The CMS 8th Scope Of Work for Tennessee Hospitals

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The CMS 8th Scope Of Work for Tennessee Hospitals

• QSource Hospital QI Program Team
• August 24, 2005
• Statewide Conference Call

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Joining the Call

• Wednesday, August 24, 2005
• 900am-1100am Central Time (1000am-1200noon
  Eastern Time)
• Call-in Number 1.800.369.1540
• Participant Code 49283 (you must enter the
  sign)
• Call will NOT be recorded
• One phone line per hospital please place on
  mute!!!

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Objectives

• Close out 7SOW
• Provide details of the CMS expectations for the
  8SOW.
• Provide details of the QSource Hospital Team
  support for the 8SOW
• Begin participant recruitment

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• The grass isnt greener on the other side. Its
  only greener where you water it.
• Joel Osteen Pastor, Lakewood Church

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What Did We AccomplishTogether During the 7SOW?

• 72 hospitals collaborated
• 49 on one clinical topic
• 15 on two topics
• 4 on three topics
• 4 on all four topics
• Overall reduction in failure rate across the four
  topics 28 - 14th best in the nation! -)

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What Did We AccomplishTogether During the 7SOW?

• 6SOW rank improvement, baseline to remeasure
  (combined inpatient and outpatient) 42nd to
  39th
• 7SOW rank improvement, baseline to remeasure
  (inpatient only) 35th to 24th ! -)

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What Did We AccomplishTogether During the 7SOW?

• Signed up for QNetExchange
• Submitted data to the QIO Clinical Warehouse
  86 pass validation 8th best in the nation!
  -)
• Joined HQA publicly reported on HospitalCompare
  
• All participating hospitals qualified for the
  full FY2005 Annual Payment Update

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Source Hosp. Generated Data 2004 Discharges
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• What we will accomplish together in the
  8th Scope of Work..

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• The right care for every person every time.
• Vision Statement for the CMS Health Care Quality
  Improvement Program

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The Right Care

• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient Centered
• Institute of Medicine

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Patient-Centered

• If we cooperate with each other and share our
  quality improvement ideas, successes, and lessons
  learned, we are saying that the patient is the
  focus.
• Manoj Jain, MD, MPH

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Every Person, Every Time

• Medicare Conditions of Participation for
  Hospitals
• Medical errors include errors of omission
• Evidence-based practices
• Redundancy / Reliability / Bundles
• Transparency continuing to build public trust

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CMS Approaches

• Four strategies for hospitals
• Clinical performance measurement and reporting
• Process improvement
• Systems improvement
• Organizational culture change
• Expectation of transformational levels of
  achievement

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• Dr. McClellan (CMS Administrator) sees
• Pay-for-Performance as his legacy.
• William Rollow, MD
• QIO Program Director
• June 15, 2005 Tri-Regional Conference
• I am determined to see pay-for-performance
  become part of the way we compensate health care
  providers.
• HHS Secretary Leavitt
• Testimony before the Senate Budget Committee
• July 20, 2005

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• The cheese is moving

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Adopter Categorization
Source The Diffusion of Innovation - Everett
Rogers, 1995.
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New CMS Approachfor Hospitals

• Identified Participant Groups (IPGs)
• Evidence-based
• Major focus
• Highest portion of funding
• Most staff support
• Statewide Groups

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New QSource Approachfor Hospitals

• Intensive individual and local collaboration
  activities for IPGs
• No IQ Series regional workshops
• New East / West divisions and support
  responsibilities

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New QSource Approachfor Hospitals

• Eligibility Matrix
• Intent to Commit Form

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• Questions ???
• Remember to mute your phone again after asking
  a question!

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PerformanceMeasurementand Reporting
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Expansion of VoluntaryPublic ReportingStatewide
Group

• Hospital Quality Alliance
• Demonstrate commitment to best patient care.
  Nancy Foster, AHA
• THA fully supports reporting
• Full hospital measure set - 22 measures
• Open to all PPS and CAHs
• AMI, HF, PNE, SIP
• Incorporate HCAHPS when tool ready

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Expansion of VoluntaryPublic ReportingStatewide
Group, cont.

• QSource assists with
• Participation forms
• Preview reports
• QNetExchange
• User registration
• Navigation
• Reports
• CMS Public Notify list-serv
• Quest

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Increasing the Validityof Reported
DataStatewide Group

• All hospitals submitting data to the QIO
  Warehouse must pass the CMS validation review
• Timely and complete record submissions
• Minimum 80 accuracy
• Appeal process available
• Valid data now a qualification requirement for
  the Annual Payment Update

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Increasing the Validityof Reported
DataStatewide Group, cont.

• QSource assists with
• Submission and/or tracking of data
• Record submission reminders
• Validation report reminders
• Data abstraction technical assistance
• Appeals processing
• Annual Payment Update process

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Increasing the Validityof Reported
DataStatewide Group, cont.

• CMS position
• It is the responsibility of every hospital to
  assure that the data the hospital submits to the
  vendor is the data that resides in the
  Warehouse.

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Critical Access HospitalsStatewide

• Hot off the Press!.
• New expectations for CAHs
• CMS list of reporting versus non-reporting
• For Reporting CAHs
• Collaboratively determine a single measure for
  statewide improvement
• Achieve 10 RFR
• For Non-reporting CAHs
• Begin submitting data to QIO Warehouse

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Critical Access HospitalsStatewide QSource
Assistance

• Reporting CAHs
• Facilitate selection of statewide measure
• Support performance improvement project
  development and implementation
• Non-reporting CAHs
• Encourage QIO Warehouse participation
• Provide technical assistance

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Critical Access HospitalsStatewide Rural
Measures

• New statewide rural-relevant measure set for CAHs
  only
• Not ready until Fall, 2006
• Abstract with CART (or vendor)
• Submit to Warehouse
• Assess baseline, identify opportunities for
  improvement, develop and implement QI plan

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Critical Access HospitalsStatewide Rural
Measures

• QSource assists with
• Education on finalized specifications
• Data abstraction definitions
• CART installation / use
• Warehouse self-reporters
• Performance improvement project development and
  implementation

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Appropriate Care Measure Identified Participant
Group

• A composite of the ten publicly reported measures
  for AMI, HF, PNE
• Denominator all pts. eligible for at least one
  of the ten measures
• Numerator pt. receives all the care specified by
  all the measures the pt. is eligible to receive
• Like a bundle all eligible measures met, or
  no credit
• No weighting

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Appropriate Care Measure Identified Participant
Group

• Restricted to 15 of acute care PPS hospitals who
  submit the ten measures (CEO must apply!)
• US Census bureau definitions
• Group represents the distribution of TN ACM
  performance and urban/rural status
• CMS Expectations
• 50 RFR from baseline to remeasurement
• Pass validation review

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Appropriate Care Measure Identified Participant
Group

• CMS and QSource choose participants
• CEOs/Administrators commit to ongoing internal
  support (full 2 years)
• Hospital collects data monthly and submits
  indicator rates to QSource
• Hospital tracks individual physician performance
  and provides feedback
• Hospital includes front line staff on improvement
  teams

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Appropriate Care Measure Identified Participant
Group

• QSource assists with
• Onsite staff education all project aspects
• Onsite QI coaching in the IHI Model for
  Improvement
• Convening mini-collaborative meetings in
  localities
• Educational and best practice sharing conference
  calls
• Monitoring and advising the list-serv
• Monthly / quarterly comparative data reports

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Appropriate Care Measure Identified Participant
Group

• Unique opportunity from QSource for participant
  hospitals
• Submission of articles about this breakthrough
  effort to national level journals
• Co-authorship with QSource byhospital CEO /
  Administrator,Medical Director, QI Director,
  andNursing Director

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• Questions ???
• Remember to mute your phone again after asking
  a question!

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Process ImprovementSIP and SCIP
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National SIP Results

• 56 hospitals (NSIP Collaborative)
• 44 hospitals, data on 35,543 surgical cases
• Measured parameters
• Antibiotic selection, timing, and duration
• Normothermia
• Euglycemia
• Infection rate decreased 27 (2.3-1.7)

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Evolution of theSurgical Infection Prevention
Project
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Surgical Care Improvement ProjectNational Goal
To reduce preventable surgical morbidity and
mortality by 25 by 2010
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Project overview available at
www.medqic.org/scip
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SCIPSteering Committee / National Partners

• American College of Surgeons
• American Hospital Association
• American Society of Anesthesiologists
• Association of peri-Operative Registered Nurses
• Agency for Healthcare Research and Quality

• Centers for Medicare Medicaid Services
• Centers for Disease Control and Prevention
• Department of Veterans Affairs
• Institute for Healthcare Improvement
• Joint Commission on Accreditation of Healthcare
  Organizations

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SIP/SCIP National Expert Panel

• American College of Surgeons
• American Hospital Association
• APIC
• IDSA
• JCAHO
• HICPAC
• Society for Healthcare Epidemiology of America
• Association of PeriOperative Registered Nurses
• American Association of Critical Care Nurses
• American College of Obstetricians Gynecologists
• Society of Thoracic Surgeons

• Surgical Infection Society
• VHA, Inc.
• American Academy of Orthopedic Surgeons
• American Society of Anesthesiologists
• American Society of Health System Pharmacists
• American Geriatrics Society
• Society of Thoracic Surgeons
• Premier, Inc.
• American Society of Colonand Rectal Surgeons
• Ascension Health
• The Medical Letter
• Sanford Guide
• Surgical Infection Society

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Surgical Care Improvement Project(SCIP)

• Outcome, Process, and Test Measures
• Pilot Project Hospitals and QIOs in three
  States - OH, OK, KY

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Surgical Care Improvement Project(SCIP)

• Preventable Complication Modules
• Surgical infection prevention
• Cardiovascular complication prevention
• Venous thromboembolism prevention
• Respiratory complication prevention

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Surgical Care Improvement ProjectMeasures

• Surgical infection prevention
• Antibiotics
• Administration within one hour before incision
• Use of antimicrobial recommended in guideline
• Discontinuation within 24 hours of surgery end
• Glucose control in cardiac surgery patients
• Glucose control in non-cardiac surgery patients
• Appropriate hair removal
• Normothermia in colorectal surgery patients
• Normothermia in patients withoutplanned
  hypothermia
• Post-operative wound infection diagnosedduring
  index hospitalization

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Focus Pre-operative shaving

• Shaving the surgical site with a razor induces
  small skin lacerations
• potential sites for infection
• disturbs hair follicles which are often colonized
  with S. aureus
• Risk greatest when done the night before
• Patient education

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Focus Perioperative Glucose Control

• 1,000 cardiothoracic surgery patients
• Diabetics and non-diabetics with hyperglycemia

Patients with a blood sugar gt 300 mg/dL during or
within 48 hours of surgery had more than 3X the
likelihood of a wound infection! Latham R, et
al. Infect Control Hosp Epidemiol. 2001.
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Focus Normothermia

• 200 colorectal surgery patients
• control - routine intraoperative thermal
  care(mean temp 34.7C)
• treatment - active warming(mean temp on arrival
  to recovery 36.6C)
• Results
• control - 19 SSI (18/96)
• treatment - 6 SSI (6/104), P0.009

Kurz A, et al. N Engl J Med. 1996. Also Melling
AC, et al. Lancet. 2001. (preop warming)
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Surgical Care ImprovementProject Measures, cont.

• Perioperative cardiac events
• Perioperative beta blockers innoncardiac surgery
  patients
• Perioperative beta blockers in patientswho are
  on beta blockers before surgery
• Intra- or post-operative AMI during index
  hospitalization and within 30 days of surgery
• Intra- or post-operative cardiac arrest
  duringindex hospitalization and within30 days
  of surgery

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FocusPerioperative Beta-blockers

• Beta-blockers offer significant
  protectionagainst cardiac morbidity in
  patientsundergoing non-cardiac surgery
• For every 100 patients treated
• 13 (NNT 8) will be prevented from havingintra-
  or postoperative ischemia
• Approximately 4 (NNT 23) will not have an MI
• Approximately 3 (NNT 32) deathswill be prevented

Stevens RD, et al. Pharmacologic myocardial
protection in patients undergoing noncardiac
surgery a quantitative systematic review. Anesth
Analg. 200397623-633.
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Perioperative Beta blockersACC/AHA Guideline

• Class I recommendation
• Beta blockers required in the recent past to
  control symptoms of angina, symptomatic
  arrhythmias,or hypertension
• Patients at high cardiac risk owing to the
  findingof ischemia on preoperative testing who
  are undergoing vascular surgery
• Class IIa
• Patients with known coronary artery disease or
  major risk factors for coronary disease

Eagle KA, et al. ACC/AHA. http//www.acc.org/clini
cal/guidelines.perio/dirIndex.htm.
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Surgical Care ImprovementProject Measures, cont.

• Prevention of venous thromboembolism
• Proportion who receive any form ofVTE
  prophylaxis
• Proportion who receive appropriate form ofVTE
  prophylaxis(based on ACCP Consensus
  Recommendations)
• Intra- and post-operativepulmonary embolism rate
• Intra- and post-operativedeep venous thrombosis
  rate

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ACCP Guidelines for VTE Prevention
Geerts WH, et al. CHEST. 2004126338S-400S.
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Surgical Care ImprovementProject Measures, cont.

• Prevention of ventilator-associated pneumonia
• Post-operative orders and documentation of
  elevation of head of bed
• Proportion of ventilator patients puton a
  weaning protocol
• Proportion of ventilator patients who
  receivepeptic ulcer disease prophylaxis
• Rate of postoperative ventilator-associated
  pneumonia cases that are diagnosedduring index
  hospitalization

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Ventilator-associated Pneumonia (VAP)

• Prevention of VAP includes
• Hand washing compliance anduniversal precautions
• Decreased frequency of vent circuit changes
• Suspending enteral feedings duringpatient
  transport
• Semi-recumbent position for ventilation

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Ventilator-associated Pneumonia (VAP)

• Semi-recumbent position reduces the frequency and
  risk for nosocomial pneumonia as compared to
  supine position
• Elevation of HOB to 30 degrees1
• 26 absolute risk reduction in clinically
  suspected nosocomial pneumonia
• 18 absolute reduction in microbiologically-confir
  med aspiration pneumonia

1Drakulovic MB, et al. Supine body position as a
risk factor for nosocomial pneumonia in
mechanically ventilated patients a randomized
trial. Lancet. 19993541851-1858.
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Surgical Care ImprovementProject Measures, cont.

• Vascular Access in ESRD Patients
• Permanent hospital ESRD vascular access
  procedures that are autogenous AV fistulas
• Global Measures
• Mortality within 30 days of surgery
• Re-admission within 30 days of surgery

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SIP and SCIP In Tennessee
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Statewide SIP Group

• Open to all hospitals
• Focus on the 3 SIP measures from 7SOW
• SIP 3 probably changing to 48 hours for CV
  surgeries!
• Same patient populations
• Submit data to Warehouse
• Publicly report through Hospital Quality Alliance
• Performance goal 25 reduction in failure rate
  (CMS surveillance data)

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QSource SIP Statewide Support

• Conference Calls
• Clinical information
• QI strategies from peers
• Email QIO Liaisons with info from SIP topic lead
  QIO
• Monitor and advise list-serv
• Qs As / technical support regarding
  abstraction, Warehouse submission or public
  reporting
• QNet Quest
• MedQIC official resource website

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SCIPIdentified Participant Group

• Restricted to 15 of acute care hospitals that
  perform at least 300 of the surgical procedures
  of interest per year (expanded list) - Medicare
  and Non-Medicare
• CEOs apply CMS and QSource choose participants
• Performance expectation 25 reduction in the
  failure rate from baseline to remeasurement

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SCIPIdentified Participant Group

• Five clinical focus areas
• Infection prevention
• Cardiovascular complications prevention
• Thromboembolic complications prevention
• Respiratory complications prevention
• Vascular Access (ESRD) Fistula First
  Network 8 is Lead Partner
• NEW minimum of two modules - if choosing only
  two, must work on infection prevention and DVT
  prevention

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SCIPIdentified Participant Group

• Abstract data monthly and submit indicator rates
  to QSource
• Choice of 3 data collection tools
• NSQIP (Amer. Coll. Surgeons) (Dec 2005)
• CART (Jan 2006)
• JCAHO Vendors (July 2006)
• Track individual physician performance and
  provide feedback
• Include front line staff on improvement teams

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QSource Support for SCIP Identified Participant
Group

• Onsite staff education
• Onsite QI coaching in the IHI Model for
  Improvement
• CART / Data abstraction definitions
• Convening local mini-collaboratives
• Educational and best practice sharing conference
  calls
• Monitoring and advising a list-serv
• Monthly / quarterly comparative data reports

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• Questions ???
• Remember to mute your phone again after asking
  a question!

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Systems Improvement OrganizationalCulture
Change
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Two Strategies Combined Two Identified
Participant Groups

• Systems Improvement and Organizational Culture
  (SIOC)
• Focus on adoption and use of information
  technology
• Rural Organizational Safety Culture (ROSC)

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SIOCIdentified Participant Group

• Open to all acute care PPS and CAHs
• Senior leadership / BOD engagement
• Progress in readiness for / adoption of
• CPOE, or
• Bar-coding, or
• Telehealth / Telemedicine
• Submitting data on the 10-measure starter set
  since Q3 Q4 2004

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QSource Support for SIOCIdentified Participant
Group

• Dissemination use of national toolkits
• Education for senior leadership
• Completion of readiness survey tool (baseline and
  remeasurement)
• Development and implementation of plan for
  adoption of CPOE, bar-coding, or telehealth
  (onsite visits as needed)
• Opportunities to network with other participants
  (conference calls, list-serv)

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ROSCIdentified Participant Group

• Open to CAHs and rural PPS hospitals
• Assess patient safety climate(baseline and
  remeasurement)
• Conduct patient safety processimprovement
  project

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QSource Support for ROSCIdentified Participant
Group

• Dissemination use of national toolkit
• Education for senior leadership
• Completion of safety climate survey tool
  (baseline and remeasurement)
• Development and implementation of patient safety
  process improvement project (onsite visits as
  needed)
• Opportunities for networking with other
  participants (conference calls, list-serv)

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SIOC ROSC Identified Participant Group

• CEOs/Administrators apply and commit to ongoing
  internal support
• CMS and QSource choose participants
• Commitment to including front line staff on
  improvement teams

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• Your Challenge..
• CMS and QSource are looking for innovators and
  early adopters who are willing to share openly
  and to transform their work processes to achieve
  exceptional levels of performance improvement!

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Pay-for-Performance

• Satisfied with your hospitals performance?
  (HospitalCompare on www.medicare.gov)
• Have opportunities for improvement?
• Ready to act?
• Apply for an Identified Participant Group
  membership (space is limited)!

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Next Steps

• Fax the Intent to Commit form to QSource if not
  submitted at workshop
• 1.901.761.3786
• IPG invitation letters / informational packets
  will be mailed (certified) to CEOs at all acute
  care and CAHs August 29-30
• Watch for more info emails!
• Statewide groups begin Sept
• IPGs begin Oct-Nov

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• Questions ???

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Thank You!
CMS 8th Scope of WorkPreparing
forPay-for-Performance

• QSource Hospital QI Program Team

This presentation and related material was
prepared by QSource under a contract with
theCenters for Medicare Medicaid Services
(CMS). Contents do not necessarily reflect CMS
policy. 7SOW-TN-GEN-2005-06