8th Scope of Work: Task 1C1

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8th Scope of Work Task 1C1
Jim Jones, RN, BSN Project Coordinator West
Virginia Medical Institute
Publication Number 7SOW-WV-1C-05-03
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8th SOW

• Begins August 1, 2005
• Significant difference from the 7th SOW
• Promotes transformational change
• Requires proof of capability
• Assess the impact of QIO work on Beneficiaries

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Transformational ChangeEvery person receives
the right care every time.

• QIOs will provide assistance in support of
  quality improvement to
• Providers
• Practitioners
• Medicare Advantage organizations
• Beneficiaries
• Other stakeholders

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Transformational ChangeEvery person receives
the right care every time.

• QIOs will promote improvements in
• Clinical performance measure results
• Clinical performance measurement and reporting
• Organizational culture
• Systems adoption and use
• Redesign of care processes

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1c1 Hospital

• Continue the work started under the 7 SOW
• Quality improvement projects
• Quarterly data submission on 4 major topics
• Acute Myocardial Infarction (AMI)
• Heart Failure (HF)
• Pneumonia (PNE)
• Surgical Care Improvement Project (SCIP)

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1c1 Hospital

• Hospitals will achieve system-level changes
  through four strategies
• Clinical performance management and reporting
• Process improvement
• Systems improvement
• Organizational culture change

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1c1 Hospital

• Statewide
• Clinical performance measurement and reporting
• Report expanded set of 22 quality measures
• Validation reliability of 80
• Process Improvement
• 12 reduction in failure rate for SCIP-1
• SCIP-1 Prophylactic antibiotic within 1 hr prior
  to incision

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1c1 Hospital

• Statewide
• Baseline data will consist of surveillance data
  for the final quarter of available data prior to
  August 2005
• Remeasurement period will be the latest quarter
  for which data are available prior to
  approximately November 2007

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Full Hospital Measure Set

• AMI 1ASA at arrival
• AMI 2ASA at discharge
• AMI 3ACEI/ARB for LVSD
• AMI 4Smoking Cessation
• AMI 5Beta Blocker at d/c
• AMI 6Beta Blocker at arrival
• AMI 7a Thrombolytic agent within 30 min. of
  arrival
• AMI 8a PCI within 120 min. of arrival

• HF 1Discharge Instructions
• HF 2LVF Assessment
• HF 3ACEI/ARB for LVSD
• HF 4 Smoking Cessation

Indicates measure required for full annual
payment update.
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Full Hospital Measure Set

• PN 1Oxygen assessment
• PN 2Pneumococcal Vac.
• PN 3bBlood Culture before 1st antibiotic
• PN 4Smoking Cessation
• PN 5bInitial Abx in 4 hrs.
• PN 6Initial Abx selection
• PN 7Influenza Vaccination

• SCIP Inf. 1Prophylactic Abx within 1 hr. prior
  to surgery
• SCIP Inf. 2Prophylactic Abx selection
• SCIP Inf. 3Prophylactic Abx d/c within 24 hrs.
  of surgery end time

Indicates measure required for full annual
payment update.
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1c1 Hospital

• Identified Participant Groups 15 of PPS
• Clinical Performance Measure Results
• Appropriate Care Measure (ACM)
• Composite of 10 original publicly reported
  measures
• AMI, HF, PNE
• Participants will work to achieve 50 RFR
• Baseline data will consist of quality measure
  performance data for the final quarter of
  available data prior to August 2005
• Remeasurement period will be the latest quarter
  for which data are available prior to
  approximately November 2007

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1c1 Hospital

• Identified Participant Groups 15 of PPS
• Process Improvement
• Surgical Care Improvement Project (SCIP)
• Must conduct at least 300 major surgical
  procedures per year
• Collect data on 24 SCIP measures
• Work to achieve 25 RFR on 13 SCIP measures
• Baseline data will consist of data collection by
  hospitals for discharges occurring Jan. 1, 2006
  through June 30, 2006
• Remeasurement will consist of the latest quarter
  available prior to approximately November 2007

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SCIP Measures

• SCIP Inf 1Prophylactic Abx within 1 hr. prior to
  surgery
• SCIP Inf 2Prophylactic Abx selection
• SCIP Inf 3Prophylactic Abx d/c within 24 hrs. of
  surgery end time
• SCIP Inf 4Perioperative glucose lt 200 major
  cardiac surgery
• SCIP Inf 5Post-op wound infect. diagnosed during
  index hospitalization
• SCIP Inf 6Appropriate hair removal

• SCIP Inf 7Post-operative normothermia
  colorectal surgery
• SCIP Inf 8 Perioperative glucose lt 200
  non-cardiac major surgery
• SCIP Inf 9Perioperative normothermia
• SCIP Card 1Perioperative beta blocker
  non-cardiac
• SCIP Card 2Perioperative beta blocker if on beta
  blocker prior

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SCIP Measures

• SCIP Card 3Intra- or post-op AMI dx during index
  hospitalization and within 30 days of surgery
• SCIP Card 4Intra- or post-op cardiac arrest dx
  during index hospitalization and within 30 days
  of surgery
• SCIP VTE 1Thromboembolism prophylaxis
• SCIP VTE 2Appropriate venous thromboembolism
  prophylaxis

• SCIP VTE 3Intra- and post-op pulmonary embolism
• SCIP VTE 4Intra- and post-op deep venous
  thrombosis
• SCIP Resp 1Post-op orders and documented HOB
  elevated
• SCIP Resp 2Post-op ventilator associated
  pneumonia during index hospitalization
• SCIP Resp 3 Peptic ulcer disease prophylaxis
• SCIP Resp 4 Ventilator weaning protocol

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SCIP Measures

• SCIP ESRD 1Permanent hospital ESRD vascular
  access procedures that are autogenous AV fistulas
• SCIP Global 1Mortality within 30 days of surgery
• SCIP Global 2Readmission within 30 days of
  surgery

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1c1 Hospital

• Identified Participant Group 15 all hospitals
  (PPS or CAH)
• Systems Improvement and Organizational Culture
  Change (SIOC)
• Computerized Physician Order Entry (CPOE)
• Barcoding
• Telehealth
• Must submit data on the 10-measure set

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1c1 Hospital

• Identified Participant Group 15 all hospitals
  (PPS or CAH)
• Measurement will be assessed using the
  readiness/use continuum tool now under
  development
• Overlap will be allowed among all 1c1 IPGs

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Summary 1c1 Hospital

• Statewide
• Reporting full set of quality measures
• Improving measurement score for SCIP-1
• Identified Participant Groups
• Appropriate Care Measure AMI, HF, PNE
• SCIP 24 measures
• SIOC CPOE, barcoding, telehealth

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Contact Information

• Jim Jones
• 1-800-642-8686 ext. 4237
• 1-304-346-9864 ext. 4237
• jjones_at_wvmi.org
• Cassie Watson
• 1-800-642-8686 ext. 4239
• 1-304-346-9864 ext. 4239
• cwatson_at_wvmi.org

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1c1 Hospital

• Questions ?