medicare beneficiary quality improvement project (mbqip ) ed transfer communication

Copyright ©2011 Georgia Hospital Association

Medicare Beneficiary Quality Improvement Project (MBQIP)

ED Transfer Communication

Abstraction TrainingJuly 2014


BackgroundThe Office of Rural Health Policy (ORHP) created the Medicare Beneficiary Quality Improvement Project (MBQIP) as a Flex Grant Program activity within the core area of quality improvement.

• The primary goal of this project is for CAHs to implement quality improvement initiatives to improve their patient care and operations.

• MBQIP provides Flex funding to support Critical Access Hospitals (CAH) with technical assistance and national benchmarks to improve health care outcomes.

• CAHs opting to participate are requested to report a specific set of annual measures determined by ORHP timeline and measures and engage in quality improvement projects to benefit patient care.


Accountable CareThis initiative takes a proactive and visionary approach to ensure CAHs are well-equipped and prepared to meetfuture quality legislation.

• Additionally, MBQIP fulfills the Flex grant Quality Improvement (QI) objectives regarding Hospital Compare reporting, and supporting participation in various multi-hospital QI initiatives.

• The main emphasis of this project is putting patients first by focusing on improving health care services, processes and administration.


MBQIPGoal: To implement informed quality improvement projects to improve patient care and CAH;s through data collection, leadership and support

“We improve what we measure”


Seamless Care: Safe patient transitions between facilities

Ensuring appropriate and timely care beyond organizational silos is essential to transforming health care.


Avoiding transition of care errors • Information silos and poor communication

between settings • Confusion about care management;

coordination across settings• Medications Errors can occur during times of

transition: upon admission, transfer, or discharge of a patient.


Avoiding transition of care errors

Communication means more than person to person, although this is of course an enormously important. Communication also means access by all the players to mission critical clinical information. In our highly fragmented or “siloed” healthcare delivery system, this is most often the greatest barrier to effective transitions of care.


ED Transfer Communication Measures:

– Administrative communication– Patient information– Vital signs– Medication information– Physician information– Nurse information– Procedures and tests


Resources


Population and sampling


Abstraction tool


EDTC-1: (NQF # 291) Administrative CommunicationDoes the medical record (MR) documentation indicate that administrative information was communicated to the receiving facility PRIOR TO departure?

• Numerator: # of patients who have a yes or NA for both measures: nurse to nurse communication and physician to physician communication

• Denominator: # All transfers from ED to another health

care facility


Abstraction tool


EDTC-2 (NQF#294) Patient Information

Does the medical record (MR) documentation indicate that the patient information was communicated to the receiving facility within 60 min of departure?

• Numerator: # of patients who have a yes or NA for all measures: name, address, age, gender, contact, insurance

• Denominator: # All transfers from ED to another healthcare facility


Abstraction tool


EDTC-3 (NQF #292) Vital Signs

Does the medical record (MR) documentation indicate that the ENTIRE vital signs record was communicated to the receiving facility within 60 min of departure?

• Numerator: # of patients who have a yes or NA for all measures: pulse, respiration, blood pressure, oxygen saturation, temperature and neurological assessment

• Denominator: All transfers from ED to another healthcare facility


Abstraction tool


EDTC- 4 (NQF# 293) Medication Information

Does the medical record (MR) documentation indicate that medication information was communicated to the receiving facility within 60 min of departure?• Numerator: # of patients who have a yes or NA for

all measures: Medications administered in ED, allergies and home medications



Abstraction tool


EDTC- 5 (NQF # 295) Physician Information

Does the medical record (MR) documentation indicate that physician information was communicated to the receiving facility within 60 min of departure?

• Numerator: # of patients who have a yes for all measures: history and physical and reason for transfer and/or plan of care



Abstraction tool


EDTC – 6 (NQF # 296) Nursing InformationDoes the medical record (MR) documentation indicate nursing information communicated to the receiving facility within 60 min of departure?

• Numerator: # of patients who have a yes or NA for all measures: assessments/interventions/response, impairments, catheter, immobilization, respiratory support, oral limitations



Abstraction tool


EDTC – 7 (NQF # 297) Procedures and Tests InformationDoes the medical record (MR) documentation indicate that procedures and tests information was communicated to the receiving facility within 60 min of departure?

• Numerator: # of patients who have a yes or NA for all measures: test and procedures done and test and procedure results sent



Data Submission via Novi surveyTransfer Dates Data Submission Deadline

Second Quarter, 2014: April 1 – June 30 July 15 2014

Third Quarter, 2014: July 1 – September 30 October 15 2014 projected

Fourth Quarter, 2014: October 1 – December 31 January 15 2015 projected


Questions


GHA Contact Information

Kathy McGowan, Vice President of Quality & [email protected] 770-249-4519Joyce Reid, Vice President of Community Health [email protected] 770-249-4545Lisa Carhuff, Quality Improvement/Patient Safety [email protected] 770-249-4553

mailto:[email protected]



medicare beneficiary quality improvement project (mbqip ) ed transfer communication

Documents

patient care

transferring hospital

receiving hospital

timely care

right care

health care services

health care outcomes

care management coordination