections after surgery. Confidential: For Quality Improvement Purposes Only

  3. HOP QDRP Hospital Outpatient Quality Data Reporting Program National Program • Progression of CMS Value-based purchasing plan. • Program is modeled on the current quality data reporting system for inpatient services (Core Measures: Heart Failure, Pneumonia, SCIP & AMI) • To meet requirements and receive full reimbursement for CY 2008 services, hospital must submit data for seven quality measures, if applicable. • Failure to report data will incur a reduction in their annual payment update factor by 2%. Confidential: For Quality Improvement Purposes Only

  4. Forces of Magnetism • Force 7: Quality Improvement • Force 11: Nurses as Teachers • Force 13: Interdisciplinary Relationships Confidential: For Quality Improvement Purposes Only

  5. AIM STATEMENT • Administer antibiotics within one hour before surgical incision • Administer appropriate antibiotic identified for select procedures Confidential: For Quality Improvement Purposes Only

  6. Department Specific Initiatives • Met with specific out-patient surgical areas to introduce project and identify improvement opportunities • Lack of consistent documentation of procedure start times • Lack of consistent documentation of antibiotic administration • Lack of consistent documentation for use of Vancomycin • Use of appropriate antibiotic Confidential: For Quality Improvement Purposes Only

  7. Quality Measures Outpatient Surgical Care • Perioperative Care: Timing of Antibiotic Prophylaxis • Perioperative Care: Selection of Prophylactic Antibiotic • Departments Involved: Ambulatory Surgery Center, Main OR, EP Lab, Labor/Delivery, & Urology • Over 200 Procedure Codes • Types of Surgeries: • Cardiac: Pacemaker revisions, battery change-outs • Vascular: grafts • Genitourinary: Transrectal prostate biopsy • Gastric biliary: peg placements, laparoscopic appendectomy • Gynecology: Vaginal hysterectomy, synthetic pubovaginal sling • Head and Neck: Treatment of jaw fractures Confidential: For Quality Improvement Purposes Only

  8. Correct Antibiotic Selection Analysis: Patients received the proper prophylactic antibiotics within one hour of surgery start time 87% of the time. Knowledge deficits of project requirements and lack of proper documentation of required elements are identified as opportunities for improvement in this new imitative. Last month’s data demonstrate improvement towards stretch goal of 95%. Stretch goal 95% Project begins 4/1/4008 Confidential: For Quality Improvement Purposes Only

  9. Antibiotics Within One Hour of Surgery/Procedure Start Time Analysis: Patients received prophylactic antibiotics within one hour of surgery start time 79% of the time. Knowledge deficits of project requirements and lack of proper documentation of required elements are identified as opportunities for improvement in this new imitative. Last two months demonstrate improvement towards stretch goal of 95%. Stretch goal: 95% Project begins 4/1/2008 Confidential: For Quality Improvement Purposes Only

  10. Next Steps • Develop physician specific reports for results • Educate departments on initiative and opportunities for improvement • Report to key stakeholders • Re-education of data abstractors to changing specifications Confidential: For Quality Improvement Purposes Only