This material was prepared by Masspro, the Medicare Quality Improvement Organization for Massachuset

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This material was prepared by Masspro, the
Medicare Quality Improvement Organization for
Massachusetts, under contract with the Centers
for Medicare Medicaid Services (CMS), an
agencyof the U.S. Department of Health and Human
Services. The contents presented do not
necessarily represent CMS policy.
8sow-ma-hosp-08-06 IntroToHospQualPPT-mar
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Introduction to Medicare, Masspro and The RHQDAPU
Program

• April 2008

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Timeline

• 1965 The Social Security Administration (SSA)
• establishes Medicare and
  Medicaid
• 1977 The HealthCare Finance Administration
• (HCFA) was created
• 1982 Peer Review Improvement Act
• 2001 HCFA renamed The Centers for Medicare
• and Medicaid Services (CMS)
• 2002 Quality Initiatives launched
• 2003 Section 501(b) Medicare Prescription
  Drug, Improvement and Modernization Act
• 2005 The Deficit Reduction Act (DRA)

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Background

• Reporting
• Initial - Medicare Prescription Drug, Improvement
  and Modernization ACT (MMA) of 2003
• Additional - Deficit Reduction Act (DRA) of 2005.
  
• Intent
• Equip consumers with quality of care information
  to make more informed decisions about health
  care.
• Encourage hospitals and clinicians to improve
  quality of care provided to all patients.
• Applies only to IPPS hospitals

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Medicare

• Medicare is the national health insurance program
  for
• - People age 65 or older
• - Some people under the age of 65 with
  disabilities
• - People with end-stage renal disease
• Medicare currently provides coverage for
  approximately
• 40 million Americans

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Quality Improvement Organizations

• QIOs
• Improving the effectiveness, efficiency, economy,
  and quality of services delivered to Medicare
  beneficiaries by
• - Protecting beneficiaries
• - Protecting the Trust Fund
• - Improving the quality of care received by
• Medicare beneficiaries

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Quality Improvement Organizations

• Protecting Beneficiaries
• QIOs are responsible for expeditiously addressing
  individual beneficiary issues
• - Medicare Helpline 800-252-5533
• - Beneficiary complaints
• - Beneficiary appeals
• - EMTALA review
• Beneficiary satisfaction with process and outcome
  measured

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Quality Improvement Organizations

• Protecting the Trust Fund
• QIOs are responsible for ensuring proper
  inpatient fee-for-service payments (HPMP)
• - Reasonable and medically necessary
• - Provided efficiently / most appropriate
  setting
• - Consistent with medical information supplied
• - Demonstrate coding validity of information
  supplied
• - Correctly billed

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Quality Improvement Organizations

• Improving Quality of Care
• QIOs are responsible for assisting providers in
  developing the capacity for and achieving
  excellence in care
• - Measuring and reporting data
• - Redesigning care processes
• - Adopting health information technology
• - Transforming organizational culture

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Quality Improvement Organizations

• Improving Quality of Care
• Assist Nursing Homes in developing the capacity
  for and achieving excellence in care
• - Improving clinical measures
• - Implementing STAR (Setting Targets Achieving
  Results)
• - Utilizing STAR, an interactive website
• - Measuring the nursing home experience and
• reducing workforce turnover

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Quality Improvement Organizations

• Improving Quality of Care
• Assist Home Health Agencies in developing the
  capacity for and achieving excellence in care
• - Improving clinical measures
• - Incorporating immunization assessment
• - Implementing and/or utilizing telehealth
• - Implementing a survey tool that measures
• organizational culture change

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Quality Improvement Organizations

• Improving Quality of Care
• Assist Hospitals in developing the capacity for
  and achieving excellence in care
• - Improving clinical measures
• - Implementing surgical care improvement (SCIP)
• - Utilizing CPOE, barcoding, or telehealth
• - Improving safety culture (CAHs)

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Quality Improvement Organizations

• Improving Quality of Care
• Assist Physician Practices in developing the
  capacity for and achieving excellence in care
• - Improving claims based clinical measures
• - Adopting a care management process
• - Utilizing an electronic health record (EHR)
• - Completing cultural competency education

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Masspro

• Contact Information
• Beneficiary Issues Cheryl Lehane
• HPMP Jo-Ann Peranelli
• Nursing Home Helen Magliozzi
• Home Health Helen Magliozzi
• Hospital Jim Liljestrand
• Physician Practices Joe Holtschlag
• Firstinitiallastname_at_maqio.sdps.org

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Hospital Responsibilities

• 6 Steps from Data Collection to Public Reporting
• Case identification
• Record abstraction
• Data submission
• Validation process
• Appeal process
• Public Reporting

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Hospital Responsibilities

• Case identification
• Cases are identified from claims data.
• Does your list of identified cases agree with
  what the finance system is billing for?

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Hospital Responsibilities

• Record abstraction
• Do you perform intra and inter rater reliability?
• Are you using QIO Clinical Warehouse Feedback
  reports?
• Validation Case Detail report

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Hospital Responsibilities

• Data submission
• Are you using QIO Clinical Warehouse Feedback
  reports?

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Hospital Responsibilities

• Validation Process
• Expect a CDAC medical record request for every
  quarter you submit 6 or more cases
• If the record is not received within 30 days, the
  case is considered to have failed validation

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Hospital Responsibilities

• Appeal Process
• Validation results are posted on Mondays
• A score of gt 80 is required to pass
• All mismatches can be appealed if hospital score
  lt 80
• The appeal must be completed with 10 business
  days of posting

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Hospital Responsibilities

• Preview Reports
• Available one month out of each quarter
• Reflects data about to be published on hospital
  compare
• Opportunity to withhold data from public
  reporting
• Data cannot be resubmitted
• Rates cannot be disputed
• Data will next be refreshed on Hospital Compare
  in June 2008

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Masspro Responsibilities

• QIOs are responsible for assisting providers in
• developing the capacity for and achieving
  excellence in care
• ___________________________________________
• Listservs
• WebEx teleconferences
• Regional meetings / collaboratives
• Telephonic assistance
• On-site consultations

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Masspro Responsibilities

• Listservs
• Liaison
• Hospmeasures
• Surgical Infection Prevention (SIP)
• HCAHPS

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CMS Provided Resources

• CMS provides online access to tools, articles,
  and links to resources about how to measure and
  report performance, redesign care processes,
  adopt health information technology, and
  transform organizational culture
• ____________________________________________
• Quality Net www.qualitynet.org
• MedQIC www.medqic.org

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CMS Provided Resources

• Quality Net
• ______________________________________
• Reports (Submission / Validation / Preview)
• Specification Manual and QUEST
• CMS Abstraction and Reporting Tool (CART)
• File Exchange and Data Upload
• News
• www.qualitynet.org

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CMS Provided Resources

• MedQIC
• ____________________________________________
• Paper tools for Quality Improvement
• Recorded Sessions on Abstraction and Care
  Delivery
• Success Stories
• Literature
• Resources Specific to Provider Type
• www.medqic.org

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QIO Clinical Warehouse Overview Flow Chart
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RHQDAPU Its Measures
This material was prepared by Masspro, the
Medicare Quality Improvement Organization for
Massachusetts, under contract with the Centers
for Medicare Medicaid Services (CMS), an agency
of the U.S. Department of Health and Human
Services. The contents presented do not
necessarily represent CMS policy.
8sow-ma-hosp-07-81 RHQDAPU_PPT-jul
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Participation Requirements

• Notice of Participation Form
• QualityNet Exchange Administrator
• Data Submission
• Data Validation
• Public Reporting
• Failure to meet all of the above requirements
  results in a 2 reduction in APU

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Participation Requirements

• Notice of Participation Form
• All IPPS hospitals had to sign a Notice of
  Participation Form last June.
• No annual requirement
• All MA hospitals have met this requirement.

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Participation Requirements

• Quality Net Administrator
• CMSs primary contact
• All MA hospitals have met this requirement
• To change or add a QNet Administrator
• Existing Admin can add others as administrators
• Recommend 2 admins per hospital.
• Contact Matt Kennedy at Masspro
• Mkennedy_at_maqio.sdps.org

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Participation Requirements

• Data Submission
• Minimum sample size per population
• Specification Manual
• Timely
• Must be received by CMS by Deadline

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Participation Requirements

• Data Validation
• Five records quarterly
• Randomly selected
• Four quarters of validation scores are aggregated
• gt 80 to Pass

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Participation Requirements

• Public Reporting
• Hospital Compare
• Required Measures (currently 30)
• www.hospitalcompare.hhs.gov

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Timeline
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6 Topics

• AMI Acute Myocardial Infarction
• HF Heart Failure
• PN Pneumonia
• SCIP Surgical Care Improvement Project
• Mortality
• HCAHPS Hospital Consumer Assessment of
  Healthcare Provider Services

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Measure Expansion

• FY 2007
• (21)
• 8 AMI
• 4 HF
• 7 PN
• 2 SCIP

• FY 2008
• (27)
• 8 AMI
• 4 HF
• 7 PN
• 5 SCIP
• 2 Mortality
• 1 HCAHPS

• FY 2009
• (30)
• 8 AMI
• 4 HF
• 7 PN
• 7 SCIP
• 3 Mortality
• 1 HCAHPS
• PopSample

• FY 2006
• (10)
• 5 AMI
• 2 HF
• 3 PN

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2009 AMI 8 measures

• Aspirin at Arrival
• Aspirin at Discharge
• Angiotensin Converting Enzyme (ACE) Inhibitor or
  Angiotensin receptor Blocker (ARB) for Left
  Ventricular Systolic Dysfunction (LVSD)
• Adult Smoking Cessation Advice/Counseling
• Beta Blocker Prescribed at Discharge
• Beta Blocker on Arrival
• Thrombolytic Agent Received Within 30 Minutes of
  Hospital Arrival
• Percutaneous Coronary Intervention (PCI) Received
  Within 90 Minutes of Hospital Arrival

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2009 HF 4 measures

• Discharge Instructions
• Left Ventricular Function (LVF) Assessment
• ACE I or ARB for LVSD
• Adult Smoking Cessation Advice/Counseling

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2009 PN 7 measures

• Oxygen Assessment
• Pneumococcal Vaccination Status
• Blood Culture Performed Before Initial Antibiotic
  
• Adult Smoking Cessation Advice/Counseling
• Initial Antibiotic received Within 6 Hours of
  Arrival
• Appropriate Initial Antibiotic
• Influenza Vaccination Status (Oct-Mar)

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2009 SCIP 7 measures

• INF 1 Prophylactic Antibiotic Received Within 1
  Hour Prior to Surgical Incision
• INF 2 Prophylactic Antibiotic Selection
• INF 3 Prophylactic Antibiotics Discontinued
  Within 24 Hours After Surgery End Time
• INF 4 Cardiac Surg Patients with Controlled 6
  AM Postoperative Blood Sugar (Q108)
• INF 6 Surgery Patients with Appropriate Hair
  Removal (Q108)
• VTE 1 Venous Thromboembolism (VTE) Prophylaxis
  Ordered for Surgery Patients
• VTE 2 VTE Prophylaxis Within 24 Hours Pre/Post
  Surgery

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Anatomy of a Care Measure

• Topic
• Measure
• Data Elements

• AMI
• Aspirin on Arrival
• Admission Date
• Admission Source
• Arrival Date
• Birthdate
• Comfort Measures Only
• Contraindication to Aspirin on Arrival
• Discharge Date
• Discharge Status
• ICD-9-CM Principal Diagnosis Code
• Transfer From Another ED
• Aspirin Received Within 24 Hours Before or After
  Hospital Arrival

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2009 Mortality 3 measures

• Mortality Measures
• AMI 30-Day Risk Adjusted
• HF 30-Day Risk Adjusted
• PN 30 Day Risk Adjusted
• PN to be publicly reported on Hospital Compare
  June 2008

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Mortality Measures

• First Outcome Measure
• Introduced by CMS in December 2006
• RHQDAPU program requirement for full APU
  beginning with FY 2008 for PPS hospitals.
• NO DATA SUBMISSION is required on the part of
  hospitals.

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Mortality Measures

• Risk Adjusted Algorithm
• Developed by statisticians over two years
• Accepted by the NQF
• AMI and HF followed by PN
• Provides range of expected mortality with
  demographic and medical condition considerations.

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Mortality Measures

• Colorado Foundation for Medical Care
• Mortalitymeasures_at_coqio.sdps.org

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HCAHPS

• Hospital Consumer Assessment of Healthcare
  Provider Services
• HCAHPS
• Patient Survey
• Purpose
• To provide a nationally standardized method for
  reporting patients perspectives on care

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HCAHPS

• 7 Topics
• Communication with doctors
• Communication with nurses
• Responsiveness of Hospital Staff
• Cleanliness and Quietness
• Pain management
• Communications about medications
• Discharge information

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HCAHPS

• Collection
• Integrate HCAHPS into an existing patient survey
• or
• Implement HCAHPS as a separate survey
• Mail, Telephone, a combination of the two or use
  of an automated response system.
• Random sample
• Non-psych
• gt 18 years
• Overnight stay
• Monthly

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HCAHPS

• Submission
• Use an approved vendor
• or
• Collect and submit your own HCAHPS data
• Submit data to CMS quarterly
• 300 complete surveys per year (minimum 100
  surveys per year for smaller hospitals)

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HCAHPS

• TIMELINE
• Feb 2006
• Initial HCAHPS training sessions offered
• April through June 2006
• First Dry Run
• October 1, 2006
• Voluntary hospitals begin ongoing data collection

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HCAHPS

• TIMELINE
• Jan 31, 2007
• Voluntary participants begin uploading data for
  Q3 06
• Jan and Feb 2007
• HCAHPS Initial Training offered online by the
  IFMC
• March 2007
• Second Dry Run

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HCAHPS

• TIMELINE
• July 1, 2007
• New hospitals begin ongoing collection of data
• Summer 2007
• All participants signed a pledge of participation
  as part of the RHQDAPU Notice of Participation.

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HCAHPS
Health Services Advisory Group (HSAG) hcahps_at_azqio
.sdps.org 1-888-884-4007 Website www.hcahpsonline
.org
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Population Sample Sizes

• Quarterly data entry
• Quality Net
• For each topic (AMI, HF etc)
• Medicare / Non Medicare
• With 1st Quarter 2008 data entry
• Deadline Aug 15, 2008

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Measure List
www.qualitynet.org gtHospitals (roll
over) gtRHQDAPU gtMeasure Comparison gt Inpatient
Hospital Quality Measures
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Resource

• Federal Register
• Proposed rules/requirements for upcoming fiscal
  years
• Annual 30 day question and comment period before
  rule is passed.
• FY 2008 and 2009 proposal found at
• http//www.cms.hhs.gov/AcuteInpatientPPS/downloads
  /CMS-1533-P.pdf
• Go to page 461

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Where do care measures come from?

• National Quality Forum (NQF)
• Healthcare Quality Alliance (HQA)
• Centers for Medicare and Medicaid (CMS)
• Research findings discussed among the NQF members
  to identify consensus on Best Practice
  Guidelines.
• HQA adopts the measures the NQF endorses as
  definitively best practice.
• Secretary of HHS chooses the CMS requirements
  from the list of HQA measures.

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MASSPRO Contacts

• Jim Liljestrand, MD MPH
• Medical Director of Quality Improvement Services
• Jliljestrand_at_maqio.sdps..org
• 781-419-2789
• Beth McConville, RN
• Hospital Quality Improvement Advisor
• Emcconville_at_maqio.sdps.org
• 781-419-2887

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Accessing and Utilizing Quality Net My Quality
Net ReportsAril 2008
This material was prepared by Masspro, the
Medicare Quality Improvement Organization for
Massachusetts, under contract with the Centers
for Medicare Medicaid Services (CMS), an
agencyof the U.S. Department of Health and Human
Services. The contents presented do not
necessarily represent CMS policy.
8sow-ma-hosp-08-05 QualNetReportsPPT-mar
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QualityNet Overview

• QualityNet.org
• News
• Resources
• Training materials
• My Quality Net
• Data submission
• Hospital specific reports
• Secure email

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My Quality Net Roles

• QIO Clinical Warehouse Data Upload role
• QIO Clinical Warehouse Submission Reports
• QIO Clinical Warehouse Feedback Reports role
• QIO Clinical Warehouse Feedback Reports
• Hospital Validation Reports (QIO/Provider Only)
• Annual Payment Update Reports(QIO/Provider Only)
• HQA Preview Reports (QIO/Provider Only)

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Available Reports

• Classifications
• Submission Reports
• Feedback Reports
• Validation Reports
• Annual Payment Update Reports
• HQA Preview Reports

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APU/RHQDAPU Provider Participation Report

• Number of Medicare claims submitted
• Number of medical records accepted into the QIO
  Clinical Warehouse
• By topic (Surgical Care Improvement Project
  SCIP are listed out by strata)
• Adding HCAHPS information in the future.

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APU/RHQDAPU Provider Participation Report
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Upper Bound Rate Report

• Displays the Annual Payment Update Validation
  Assessment Upper Bound on Reliability rate
• NOTE Upper Bound Rate report can only be run by
  providers during set time periods

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Upper Bound Rate Report
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Hospital Quality Alliance Preview Report

• Provides a preview of a hospital's performance on
  hospital quality measures to be publicly reported
  for a selected preview period.
• Download and view Preview Report on a quarterly
  basis (within the set preview time period)
• Report is only available during the 30 day
  preview period

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Hospital Quality Alliance (HQA) Preview Report
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Data Submission Detail Report

• Details of cases submitted to the Warehouse
  including submission status and error messages
  per case.
• Displays demographic information
• Topic
• admission/discharge date
• file name
• status accepted or rejected from the warehouse

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Data Submission Detail Report
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Measure Status Summary Report

• For cases ACCEPTED in to the warehouse
• Measures submitted
• of cases included in each measure
• of cases excluded from measure

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Measure Status Summary Report
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QualityNet Exchange Self Serve
Vendor Authorization
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QualityNet Exchange Self Serve
Vendor Authorization
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End
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Questions ?

• QIO contacts
• Mat Kennedy (for Quality Net Access)
• Mkennedy_at_maqio.sdps.org
• 781-419-2807
• Beth McConville
• Emcconville_at_maqio.sdps.org
• 781-419-2887
• Quality Net Help Desk
• E-mail qnetsupport_at_ifmc.sdps.org
• Phone [phone]
• Fax [phone]