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Title: Federal Health Quality and Health IT Landscape Quarterly Update


1
Federal Health Quality and HealthIT Landscape
Quarterly Update
April 28, 2008
2
Table Of Contents
  • Introductions and Purpose of Updates
  • Quality MeasurementEvolution and Implications
    for Hospitals
  • Never Events/Preventable Events
  • AHIC Quality Workgroup
  • QA
  • Appendix

3
Booz Allen, through its deliverables, will keep
Premier current on national trends and
significant events impacting the quality and
health information technology markets
  • Booz Allen will monitor on an ongoing basis
    national initiatives that Premier customers
    should be aware of, as they relate to
  • Quality Measurement Provide insight on new
    measures that are likely to be publicly reported
    at the national level and any trends in data
    sources for new measures.
  • Data Stewardship and Health Information
    Technology Report on national policies that are
    likely to impact the business model for data
    aggregators and how health information technology
    is likely to influence the direction of
    regulatory reporting requirements.
  • Dates for the next customer presentations are
  • July 14, 2008
  • October 6, 2008

4
2007 and 2008 are additional building years
for quality continuing past work
AHIC Quality Workgroup Approved
AQA - HQA Steering Committee Formed
Executive Order Issued on Promoting Quality
Alliance for Pediatric Quality launched
Pharmacy Quality Alliance launched
IOM Report To Err is Human Building a Safer
Health System
Deficit Reduction Act mandates expansion of
measurement and sets precedent for lack of add-on
payment for errors
Medicare Modernization Act ties hospital market
basket updates to quality reporting for 10
measures
Hospital Compare expanded to payment and volume
information and HCAHPS patient experience data
JCAHO launches the core measures initiative
IOM Report Performance Measurement Accelerating
Improvement
National Quality Forum constituted
CMS Nursing Home Compare launched
Value-Based Purchasing Report to Congress on the
Plan to Implement a Medicare Hospital VBP Program
  • IOM Report
  • Crossing the Quality Chasm
  • Focused on a redesign of health care delivery
  • Called for creation of performance-based payment

Premier Hospital Quality Incentive Demo launched
CMS Roadmap to Quality launched
JCAHO launches the ORYX Initiative
Hospital Compare launched
CMS Home Health Compare launched
Creation of The Leapfrog Group
Creation of Bridges to Excellence
Hospital Quality Alliance launched
CMS Preventable Events
Ambulatory Quality Alliance launched
2007
1990s
2000
2001
2002
2003
2004
2005
2006
2008
5
Table Of Contents
  • Introductions and Purpose of Updates
  • Quality MeasurementEvolution and Implications
    for Hospitals
  • Never Events/Preventable Events
  • AHIC Quality Workgroup
  • QA
  • Appendix

6
Through the proposed IPPS rule released earlier
this month, CMS has proposed to add 43 quality
measures to the list hospitals must report under
the RHQDAPU program
  • Under the proposed rule, in order to get their
    full marketbasket update for FY 2010, hospitals
    would need to report the following measures
    beginning at various dates throughout in FY 2009
  • Surgical Care Improvement Project (SCIP) - 1 new
    measure
  • Hospital readmissions - 3 new measures
  • Nursing care - 4 new measures
  • Patient Safety Indicators (AHRQ)- 5 new measures
  • Inpatient Quality Indicators (AHRQ) - 4 new
    measures
  • Venous thromboembolism measures (VTEs) - 6 new
    measures
  • Stroke measures (STK) - 5 new measures
  • Cardiac surgery measures - 15 new measures
  • CMS proposes to retire one measure that has
    topped offoxygenation assessment (PN)
  • CMS also listed an additional 59 measures and 4
    measure sets that could be candidates for the
    RHQDAPU program in FY 2011 and beyond

Source FY 2009 IPPS Rule www.cms.hhs.gov/AcuteInp
atientPPS/downloads/CMS-1390-P.prf
7
CMS is proposing different implementation dates
based on such factors as pilot testing, NQF
endorsement, and decisions about how CMS will
receive the data
Source FY 2009 IPPS Rule www.cms.hhs.gov/AcuteInp
atientPPS/downloads/CMS-1390-P.prf, Booz Allen
Analysis
8
Proposed IPPS Rule cont.
Source FY 2009 IPPS Rule www.cms.hhs.gov/AcuteInp
atientPPS/downloads/CMS-1390-P.prf, Booz Allen
Analysis
9
Proposed IPPS Rule cont.
Source FY 2009 IPPS Rule www.cms.hhs.gov/AcuteInp
atientPPS/downloads/CMS-1390-P.prf, Booz Allen
Analysis
10
Proposed IPPS Rule cont.
Source FY 2009 IPPS Rule www.cms.hhs.gov/AcuteInp
atientPPS/downloads/CMS-1390-P.prf, Booz Allen
Analysis
11
Proposed IPPS Rule cont.
Source FY 2009 IPPS Rule www.cms.hhs.gov/AcuteInp
atientPPS/downloads/CMS-1390-P.prf, Booz Allen
Analysis
12
The proposed new measures represent the continued
evolution of measure types and help CMS move
closer to the ability to implement value-based
purchasing (a/k/a P4P)
  • By adding readmission measures (efficiency
    measures), patient safety measures, and
    additional outcomes measures, CMS is continuing
    to evolve its measurement strategy that began
    with a focus on disease-specific process
    measures (HF, AMI, PN)
  • The three proposed readmission measures (30 day
    risk standardized readmission for HF, AMI, and
    PN) fulfill the statutory mandate that a
    value-based purchasing (VBP) plan include
    efficiency measures
  • The addition of measures focused on specific
    diseases or procedures (stroke, cardiac surgery),
    as well as cross-cutting measures (nursing
    sensitive measures, patient safety measures)
    makes the idea of applying VBP incentives to the
    entire range of Medicare discharges more
    acceptable

But what are the implications for hospitals?
13
Implications for hospitals for expanded clinical
process measures (e.g., VTE measures, stroke
measures)
Domains
Implications
  • Volume of new process measures requiring chart
    review will mean additional strain on QI
    department staffing
  • Concurrent review allows immediate intervention
  • Focus on identifying patient population upfront
    (important even if gathering data
    retrospectively) to support concurrent care
    management and adequate documentation

1
Improvement
Source Booz Allen Analysis
14
Implications for hospitals for expanded outcome
measures(e.g., readmissions, complications,
in-hospital mortality)
Domains
Implications
  • To decrease potential for readmission, care
    processes need to renew focus on discharge
    instructions/discharge planning
  • Concurrent care management may be most effective
    at yielding better outcomes and assuring
    appropriate LOS
  • Accuracy of clinical documentation (e.g. present
    on admission) and coding are key considerations
    for complication and infection measures

1
Improvement
  • More sophisticated data mining is required to
    uncover the care processes that most impact
    outcomes
  • Sharing data across settings may help forestall
    readmission

2
IT Systems/ Information Management
  • Clinicians will challenge risk adjustment even
    if public, they feel black box
  • Data from administrative sources are older and
    will not motivate change without a more rapid
    internal feedback loop
  • Connections to community-based providers gain in
    importance

3
Clinician Engagement
Source Booz Allen Analysis
15
Table Of Contents
  • Introductions and Purpose of Updates
  • Quality MeasurementEvolution and Implications
    for Hospitals
  • Never Events/Preventable Events
  • AHIC Quality Workgroup
  • QA
  • Appendix

16
Many nationally-recognized quality-focused
organizations are targeting preventable events
  • According to the National Quality Forum (NQF),
    never events are errors in medical care that
    are clearly identifiable, preventable, and
    serious in their consequences for patients, and
    that indicate a real problem in the safety and
    credibility of a health care facility. NQF
    currently owns a list of 28 events, grouped into
    six categories surgical, product or device,
    patient protection, care management,
    environmental and criminal.
  • In an effort to facilitate the use of information
    to influence change, CDC has implemented the
    National Healthcare Safety Network (NHSN), a
    surveillance system that allows participating
    healthcare facilities to enter data associated
    with healthcare safety, such as surgical site
    infections, antimicrobial use and resistance,
    bloodstream infections, dialysis incidents, and
    healthcare worker vaccinations. NHSN provides
    analysis tools that generate reports using the
    aggregated data. NHSN also provides links to best
    practices, guidelines, and lessons learned.
  • As a part of their 5 million lives campaign,
    Institute for Healthcare Improvement (IHI) has
    developed new harm interventions including
    Prevent Harm from High-Alert Medications Reduce
    Surgical Complications Prevent Pressure Ulcers
    Reduce Methicillin-Resistant Staphylococcus
    aureus (MRSA) Deliver Reliable, Evidence-Based
    Care for Congestive Heart Failure Get Boards on
    Board.
  • Also focused on patient safety, AHRQ has
    developed Patient Safety Indicators, which are a
    set of measures that screen for adverse events
    that patients experience as a result of exposure
    to the health care system. These events are
    likely amenable to prevention by changes at the
    system or provider level. PSIs are defined on two
    levels the provider level and the area level.

Source NQF, IHI http//www.ihi.org/IHI/Programs/C
ampaign/Campaign.htm?TabId1 , CDC NHSN
http//www.cdc.gov/ncidod/dhqp/nhsn.html, Booz
Allen Analysis
17
The proposed IPPS rule specifies 17 conditions
for which Medicare will no longer pay hospitals
at a higher rate if the conditions were not
present on admission (as of 10/01/08)
  • The Hospital-acquired conditions (HAC) provisions
    in Medicare regulations required hospitals to
    begin reporting on their Medicare claims on
    October 1, 2007, whether certain specified
    diagnoses were present when the patient was
    admitted. The first eight conditions, which were
    selected last year because they greatly
    complicate the treatment of the illness or injury
    that caused the hospitalization, resulting in
    higher payments to the hospital for the patients
    care by both Medicare and the patient, were
  • Object inadvertently left in after surgery
  • Air embolism
  • Blood incompatibility
  • Catheter associated urinary tract infection
  • Pressure ulcer
  • CMS is proposing to expand the list of conditions
    that need to be reported if present when a
    patient is first admitted. If these additional
    candidate HACs are selected in the FY 2009 IPPS
    final rule, the payment provision will take
    effect for these candidate HACS on October 1,
    2008 as well. The list in the proposed rule
    includes
  • Vascular catheter associated infection
  • Surgical site infection- Mediastinitis
  • Certain types of falls and trauma
  • Delirium
  • Ventilator-associated pneumonia
  • Deep vein thrombosis/Pulmonary embolism
  • Staphylococcus aureus septicemia
  • Clostridium difficile associated disease
  • Surgical site infections following certain
    elective procedures
  • Legionnaires disease
  • Extreme blood sugar derangement
  • Iatrogenic pneumothorax

Source CMS IPPS Rule , Booz Allen Analysis
18
States and health insurers are following CMSs
lead and aim to improve patient safety and reduce
healthcare costs
  • According to NQF, as of October 2006, eleven
    states use the NQF never event lists to report in
    whole or in part as the basis of their
    state-based public reporting system. The states
    include
  • California
  • Connecticut
  • Illinois
  • Indiana
  • Private insurers are looking at banning
    reimbursements for care resulting from serious
    errors
  • Aetna announced on 1/2008 that it included "never
    events" in its hospital contracts for
    negotiations or renegotiations. The approach
    calls for hospitals to report this type of event
    to a select group of patient safety organizations
    within 10 days of becoming aware it had occurred
    take action to prevent future events waive all
    costs related to a serious reportable event
    ("never event") and apologize to the patient
    and/or family affected by the never event.
  • WellPoint Inc., announced on 4/2008 that it is
    extending to its 14-state plans a new policy
    targeting "never" events. A phase of this
    initiative will prevent hospitals from billing
    patients on any of all of the eight preventable
    events used by CMS.
  • UnitedHealth Group Inc. and Cigna Corp. say
    they're exploring policies similar to CMS.
  • The Blue Cross Blue Shield Association says that
    its 39 member health plans are looking at
    approaches similar to Aetna's or working with
    hospitals on reducing errors.
  • Some hospitals and others are concerned that the
    new strategy could drive up medical costs as
    hospitals absorb or pass on the expense of
    introducing the safety and screening procedures
    needed to help avoid mistakes. Others argue the
    efforts will trigger safety improvements and
    savings for patients.
  • Minnesota
  • New Jersey
  • Oregon
  • Massachusetts
  • Vermont
  • Washington
  • Wyoming

Source Hospitals and Health Networks
http//www.hhnmag.com/hhnmag_app/jsp/articledispla
y.jsp?dcrpathHHNMAG/Article/data/04APR2008/080401
HHN_Online_Friedmandomain HHNMAG, Aetna Press
Release http//www.aetna.com/news/2008/0307.htm,
WSJ http//www.bizjournals.com/sanjose/stories/200
8/03/31/daily74.html and http//s.wsj.net/public/r
esources/documents/WSJ_PRSeriousReportableEvents10
-15-06.pdf
19
CMS list of preventable conditions refers to
some of the same measures advanced by others
PATIENT SAFETY ACTIVITY
  • IHI and CMS
  • Blood Incompatibility
  • Hospital Acquired Injuries
  • Retention of Foreign Object
  • Pressure Ulcers
  • Clostridium difficile
  • Bloodstream Infection
  • Vascular catheter-
    associated infection
  • Catheter Associated UTI
  • Ventilator Associated Pneumonia
  • DVT/PE
  • Surgical site infection
  • CDC-NHSN and CMS
  • Central-Line Catheter Related Blood Stream
    Infections
  • Catheter Associated UTI
  • Ventilator Associated Pneumonia

CMS Preventable Conditions
  • NQF and CMS
  • Object left in surgery
  • Pressure ulcers
  • Air embolism
  • Blood incompatibility
  • Hospital-acquired injuries
  • AHRQ and CMS
  • Object left in surgery
  • Pressure ulcers

Source CMS DRA, UAB Health System
http//www.uabhealth.org/33800/ , NQF, CMS DRA,
UAB Health System http//www.uabhealth.org/33800/
, AHRQ PSI http//www.qualityindicators.ahrq.gov/p
si_overview.htm, Booz, Allen Analysis
20
AHRQ, CDC, CMS, IHI and NQF efforts to prevent
harm in the clinical setting do overlap, but each
organization also offers unique measures
Source CMS DRA, UAB Health System
http//www.uabhealth.org/33800/ , NQF, CMS DRA,
UAB Health System http//www.uabhealth.org/33800/
, AHRQ PSI http//www.qualityindicators.ahrq.gov/p
si_overview.htm, Booz Allen Analysis
21
Table Of Contents
  • Introductions and Purpose of Updates
  • Quality MeasurementEvolution and Implications
    for Hospitals
  • Never Events/Preventable Events
  • AHIC Quality Workgroup
  • QA
  • Appendix

22
The American Health Information Community (AHIC)
is a federally-chartered advisory committee
formed to facilitate the adoption of electronic
health records
  • Health and Human Services (HHS) created this
    public-private collaboration in 2005 to help
    advance efforts to reach President Bushs call
    for most Americans to have electronic health
    records within ten years. AHIC provides input and
    recommendations to HHS on how to make health
    records digital and interoperable, and to assure
    that the privacy and security of those records
    are protected, in a smooth, market-led way.
  • In August 2006, AHIC formed the Quality Workgroup
    (QWG)
  • Broad charge of the AHIC QWG
  • ? Make recommendations to the AHIC so that
    breakthroughs in health information technology
    (health IT) can provide the data needed for the
    development of quality measures that are useful
    to patients and others in the health care
    industry, automate the measurement and reporting
    of a comprehensive current and future set of
    quality measures, and accelerate the use of
    clinical decision support that can improve
    performance on those quality measures. Also, make
    recommendations for how performance measures
    should align with the capabilities and
    limitations of health IT.
  • Specific charge of the AHIC QWG
  • ? Make recommendations to the American Health
    Information Community that specify how certified
    health information technology should support the
    capture, aggregation, and reporting of data for a
    core set of ambulatory and inpatient quality
    measures.

Source AHIC website http//www.hhs.gov/healthit/a
hic/, AHIC QWG Letter to the Secretary 4/22/08,
Booz Allen Analysis
23
The American Health Information Community Quality
Workgroup has defined a Vision of the Future that
includes integration of HIT and Quality
Mr. Jones, who has congestive heart failure,
experiences shooting pain down his left arm,
sweating, and shortness of breath. His family
rushes him to the local emergency department
where he is given aspirin by his nurse.
Dr. Smith places an order for a beta blocker to
immediately be dispensed and administered. The
EHR alerts Dr. Smith of a contraindication (Mr.
Jones has a history of asthma). Mr. Jones is
admitted for tests.
Dr. Smith also reviews the EHR for Mr. Jones
past medical history, which is available despite
Mr. Jones moving around the country recently.
As part of discharge planning, Dr. Smith answers
questions, electronically orders Mr. Jones
prescription, and completes the required fields
in the discharge module.
Hospital Quality Datastore
Pharmacy
24
A Vision of the Future A Patients Perspective
Mr. Jones picks Dr. Thomas who reviews Mr. Jones
medical information through an EHR, including the
details of his recent admission, medication
history and lab results. A care management plan
is developed and recorded in the EHR.
Back at home, Mr. Jones uses his PHR to track
procedures, test results and prescriptions
following his recent hospital stay.
Mr. Jones needs to select a new physician. He
goes online to compare ratings of different
physicians and to compare the ratings with cost
information.
Dr. Thomas is getting ready to exit the EHR when
the CDS prompts Dr. Thomas as to whether he has
counseled Mr. Jones on quitting smoking.
Mr. Jones resumes his daily course of living but
is now a much more active participant in managing
his health.
25
Through testimony and the development of their
vision, QWG identified four specific areas that
must be addressed
1
3
Automate data capture and reporting to support
core sets of AQA clinician-focused and HQA
inpatient quality measures
Enable data aggregation to allow public reporting
of quality measures based on comprehensive
clinical data that are pooled across providers
and merged, as appropriate, with other data
sources
4
2
Align performance measurement with the
capabilities and limitations of health
information technology
Create a common framework of workflow activities
that underpin performance measurement and
improvement with clinical decision support, so
that these inter-related activities can occur
seamlessly within care delivery
For each of these areas, the Quality Workgroup
developed an initial set of recommendations,
which were submitted to the Secretary in March
2007.
Source AHIC QWG Meeting 2/27/2008, Booz Allen
Analysis
26
To move towards this end vision and make
recommendations to help drive this movement, the
QWG recognizes changes must occur in a number of
key areas
2009
2010
2012
2007
2008
2011
2013
2014
Future State Components
Changes to current payment system
P4P/VBP programs in existence
Consensus reached on payment reform
Payment change/reform implemented
Payment principles established
Payment change/ reform legislated
Incentives
NOTIONAL DRAFT
Setting-specific metrics used, NQF Exploring
Longitudinal Measures
Consensus-based patient-centric quality metrics
field tested
Single Set of patient -centric quality metrics
used
Measure Set Evolution
Legal Framework for Data Sharing
State Agreement on Common Framework
HISPC Implementation Plan Developed
HISPC Reports Released
Broad Agreement on Need
Policies Procedures Developed
Sample HIE Agreements Developed
Stewards Identified
Stewards Certified Compliance w/ Rules
Established
Data Stewardship
State Agreement on Common Framework
Technical principles / best practices established
Accountability for Matching Methods Established
Multiple methods used Demos and pilots in place
Patient Record Matching
Accountability for Matching Methods Established
Multiple methods used Demos and pilots in place
Technical principles / best practices established
Provider Entity Record Matching
Multiple Loci for Record De-Identification
Policies / Procedures Established
Policies / Procedures Implemented
Patient Record De-Identification
Increased Data Aggregation for P4P (Increased use
of Clinical Data with Claims Data)
Established Longitudinal Data Aggregation
(Multi-Source Patient-Centric Data Used incl.
Clinical Data, Claims, and other Sources)
Limited Aggregation (Highly Claims Data)
Data Exchange and Aggregation
Post Acute Care QDS Established
Inpatient Care QDS Established
Ambulatory Care QDS Established
Hospital Outpatient QDS Established
Patient-Centered Long. QDS Established
Quality Data Set
CCHIT incorporates standards for quality
measurement into its EHR certification process
HITSP identifies standards for elements required
for quality measurement on ongoing basis
HITEP Sends HITSP Recommendations
Expanded Data Element Standardization
Continuous / Ongoing effort to improve coding of
diagnosis and treatment
Coding Improvements
EHRs w/CDS other CDS tools certified
Best practices for patient-centric CDS established
Non-standard-ized CDS Use
Pilot Studies of standardized CDS Implemented
CCHIT incorporates best practice patient-centric
CDS
CDS Patient Provider
Potential Accelerant
The vision is continuously evolving as we move
closer to it becoming a reality. Accordingly the
representations in the diagram, while shown as
linear, are also evolving and will require cycles
to remain current.
KEY
Activity
27
The QWG aims to translate the vision roadmap into
actionable recommendations
  • The vision roadmap provides guidance for the
    efforts of current and future quality improvement
    efforts for groups such as the AHIC and its
    successor.
  • The Quality Workgroup recognizes that the scope
    of the vision roadmap is quite broad. Therefore,
    the workgroup has chosen a few components about
    which to make formal recommendations, areas where
    substantive progress could be made within the
    next year and which have the potential to create
    a cycle of progress towards the eventual
    realization of the future state vision.
  • The recommendations are focused on improving the
    quality of data used for quality measurement and
    reporting through

Facilitating the alignment of initiatives to
develop and implement measures for quality
improvement
Developing and implementing a quality data set to
support quality measurement and reporting
Prioritizing the creation of standards for
structuring selected clinical data
Source AHIC QWG Letter to the Secretary 4/22/08,
Booz Allen Analysis
28
Hospitals can take independent action to foster
interoperability and prepare for automation of
quality measures
  • Standardize medical concepts across hospitals
  • Structure clinical documentation to minimize the
    reliance on free text clinical documentation that
    uses non-standardized nomenclature
  • Begin planning for implementation of clinical
    documentation modules early in the EHR
    installation process, as these modules require
    significant change management for clinicians and
    they have great impact on automation and CDS
  • Leverage active and passive means to encourage
    the required documentation to support automated
    quality measurement through EHRs

Source Booz Allen Analysis
29
Table Of Contents
  • Introductions and Purpose of Updates
  • Quality MeasurementEvolution and Implications
    for Hospitals
  • Preventable Events/Never Events
  • AHIC Quality Workgroup
  • QA
  • Appendix

30
Appendix
  • NQF Never Events
  • Prevent Harm Measures Links to Organizations
  • Quality Work Group Actionable Recommendations
  • Proposed NQF Voluntary Consensus Standards for
    Hospital Care (voting active)
  • Measures recommended by HQA for adoption

31
The National Quality Forum has identified 28
never events
NQF NEVER EVENTS
  • Surgical Events
  • Surgery performed on the wrong body part
  • Surgery performed on the wrong patient
  • Wrong surgical procedure on a patient
  • Unintended retention of a foreign object in a
    patient after surgery or other procedure changed
  • Intraoperative or immediately post-operative
    death in a normal healthy patient in an ASA class
    I patient
  • Product or Device Events
  • Patient death or serious disability associated
    with the use of contaminated drugs, devices, or
    biologics provided by the healthcare facility
  • Patient death or serious disability associated
    with the use or function of a device in patient
    care in which the device is used or functions
    other than as intended
  • Patient death or serious disability associated
    with intravascular air embolism that occurs while
    being cared for in a healthcare facility
  • Patient Protection Events
  • Infant discharged to the wrong person
  • Patient death or serious disability associated
    with patient elopement (disappearance) changed
  • Patient suicide, or attempted suicide resulting
    in serious disability, while being cared for in a
    healthcare facility
  • Criminal Events
  • Any instance of care ordered by or provided by
    someone impersonating a physician, nurse,
    pharmacist, or other licensed healthcare provider
  • Abduction of a patient of any age
  • Sexual assault on a patient within or on the
    grounds of a healthcare facility
  • Death or significant injury of a patient or staff
    member resulting from a physical assault (i.e.,
    battery) that occurs within or on the grounds of
    a healthcare facility
  • Care Management Events
  • Artificial insemination with the wrong donor
    sperm or donor egg new event
  • Patient death or serious disability associated
    with a medication error (e.g., errors involving
    the wrong drug, wrong dose, wrong patient, wrong
    time, wrong rate, wrong preparation or wrong
    route of administration) changed
  • Patient death or serious disability associated
    with a hemolytic reaction due to the
    administration of ABO/HLA-incompatible blood or
    blood products changed
  • Maternal death or serious disability associated
    with labor or delivery on a low-risk pregnancy
    while being cared for in a healthcare facility
  • Patient death or serious disability associated
    with hypoglycemia, the onset of which occurs
    while the patient is being cared for in a
    healthcare facility
  • Death or serious disability (kernicterus)
    associated with failure to identify and treat
    hyperbilirubinemia in neonates
  • Stage 3 or 4 pressure ulcers acquired after
    admission to a healthcare facility
  • Patient death or serious disability due to spinal
    manipulative therapy
  • Environmental Events
  • Patient death or serious disability associated
    with an electric shock or elective cardioversion
    while being cared for in a healthcare facility
    changed
  • Any incident in which a line designated for
    oxygen or other gas to be delivered to a patient
    contains the wrong gas or is contaminated by
    toxic substances
  • Patient death or serious disability associated
    with a burn incurred from any source while being
    cared for in a healthcare facility
  • Patient death or serious disability associated
    with a fall while being cared for in a healthcare
    facility changed
  • Patient death or serious disability associated
    with the use of restraints or bedrails while
    being cared for in a healthcare facility

Source NQF, CMS Eliminating Serious,
Preventable, and Costly Medical Errors Never
Events, Booz Allen Analysis
32
CDC NHSN, IHI, and AHRQ all have measures that
focus on preventing harm
PREVENT HARM MEASURES LINKS TO ORGANIZATIONS
  • CDC-NHSN
  • http//www.gao.gov/new.items/d08673t.pdf
  • IHI
  • http//www.ihi.org/IHI/Topics/PatientSafety/Safety
    General/Tools/IntrotoTriggerToolsforIdentifyingAEs
    .htm
  • AHRQ Patient Safety Indicators Technical
    Specifications
  • http//www.qualityindicators.ahrq.gov/downloads/ps
    i/psi_technical_specs_v32.pdf

33
Facilitating the alignment of initiatives to
develop and implement measures for quality
improvement
QUALITY WORK GROUP ACTIONABLE RECOMMENDATIONS
  • Recommendation 1.1 HHS, including the Office of
    the National Coordinator for Health IT and the
    Agency for Healthcare Research and Quality, in
    coordination with the Quality Alliance Steering
    Committee and the AHIC successor, should convene
    forums at regular intervals through December 2008
    in order to facilitate the alignment of quality
    improvement and health information technology
    initiatives in particular, those initiatives
    supporting quality measure development and
    implementation. Representatives of specific
    organizations should be included in the forums,
    such as the Centers for Medicare and Medicaid
    Services, the Federal Health Architecture,
    NIH/National Library of Medicine, the National
    Quality Forum, HITSP, CCHIT, Integrating the
    Healthcare Enterprise (IHE) and the AMA-NCQA
    Collaborative. Additionally, representatives of
    organizations such as guideline developers, AQA,
    HQA, the Joint Commission, and standards
    development organizations (SDOs) may be invited.
    As an outcome of the forums, HHS, in
    collaboration with the represented organizations,
    should develop a plan by October 28, 2008, for
    continued public-private cooperation to align the
    initiatives.

Source AHIC QWG Letter to the Secretary 4/22/08,
Booz Allen Analysis
34
Developing and implementing a quality data set to
support quality measurement and reporting
QUALITY WORK GROUP ACTIONABLE RECOMMENDATIONS
  • Recommendation 2.1 HHS, including the Agency for
    Healthcare Research and Quality and the Centers
    for Medicare and Medicaid Services, should
    collaborate with key private sector stakeholders,
    including measure developers, health IT vendors,
    clinicians, providers, and quality organizations,
    to define a quality data set that would support
    quality measurement that is automated,
    patient-centric, and longitudinal with the goal
    of improving care delivery and outcomes. The
    quality data set should include, at a minimum,
    relevant data captured during inpatient and
    physician office visits, and data required to
    support transitions of care among other provider
    settings.
  • Recommendation 2.1.1 By December 31, 2008, the
    collaborative effort named in recommendation 2.1
    should review existing data sets used for quality
    measurement, including those developed by the
    Centers for Medicare and Medicaid Services for
    its CARE tool, by the HITEP in its initial work,
    by the Joint Commission for transfers of care,
    and by others as appropriate, as the basis of a
    harmonized minimum set of data types or elements
    that can be used for automating quality measures.
    The effort should also incorporate into the
    harmonized quality data set those data types or
    elements needed to support measure sets and
    national priority areas. The effort should
    assign a priority level to each data type or
    element within the quality data set as an aid to
    implementation.
  • Recommendation 2.1.2 The Centers for Medicare
    and Medicaid Services, in expanding its set of
    quality measures, should work with the Indian
    Health Service to test the effectiveness of the
    harmonized minimum set of data types or elements,
    as developed in Recommendation 2.1.1, to capture
    and aggregate data from electronic health records.

Source AHIC QWG Letter to the Secretary 4/22/08,
Booz Allen Analysis
35
Developing and implementing a quality data set to
support quality measurement and reporting cont.
QUALITY WORK GROUP ACTIONABLE RECOMMENDATIONS
  • Recommendation 2.1.3 HHS, in coordination with
    the Quality Alliance Steering Committee and the
    AHIC successor, should maintain the minimum
    quality data set over time, modifying the quality
    data set as needed to address new measures and
    national priorities for quality measurement, and
    obtaining feedback on the quality data set from
    measure developers, health IT vendors,
    clinicians, providers, and quality organizations.
  • Recommendation 2.2 Within three years following
    the identification of a quality data set, the
    Centers for Medicare and Medicaid Services should
    promote the use of the quality data set in its
    requirements for quality measurement and
    reporting across care settings.
  • Recommendation 2.3 To accomplish some quality
    objectives, electronic health records must not
    only exchange data but also use and store certain
    data types or elements within electronic health
    records. Therefore, the Healthcare Information
    Technology Standards Panel (HITSP) should
    identify the data standards needed to fill
    identified gaps for inclusion of the identified
    quality data set for use in both ambulatory and
    inpatient electronic health records.
  • Recommendation 2.4 The Certification Commission
    for Healthcare Information Technology (CCHIT)
    should consider developing the appropriate
    criteria necessary to support the inclusion of
    the identified quality data set in both
    ambulatory and inpatient electronic health
    records. This requirement should be submitted for
    inclusion on the CCHIT Roadmap in sufficient time
    for implementation in 2010.

Source AHIC QWG Letter to the Secretary 4/22/08,
Booz Allen Analysis
36
Prioritizing the creation of standards for
structuring selected clinical data
QUALITY WORK GROUP ACTIONABLE RECOMMENDATIONS
  • Recommendation 3.1 The Agency for Healthcare
    Research and Quality, in collaboration with the
    Office of the National Coordinator for Health IT
    and in consultation with NIH/National Library of
    Medicine, should conduct an environmental scan of
    current initiatives where electronic clinical
    data is being used to inform quality improvement
    initiatives in order to identify areas where data
    standards for structured clinical data are
    needed. Initiatives for review include, but are
    not limited to, the Better Quality Information to
    Improve Care for Medicare Beneficiaries (BQI)
    pilots and the Nationwide Health Information
    Network (NHIN) Trial Implementation sites. In
    preparing the environmental scan, which should be
    completed by November 30, 2008, experts could be
    convened from the BQI and NHIN sites that have
    experience in combining clinical and
    administrative data from multiple sources.
  • Recommendation 3.2 The Agency for Healthcare
    Research and Quality, in collaboration with
    Office of the National Coordinator for Health IT
    and in consultation with NIH/National Library of
    Medicine, should use the results of the
    environmental scan from Recommendation 3.1 as
    well as the work of the National Quality Forums
    Health Information Technology Expert Panel
    (HITEP) to develop recommendations to the
    Healthcare Information Technology Standards Panel
    (HITSP) for the identification of standards for
    structuring clinical data. These recommendations
    should be submitted to HITSP by January 31, 2009.

Source AHIC QWG Letter to the Secretary 4/22/08,
Booz Allen Analysis
37
Prioritizing the creation of standards for
structuring selected clinical data cont.
QUALITY WORK GROUP ACTIONABLE RECOMMENDATIONS
  • Recommendation 3.3 Through its convening
    function, the Agency for Healthcare Research and
    Quality, in collaboration with the Office of the
    National Coordinator for Health IT and in
    consultation with NIH/National Library of
    Medicine, should produce an action agenda by
    March 31, 2009. The action agenda should
    prioritize areas for structuring selected
    clinical data used across care settings, and
    identify opportunities to align efforts that are
    already underway to create standards related to
    clinical data. This work should be guided by an
    expert panel comprised of members of the EHR
    vendor community, clinicians, providers,
    specialty societies, standard development
    organizations, the National Quality Forum,
    guideline developers, measure developers, health
    plans, the Quality Alliance Steering Committee,
    the AHIC successor and others as appropriate, to
    ensure that standardization of documentation is
    aligned with care delivery and the development of
    executable guidelines and automatable quality
    measures.

Source AHIC QWG Letter to the Secretary 4/22/08,
Booz Allen Analysis
38
An additional 43 candidate voluntary consensus
standards for hospital care quality are up for a
vote at NQF
PROPOSED NQF VOLUNTARY CONSENSUS STANDARDS FOR
HOSPITAL CARE
  • The recommended performance measures focus on the
    areas of patient safety in both adult and
    pediatric populations as well as morbidity and
    mortality, anesthesia and surgery (including
    surgical volume and mortality), utilization rates
    for high-risk (or often unnecessary) procedures,
    and readmission rates and length of stay (LOS).

Source NQF http//www.qualityforum.org/pdf/projec
ts/hosp-priorities/2.25vote/HCPt2VotingReportCombi
nedpdf.pdf , Booz Allen Analysis
39
Candidate voluntary consensus standards for
hospital care quality for addition to the
existing set (cont.)
PROPOSED NQF VOLUNTARY CONSENSUS STANDARDS FOR
HOSPITAL CARE
Source NQF http//www.qualityforum.org/pdf/projec
ts/hosp-priorities/2.25vote/HCPt2VotingReportCombi
nedpdf.pdf , Booz Allen Analysis
40
Candidate voluntary consensus standards for
hospital care quality for addition to the
existing set (cont.)
PROPOSED NQF VOLUNTARY CONSENSUS STANDARDS FOR
HOSPITAL CARE
Source NQF http//www.qualityforum.org/pdf/projec
ts/hosp-priorities/2.25vote/HCPt2VotingReportCombi
nedpdf.pdf , Booz Allen Analysis
41
Candidate voluntary consensus standards for
hospital care quality for addition to the
existing set (cont.)
PROPOSED NQF VOLUNTARY CONSENSUS STANDARDS FOR
HOSPITAL CARE
Source NQF http//www.qualityforum.org/pdf/projec
ts/hosp-priorities/2.25vote/HCPt2VotingReportCombi
nedpdf.pdf , Booz Allen Analysis
42
Candidate voluntary consensus standards for
hospital care quality for addition to the
existing set (cont.)
PROPOSED NQF VOLUNTARY CONSENSUS STANDARDS FOR
HOSPITAL CARE
Source NQF http//www.qualityforum.org/pdf/projec
ts/hosp-priorities/2.25vote/HCPt2VotingReportCombi
nedpdf.pdf , Booz Allen Analysis
43
Candidate voluntary consensus standards for
hospital care quality for addition to the
existing set (cont.)
PROPOSED NQF VOLUNTARY CONSENSUS STANDARDS FOR
HOSPITAL CARE
Source NQF http//www.qualityforum.org/pdf/projec
ts/hosp-priorities/2.25vote/HCPt2VotingReportCombi
nedpdf.pdf , Booz Allen Analysis
44
Measures recommended by the Hospital Quality
Alliance (HQA) for adoption in FY2010
HQA RECOMMENDED MEASURES FOR PUBLIC REPORTING
Source HQA
45
Measures recommended by the Hospital Quality
Alliance (HQA) for adoption in FY2010 (cont.)
HQA RECOMMENDED MEASURES FOR PUBLIC REPORTING
Source HQA
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