series: moving from retrospective to concurrent ecqm ......2 © 2018 the joint commission. all...

Pioneers in Quality™ Proven Practices Series: Moving from Retrospective to Concurrent eCQM Review to Streamline eCQM Accuracy Activities and Improve Results

11:00 am-Noon (PT)

Noon-1:00 pm (MT)

1:00-2:00 pm (CT)

2:00-3:00 pm (ET)

September 12, 2019

2

© 2018 The Joint Commission. All Rights Reserved.

Pioneers in Quality™ Proven Practices Series: Moving from Retrospective to Concurrent eCQM Review to Streamline eCQM Accuracy Activities and Improve Results

3


Proven Practices Series: Moving from Retrospective to Concurrent eCQM Review to Streamline eCQM Accuracy Activities and Improve Results

Proven Practices Series:

― Launched in 2017

― Peer to peer learning opportunity

― Accredited hospitals/health systems can submit their proven

eCQM solutions each year

― Pioneers in Quality Advisory Panel reviews submissions and

nominates the “Expert Contributors” to present

― All other submitters are “Solution Contributors”

4



Congratulations 2019 Expert Contributors!Improving eCQM Accuracy to Drive Quality Improvement

Featured during Aug 27 webinar

UPMC (Pittsburgh, PA) &

Baptist Health (Jacksonville, FL)

Moving from Retrospective to Concurrent eCQM Review to Streamline eCQM

Accuracy Activities and Improve Results

Featured on today’s webinar

John Hopkins Health System (Baltimore, MD) &

Terre Haute Regional Hospital/HCA (Terre Haute, IN)

Proactive Hospital/Health System Engagement to Undertake eCQM Development

and Testing

To be featured during Sept 24th webinar 11am (CT)

• Memorial Hermann/QPSIC & ISD Enterprise Analytics (Houston, TX)

5



At the end of this session, participants will be able to:

― Verbalize critical eCQM data collection and

submission practices.

― Make key process or documentation changes

related to eCQM submissions.

― Explain eCQM challenges presented and potential

strategies to overcome them.

6



Slides are available now!

⎻ To access the slides, see the

Event Resources Pane

⎻ Click on the link to access the

slides for today’s session

⎻ A new window will open

permitting you to save or print

the PDFs

7



This program is designed to be interactive.

⎻All participants are connected in

listen-only mode

⎻Ask questions through the Ask a

Question pane

⎻Visit the links and resources noted

in the slides

⎻Download the slides and share

the recording

8



Registration is open for the

September 24 Proven

Practices Webinar

https://www.jointcommission.org/

proven_practices_webinar_series/

Follow-up materials for all

series sessions including

the slide deck, recording,

and Q&A will also be found

at this link within several

weeks of each session

https://www.jointcommission.org/proven_practices_webinar_series/

9



This webinar is approved for 1.0 Continuing Education Credit for:

⎻ Accreditation Council for Continuing Medical Education (ACCME)

⎻ American Nurses Credentialing Center (ANCC)

⎻ American College of Healthcare Executives (ACHE)

⎻ California Board of Registered Nursing

⎻ International Association for Continuing Education and Training (IACET) (.1

credit)

Continuing Education credits are available for the live webinar

presentation only. Credits will not be available for webinar replays.

10



To claim credit, you must have:

⎻1) Individually registered

⎻2) Listened to the entire live webinar*

⎻3) Completed a post-program evaluation/attestation**

* Listening with colleagues and did not use your own computer to join? You

can still claim CE credit if you meet these criteria.

** Program evaluation/attestation survey link will be emailed to participants

tomorrow.

PDF certificates will be emailed 2 weeks after the session; all participant CE

certificates are sent at the same time.

⎻ For more information on The Joint Commission’s continuing education policies, visit this

http://www.jcrinc.com/store/learning-events/continuing-education/

http://www.jcrinc.com/store/learning-events/continuing-education/

11



Disclosure Statement

These staff and speakers have disclosed that neither they nor their

spouses/partners have any financial arrangements or affiliations with corporate

organizations that either provide educational grants to this program or may be

referenced in this activity:

⎻ Lisa Anderson, MSN, RN-BC Project Director, eClinical, Department of Quality

Measurement, The Joint Commission

⎻ Suzanne LaMarche, DHA, MBA, CPHQ, The Johns Hopkins Hospital

⎻ Lauren A. Johnson, M.S., R.T.(R)(CV), CPHQ, The Johns Hopkins Hospital

⎻ Karen Hescher, BSN, RN, Terre Haute Regional Hospital/HCA

eCQM Review, Validation and Submission for

Reporting Year 2019

Johns Hopkins Health System, Johns Hopkins Medicine

Presented by:

Suzanne LaMarche, DHA, MBA, CPHQ

Lauren Johnson, MS, RT (R)(CV), CPHQ

Prepared in collaboration with:

Katrina Houston, BS, RN, CPHQ

Jennifer Thaniel, RN

Sara Evans, MS

Bala Kulandaivel, MS, RN-BC, PMP

The Johns Hopkins Heath System (JHHS)

– Johns Hopkins Medicine (JHM)

Locations

JHM Fast Facts

• 40,000 full-time faculty and staff members

• 6 academic and community hospitals

– 111,000 Inpatient Admissions

– 360,000 Emergency Visits

• 10 Ambulatory Surgery Centers

• 40 Primary and specialty care outpatient areas (JHCP)

– 2.8 million outpatient encounters per year

• JHM International

– Management and consulting services in North America, Latin America, Europe, the

Middle East, and Asia

• Home Care

– Full Service home care provider

– 171,000 Adults and Children in MD

• Managed Care

– 419,000 enrolled in four unique populations

Submission Requirements

For the 2019 reporting period, hospitals were required to:

• Report four eCQMs for a minimum of one self-selected quarter of

CY18

• Use Health IT certified by the Office of the National Coordinator for

Health IT (ONC) to the 2014 and/or 2015 Edition

• Submit data file to the CMS by February 28, 2019

• Submit data file to Joint Commission by March 15, 2019

EHR-Based Clinical Process of Care Measures, CY 2019 ReportingMeasure Short

Name CMS Name Measure Description

AMI-8a CMS53v7 Primary PCI Received Within 90 Minutes of Hospital Arrival

CAC-3 CMS26v6 Home Management Plan of Care Document (HMPC) Given to Patient/Caregiver

ED-1 CMS55v7 Median Time from ED Arrival to ED Departure for Admitted ED Patients

ED-2 CMS111v7 Median Admit Decision Time to ED Departure Time for Admitted Patients

ED-3* CMS32v8 Median Time from ED Arrival to ED Departure for Discharged ED Patients

EHDI-1a CMS31v7 Hearing Screening Prior to Hospital Discharge

PC-01 CMS113v7 Elective Delivery

PC-05 CMS9v7 Exclusive Breast Milk Feeding

STK-2 CMS104v7 Discharged on Antithrombotic Therapy

STK-3 CMS71v8 Anticoagulation Therapy for Atrial Fibrillation/Flutter

STK-5 CMS72v7 Antithrombotic Therapy By End of Hospital Day 2

STK-6 CMS105v7 Discharged on Statin Medication

STK-8 CMS107v7 Stroke Education

STK-10 CMS102v7 Assessed for Rehabilitation

VTE-1 CMS108v7 Venous Thromboembolism Prophylaxis

VTE-2 CMS190v7 Intensive Care Unit Venous Thromboembolism Prophylaxis

Reporting Year 2019 eligible eCQMs

JHHS eCQM selections

*ED-3 is an outpatient measure and not applicable for Hospital IQR Program aligned credit; ED-3 is not listed as an eligible eCQM for The Joint Commission’s 2019 submission;

STK-8 and STK-10 are not listed as eligible eCQMs for the Joint Commission’s 2019 submission; eCQM EDHI-1a is not included in this table.

NOTE: EHR = Electronic Health Record, CY=Calendar Year, ED=Emergency Department, PCI=Percutaneous Coronary Intervention.

Published by CMS, January 2019.

Source: https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228773849716

https://www.jointcommission.org/assets/1/18/2017_2018_ORYX_Reporting_Requirements_20180131.pdf

https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228773849716

https://www.jointcommission.org/assets/1/18/2017_2018_ORYX_Reporting_Requirements_20180131.pdf

eCQM Multidisciplinary Team

The decision was made to harmonize our eCQM submissions across the

health system. A multidisciplinary team was formulated to facilitate

eCQM development for JHHS:

– JHHS Leadership

– Armstrong Institute

– EHR Vendor JHHS Support

– EHR Vendor Analyst

– Clinical Analytics

– Quality Improvement

– Stroke Team

– Clinicians

– Coding

Timeline

• The multidisciplinary team met monthly from end of 1Q18 until submission

• Additional ad hoc meetings were scheduled for discussions on the validation

process, newly identified issues, implementation of solutions and submission prep

• After defining the discharge period, a timeline was developed for review, validation

and submission of the JHHS eCQM selections

Preparing for the Review and Validation

Process

• EHR Vendor updated the logic to align with CMS/TJC eCQM reporting

requirements

• JHHS EHR Vendor Support team ensured fields were mapped appropriately

to flow into the eCQM reports

• Once updates were complete, the JHHS EHR Vendor Support team gave the

‘all clear’ for review and validation to begin

• The Quality Teams at each hospital began the process of case-level review

and validation

Concurrent Review Process

• Using the EHR Vendor eSTK

report, each JHHS hospital

reviewed their performance

for July, August, September

2018 on a bimonthly basis

• Conducted case-level

reviews for all failures to

identify:

Quality of care concerns

Documentation

opportunities

QRDA mapping issues

Concurrent Review Process

• A small percentage of cases from

other category assignments were

also reviewed to validate

appropriate category assignment

of passed/excluded cases

• The report population was

validated using reports from the

clinical Stroke Teams and/or other

census reports

• Followed up on all failures during

the monthly Multidisciplinary

eCQM team meetings and with

the clinical care team during

monthly QI meetings

Category

Assignment

Quick Definition Detailed Definition

B Not in Measure

Population

Patient is excluded from the measure

population. Patient is not counted in

either the numerator or denominator for

the measure. (Excluded)

D In Measure

Population

Patient is included in the denominator

for the measure. Patient is in the

measure population and patient's care

did not comply with performance

measure. (Fail)

E In Numerator

Population

Patient is included in the denominator

and the numerator for the measure.

Patient is in the measure population

and patient's care complied with

performance measure. (Pass)

P In Initial Population Patient is included in the initial patient

population (NOT part of the

denominator)

X Data Missing Data is missing. The patient's chart

does not have data needed to evaluate

whether the patient's care complied

with the performance measure.

Y Unable to

determine

Unable to determine.

Z Measure Exception Discreet documentation exists

indicating an exception for performance

measure.

Retrospective Validation Process

• At the end of the quarter, the QRDA files were uploaded to our

Core Measure vendor for validation prior to submission

• The Quality Teams at each hospital utilized the test environment

of the vendor’s submission platform to visualize the status of the

files

• Each hospital conducted file-level reviews to verify:

Vendor file reflected concurrent review findings

Vendor file format pulled correctly for submission to CMS and The

Joint Commission

Prior to Submission

eCQM data was reviewed and validated

on several levels to assess:

• Accurate mapping?

• Correct file structure?

• Does the file offer a true

representation of chart

documentation?

• Status of missing information or

case rejections?

• What can we learn from our “true”

failures and how can we improve?

Submission

• The multidisciplinary team confirmed that the review and validation

efforts were complete and no outstanding issues were present

• The Project Manager gave the approval for the vendor to submit the

eCQM files to CMS and TJC as their respective submission windows

opened

• Final eCQM submissions were made and results were shared with

hospital leadership and the appropriate clinical teams

Review and Validation Findings

Three Categories:

• Report Mapping

• File Mapping

• Documentation/Quality

Report Mapping

Issue Resolution

EHR eCQM report populations did not

match internal census reports

Education: Review of eCQM population

criteria revealed differences when

compared to other Stroke report

populations.

Duplicative cases identified in the files

causing an increased rate of non-

compliance

Systemic Issue: Individual patients

appeared, in our files, as having

duplicative encounters. This was a result

of how departments and visit types were

originally mapped in the EHR. The eCQM

team collaborated to define the

problematic areas and EHR Vendor

Support implemented changes to resolve

the issue.

Duplicate Encounters Error

• Some departments were set up incorrectly to have a separate

encounter in certain areas when an inpatient procedure was

performed; this caused duplicate encounters to display since the

documentation did not align to the inpatient admission

• We ran a utility in our EMR to identify all departments that were set up

incorrectly

• The JHM EHR Vendor support team worked with each individual

application team to fix the initial settings in these departments

File Mapping

Measure Name Issue Resolution

eSTK-2 Discharged on

Antithrombotic

Therapy

Reason for “not

prescribing” feature

used but not

recognized in the file.

Needed to map

additional order

questions.

eSTK-5 Antithrombotic

therapy by end of

hospital day 2

Heparin drip was not

recognized in the file

as an approved

antithrombotic.

Heparin medication

record was pointing

to wrong proxy

medication.

Pharmacy

application needed to

switch to correct

proxy med that has

correct mapping

RxNorm code.

Documentation/Quality

Measure Description Issue Resolution

eSTK-5 Antithrombotic therapy

by end of hospital day

2

No documentation of

antithrombotic by day

2.

Deemed true failure,

education provided to

Physician.

Reason for not

prescribing

antithrombotic therapy

was documented in

free text.

Hard stop and

informational training

sheets were created to

resolve this issue

moving forward.

eSTK-6 Discharged on Statin Provider documented

in free text.

Hard stop and

informational training

sheets were created to

resolve this issue

moving forward.

Statin was not

included in discharge

orders.

Deemed true failure,

education provided to

provider.

Reason for “No” order

• The JHHS EHR Vendor Support team worked

with the appropriate stakeholders to create a

list of “Reason for No Orders” so that

providers were able to discreetly capture the

reason for not ordering a statin or

antithrombotic agent

Results

Measure Initial Compliance Final Compliance

eSTK-2 58/59 (98.3%) 58/58 (100%)

eSTK-3 6/6 (100%) 6/6 (100%)

eSTK-5 44/47 (93.6%) 45/47 (95.7%)

eSTK-6 42/43 (97.6%) 42/43 (97.6%)

Compliance shown as numerator/denominator: measure ‘pass’ cases over total sum of ‘pass’ & ‘fail’ cases; excluded,

excepted and initial population cases are not included in the totals above

eCQM Review, Validation and

Submission Program Strengths

• JHHS has developed a methodology for reviewing eCQM

performance at the case and file level prior to submitting the eCQM

data

• The review process provides timely feedback to the clinical teams

regarding documentation and quality of care issues

• Review and validation affords us the opportunity to identify & address

systemic and technical issues before we submit the final data

• Rigorous review and validation prior to submission ensures the data

is an accurate reflection of the care provided in our hospitals

• Multidisciplinary teamwork enables JHHS to assess performance and

address issues from different perspectives & areas of expertise

Future Opportunities

As we move forward in our eCQM reporting, we are looking at

opportunities with:

• Addressing remaining issues (duplicate cases in other areas)

• The addition of other measures (VTE, Opioid)

• Improving efficiencies within the review and validation processes

• Exploring the potential of employing dashboards for continuous

monitoring and review

• Self-submission through the TJC and CMS platforms

eCQMs @ JHH – CMS & JOINT

COMMISION RESOURCES

• eCQI Resource Center – CMS’ one-stop shop for everything eCQM

• eCQM Tools & Resources – List of eCQM related terms & sites

• QualityNet.org eCQM page – CMS QNet overview of eCQMs & eCQM

resources

• QualityNet.org Hospital Inpatient Quality Reporting (IQR) Program –

Details about all IQR program measures (including eCQM)

• QualityNet.org eCQM Resource Page – List of a variety of eCQM

resources

• The Joint Commission Pioneers in Quality Page – A Joint Commission

page for supporting hospitals in adoption of eCQMs

https://ecqi.healthit.gov/

https://ecqi.healthit.gov/ecqms#quicktabs-tabs_ecqm3




https://www.jointcommission.org/topics/pioneers_in_quality.aspx

36



⎻ Ask questions now through

Ask a Question pane

⎻ Include:

•Slide number

•To which organization your

question pertains

CONFIDENTIAL – Contains proprietary information.

Not intended for external distribution.37

Karen Hescher, BSN RN

Lead Performance Improvement Coordinator

Anita Russell, RN BSN

Performance Improvement Coordinator

Terre Haute, Indiana

Concurrent and Retrospective Review of VTE Prophylaxis Initiatives

Terre Haute Regional Hospital

September 12, 2019


Not intended for external distribution.

Who are we?278 bed HCA Hospital in Indiana

24,000+ ER visits per year

6,700+ Inpatient admissions per year

46,000+ Outpatient visits per year

600+ Employees

300+ Medical Staff

2017 Data


Not intended for external distribution.

Our Mission

Above all else, we are committed to the

care and improvement of human life.

Our PromiseOur promise is to provide the highest

quality, compassionate care –

every patient, every time.



• Migrating to electronic data collection

o Adopted eCQM process for VTE Prophylaxis in 3rd Quarter 2014

• Need for more real-time documentation

• Need for a concurrent review process of all patients

• Need for increased staff education

• Need to perform retrospective review of outliers

The Problem




• Accurately reflect the quality of care provided using the

electronic data collection process

• Increase staff awareness of the electronic data collection

process

• Involve all direct patient care staff in educational opportunities

• Reduce the number of outliers using real-time documentation

• Eliminate the incidence of potentially-preventable venous

thromboembolisms in our hospitalized patients

Goal




Our Team


Patient

Nursing

Physician

Quality

Abstractor

Information

Technology

Pharmacy

Education



• Education

oPrimary Focus: Staff Nurses, Charge Nurses, Physicians, Pharmacists

Unit Meetings, Medical Staff Meetings

Paper flyer communication

Electronic communication

New Hire Orientation

One-on-One Educational Opportunities

The Interventions




• Concurrent Review

o Every patient 18 years of age or older

o Required by the day after admission

o VTE Prophylaxis ordered timely

o Timely application & documentation of mechanical VTE Prophylaxis in the

eCQM recognizable field

o Timely scanning & administration of pharmacologic VTE Prophylaxis

o Timely documentation of contraindication to both mechanical & pharmacologic

VTE Prophylaxis

o Communicate outstanding VTE Prophylaxis needs to unit charge nurses daily

The Interventions




• Retrospective Review

o All outliers or negative numerator cases reviewed

o Provide additional education when eCQM programming and algorithms

changed

o Implemented changes to Labor & Delivery, Post-Partum, Behavioral Health

order sets as a result

o Eliminated duplicate documentation fields

o Eliminated conflicting terminology

The Interventions




• eCQM Dashboard

o HCA Corporate unique

development

The Interventions

o Additional education

provided to charge

nurses and leaders

o Quick reference when

Quality department is

closed




• VTE Prophylaxis must be documented AFTER the inpatient order

date/time

• VTE Prophylaxis must be documented AFTER the ICU arrival date/time

• VTE Prophylaxis needs addressed on our Behavioral Health Unit, Labor

& Delivery Unit, Post-Partum Unit, and Acute Inpatient Rehab Unit

• Mechanical Prophylaxis documented in the OR module is not recognized

• Anticoagulants need a “VTE Prophylaxis Status” CPOE order entered

Lessons Learned

Title Name or Department Name



1. One-on-one educational efforts coupled with hands-on learning was the

number one contributing factor to the increase in knowledge of eCQMs.

2. Concurrent review of real-time documentation thus providing real-time

feedback to staff was the number one contributing factor that lead to the

decrease in outliers over time.

3. Retrospective review of negative numerator cases was the number one

contributing factor to the increase in knowledge of eCQMs by our

abstractors.

4. Development of the eCQM dashboard has streamlined the data

collection process thus allowing more time for education and review.

The Results




The Results: VTE-108


• 3Q14:

Adopted eCQMs

• 1Q15:

Education began

• 1Q16:

Transitioned from

chart abstraction

to eCQMs alone



The Results: VTE-190


• 3Q14:

Adopted eCQMs

• 1Q15:

Education began

• 1Q16:

Transitioned from

chart abstraction

to eCQMs alone



The Results: Incidence of Potentially-Preventable

Venous Thromboembolisms

Title Name or Department Name

• ZERO

Hospital Acquired

VTEs that were

preventable (meaning all included

patients had VTE

Prophylaxis by the day after

admission)

52



⎻ Ask questions now through

Ask a Question pane

⎻ Include:

•Slide number

•To which organization your

question pertains

53



REMINDER - Slides are available now!

⎻ Event Resources Pane

⎻ Select the link for PDF of slides

⎻ A new window will open permitting

you to save or print the PDF

54



Follow-up materials including

the slide deck, recording, and

Q&A will be found at this link

within several weeks of this

session

https://www.jointcommission.org/

proven_practices_webinar_series/

https://www.jointcommission.org/proven_practices_webinar_series/

55



• Final 2019 Proven Practice webinars is on

o Tuesday, September 24 (11AM CT)

If the above link is not clickable, visit https://goto.webcasts.com/starthere.jsp?ei=1253559&tp_key=b1dbe148c2

• The above link will take you to the registration page

REGISTRATION OPEN!

Pioneers in Quality

Proven Practices

Webinar Series

https://goto.webcasts.com/starthere.jsp?ei=1253559&tp_key=b1dbe148c2

56



CE Session Evaluation Survey and Certificate

You will receive an automated email that will direct

you how to access the evaluation survey.

We use your feedback to inform future content and

assess the quality of our sessions.

The evaluation closes in 2 weeks. The evaluation closes in 2 weeks.

After the evaluation period closes, a printable

certificate will be emailed to all participants that

complete the survey and meet all CE

requirements.

57



series: moving from retrospective to concurrent ecqm ......2 © 2018 the joint commission. all...

Documents