FMQAI

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FMQAI

• Introduction
• to
• National
• Hospital Quality Measures
• or
• Core Measures

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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

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FMQAI

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

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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

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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

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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

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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.

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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)

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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)

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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

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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)

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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)

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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)

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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)

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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

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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)

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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

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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)

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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

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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

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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

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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

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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

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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

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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)

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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.

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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.

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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.

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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

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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.

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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.

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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.

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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.

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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

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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
  systems performance on safety, evidence-based
  practice, and patient satisfaction.

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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

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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

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Which National Quality Measures are Impacted by
Nurses?

• Maybe we should ask
• Which ones arent?

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FMQAI

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

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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 FL20071CF1C01251044
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