inpatient psychiatric facility quality reporting ... · – age strata c had a total of 253 minutes...

Inpatient Psychiatric Facility Quality Reporting Abstraction Help Resources

Telligen Jane Tehel RN, BS Tressa Clemens RN, BSN Abby Gervais BS

March 14, 2013

Agenda

• Program Announcements – QualityNet Registration Process Change – Notice of Participation- Submission Instructions – CMS IPF Question and Answer Tool – Facility Profiles

• Abstraction Help Resources – Event Tracking Log – Paper Abstraction Tools

• Frequently Asked Questions 2

QualityNet Registration Change in instruction for facilities with an existing account

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Inpatient Psychiatric Facilities new to CMS Hospital Reporting:

– Register with QualityNet before the IPF begins reporting, regardless of the method used for submitting the data.

– Identify a QualityNet Administrator who follows the registration process.

NOTE: When a facility has participated in another Hospital Reporting Program and has an existing QualityNet account, they do NOT need complete a new registration for participation in the IPFQR Program.

Mailing the Registration Form

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Note: Mail original forms. No photocopies accepted.

Forms mailed to QualityNet Help Desk.

Do NOT mail to Telligen or the QIO.

Contacts for QualityNet Registration Questions

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For questions regarding the QualityNet Registration form QualityNet Help Desk 7 a.m. - 7 p.m. CT

Monday - Friday E-mail: qnetsupport@sdps.org

Phone: (866) 288-8912 TTY: (877) 715-6222 Fax: (888) 329-7377

Notice of Participation Paper Form Reminders for Completion

• Must be signed by CEO, not other hospital representatives.

• Remember to include the facility CCN (provider number).

• Write legibly. The content will be entered into the Notice of Participation (NOP) application once it is available.

• Confirm the email address is accurate.

• Do NOT send the NOP to the QualityNet Help desk.

• Do NOT send by email.

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Notice of Participation Paper Form

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Steps for Completion

1. Read the Notice of Participation Agreement.

2. Enter the Provider ID in the box provided.

3. Select the appropriate action by entering an “X” in the box.

NOP Paper Form (continued)

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Steps for Completion (continued)

4. Read the acknowledgement and pledge statement and indicate agreement by entering an “X” in the box.

5. Enter the Facility Name. 6. CEO signs the form in the box

(not other facility staff). 7. Enter date of CEO signature in

the box. 8. Enter CEO Email address in the

box.

Submitting the Paper NOP form

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Facility Profile Form Reminder

When the facility elects to send the completed Facility Profile form by mail, please remember to keep a copy for your records.

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CMS Q&A Tool for IPFQR Program Now Available

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The Q& A Tool is an alternate source for submitting program questions to the IPF Support Contractor rather than through the IPF-PCH Help Desk.

Do not submit the same question to both the Help Desk and the Q&A Tool - choose one source.

How to access the Q&A Tool

• To access the application, open an Internet Explorer (IE) window and navigate to Qualitynet.org. (https://www.qualitynet.org)

• Internet Explorer 8.0 or higher is the recommended and supported web browser.

• The current location of the Q&A URL is on the right side of the QualityNet homepage under Questions and Answers.

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QualityNet Home Page

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Inpatient Q&A Page

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NOTE:

Although the Title bar at the top displays as QualityNet, you are in the Q&A Application.

You will not use your QualityNet User ID to submit a question unless you set up your registration to use the same User ID.

Select the appropriate program.

Topics for Inpatient Psychiatric Facilities

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IPF topics and subtopics that are available to select when searching for answers or submitting a new question.

Use ONLY IPF topics to direct your question to the correct program.

Data Collection for HBIPS 2 and 3 (Event Measures)

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• HBIPS 2 Hours of physical restraint use.

• HBIPS 3 Hours of seclusion use.

Instructions for Hospital-Based Inpatient Psychiatric Services (HBIPS) Event Tracking log

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• Purpose – To serve as an optional help document for

facilities to assist with data collection for CMS reporting of measures under the Inpatient Psychiatric Facility Quality Reporting Program.

– Facilities can choose to track the events daily, weekly, monthly, or quarterly.

Step 1

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Track each event by completing the Numerator and Denominator sections.

Suggestion: Print two Event Tracking Logs, one for HBIPS-2: Hours of Physical Restraint and a second for HBIPS-3: Hours of Seclusion use.

Sample Numerator Section

Step 2

• Calculate the Numerator – Sort or Filter each event per age strata. – Add the Total Minutes per age strata. – Divide each age strata total by 60 minutes. – Enter the totals per age strata into the numerator

files of the Total section.

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Numerator Example

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• Example – Age strata C had a total of 253 minutes in

restraints (or seclusion). – Take 253 total minutes in restraints (or seclusion)

divided by 60 minutes = 4.216. – The total Numerator for age strata C is 4.216

hours in restraint (or seclusion).

Sample of Total Section Numerator

Step 3

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• Calculate the Denominator – Add the total number of Inpatient Days in the

Denominator section per age strata. – Add the total number of Leave Days in the Denominator

section per age strata. – Subtract the Total Number of Inpatient Day from Total

Leave Days per age strata. – Multiply by 24 hours. – Divide by 1,000 hours. – Enter the total into the Denominator fields per age strata

in the Total section.

Screen Shot of Denominator Section

Denominator Example

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• Example – The Total Inpatient Days for age strata C = 778. – The Total Leave Days for age strata C = 11. – 778 – 11 = 767. – Multiply 767 by 24 hours = 18,408 hours. – Divide 18,408 hours by 1,000 hours = 18.408. – The total denominator for age strata C = 18.408.

Screen Shot of Total Section Denominator

Definition of Leave Day

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The Specifications Manual for Joint Commission National Quality Measures, defines a leave day as an authorized or unauthorized absence from a facility, excluding discharges, during which the patient is absent from the facility at the time of the daily census and is not under the direct supervision of facility staff while (v2013A1).

Example of a Leave Day

• If a patient leaves on 03/01/2013 at 0600 and returns 03/01/2013 at 2359 this is not considered a leave day because the patient returned before the midnight census

• If a patient leaves 03/01/2013 at 0600 and returns 03/02/2013 at 0900 this is considered 1 leave day because the patient was not in the midnight census for 03/02/2013.

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Event Measures Abstraction Reminders

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• HBIPS-2 and 3 do not include any events that occur prior to the patient’s arrival to the psychiatric unit.

• Each individual calendar day that a patient is in restraints or seclusion is abstracted independently. If the event goes over the midnight hour there is two event dates and each date would be abstracted independently.

• For additional information about restraints and seclusion, please refer to the CMS website, Internet Only Manuals. The Interpretive Guidelines (Appendix PP) in the CMS State Operations Manual, Publication 100-07, section 482.13, Standard Restraint or Seclusion. (http://cms.hhs.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS1201984.html)

• Per the Specifications Manual, up to six decimal places (0.000000) are to be used when entering the time for physical restraints or seclusion. There should be no rounding when converting from minutes to hours.

Data Collection for Discharge Measures HBIPS 4 - 7

• HBIPS 4 Patients discharged on multiple antipsychotic medications .

• HBIPS 5 Patients discharged on multiple antipsychotic medications with appropriate justification.

• HBIPS 6 Post discharge continuing care plan created. • HBIPS 7 Post discharge continuing care plan

transmitted to next level of care provider upon discharge.

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Abstraction Paper Tool

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Hospital-Based Inpatient Psychiatric Services (HBIPS) Paper tool for discharge Measures (HBIPS-4 through HBIPS-7)

This paper abstraction tool is provided as an optional, informal mechanism to aid psychiatric facilities and hospital psychiatric units in the collection of the measures for the CMS Inpatient Psychiatric Facility Quality Reporting Program. The tool is designed to collect patient specific data; however, once abstracted, the data will need to be complied and reported to CMS in aggregate. It should be noted that skip logic is not contained within the paper abstraction tool. If there are any questions or concerns regarding use of this paper abstraction tool, please contact the IPFQR Program Support Contractor at IPF-PCHQRSupport@Telligen.org.

Abstraction Paper tool for HBIPS Discharge Measures

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Paper Abstraction Tools

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4th Quarter 2012 Use the paper tool for the discharge period

October 1, 2012 through December 31, 2012.

1st Quarter 2013 Use the paper tool for the discharge period

January 1, 2013 through June 30, 2013.

Reporting Period for FY 2014

• 4 Q 2012 (October 1, 2012 through December 31, 2012).

• 1Q 2013 (January 1, 2013 through March 31, 2013).

• Data Submission Period- July 1, 2013 through August 15, 2013 by 11:59 P.M. Pacific Time.

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Questions

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Review of Questions in the Webinar Queue

Future Webinars

Topic - CMS Listening Session on the proposed changes for Inpatient Psychiatric Facility Quality Reporting based on the IPPS proposed rule. Tentative Date: May 2, 2013

2 p.m. – 3 p.m. Eastern Time

1 p.m. – 2 p.m. Central Time

12 p.m. – 1 p.m. Mountain Time

11 a.m. – 12 p.m. Pacific Time 36

Contact Information

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Questions regarding the IPFQR Program may be directed to the Telligen help desk, weekdays from 8 a.m. to 5 p.m. Central Time:

IPFQR Support Help Desk Phone: (888) 961-6425 E-mail: IPF-PCHQRSupport@Telligen.org