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 hlqat@ifmc.orgwith 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 901-273-2613jweddle@tnqio.sdps.org

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