Quality Improvement Plans QIPs in Case Review

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Quality of Care Concerns

• Beneficiary Complaints
• IPRO physician consultant (PC) determines if care
  meets/does not meet applicable professionally
  recognized standards of care
• References relevant guidelines and/or textbook
  used in reaching an adverse determination
• IPRO Medical Director must concur with PC
  decision before determination considered final

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Quality of Care Concerns

• IPRO physician consultant also makes initial
  recommendation as to need for QIP
• IPRO Medical Director must concur with
  recommendation for QIP
• When there is not concurrence Medical Director
  discusses case with physician consultant as part
  of IPRO IQC process

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QIP Required

• Identification of index QIP Cases

Why a QIP for this case???
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QIP Required

• When care could have been better or
• When care failed generally accepted guidelines or
  usual practice
• AND
• There is a potential for better care to result
  from improvement in the system(s) or process of
  care delivery and/or practitioner participation
  in an education program or change in practice
• CMS/BPQIOSC Guide to Quality of Care Issues for
  Physician Reviewers

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QIP Required

• In other words, there is an opportunity for the
  pattern of practice to be improved.

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QIP Not Required

• Case where individual judgment is in error.
• Example 82 year old HTN with lacunar CVA did
  trans-esophageal echo (TEE) perforated
  esophagus. While literature supports TEE in CVA,
  this case was an exception to rule. Requires
  common sense thinking Not process change!!!!

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Key Components

• QIPs must include
• The methodology(ies) that will be utilized to
  achieve improvement(s).
• The methodology that will be utilized to measure
  improvement(s).
• Documented evidence that the improvement has been
  achieved.
• The methodology that will be utilized to assure
  that the improvement(s) are sustained.

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QIP Evaluation
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Example

• Index Case Beneficiary complaint in regard to
  care received by father in ICU.
• Issues Failure by nurse to recognize that
  increasing patient agitation was due to hypoxia.
  Called for additional sedation order/which was
  then given based on verbal order given by P.A.
  (who never evaluated patient). Scanty
  documentation regarding patients subsequent
  respiratory arrest.

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Example

• Hospital QIP sent to IPRO includes
• Ongoing education to nursing staff re importance
  of respiratory assessment oxygen saturation
  values, emphasizing reporting to MD/PA.
• Competency evaluations ongoing
• Monthly concurrent chart reviews with staff
  follow-up, as needed.
• Reports to Performance Improvement Council

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Example

• Are the required key components met by this QIP.
• Methodologies??
• Measure(s)??
• Evidence??
• Ongoing assurances??
• What do you think?

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For additional information, please contact

• agoldstein_at_nyqio.sdps.org
• [phone], ext. 364
• Thank you!