Newsletter Spotlight Spring 2009

8/9/2019 Newsletter Spotlight Spring 2009

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SAFE JOURNEY 2

SPRING 2009 | VOL. 7 NO. 2 | WWW.OHIOKEPRO.COM

PREVENTION EHR INITIATIVE 15

TOOLS OF THE TRADE: PROCESS MAPPING 3

REGULATORY UPDATE

14

HELP FOR PROVIDERS AND BENEFICIARIES 5

NURSING HOME DISPARITIES PROJECT 11

CALENDAR/REMINDERS 13

MRSA SURVEILLANCE SYSTEMS: THEN & NOW 9

PROMOTING PREVENTIVE CARE 7

QUALITYSPOT L I GH T

O N

A N E W S L E T T E R A B O U T O H I O S H E A L T H C A R E Q U A L I T Y I M P R O V E M E N T


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levator rim - Set for takeoffMixture - RichTrottle- 1700 rpmMagnetos - CheckEngine Instruments -GreenComm/Nav/Radios/Avionics - SetFlaps - Set

for akeoffRomeo Sierra 192448 ready for takeoff.Te before takeoff run-up check - it was automatic. Ilearned it the first day I stepped into the cockpit of theCessna. It was not optional. My life depended on it.

When we step into the operating room, we embark upona mission far more complex than flying a single engineaircraft. Te surgical team is a multifaceted crew ofmedical talent and disparate resources that must operatein a highly integrated manner. Te success of theprocedure requires it. Te patients life depends on it. Yet,

Safe Journey

all too often, the before takeoff run-up checkconsists simply of Scalpel!

Fortunately, there is growing support anddemand for the use of checklists in medicine,including but not limited to such settingsas the ICU and the operating room. Te

World Health Organization has proposeda surgical safety checklist,1and a recentstudy of over 3,700 patients at eight sites

worldwide documented a reduction in mortality

from 1.5 percent at baseline to 0.8 percent(p=0.003) after introduction of the checklist,and a corresponding reduction in inpatientcomplications from 11.0 percent to 7.0 percent(p


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Is your organization getting less-than-optimal results on particular clinical measures,despite having thorough and well-written policies, procedures and protocols for staffto follow? For example, your organization may have a well-thought-out approach topreventive skin care, but still be struggling with the incidence of nosocomial pressureulcers.

Poor outcomes are often associated with poorly designed processes, but theunderlying problem may be in the way staff members implementthe process,rather than in the process itself. Because these implementation issues are often farfrom obvious, process mapping can be extremely valuable in facilitating qualityimprovement efforts. Process mapping can help your organization objectively definehow a process is carried out while identifying specific partsof an established processthat contribute to poor outcomes.

BenefitsProcess mapping is a quality improvement toolendorsed by such industry leaders as the UnitedKingdoms National Health Service (NHS)Modernisation Agency, which describes it asa key starting point for quality improvementefforts, and the Agency for Healthcare Researchand Quality (AHRQ), which notes thatprocess mapping can help mistake-proof anorganizations processes.

Used properly, this tool enables each teammember to freely discuss their actual steps inday-to-day processes (even if they dont quiteadhere to official policies and procedures),allowing for the identification of previouslyunknown or unresolved issues. It fosters a cultureof ownership, responsibility and accountability,and offers such benefits as:

A clearly dened overview of a specic process

An eective aid in planning and testingquality improvements, and

A highly visual, easy-to-understand endproduct.

Getting StartedTe best way to begin process mapping is byassembling a multidisciplinary team includingstaff members who contribute to, or who areimpacted by, the process. It is crucial to involvedirect care staff, as they have the most intimate

understanding of how individual steps of theprocess are actually performed in day-to-daypatient care.

Te task can be rather complex, but building agood process map involves three basic steps:

Dning t cunt pc. Write out each step as everyone agrees it is

carried out.

Anayzing t cunt pc. Decide how often each step is carried outthe right way, by the right person, at the righttime.

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Tools of The TrADe:

Pc Mapping

A NEWSLEER ABOU HEALHCARE QUALIY IMPROVEMEN 3


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4 SPOLIGH ON QUALIY SPRING 2009

Tip succIn addition to an environment of complete honesty,team engagement and participation are essential tothe success of process mapping. Group leaders canhelp foster positive team dynamics and productivediscussion by:

staying cud.

Other important issues are often uncoveredthrough process mapping, but these should be setaside for discussion in separate meetings.

Bing t gup cncinc.Reinforce and encourage honesty among allparticipants by asking questions such as Are wesurethats what reallyhappens? and How oftendoes that step happen completely and accurately?

Awing tim.Allow sufficient time for all team members todiscuss the steps in a process.

etabiing a a nvinmnt.Complete honesty can only be possible in ablame-free environment that is free ofaccusation and retribution.

M Pc MappingTis article describes a very simple approach toprocess mapping for healthcare organizations;the concepts behind this tool originated in themanufacturing industry in the Ford and oyota

- Leasa Novak, LPN, BAQuality Improvement Project Coordinator

[email protected]

- Ann Fitzsimons, RN, MBA Quality Improvement Specialist

[email protected]

FROM PAGE 3

Making impvmnt. Determine what changes need to be made

to improve performance at each step.

An abbreviated example of a process map isillustrated in Figure 1.

Fig. 1: Sample Process Map

Process mapping can helpyour organization define howa process is carried out whileidentifying specific parts of

an established process thatcontribute to poor outcomes.

Motor Corporations. From these conceptscame two process mapping models nowcommonly used in quality improvementefforts in healthcare and other industries:Value Stream Mapping (Lean EnterpriseInstitute) and Material and Information FlowMapping (oyota Production System). More

information on these models is available atthe Lean Enterprise Institute (http://www.lean.org) and oyota (http://www.toyota.co.jp/en/vision/production_system/index.html) Web sites.

Other valuable resources: Te NHS Modernisation Agency.

Process Mapping, Analysis and RedesignImprovement Leaders Guide 1.2.

Available at www.institute.nhs.uk/index.php?option=com_content&task=view&id=134&Itemid=351.

Agency for Healthcare Research andQuality (AHRQ).Mistake-Proofingthe Design of Health Care Processes

Available at www.ahrq.gov/qual/mistakeproof.

Regardless of which approach you take,troubleshooting processes can facilitatequality improvement efforts at yourorganization. Commit to improved care for

your patients and staff by using a processmap as your next quality improvementintervention!

Note: Tis is an abbreviated example of process mapping. Te percentages listed in the diagram reflecthow often each step is carried out completely and accurately.

Resident is

admitted

Resident is

discharged

Charge nurse

completes Braden

Scale on day of

admission

90%

Charge nurse

completes visual

skin inspection

within two hours

of admission

50%

Charge nurse writesstanding orders for

pressure ulcerprevention, perfacility protocol

(turning schedule,moisture barrier, etc.)

by end of shift

75%

Continue step-

by-step process

breakdown and

evaluation

100%


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Te Helpline is accessible seven days a weekduring working hours (8 a.m. to 4:30 p.m.) at800-589-7337. Staffed by administrativepersonnel, it serves as a triage of sorts, from whichcalls are forwarded to the appropriate personnelor agency. Over the past ten years, weve processedand acted upon nearly 30,000 Medicare medicalreview cases initiated through the Helpline. Tesecases include those related to discharge appeals,Diagnosis Related Group (DRG) review, andbeneficiary complaints. Misdirected calls (such asthose regarding billing issues or plans other thanMedicare) are referred to the appropriate agencies.

Dicag AppaWe perform patient-initiated appeals for allMedicare beneficiaries, including those enrolledin a Medicare Advantage plan. We also performappeals for patients in hospitals, skilled nursingfacilities, home health agencies, comprehensiveoutpatient rehabilitation facilities, and long-termacute care hospitals. For each appeal, our staffrequests medical records from the provider(s)involved and sends the records to a Board-certified physician for review. If the notice isupheld, beneficiaries or their representatives havethe opportunity for reconsideration.

DrG rviwDRG reviews are performed on all medicalrecords for which the hospital has billed at ahigher DRG. Ohio KePRO requests the medical

As Ohios Medicare QualityImprovement Organization, OhioKePRO works with healthcareproviders to improve patient

outcomes and reduce medical errorsthroughout the healthcare system. Aspart of our contract with the Centersfor Medicare & Medicaid Services(CMS), we provide Helpline servicesto Medicare beneficiaries, and processbeneficiary discharge appeals casesinitiated by healthcare facilitiesthroughout the state.

Ohio KePRO performs patient-initiated appeals for all Medicarebeneficiaries.


records from the provider and performs aninitial screening of the chart. If the stay meetsInterQual criteria and the higher DRG is

justified, the case is approved. If the stay failsInterQual criteria and/or the medical record lacksthe documentation to support the higher DRG,the medical record is sent to an independent,Board-certified physician reviewer. Based on thedetermination made by the reviewer, the provider

and practitioner may be given an opportunityfor discussion. Te provider and/or practitionerthen submit the billing rationale in writing, andthis response is sent back to the same physicianreviewer for consideration. If the reviewer stillfeels that the stay did not meet medical criteria,or disagrees with the higher DRG, the stay

is denied. Te provider and practitioner arethen given an opportunity for reconsideration.When this occurs, the medical record is sent toa second, independent physician reviewer. If thesecond physician reviewer upholds the decisionmade by the initial reviewer, there is no furtheropportunity for discussion. Alternatively, if thesecond physician overturns the original decision,the hospital is reimbursed for the stay. CONTINUED ON NEXT

hp Pvid and Bnciai


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Quaity Ca rviwQuality of care reviews are performed on all cases submitted to Ohio KePRO, regardless of thereview type (appeals, DRG reviews, or utilization reviews). All beneficiary complaints undergo aquality of care review. Tese calls are directed by the Helpline operator to a nurse reviewer, whothen requests the medical records and sends the chart to a physician reviewer. For such cases, weare careful to perform a specialty and like practice match, meaning that we always ensure that thephysician reviewer has the same area of specialization as the physician under review, and we attemptto select a reviewer who also practices in a like setting. In order to facilitate the most accuratereview possible, we try to avoid, for example, sending a chart from a tertiary medical center to asmall town practice, and vice versa. As with other reviews, the provider and practitioner are given anopportunity for discussion, and an opportunity for reconsideration when appropriate.

When a quality of care concern is identified, Ohio KePRO initiates action with the provider orpractitioner, which can range from a simple letter with suggestions for future care to a completequality improvement plan (QIP). In cases calling for QIPs, we work with the provider orpractitioner to formulate a corrective action plan, and monitor the implementation through self-reporting mechanisms.

Last year, Ohio KePRO conducted 2,441 quality of care reviews. Details are provided in Figure 2.

- Jennifer Bitterman, RHIA, MBA

Review Director

[email protected]

FROM PAGE 5

Source: Case Review Information Systems (CRIS) data, 2008

Fig. 2: Ohio KePRO Quality of Care Reviews, 2008

Cases resolved at nurselevel of review (1C)

Cases resolved atphysician reviewer frstreview (1P)

Cases resolved atphysician reviewer secondreview (2P)

Cases confrmed atphysician reviewer secondreview (2P)

Quality of Care Review Case Volume

73.78%

5.98% 2.25%

17.98%


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FROM PAGE 7

Fig. 3: CRC Screening Rates by Ohio Region

Source: CMS claims data for Medicare fee-for-service beneficiaries aged 50-80

teams can aid in these efforts by talking withMedicare beneficiaries about:

Individua ik act.Tese include racial/ethnic background,and personal and family history.

Mdica-cvd vic.Breast cancer screenings and colorectal cancerscreenings are covered by Medicare.

Ohios economic climate will be a challengefor all of us as we strive to meet our goals inimproving patient care, but we encourage youto remind your patients of the importance ofpreventive services. Visit our Web site(www.ohiokepro.com) to access no-costtools and interventions, or look for resourcesfrom community-based services such asSusan G. Komen for the Cure, regionalorganizations, and county health departments.

I yu av a paticua aa intt andwud ik p in idntiying cmmunity-bad vic in yu gin, cntact eicastantn, quaity impvmnt pciait, [email protected] 440-321-2929.

1 Kaiser Family Foundation. State Health Facts.org. Available at www.statehealthfacts.kff.org. Accessed January 31, 2009.2Ibid.3 rivedi AN, Rakowski W, Ayanian JZ. Effect of cost sharing onscreening mammography in Medicare health plans.N Engl J Med. 2008;358:375.4 Te American Cancer Society. How to Increase Colorectal Cancer ScreeningRates in Practice: A Primary Care Clinicians Evidence-Based oolbox andGuide. Atlanta, GA: Te American Cancer Society, 2006.5 Kaiser Family Foundation. State Health Facts.org. Available at www.statehealthfacts.kff.org. Accessed January 31, 2009.6Ibid.7 Te American Cancer Society. Te American Cancer Society Web site.Available at www.cancer.org. Accessed February 20, 2009.8 U.S. Cancer Statistics Working Group. United States Cancer Statistics:19992005 Incidence and Mortality Web-based Report. Atlanta: U.S.Department of Health and Human Services, Centers for Disease Controland Prevention and National Cancer Institute; 2009. Available at: www.cdc.gov/uscs.9Ibid.


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ethicillin-resistant Staphylococcusaureus(MRSA) hasnt exactly been

a household name, but MRSAinfections have been in the U.S. forthe past four decades.1And, withrecent coverage in local and nationalnews publications such as TeNewYork imes2and TeWashingtonPost 3identifying the infection as astaph superbug, its clear that thepublics interest is increasing.


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MrsA sUrVeIllANCesYsTeMs:THEN & NOW

In contrast, epidemiology surveillance ofMRSA has been going on for many years. In1974, MRSA infections accounted for just 2percent of the total number of healthcare-associated staphylococcus infections in U.S.Intensive Care Units (ICUs), but this rateincreased to 22 percent in 1995 and 63 percentin 2004.4In this time, MRSA has beenmonitored by the Centers for Disease Controland Prevention (CDC) as part of the agencys

surveillance of drug-resistant organisms. TeCDC has established several monitoringsystems for this purpose, in an effort to obtainthe information needed to prevent the incidenceand transmission of such infections.

One of the early systems created for thispurpose was the National Nosocomial InfectionSurveillance (NNIS) system, which monitoredthe incidence of healthcare-associated infectionsand the risk factors and pathogens associated

with those infections.5Developed in the early1970s, NNIS was the only national system for

tracking healthcare-associated infections at thattime. Its objectives were to detect and monitoradverse events, assess risk and protective factors,evaluate preventive interventions, and provideinformation and partner to implement effectiveprevention strategies. Te NNIS database wasused to study the epidemiology, associatedantimicrobial resistance, and aggregate rates tobe used for interhospital comparisons. Becausethe use of this voluntary participation system

was limited to hospitals meeting the infectioncontrol staff and bed size requirements, thenumber of reporting facilities was never verylarge, reaching approximately 300 at its peak.6

In 1995, the Active Bacterial Core surveillance(ABCs) system was established as acollaboration between the CDC, state healthdepartments, and universities.7Initiallyestablished in just four states, participation hasincreased to 10 state sites. Tis active

surveillance system monitors six pathogensincluding MRSA, and uses case reports sent tothe CDC and reference laboratories to collectdemographic information and bacterial isolates.

Tese samples and data are used for research instudying disease trends, identifying risk factors,evaluating vaccine effectiveness, andmonitoring the effectiveness of preventionpolicies. Lessons learned from researchstemming from ABCs served as the impetus

for the development of a program to assist stateand local health departments with surveillancefor MRSA and drug-resistant Streptococcus

pneumoniae.8

Monitoring systems and technological

advancements make it possible for us to moreeffectively study MRSA and other infections,and work to prevent them.


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- Linda Stokes, MSPH, ABD

Senior Scientis

[email protected]


FROM PAGE 9

1 Centers for Disease Control and Prevention. Management ofMultidrug-Resistant Organisms in Healthcare Settings, 2006.Available at www.cdc.gov/ncidod/dhqp/pdf/armdroGuideline2006.pdf. Accessed October 20, 2008.

2 Robin RC. Childrens staph infections increasingly resistant todrugs. Te New York imes. 21 January 2009. Available atwww.nytimes.com/2009/01/21/health/research/21staphhtml?scp=5&sq=staph&st=cse. Accessed February 23, 2009.

3 anner L. ICUs see a big drop in dangerous staph superbugs.Te Washington Post. 17 February 2009. Available at www.washingtonpost.com/wp-dyn/content/article/2009/02/17/AR2009021702299.html. Accessed February 23, 2009.

4 Centers for Disease Control and Prevention. S. aureusandMRSA Surveillance Summary 2007. Available atwww.cdc.gov/ncidod/dhqp/ar_mrsa_surveillanceFS.html.Accessed February 24, 2009.

5 Centers for Disease Control and Prevention. NationalNosocomial Infections Surveillance System (NNIS). Available atwww.cdc.gov/ncidod/dhqp/nnis.html. Accessed February 22, 2009.

6 Ibid.7 Centers for Disease Control and Prevention. Active Bacterial Core

Surveillance. Available at www.cdc.gov/ncidod/dbmd/abcs/team-start.htm#background. Accessed February 22, 2009.

8 Ibid.9 Centers for Disease Control and Prevention. National Healthcare

Safety Network (NHSN). Available at http://www.cdc.gov/ncidod/dhqp/nhsn.html. Accessed February 22, 2009.

10Ibid.

In addition to this collaborative system, theCDC took advantage of innovations madepossible in this digital age to establish theNational Healthcare Safety Network (NHSN)as the Internet-based successor to NNIS.Participation was restricted when the system

was originally established in 2005, but by 2007,enrollment was open to any hospital oroutpatient dialysis center in the U.S.9Usinginformation technology for secure datacollection and for selective data sharing whenappropriate, NHSN monitors adverse events,adherence to prevention practices, trends,interfacility comparisons and qualityimprovement, patient or personnel safetyproblems, prompt interventions, andcollaborative research. Te system allows fortimely data sharing between a facility andpublic health agencies, with other facilities, orfor research or quality improvement activities.10

NHSNs latest addition is the Multi-DrugResistant Organism (MDRO) module,

which will be used for surveillance of the manydrug-resistant organisms we deal with today,including MRSA. Not surprisingly, the NHSNsystem and the new MDRO module are beingutilized in the current Quality ImprovementOrganization (QIO) project related totracking MRSA cases in hospitals in eachstate. Te facilities participating in this projectin Ohio will be contributing to the nationalsurveillance database of MRSA cases andallow for a sample of Ohio data to be compiled.

Te aggregation of this data will be compiledon a monthly basis and will be available to beshared with the participating facilities.

Te prevalence of MRSA may be on the rise,but tools such as these make it possible for usto more effectively study this and otherinfections, and work to prevent their spread.Our ability to collect data and share it foranalytic purposes on a nearly real-time basis isa significant epidemiological advancement,giving us better, more current information tofight MRSA and other superbugs.


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In the current Quality Improvement Organization (QIO) contract cycle, theCenters for Medicare & Medicaid (CMS) has directed QIOs to examine

issues and factors that are pertinent to the states population and that mayhave an influence on healthcare disparities in the nursing home population.QIOs will submit reports to CMS every six months throughout the durationof the 9thStatement of Work (SOW). Ohio KePRO plans to focus on a

Nuing hmDipaiti Pjct

different factor or aspect of care that mayidentify a disparity in each of the reports.

Te following is a summary of the analysisconducted by Ohio KePRO in the firstreporting period.

BackgundTis initial report is focused on determiningif there is any disparity seen in the qualityof care in nursing homes, as representedby Quality Indicator/Quality Measures(QI/QM) between urban and rural facilitylocations in Ohio. Previous research hasexamined a number of possible factors aspotential indicators of disparity of care inrural versus urban settings. An issue paperpublished by the National Rural Health

Association (2001)1voiced concerns aboutthe quality of care found in nursing homes in

rural areas, and studies conducted by Coburnet al (1994)2and Phillips et al (2000, 2001,2004)3,4,5found no significant difference inthe quality of care between urban and ruralnursing homes for the indicators examined.

With 12 percent of the population, 17 percentof nursing homes, and 14 percent of totalnursing home certified beds being located in

rural areas in Ohio, it seemed appropriate todetermine what quality disparities, if any, couldbe identified between the states rural and urbannursing facilities in the state.6

MtdgyOhio KePRO extracted 3rdQuarter 2008 QI/

QM data from CASPER for all Ohio nursinghomes in ten selected measures (See able1). Tese measures were selected due to theirsimilarity to those referenced in the studiesby Coburn et al and Phillips et al. In order toincorporate OSCAR survey results, NursingHome Compare Five-Star ratings for Ohionursing homes were extracted (on January 22,2009) to include ratings through September2008. Nursing homes were classified as ruralor urban, based on the county location andCore Based Statistical Area (CBSA).7Te

study examined a total of 924 nursing homes;155 were classified as rural and 769 wereclassified as urban. Facilities with missing datain multiple measures were excluded from thisstudy.

Te analysis included conducting a t-testcomparing each of the QI/QM measures forthe urban and rural groups to determine if a

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1.2 Falls 14.4% 19.1% 19.2% 4.7% 4.8%

2.1 Depression 19.3% 29.6% 28.1% 10.3% 8.8%

4.1 Cognitive Impairment 11.7% 21.1% 24.4% 9.4% 12.7%

5.3 Incontinent w/o Toileting Plan 51.4% 76.5% 80.2% 25.1% 28.8%

7.1 Weight Loss 9.4% 12.8% 13.5% 3.4% 4.1%

8.1 Pain 7.9% 13.8% 14.1% 5.9% 6.2%

9.1 ADL Decline 13.9% 21.7% 21.2% 7.8% 7.3%

10.1 Antipsychotic Use 19.2% 31.3% 29.0% 12.1% 9.8%

11.1 Restraints 4.8% 9.1% 10.4% 4.3% 5.6%

12.1 Pressure Ulcers 12.7% 17.7% 18.5% 5.0% 5.8%

QI/QM MeasureState

AverageScore

RuralFacilitiesAverage

Score

UrbanFacilitiesAverage

Score

RuralVariation

from State

Average

UrbanVariation

from State

Average

Table 1: QI/QM Measure Averages


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significant difference existed. QI/QM scores were alsocompared to the state average score for each measure.Nursing homes with a QI/QM score greater than thestate average were considered to be exceeding the stateaverage in that measure. Te average for each of the QI/QM measures was calculated and then used to determinethe difference of the measure average score and the state

average score. Also determined were the maximum andminimum scores, the percentage of facilities that wereexceeding the state average in each measure, the numberof measures (0-10) exceeding the state average pernursing home, and the percentage of nursing homes pernumber of measures exceeding the state average.

Five-Star ratings (1-5 stars) were shown as a percentageof the total facilities per rating. Tese ratings were alsoaggregated to above average (4-5 stars), average (3stars), and below average (1-2 stars), and shown as apercentage of total facilities.

rutTere were no significant differences found in the QI/QMmeasures examined between urban and rural nursinghome facilities in Ohio in this time frame. No significantdifference between urban and rural facilities was found infacility average scores for the selected measures. In a reviewof the minimum and maximum scores for each measure foreach facility (except for three outlier urban facilities withhigh maximum scores), high and low scores for both urbanand rural nursing homes were found to be comparable(See able 1, previous page). In the t-test comparing QI/QM measures, none of the measures showed a significant

difference (p


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Reminders

Tearoutthiscalendarandpostitasareminderofupcomingdeadlinesandevents.

ReportingHospitalQualityDataforAnnualPayme

ntUpdate(RHQDAPU)Pro

gramCalendar-2Q09repor

tingdeadlines:

April

A

pril

May

Ju

ne

NationalCancerControlMonth

NationalMinorityHealthAwarenessMonth

April7,2009

WorldHealthDay

April8,2009

Submit4Q08surveydatatotheClinicalData

Warehouse(CDW).

May

OlderAme

ricansMonth

American

StrokeMonth

NationalA

rthritisAwarenessMonth

NationalC

ancerResearchMonth

NationalH

ighBloodPressureEducationMonth

NationalO

steoporosisAwareness&Prevention

Month

May1,2009

Submit4Q

09inpatientandoutpatientICD-9

population

andsamplingcountstotheCDW.

May10-16,2009

NationalW

omensHealthWeek

May11,2009

NationalW

omensCheckupDay

May15,2009

Submit4Q

08inpatientandoutpatientquality

measures

datatotheCDW.

June

June1,2009

CDACtosendout4Q08validationchart

requests.

June15-21,2009

NationalMensHealth

Week

June30,2009

Submit4Q08validatio

nchartstotheCDAC.

ForallOhioHealthcareProviders

Onlineresources.Weveaddednew

onlineresourcesforhealthcareproviderstoour

Website,includingthoserelatedto

CMS,HCAHPS,ICD-10,andlegislation

.Justclickon

thelinkfromourhomepage,orgodirectlytotheHealthcareProviderssec

tionatwww.

ohiokepro.com/providers.asp.

LOOKINGAHEAD:

July

July1,2009

Medicalrecordsdueto

theCDAC.

July8,2009

Deadlineforsubmissio

nof1Q09HCAHPS

surveydata.

Hospitals

Hasyour

hospitalexperiencedachangeinoneofthefollowingpersonnel:

CEO,QIc

ontact,medicalrecordscontact,orQ

Netsecurityadministrator?

Ifso,plea

[email protected],

ext.2115

.FranisyourcontactforimportantCM

Spublicreportingprogram

h g d d d l iR

eportingHospitalQualityDataforAnnualPaymentUpdate

(RHQDAPU)

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Retired Quality Measures(Effective with 1Q09 Discharges)

PN-1 Pneumonia Patient with Oxygenation AssessmentTis measure was found to be consistently at 100%compliance.

PN-5b Pneumonia Patients who Receive Teir InitialAntibiotics Within 4 Hours of Hospital ArrivalTe National Quality Forum (NQF) has withdrawn itsendorsement of this measure.

AMI-6 Acute Myocardial Infarction Patients WithoutBeta-Blocker Contraindications who Received a Beta-Blocker Within 24 Hours of Hospital Arrival

Te American College of Cardiology (ACC) and theAmerican Heart Association (AHA) withdrew theirendorsement of this measure in November 2008, and CMShas removed AMI-6 from Hospital Compare as of

January 15, 2009.However, data abstractors are requiredto continue to submit data on AMI-6 through the end of the1Q09 discharges. For background on the retirement of

AMI-6 and details about data collection and submissionrequirements, please refer to the AMI-6 fact sheet,available in the Downloads section of the Hospital Quality

Initiatives page of the CMS Web site (www.cms.hhs.gov/HospitalQualityInits/).

REGULATORY

UPDATE


QualityNet

Quest Te QualityNet Quest online question and answer

system is now available, with recent upgrades toenhance performance and stability. Users may nowaccess Quest to submit questions regarding SDPSapplications, quality measures, communicationspartnerships, and other Teme-specific issues, as wellas to perform searches of past Q&As based onkeyword or topic.

QNet SAsEach facility should have more than one designatedQualityNet Security Administrator (QNet SA).Having a backup QNet SA allows work related toCMS public reporting initiative to continueuninterrupted if the primary contact is not available.

APU DashboardTis new monitoring tool will help assess yourorganizations status in terms of meeting RHQDAPUprogram requirements. Te dashboard provides a real-time status report with links to specific QNet reportsproviding greater detail. Contact your internal QNet

SA if you cannot currently access this dashboard reporand would like to be able to do so.

Other Updates

Hospital CompareData on Medicares Hospital Compare site(www.medicare.gov/hospital) were updated in March.

Te Mortality Measures data were not updated, as thisinformation is updated annually; the next update of these

measures is scheduled for June 2009.

PEPPERReview activity and reports Support for the Program forEvaluation of Payment Patterns Electronic Report(PEPPER) activity is no longer a component of the QIOProgram in the 9thStatement of Work. However, providersmay access valuable information on this topic at theHospital Payment Monitoring Program Web site(www.hpmpresources.org), including:

Hospital Payment Monitoring Program ComplianceWorkbook (updated March 2008)

National payment error data (updated January 2009),and

Information on PEPPER summary statistics ofadministrative claims data for CMS target areas

(areas likely to have payment errors due to billing,DRG/coding, and/or admission necessity issues).

RAC Program CMS announced on February 2 that the parties

involved in protesting the award of contracts in theRecovery Audit Contractor (RAC) Program settledtheir protests. Te stop work order has been lifted, andCMS will now continue its implementation of the RACProgram. Information on the program is available onthe CMS Web site at www.cms.hhs.gov/RAC/.

Contact Fran Hober at [email protected] or 216-447-9607, ext. 2115 with any questions about CMS publicreporting program changes and deadlines.


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All material presented or referenced herein is intendedfor general informational purposes and is not intendedto provide or replace the independent judgment of aqualifed healthcare provider treating a particular patient.Ohio KePRO disclaims any representation or warranty withrespect to any treatments or course of treatment basedupon information provided.

Publication No. 900100-OH-135-3/2009. This materialwas prepared by Ohio KePRO, the Medicare QualityImprovement Organization for Ohio, under contract withthe Centers for Medicare & Medicaid Services (CMS),an agency of the U.S. Department of Health and HumanServices. The contents presented do not necessarilyreect CMS policy.

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SAFEJOURNEY 2

SPRING 2009 | VOL. 7 NO. 2 | WWW.OHIOKEPRO.COM

PREVENTIONEHR INITIATIVE 15

TOOLSOFTHETRADE:PROCESSMAPPING 3

REGULATORY UPDATE

14

HELPFOR PROVIDERSANDBENEFICIARIES 5

NURSING HOMEDISPARITIESPROJECT 11

CALENDAR/REMINDERS 13

MRSASURVEILLANCESYSTEMS:THEN& NOW 9

PROMOTING PREVENTIVECARE 7

QUALITYSPOTL IGHT

O N

A N EWSL ET T ER ABO U T O H IO S H EAL T H CARE Q U AL I T Y IMPRO VEMEN T

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Newsletter Spotlight Spring 2009

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