Andrei Kuznetsov

1
CMS Plans for Clinical Performance and Validation
Andrei Kuznetsov Director of Analytical
Services August 25, 2005
MO-05-15-INPT This material was prepared by
Primaris, the Medicare Quality Improvement
Organization for Missouri, 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 reflect CMS policy.
2
HQA RHQDAPU
3
HQA RHQDAPU
4
HQA RHQDAPU
5
The end of RHQDAPU?

• Federal FY-2007 starts Oct 1, 2006
• Last discharge quarter falling under RHQDAPU
  1Q-2006
• Cheering? Not so fast
• HQA predated RHQDAPU but did not forestall
  federal mandate
• Signs federal government planning to push public
  reporting of hospital data

6
Near future of HQA

• Further promote the 22 measure set
• Primaris will publicly recognize those submitting
  full HQA set
• Add HCAHPS / patient experience survey
• New measure sets???

7
Commitment to Quality Full HQA set in 1Q-2005

• Audrain Medical Center
• Barnes Jewish Hospital
• Barnes Jewish St. Peters Hospital
• Barnes Jewish West County Hospital
• Boone Hospital Center
• Capital Region Medical Center

8
Full HQA measure set, continued

• Christian Hospital Northeast
• Doctors Hospital of Springfield
• Fitzgibbon Memorial Hospital
• Forest Park Hospital
• McCune Brooks Hospital
• Mineral Area Regional Medical Center

9
Full HQA measure set, continued

• Missouri Baptist Hospital - Sullivan
• Missouri Baptist Medical Center
• Parkland Health Center
• Southeast Missouri Hospital
• SSM St. Joseph Health Center
• SSM St. Joseph Hospital West

10
Full HQA measure set, continued

• St. Alexius Hospital
• St. Johns Regional Medical Center - Joplin
• Ste. Genevieve County Memorial Hospital
• Texas County Memorial Hospital
• Three Rivers Healthcare, a.k.a. Poplar Bluff
  Medical Center
• Twin Rivers Regional Medical Center

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Clues from QIO 8SOW contract

• Appropriate Care Measure (ACM)
• Surgical Infection Prevention (SIP) measurement
• Surgical Care Improvement Project (SCIP) and
  measures
• Rural / Critical Access Hospital Measures
• Continued Validation

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Appropriate Care Measure (ACM)

• Across all measures in AMI, HF or PN set
• Did patient receive appropriate care on all
  applicable measures?
• Example of ACM for PN pts
• Antibiotics in 4 hrs 94
• Blood cultures before antibx 86, etc.
• Pneumococcal Vaccination status 63
• ACM for PN patients 56

13
Appropriate Care Measure

• CMS will distribute ACM reports to hospitals
• Berwicks IHI also uses this metric
• A measure of excellence
• No plans for public reporting of ACM
• AMI, HF and PN data all three required
• Big gaps identified, 50 improvement expected

14
Surgical Infection Prevention (SIP)

• SIP-1 On-time Prophylactic antibiotic
  administration
• SIP-2 Appropriate selection of prophylactic
  antibx
• SIP-3 Prophylactic antibx discontinued within
• 24 hours
• SIP-2 and 3 collected but not publicly reported
  due to changing guidelines
• CMS will track progress on SIP-1

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Surgical Care Improvement Project

• SCIP for short
• Six modules, 24 measures
• Infection 9 measures (including 3 SIP measures)
• Ex Appropriate hair removal
• Cardiovascular 4 measures
• Ex Major non-cardiac surgery pts received
  Beta-blockers during perioperative period

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SCIP

• Thromboembolism 4 measures
• Ex Appropriate venous thromboembolism
  prophylaxis
• Respiratory 4 measures
• Ex Ventilator-weaning protocol
• Vascular access 1 measure
• Fistula use for ESRD vascular access
• Global (2, mortality and readmission rates)

17
SCIP

• Measurement tools to be available for review of
  7/1/06 discharges
• ORYX vendor tools and CART tool to be rolled out
  together
• JCAHO adopting SCIP as a module
• A serious chart review workload
• Incremental adoption by module possible

18
Rural / CAH measures

• CAHs options
• Continue with HQA reporting
• Switch to new set of measures
• Some ORYX vendors set to offer this set
• Core of old AMI, HF and PN measures
• No exclusion for transfers from another hospital
  for 4 of 7 AMI measures
• Added Emergency Dept Transfer Communication
  composite of 16 items

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CAH measures AMI

• AMI-1 ASA administered at arrival no transfer
  exclusion
• AMI-2 ASA prescribed at discharge
• AMI-3 ACEI or ARB for LVSD
• AMI-6 Beta Blocker at arrival no transfer
  exclusion

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CAH measures AMI

• AMI-5 Beta Blocker at discharge
• AMI-new measure Time to EKG no transfer
  exclusion
• AMI-7 Time to thrombolytics no transfer
  exclusion test measure only

21
CAH measures HF and PN

• HF-2 LVF Assessment
• HF-3 ACEI or ARB for LVSD
• PN-1 Oxygenation assessment
• PN-2 Pneumococcal vaccination
• PN-5b Initial Abx within 4 hrs of arrival

22
CAH set transfer documentation

• Were these sent with the transferred patient to
  another acute care hospital?
• Nurse communication with receiving hospital
• Doctor communication with receiving hospital
• Pt. Name
• Pt. Address
• Pt. Age
• Pt. Gender
• Pt.s Significant others contact info

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CAH set - transfer documentation

• Vital signs
• Physician hx and physical includes physical
  exam, history of current event, chronic
  conditions
• Physician orders and plan
• Nurse documentation includes assessment/
  interventions/response
• Medication administration, allergies, adverse
  events
• Treatment documentation

24
Continued validation

• Pass on validation if 80 agreement
• Five records selected from all cases submitted
  for a quarter
• Primaris will publicly recognize high performers

25
New JCAHO measure sets

• ICU care
• Pediatric care
• Pain management
• Hospital-based psychiatric care test set
• VTE/DVT prophylaxis
• Nursing care

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Brave new world of performance measurement

• Continue with HQA
• Bye-bye, APU program!
• More variety, more options
• More customization (CAH set)
• Strong push by CMS to keep the bases covered
• Ongoing quality control of data (ACM)
• Surgical care a huge priority (SCIP)

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Questions?

• Primaris will be there for you every step of the
  way!
• [phone]
• www.primaris.org