QIO Update Judy Weddle, RN, BSN, MEd, CPHQHospital QI SpecialistQSource Patient Safety Team
August 2009THA Patient Safety Center“Reducing Hospital Acquired Infections” CollaborativeRegional Networking Meetings
• SCIP national measure changes• Stroke/VTE/ED “Core Measures” comments• QSource’s CMS MRSA Project progress• TeamSTEPPS training workshops• HLQAT national and TN launch
• Informal – please ask questions throughout!
Discussion Topics for Today
“The right carefor every person,every time.”
CMS Vision StatementFor the National Healthcare Quality Improvement Program
• Safe
• Timely
• Effective
• Efficient• Equitable
• Patient-centered The Institute of Medicine
The “Right Care”
• Available for discharges from 10/01/09 forward• Remove: Inf-7 – Colorectal Surgery Patients with
Immediate Postoperative Normothermia• Add: Inf-10 – Surgery Patients with Perioperative
Temperature Management• Add: Inf-9 – Urinary Catheter Removed on
Postoperative Day 1 or Postoperative Day 2, with Day of Surgery Being Day Zero
SCIP Core Measures Changes
• Measure Information Form (MIF) available on www.qualitynet.org within the TJC/ CMS-aligned Specifications Manual – “Hospitals - Inpatient” tab– “Specifications Manual” link– “Version 3.0a” link
Detailed Information on New Measures
• Measure Information Form (MIF) Contents– Measure short name– Data element list– Population and sampling information– Measure-specific information (e.g., rationale,
numerator/denominator statements, included/ excluded populations, selected “evidence” references from medical literature, analysis algorithm)
Detailed Information, cont.
• Key Points from MIF– Rationale: Postoperative patients with > 2 days
duration of indwelling urinary catheters• 21% more likely to develop UTI• Significantly less likely to be discharged to home• Significant increase in mortality at 30 days
(As we all know… “catheter-associated UTI” is one of the Hospital Acquired Conditions (HAC) for which a higher-DRG payment is not allowed by CMS)
SCIP Inf-9 – Urinary Catheter Removed
• Key Points from MIF, cont.– Denominator:
• All SCIP surgery types (Appendix A, Table 5.10)• Urinary catheter in place post-op• Exclude patients with LOS < 2 days post-op• Several exclusions related to specific urinary-
type surgeries and infections prior to surgery• Exclusion for patients with MD/APN/PA
documentation of reason for not removing the catheter
SCIP Inf-9 – Urinary Catheter Removed, cont.
• Key Points from MIF, cont.– 3 New Data Elements to be Abstracted
• See Data Dictionary in Specifications Manual• “Urinary catheter”• “Catheter removed”• “Reasons for continuing urinary catheterization”
SCIP Inf-9 – Urinary Catheter Removed, cont.
• Chart audits to determine ease of collecting the 3 new data elements (simple, home-grown audit tool)
• Educate surgeons• Educate surgery and post-op staff
SCIP Inf-9 – Preparing
• Update EMRs/Standing Order Sets– Examples from national SCIP List Serv:
• Add “catheter placed” + date documentation field • Add “assess for removal” type of prompt timed to
“catheter placed” field• Add “catheter removed” + date documentation field • Add documentation field to capture any reason for
continuation
SCIP Inf-9 – Preparing, cont.
• IHI Improvement Map Resource– “Getting Started Kit: Prevent Catheter-
Associated Urinary Tract Infections – How To Guide”
– Free download (after log-in) from www.ihi.org (you will have to “register” [free and simple] if not already a member)
SCIP Inf-9 – Preparing, cont.
• IHI Improvement Map Resource, cont.– Kit includes detailed information on four
recommended components of care:• Avoid unnecessary urinary catheters• Insert urinary catheters using aseptic technique• Maintain catheters based on recommended
guidelines• Review urinary catheter necessity daily and
remove promptly
SCIP Inf-9 – Preparing, cont.
• Key Points from the MIF– Rationale: “Unplanned perioperative hypothermia
has been correlated with impaired wound healing, adverse cardiac events, altered drug metabolism, and coagulopathies.”
• SSIs 3 times higher (certain SSIs are HACs)• Increased chance of blood products administration,
myocardial infarction, and mechanical ventilation• Prolonged hospital stays and increased costs
SCIP Inf-10 – Perioperative Temperature Management
• Key Points from MIF, cont.– Numerator:
• Surgery patients for whom either active warming was used intraoperatively…or who had at least one body temperature equal to or greater than 96.8F/36C recorded within the 30 minutes immediately prior to or the 15 minutes immediately after Anesthesia End Time.
SCIP Inf-10 –Perioperative Temperature Management, cont.
• Key Points from MIF, cont.– Denominator:
• All SCIP surgery types (Appendix A, Table 5.10)• All ages• General or neuraxial anesthesia greater than or
equal to 60 minutes duration• Exclusion for patients with MD/APN/PA
documentation of intentional hypothermia for the procedure
SCIP Inf-10 – Perioperative Temperature Management, cont.
• Key Points from MIF, cont.– 2 New Data Elements to be Abstracted
• See Data Dictionary in Specifications Manual• “Intentional hypothermia” (no specific
inclusion words for surgery involving cardiopulmonary bypass)
• “Temperature”
SCIP Inf-10 – Perioperative Temperature Management, cont.
• Conduct chart audits to determine ease of collecting the 2 new data elements (simple, home-grown audit tool)
• Discuss with surgical team members who participated in the process improvements related to the previous normothermia measure
• Educate surgeons/anesthesia staff• Educate surgical staff• Update EMRs/Standing Order Sets/Anesthesia
Records
SCIP Inf-10 – Preparing
• July 31, 2009 – CMS IPPS Final Rule– Both measures finalized for the FY 2011
RHQDAPU payment determination– Submission to the QIO Clinical Warehouse
required beginning with 1st quarter 2010 discharges
• Highly recommend taking advantage of the 4th quarter 2009 discharges submission period to “get ready” – talk to your vendor!
SCIP Inf-9 and Inf-10CMS Requirements
• Accepted by The Joint Commission only - for discharges Oct-Dec 2009 and forward
• “Informational” for CMS - not accepted into the QIO Clinical Warehouse at this time
• July 31, 2009 RHQDAPU Final Rule: CMS received public support and will likely propose these measures for the FY 2012 payment determination
• Full MIFs available on www.qualitynet.org• If interested, contact your vendor to see if they will
offer data abstraction fields for these measures
Stroke and VTE “Core Measures”
• Informational only
• Not accepted by The Joint Commission or CMS at this time
• July 31, 2009 RHQDAPU Final Rule: CMS received public support and will likely propose these measures for the FY 2012 payment determination
• Full MIFs available on www.qualitynet.org
• If interested, contact your vendor to see if they will offer data abstraction fields for these measures
Emergency Department “Core Measures”
• 19 of the 29 participant hospitals successfully submitted MDRO baseline data and conferred data rights to QSource and the national QIO Support Contractor (not CMS) through NHSN
• If your hospital is in both MRSA projects (QSource & THA), confer data rights to TDOH (Dr. Kainer) also
QSource’s CMS MRSA Project Progress to Date
• A TN hospital and QSource worked together to identify a “glitch” in the new MDRO module system and submitted it to the CDC/NHSN Help Desk for resolution
• Continue to submit data monthly! Due by the end of the following month
• THANK YOU for your patience and perseverance!!!
QSource’s CMS MRSA Project Progress to Date, cont.
• Developed by the Department of Defense (DoD) and the Agency for Healthcare Research and Quality (AHRQ)– Focus: patient safety– Teamwork and communication skills
• CMS provided Train-the-Trainer education for all QIOs
• In turn, QIOs provide TeamSTEPPS training
QSource TeamSTEPPS Training
• Upcoming QSource regional training workshops:– Attendance required for all QSource CMS
SCIP/HF and MRSA project hospitals– Also open to all other TN hospitals and
QSource partners and stakeholders
• Training focus: communication skills• Target audience: Infection Preventionists,
QI staff, unit managers, and frontline staff
QSource TeamSTEPPS Training, cont.
• Regional workshops: 1:00–3:00pm (local time)– Chattanooga, Tuesday Oct. 20th
– Knoxville, Wednesday Oct. 21st
– Tri-Cities, Thursday Oct. 22nd
– Memphis, Tuesday Nov. 10th
– Jackson, Wednesday Nov. 11th
– Nashville, Thursday Nov. 12th
• Watch for registration information email!!!
QSource TeamSTEPPS Training, cont.
• “Helps hospitals identify and improve those structures, processes, and leadership activities associated with high performance in clinical quality”
• Developed by a national, collaborative panel of experts
• Enhances and is complementary to the AHRQ Patient Safety Culture Survey tool (elicit differences in perception between leadership and frontline staff)
• No plans by CMS for making it mandatory or publicly reported
Hospital Leadership and Quality Assessment Tool (HLQAT)
• Knowledge-seeking• Established goals and priorities• Effective communication• Collaboration• Clear roles• Collaborative, supportive culture• Public reporting• Process improvement tools and techniques• Adequate resource allocation• QI education• Monitoring and evaluation• Rewards/recognition
12 HLQAT Domains
• Consists of two survey components:– Senior leadership (includes boards/trustees)– Clinical management
• Minimum # of responses required:– 3 board members– 4 members of executive team (CEO,
CMO, CNO, and CFO)– 6-10 clinical managers
HLQAT Details
• Free to all hospitals• Survey information is “the property
of the hospital”• No individual survey-respondent
information will be made availableto the hospital
• Online access to surveys –approx 30 min. to complete
HLQAT Details, cont.
• Online access to hospital and comparative reports– Only the hospital can share its results
• Online access to “Resources for Leadership Interventions” (RLIs) for each of the 12 Domains:
• Website links• Evidence-based literature• Tools (templates, workbooks, toolkits)
HLQAT Details, cont.
• Required activity for hospitals participating in the QSource/CMS SCIP/HF and MRSA projects– See next slide on “Getting Started”– Your QSource project contact will also provide you
with specific support as needed
• Recommended activity for all hospitals (be a top performer when P4P is implemented!)
HLQAT Details, cont.
• Register: send an email to [email protected] the subject line HLQAT Participant
• Receive a “Welcome Packet” and your hospital’s “Unique Identifier Codes” for respondents
• Visit www.HLQAT.org – FAQs and support documents– Survey tool copies/take the survey– Reports– Intervention resources
HLQAT – Getting Started
Judy Weddle [email protected]
Thank You!
This presentation and related materials were developed by QSource, the Medicare Quality Improvement Organization for Tennessee, under contract with the Centers for Medicare & Medicaid Services (CMS), a division of the Department of Health and Human Services. Contents do not necessarily reflect CMS policy. QSOURCE-TN-109.62-2008-10
