The Medicare Beneficiary Quality Improvement Project (MBQIP)
Monthly Performance Improvement CallApril 16, 2015
Amber Theel, Executive Director Patient Safety
Susan Rivera-Lee, WSHA Consultant MBQIP
MBQIP - Goal
• Improve the quality of care provided in critical access hospitals (CAHs).
• Data comparison with like organizations.
• Demonstrating value by providing cost efficient, quality care is the future of health care reimbursement. MBQIP takes a proactive approach to ensure CAHs are well-prepared to meet future quality requirements.
1 – 4th Q 2014 1 Q 2015 – 3 Q 2015 4 Q 2015Inpatient
(Phase 1)
• PN-3b: Blood Cultures Performed in
the ED Prior ABX
• PN-6b: Initial ABX Selection for CAP
• HF-1: Discharge Instructions
• HF-2: Evaluation of LVS Function
• HF-3: ACEI or ARB for LVSD
PN-6b: Initial ABX Selection for CAP
HF-2: Evaluation of LVS Function
• IMM-2: Influenza Immunization
Outpatient
(Phase 2)
• OP-1: Median Time to Fibrinolysis -ED
• OP-2: Fibrinolytic Therapy Received
Within 30 Minutes of Arrival in the
Emergency Department
• OP-3: Median Time to Transfer to
another Facility for Acute Coronary
Intervention in the ED
• OP-4: Aspirin at Arrival in ED
• OP-5: Median Time to ECG in the ED
• OP-6: Timing of ABX Prophylaxis
• OP-7: Prophylactic ABX Selection
HCAHPS
• OP-1: Median Time to Fibrinolysis -ED
• OP-2: Fibrinolytic Therapy Received
Within 30 Minutes of Arrival in ED
• OP-3: Median Time to Transfer to
another Facility for Acute Coronary
Intervention in the ED
• OP-4: Aspirin at Arrival in ED
• OP-5: Median Time to ECG in the ED
HCAHPS
• OP-1: Median Time to Fibrinolysis -ED
• OP-2: Fibrinolytic Therapy Received
Within 30 Minutes of Arrival in ED
• OP-3: Median Time to Transfer to
another Facility for Acute Coronary
Intervention in the ED
• OP-5: Median Time to ECG in the ED
• OP-20: Door to diagnostic evaluation by a qualified medical professional
• OP-21: Median time to pain management for long bone fracture
• OP-22: Patient left without being seen
• OP-27 HCP /: Influenza vaccination
coverage among healthcare personnel
HCAHPS
ED Transfer
Comm.
(Phase 3)
• EDTC-1: Admin. Communication
• EDTC-2: Patient Information
• EDTC-3: Vital Signs
• EDTC-4: Medication Information
• EDTC-5: Provider generated information
• EDTC-6: Nurse generated information
• EDTC-7: Procedures and Tests
• EDTC-1: Admin. Communication
• EDTC-2: Patient Information
• EDTC-3: Vital Signs
• EDTC-4: Medication Information
• EDTC-5: Provider generated info
• EDTC-6: Nurse generated info
• EDTC-7: Procedures and Tests
Reading Data Reports – What do I look for?
• Lack of Consistent Process
• Process May Need Adjustment
• Understanding Variation
• Variation Outside of a Limit
MBQIP – Inpatient Metrics
MBQIP – Outpatient Metrics
N/A Reports
•Data was not submitted/reported by the CAH•Data was submitted but was rejected/not accepted into
the Quality Improvement Organization (QIO) Clinical Warehouse
Zero on Reports
•Zero (0) Patients means that data was submitted and accepted to the QIO Clinical Warehouse; however, case(s) were excluded from a particular measure
AMI – Care Best Practices
ECG within 10 minutes of ED arrival
• DX the patient as early as possible.
• Promptly identify patients requiring ECG
• Nurse interview prior to registration
• Provide necessary training to registration personnel.
• Processes/protocols for rapidly acquiring ECG
• Having ECG equipment in the ED
• Specifying a location with prompt access and adequate pt privacy.
AMI – Care Best Practices
Aspirin at arrival (within 24 hrs before ED arrival or prior to transfer)
• Raise awareness among general population re: heart attack symptoms, calling 911 and taking ASA.
• Work with EMS providers to ensure standard protocol/process for giving ASA if suspected AMI.
• Establish standard protocol for chest pain to include assessment and documentation of ASA prior to ED arrival.
AMI – Care Best Practices
Fibrinolytic TX received w/in 30 minutes of ED arrival
• DX patient as early as possible (e.g. enable EMS to diagnose STEMI pts and/or notify ED of possible STEMI to initiate preparation process).
• Ensure the ED physician on duty activates the reperfusion plan according to established local guidelines/care pathways.
• Treat registration for pts with AMI similar to trauma pts with the ability to fast-track critical labs, i.e. creatinine and PT/INR.
• Store fibrinolytic agent in the ED and/or establish ability to reconstitute and administer fibrinolytic in the ED.
AMI – Care Best Practices
Time to transfer - acute coronary intervention w/in 90 min
• Diagnose the patient as early as possible.
• Work with EMS providers and regional centers to establish processes/protocols to expedite communication and transfer.
• Establish initial and backup plan for transfer or transport to a STEMI-receiving hospital.
AMI/Chest Pain – Abstraction Best Practices
• Correct identification of patient population to abstract
• most current ICD and E/M codes and criteria.
• Proper use of data elements: arrival time, transfer out time, medication administration time, initial ECG time.
• Interpret data elements: reason for delay in fibrinolytic therapy, probable cardiac chest pain, reason for no aspirin at arrival.
• Knowledge of EMR – ability to locate all the data elements.
AMI/Chest Pain – Tracking Best Practices
• Recognize “misses” or “fallouts” as you abstract (close to real-time or concurrent review)
• Actual timely reporting by nurses or physicians when “misses” or “fallouts” occur - case can be reviewed right away and corrective steps taken.
• Use of auditing/audit tools to assess compliance with measures.
Questions?