Core Options CMS and JCAHO Alignment January Changes 2005

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Core Options?CMS and JCAHO Alignment(January
Changes 2005)

• December 1 2, 2004
• Chris Wieland, RN
• Performance Measurement Consultant

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Agenda

• Review Web Cast Objectives (5 minutes)
• Review July Changes (5 minutes)
• Review Current Changes (20 minutes)
• Review ACEI and ARB Changes (10 minutes)
• Review Sampling Changes (10 minutes)
• Summary (5 minutes)
• Questions

(Slide 2)
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July Changes Additions

• Transfer from another ED
• Blood culture prior to arrival
• Antibiotics prior to arrival
• Compromised
• Antibiotics 36 hours
• Pneumococcal Vaccination Status Two questions,
  Pneumococcal Vaccination Status and Pneumococcal
  Vaccination Given combined into one.
• Influenza Vaccination Status Two questions,
  Influenza Vaccination Status and Influenza
  Vaccination given combined into one.
• PN two new measures, both rate measures PN-5a
  PN-5b.
• AMI two new measures, both rate measures
  AMI-7a AMI-8a.

(Slide 3)
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July Changes Deleted Questions

• Two questions related to Pediatric Smoking
• Co-morbid conditions
• Hospitalization within previous 14 days
• Pneumococcal Vaccination given
• Influenza Vaccination given

(Slide 4)
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Why the new changes and alignment?
The alignment Version 1.0 - 1.01 represents the
results of discussions by the Centers for
Medicare Medicaid Services (CMS) and the Joint
Commission on Accreditation of Healthcare
Organizations (JCAHO). The reason for the
alignment are

• To achieve alignment of common national
  performance measures
• To share one set of documents
• To minimize data collection efforts for these
  common measures
• To focus efforts on the use of data to improve
  the health care delivery process

(SLIDE 5)
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Changes, starting with January 2005 Discharges

• Core Performance Measures name changed to
  National Hospital Quality Measures
• The initiative name National Voluntary Hospital
  Reporting Initiative (NVHRI) has been changed to
  Hospital Quality Alliance (HQA)

(SLIDE 6)
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? Change number of Antibiotics Allowed in
the cases of PN SIP, changes have been
made to allow for 75 distinct occurrences
of antibiotic administration for the
following data elements ? Antibiotic
Name ? Antibiotic Administration Date
? Antibiotic Administration Time ?
Antibiotic Administration ? Route and
Prophylactic Antibiotic (SIP)
Current Changes
(Slide 7)
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Current Changes

• Change in allowable values for data element Adult
  Smoking History from Y, N, Z to Y, N due to
  merging of N and Z values
• Change in all data elements where Emergency Room
  Record is listed under Suggested Data Source to
  Emergency Department Record
• Change in definition for data element Antibiotic
  Name previously known as Name of Antibiotic

(Slide 8)
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Current Changes

• Removed in data element Antibiotic
  Administration Route, Allowable Value, option 6
  Mixed in cement and add RETIRED VALUE No
  longer an option
• Deleted data element Antibiotic Administered
  During the First 36 Hours of Arrival
• Removed the Question Data Elements Initial
  Antibiotic Date and Initial Antibiotic Time
• Renamed data element Admission Diagnosis for SIP
  to Admission Diagnosis of Infection

(Slide 9)
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Current Changes

• Comfort Measures to Guidelines and Inclusion
  add to the end of phrase or patients condition
  is grave or that death is imminent and continue
  supportive care and comfort measures provided
• Compromised

• Allowable Values change phrase
  Immunosupressivetherapy within last three
  months to read Systemic immunosuppressive
  therapy within last three months
• Notes for Abstraction change None to A single
  dose does not constitute therapy
• Guidelines for Abstraction add corticosteroid
  therapy and malignancy within past 3 months

(Slide 10)
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? Abstraction Date? Abstractor
Identification Number? Hispanic Ethnicity?
Race? First Name? Last Name
Note In the present Core Options Help Screen
have a description of the question. Please note
that a more detailed description of the question
has been added to the Suggested Data Collection
Question
Added New Data Element all sections of the
manual, all records
(SLIDE 11)
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? New Element First PCI Date and First PCI
Time for AMI records only ? New
Measures ? PN-3a
Blood Culture within 24 hours prior
to or after arrival (CMS only) ?
PN-6 Initial antibiotic Selection for CAP in
immunocompetent patient (CMS only)

New Element New Measures
(SLIDE 12)
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Definitions Expanded or Modified Data Elements

• ACEI Prescribed at Discharge
• Antibiotic Received
• Aspirin Prescribed at Discharge
• Aspirin Received Within 24 hours Before or After
  Hospital Arrival
• Beta Blocker Prescribed at Discharge
• Beta Blocker Received Within 24 hours After
  Hospital Arrival
• Blood Culture Collected After Arrival
• Blood Cultures Prior to Arrival
• Case Identifier
• Compromised
• Contraindication to ACEI at Discharge
• Contraindication to Aspirin at Discharge
• Contraindication to Aspirin at Arrival

(SLIDE 13)
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Definitions Expanded or Modified

• Contraindication to Beta Blocker at Discharge
• Discharge Status
• First PCI Time
• ICD Population Size
• Initial Blood Culture Collection Date and Time
• Influenza Vaccination Status
• Initial ECG Interpretation
• LVF Assessment
• LVSD
• Pneumococcal Vaccination Status
• Prophylactic Antibiotic
• Thrombolytic Administration
• Thrombolytic Administration Date
• Thrombolytic Administration Time

(SLIDE 14)
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Combined Relevant Data Elements Changes for PN
SIP

• FROM Name of Antibiotic (SIP), Name of
  Antibiotic Administered During First 36 Hours
  (PN) TO Antibiotic Name
• FROM Date of Antibiotic (SIP), Start Date of
  Antibiotic Administration (PN) TO Antibiotic
  Administration Date
• FROM Time of Antibiotic (SIP), Start Time of
  Antibiotic Administration (PN) TO Antibiotic
  Administration Time

(SLIDE 15)
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Combined Relevant Data Elements Changes for PN
SIP

• FROM Route of Antibiotic (SIP), Route of
  Antibiotic Administration (PN) TO Antibiotic
  Administration Route
• FROM Antibiotic Allergy (SIP) History of
  Antibiotic Allergy (PN) TO Antibiotic Allergy
• FROM Antibiotics Prior to Arrival (SIP),
  Antibiotics Prior to Arrival (PN) TO Antibiotics
  Prior To Arrival

(SLIDE 16)
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Short Term Steps
ACEI AND ARBS

• Change current data element names from ACEI
  Prescribed at Discharge to ACEI or ARB
  Prescribed at Discharge
• Change Contraindication to ACEI at Discharge to
  Contraindications to Both ACEI and ARB at
  Discharge
• Notes for abstraction, inclusion/exclusion lists,
  etc. within the definitions will be revised and
  reworded accordingly

(SLIDE 17)
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ACEI AND ARBS
Short Term Steps Cont.

• Revise AMI/HF measure names ACEI or ARB for
  LVDS
• In all CMS-JCAHO manuals, reflect data element
  and measure name changes e.g. Data Element Lists,
  Data Dictionary, Measure Information Forms
• Add new medication table in Appendix C containing
  the list of ARBsLong Term Changes do not go
  into effect until October 1, 2005, therefore, not
  included.

(SLIDE 18)
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SAMPLING METHODS

• OPTION A
• Quarterly required sample size at least 20
  of the measure set population Core Options uses
  only Option B
• OPTION B
• Monthly required sample size at least 20 of
  the measure set population

(SLIDE 19)
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SAMPLE SIZEAcute Myocardial Infarction AMI
(SLIDE 20)
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SAMPLE SIZEHeart Failure(HF)
(SLIDE 21)
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SAMPLE SIZEPneumonia(PN)
(SLIDE 22)
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SAMPLE SIZEPregnancy and Related (PR)
(SLIDE 23)
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SAMPLE SIZESurgery Infection Prevention (SIP)
(SLIDE 24)
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JCAHO Website for the Specifications Manual
Core Options Web Page Help Core Options on the
Web Resources Specifications Manual
for National Hospital Quality Measures -
2005
(SLIDE 25)
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Questions
Chris Wieland, RN Performance Measurement
Consultant cwieland_at_mha.org ? 517-886-8209