CMS HOSPITAL CONDITIONS OF PARTICIPATION (COPS) 2014 PI Standards and PI Worksheet - PowerPoint PPT Presentation

Loading...

PPT – CMS HOSPITAL CONDITIONS OF PARTICIPATION (COPS) 2014 PI Standards and PI Worksheet PowerPoint presentation | free to download - id: 646e2d-MWQzZ



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

CMS HOSPITAL CONDITIONS OF PARTICIPATION (COPS) 2014 PI Standards and PI Worksheet

Description:

CMS HOSPITAL CONDITIONS OF PARTICIPATION (COPS) 2014 PI Standards and PI Worksheet * QAPI Standards Standard: Program Data (Tag 273) Hospital must ensure that the ... – PowerPoint PPT presentation

Number of Views:31
Avg rating:3.0/5.0
Date added: 22 April 2020
Slides: 125
Provided by: TDC1
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: CMS HOSPITAL CONDITIONS OF PARTICIPATION (COPS) 2014 PI Standards and PI Worksheet


1
CMS HOSPITAL CONDITIONS OF PARTICIPATION (COPS)
2014 PI Standards and PI Worksheet
2
Speaker
  • Sue Dill Calloway RN, Esq. CPHRM, CCMSCP
  • AD, BA, BSN, MSN, JD
  • President of Patient Safety and Education
    Consulting
  • Board Member Emergency
    Medicine Patient Safety Foundation at
    www.empsf.org
  • 614 791-1468
  • sdill1_at_columbus.rr.com

2
2
3
You Dont Want One of These
4
The Conditions of Participation (CoPs)
  • Regulations first published in 1986
  • Manual updated January 31, 2014 and 456 pages
  • Tag number 0001 through 1164 and PI starts at
    tag 263
  • First regulations are published in the Federal
    Register then CMS publishes the Interpretive
    Guidelines and some have Survey Procedures 2
  • Hospitals should check this website once a month
    for changes
  • 1www.gpoaccess.gov/fr/index.html
    2www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/l
    ist.asp
  • az

5
Location of CMS Hospital CoP Manuals
CMS Hospital CoP Manuals new address www.cms.hhs.
gov/manuals/downloads/som107_Appendixtoc.pdf
6
CMS Hospital CoP Manual June 7, 2013
7
CMS Hospital CoP Manual
8
CMS Survey and Certification Website
www.cms.gov/SurveyCertificationGenInfo/PMSR/list.a
spTopOfPage
9
(No Transcript)
10
Access to Hospital Complaint Data
  • CMS issued Survey and Certification memo on March
    22, 2013 regarding access to hospital complaint
    data
  • Includes acute care and CAH hospitals
  • Does not include the plan of correction but can
    request
  • Questions to bettercare_at_cms.hhs.com
  • This is the CMS 2567 deficiency data and lists
    the tag numbers
  • Will update quarterly
  • Available under downloads on the hospital website
    at www.cms.gov

11
Number of Deficiencies for PI
  • CMS issued its first deficiency report in March
    of 2013
  • CMS plans to update quarterly
  • Issued reports in June and November of 2013
  • Issues report in January of 2014
  • Reports lists the name and address of all
    hospitals receiving deficiencies

12
Access to Hospital Complaint Data
13
Deficiency Data January 2014
Tag Number Section Number
263 QAPI 77
270 Provision of Services 13
271 272 Patient Care Policies 22
273 Data Collection and Analysis 142
274 Policy Emergency Services 4
14
Deficiency Data January 2014
Tag Number Section Number
276 Policies Drug Management 6
277 Policies Med Errors ADR 2
278 Policies Infection Control 11
279 Policies Nutrition 3
280 Patient Care Policies 6
15
Deficiency Data January 2014
Tag Number Section Number
280 Patient Care Policies 6
281-282 Patient Services 9
283 QI Activities 145
284 Patient Services 1
286 Patient Safety 191
16
Hospital CoPs for QAPI
  • CMS issued new hospital COPs memo for QA and
    Performance Improvement (QAPI)
  • CMS issues Memo March 15, 2013 on AHRQ Common
    Formats
  • Hospitals are required to track adverse events
    for PI
  • Starts with tag number 0263
  • Short section because the hospital compare
    program is not part of the CMS CoP
  • Hospital compare is the indicators that must be
    sent to CMS to receive full reimbursement rates

17
Report Adverse Events to PI
18
Adverse Event Reporting
  • Hospitals are required to track AE (adverse
    events)
  • Several reports show that nurses and others were
    not reporting adverse events and not getting into
    the PI system
  • OIG recommends using the AHRQ common formats to
    help with the tracking
  • States could help hospitals improve the reporting
    process
  • Encouraged all surveyors to develop an
    understanding of this tool

19
Adverse Event Reporting
  • IOM report discussed the need for comprehensive
    patient safety reporting to address the alarming
    high incidence of AE occurring in hospitals (Pg.
    2)
  • OIG report November, 2010 AE in Hospitals
    National Incidence Among Medicare Beneficiaries
    encouraged internal reporting of all AE, whether
    preventable or not
  • OIG issues report in January 2012 Hospital
    Incident Reporting Systems Do Not Capture Most
    Patient Harm
  • 86 of AE are never reported to the PI program
  • 44 are considered preventable

20
http//oig.hhs.gov/oei/reports/oei-06-09-00091.asp
21
http//oig.hhs.gov/oei/reports/oei-06-09-00090.pdf
22
Adverse Event Reporting
  • CMS PI section requires hospital to track AEs and
    analyze the causes and implement actions to
    prevent in the future
  • Need to include near misses
  • The internal hospital reporting system represents
    a foundational capability to determine if the
    hospital can maintain compliance with the CoPs
  • The AHRQ Common Formats are evidenced based
  • Common Formats allow for identification and
    reporting of any AE even if rare and includes NQF
    29 never events such as falls and medication
    errors

23
Events That Should be Reported
24
9 Modules in the Common Formats
  • 1. Blood or Blood Product
  • 2. Device or Medical/Surgical Supply, including
    Health Information Technology (HIT)
  • 3. Fall
  • 4. Healthcare-associated Infection
  • 5. Medication or Other Substance
  • 6. Perinatal
  • 7. Pressure Ulcer
  • 8. Surgery or Anesthesia
  • 9. Venous Thromboembolism
  • 10. Other (allows collection of information on
    all other types of events)

25
https//psoppc.org/web/patientsafety
26
Hospital Common Formats
27
The Conditions of Participation (CoPs)
  • The manual is known as the conditions of
    participation or the CoPs for short
  • The CoP sections are called tag numbers
  • When IG are final they are printed in a
    transmittal
  • All the sections contain a tag number so it is
    easy to go back and look up that section if you
    want to read more about it
  • There are currently 456 pages in the current
    manual
  • There were many changes in the manual effective
    June 7, 2013 but none to the PI section

28
Transmittals
www.cms.gov/Transmittals/01_overview.asp
29
Feb 4, 2013 Proposed Changes
  • CMS issues 114 pages related to proposed changes
    to the CMS CoP but none in PI section
  • Hospital privileges for RD to write diet orders
  • Board must consult with chief medical officer for
    each individual hospital regarding quality of
    medical care provided in the hospital
  • Confirmed each hospital must have separate
    medical staff
  • MS can include PharmD, dieticians, PA, NP, etc.
  • No requirement for board to include MD/DO

30
Feb 4, 2013 Proposed Changes
  • Allow practitioners not on MS to order outpatient
    services
  • Allow in-house preparation of radiopharmaceuticals
    on off hours without a physician or a pharmacist
    being present
  • 3 changes for hospitals that are transplant
    centers
  • ASC change for radiology services incident to the
    surgery
  • Swing beds move to Part D so accreditation
    organizations can survey
  • CAH PP committee deleted requirement for non
    staff member requirement

31
Feb 4, 2013 Proposed Changes
www.ofr.gov/inspection.aspx
32
CMS Worksheets Infection Control, Discharge
Planning and PI
33
CMS Hospital Worksheets Third Revision
  • October 14, 2011 CMS issues a 137 page memo in
    the survey and certification section
  • Memo discusses surveyor worksheets for hospitals
    by CMS during a hospital survey
  • Addresses discharge planning, infection control,
    and QAPI (performance improvement)
  • It was pilot tested in hospitals in 11 states and
    on May 18, 2012 CMS published a second revised
    edition
  • Piloted test each of the 3 in every state over
    summer 2012
  • November 9, 2012 CMS issued the third revised
    worksheet which is now 88 pages

34
CMS Hospital Worksheets
  • This is the third and final pilot and in 2014
    will be slightly revised
  • Will use whenever a validation survey or
    certification survey is done at a hospital by CMS
  • Third pilot is non-punitive and will not require
    action plans unless immediate jeopardy is found
  • Hospitals should be familiar with the three
    worksheets
  • Already assigned the number of hospitals to do in
    2014
  • Has money in the budget for states that want to
    do more

35
Third Revised Worksheets
www.cms.gov/SurveyCertificationGenInfo/PMSR/list.a
spTopOfPage
36
(No Transcript)
37
CMS Hospital Worksheets
  • Goal is to reduce hospital acquired conditions
    (HACs) including healthcare associated infections
  • Goal to prevent unnecessary readmission and
    currently 1 out of every 5 Medicare patients is
    readmitted within 30 days
  • Many hospitals (66) financially penalized after
    October 1, 2013 because they had a higher than
    average rate of readmissions
  • Forfeited 280 million dollars in 2013 and 216
    million in2014
  • The underlying CoPs on which the worksheet is
    based did not change

38
CMS Hospital Worksheets
  • However, some of the questions asked might not be
    apparent from a reading of the CoPs
  • A worksheet is a good communication device
  • It will help clearly communicate to hospitals
    what is going to be asked in these 3 important
    areas
  • Hospitals might want to consider putting together
    a team to review the 3 worksheets and complete
    the form in advance as a self assessment
  • Hospitals should consider attaching the
    documentation and PP to the worksheet

39
CMS Hospital Worksheets
  • This would impress the surveyor when they came to
    the hospital
  • The worksheet is used in new hospitals undergoing
    an initial review and hospitals that are not
    accredited by TJC, DNV, CIHQ, or AOA who have a
    CMS survey every three or so years
  • The Joint Commission (TJC), American Osteopathic
    Association (AOA) Healthcare Facility
    Accreditation Program, CIHQ, (Center for
    Improvement in Healthcare Quality) or DNV
    Healthcare
  • It would also be used for hospitals undergoing a
    validation survey by CMS

40
CMS Hospital Worksheets
  • The regulations are the basis for any
    deficiencies that may be cited and not the
    worksheet per se
  • The worksheets are designed to assist the
    surveyors and the hospital staff to identify when
    they are in compliance
  • Will not affect critical access hospitals (CAHs)
    but CAH would want to look over the one on PI and
    especially infection control
  • Questions or concerns should be addressed to Mary
    Ellen Palowitch at PFP.SCG_at_cms.hhs.gov

41
CMS Hospital Worksheets
  • First part of the pilot program draft version
    included identification information
  • Name of the state survey agency which in most
    states is the department of health under contract
    by CMS
  • In Kentucky it is the OIG or Office of Inspector
    General
  • It will ask for the name and address of the
    hospital, CCN number, number of surveyors, time
    spent on completing the tool, date of survey etc.

42
CMS Hospital Worksheets
  • Questions or concerns should be addressed to
    PFP.SCG_at_cms.hhs.gov
  • First part of the pilot program draft version
    included identification information
  • Name of the state survey agency which in most
    states is the department of health under contract
    by CMS
  • In Kentucky it is the OIG or Office of Inspector
    General
  • It will ask for the name and address of the
    hospital, CCN number, number of surveyors, time
    spent on completing the tool, date of survey etc.

43
CMS Worksheet QAPI
44
(No Transcript)
45
CMS Hospital Worksheets
  • CMS uses the term tracers for the first time
  • The first worksheet is on QAPI which stands for
    Quality Assessment Performance Improvement
  • CMS previously called it Quality Assurance
    Performance Improvement and changed June 7, 2013
  • The worksheet is a document that the surveyor
    will sit down with the hospital and fill out
  • The first column includes the elements to be
    assessed and there are boxes to fill in

46
Quality Indicator Tracers
47
PI Tracer Data Collection Analysis
  • This section is 21 pages long
  • First select three quality indicators related to
    PI activities or projects
  • An example might be the timing of medications and
    PI data to show medication was given on time and
    number of medication errors or missed or omitted
    doses
  • Number of catheter associated UTIs
  • Write the quality indicator at the top and answer
    the following questions for each one

48
PI Tracer Data Collection Analysis
  • Hospitals collect all kind of data
  • TJC requires data to be collected in a number of
    areas
  • Data on medication management (ADR, medication
    errors), FMEA, patient flow, staff compliance
    with employee health screening requirements,
    patient satisfaction, pediatric asthma, ED
    measures, infection control surveillance data
  • Data on RS use, patient perception of care,
    organ donation, blood transfusion reactions, ORYX
    data, medical record deficiency data, staffing,
    data on how patient communication needs are met,
    race and ethnicity etc.

49
PI Tracer Data Collection Analysis
  • CMS has hospital compare with data on number of
    MI patients who get thrombolytics timely or
    pneumonia patients who get their antibiotics
    timely
  • Measure patient experience or patient
    satisfaction data
  • Measure some or all of the AHRQ patient safety
    indicators
  • National Quality Forum includes lists of quality
    indicators that are evidence based that hospital
    may measure

50
PI Tracer Data Collection Analysis
  • Can you show evidence that each quality indicator
    is related to improved health outcomes?
  • Based on QIO, national guidelines, evidence based
    studies etc.
  • Is the scope of data collection appropriate to
    the indicator
  • Hand hygiene would require data from multiple
    parts of the hospital
  • ED or LD might be specific to date from that
    area such as the average LOS in the ED or the
    number of elective C-sections performed with
    premature infants

51
PI Tracer Data Collection Analysis
  • Is the method and frequency of data collection
    specified?
  • Such as chart reviews or monthly observations
  • Is the data collected in the manner specified and
    it is done as often as specified such as will do
    30 charts per month for ED documentation criteria
  • If unit staff play a role in data collection then
    is the data collection consistent with the
    specifications
  • Example OR staff complete a data collection tool
    with number of cases time out is taken and
    documented, HP and consent on chart before
    surgery, etc.

52
PI Tracer Data Collection Analysis
  • Are data collected aggregated in accordance with
    hospital methodology specified for this
    indicators
  • Is the data analyzed?
  • If indicator is type that measures rate are the
    rates calculated for points in time and compared
    to benchmark data set out by national
    organizations when available?
  • Pneumonia patients should get their first dose of
    antibiotics within 6 hours or MI patients
    thrombolytics in 30 minutes

53
PI Tracer Data Collection Analysis
  • Is data broken down into subsets that allow for
    comparison among hospital units
  • Such as hand hygiene or the fall rate
  • If data identified area that needs improvement
    then is there evidence the issue was addressed
  • Such as an infant abduction risk, high fall rate,
    high medication error rate
  • Are the interventions evaluated for success?
  • If not, what did the hospital do?

54
PI Tracer Data Collection Analysis
  • Does PI focus on high risk, high volume, or
    problem prone areas?
  • Orthropedic hospital does lots of Orthropedic
    projects or hospital that does CABG do PI on
    these
  • Can hospital prove it conducts distinct PI
    projects?
  • Should of course be reflected in the PI minutes
  • Every department should participate in PI process
  • Is number of projects proportional to the scope
    and complexity of the hospitals service and
    operations
  • Larger hospital expected to do more projects

55
PI Tracer Data Collection Analysis
  • Can hospital show evidence of why each project
    was selected?
  • CMS then has a section on patient safety that
    discusses adverse events (AE) and medical error
  • This part is to evaluate the hospitals
    leadership expectation for patient safety
  • Is there staff training or communications related
    to expectation for patient safety to all staff?
  • Is there a PP on non-punitive approach to staff
    reporting medical errors which includes near
    misses?

56
PI Patient Safety AE and Medical Errors
  • Can staff on each unit explain hospitals
    expectation for their role in promoting patient
    safety?
  • Is there a systematic process to identify medical
    errors which include near misses and AEs
  • On every unit, can the staff describe what is a
    medical error?
  • Can they explain how to report?
  • Does hospital employ other methods to find
    medical errors such as trigger tools, chart
    reviews, review of claims, patient grievances,
    interview patients etc.

57
Patient Safety LD, AE and Medical Error
58
PI Patient Safety AE and Medical Errors
  • Can hospital provide evidence of medical errors
    and AEs identified through staff reports?
  • Is there a PI program with the infection
    preventionist (IP) to track avoidable HAI?
  • IC section requires this and starts at tag 747
  • Are problems identified by the IP addressed
    through PI?
  • Does the PI program track medication errors and
    ADE and drug incompatibilities
  • Tag 508 revised May 20, 2011 to require this

59
PI Patient Safety AE and Medical Errors
  • Is there a process to report blood transfusion
    reaction and determine if due to medical error?
  • Did the survey team have prior knowledge of any
    serious AE that the hospital failed to identify?
  • Were any identified by the surveyors?
  • Has a RCA been done on all serious preventable
    AEs?

60
PI Causal Analysis Tracers Part 5
  • The next question discuss the causal analysis
    tracers
  • Causal analysis searches for the cause and effect
    or causes of the particular event or adverse
    outcome
  • More commonly referred to as a RCA or root cause
    analysis
  • The surveyor will select three causal analysis
    done for single event or near miss
  • Were underlying causes identified?

61
Causal Analysis Tracers
62
PI Causal Analysis Tracers
  • Was preventive actions developed based on the
    RCA?
  • TJC has a matrix which contains elements that
    must be included in a reviewable sentinel event
  • Has the hospital evaluated the impact of the
    preventable actions including tracking a
    reoccurrences or near misses?
  • Has the hospital implemented the preventable
    actions found to be effective unless there is a
    documented reason for not doing so?

63
TJC Framework for Conducting RCA
www.jointcommission.org/sentinel_event.aspx
64
TJC Sentinel Event Policy with Matrix
www.jointcommission.org/Sentinel_Event_Policy_and_
Procedures/
65
(No Transcript)
66
Broad PI Requirements Leadership
  • Part 6 addresses broad PI requirements and
    leadership responsibilities
  • Does the hospital have a formal PI program?
  • Most hospitals have a PI plan that discusses the
    PI program
  • Is there a written PP on the PI program?
  • Is there budgeted resources so staff can attend
    education programs and data can be collected?
  • Is there responsible staff to do PI
  • Is the PI program approved by MS, CEO, and the
    board?

67
Broad PI Requirements and Leadership
68
Broad PI Requirements and Leadership
  • Is there evidence of PI review for contracted
    services?
  • Is there evidence that the board, CEO, MS
    leadership and senior leaders have a role in PI
    planning and implementation?
  • Is there evidence of PI review in the board
    minutes?
  • Does the board approve the PI program quality
    indicators and how often the data is collected?
  • Determine how many projects for next year?
  • Does board hold CEO accountable for effectiveness
    of PI program?
  • CMS Board section starts at tag 38

69
CMS HOSPITAL CONDITIONS OF PARTICIPATION (COPS)
2014 What PPS Hospitals Need to Know About the
QAPI Section
70
CMS CoP PI Section Starts at Tag 263
71
Hospital CoPs for PI 263
  • QAPI stands for quality assessment performance
    improvement
  • Use to stand for Quality Assurance and
    Performance Improvement but changed June 7, 2013
  • Referred to in short as PI
  • Must have PI program that is ongoing,
    hospital-wide, data driven, and effective
  • The board must make sure the program reflects the
    complexity of the hospitals services

72
Hospital CoPs for PI
  • Includes all departments even if contracted
    services
  • Must focus on indicators related to improve
    health outcomes
  • How do you improve outcomes in the patient with
    hyponatremia?
  • How to improve outcomes in the diabetic patient
    admitted with hyperosmolar syndrome?
  • Must focus on the prevention and reduction of
    medical errors
  • What do you to prevent medical errors such as
    medication errors which is the most common type?

73
Program Scope 264
  • Standard The hospital must ensure that the
    program scope requirements are met
  • So what is the scope of activities of your PI
    program?
  • Is the scope your PI program to include an
    overall assessment of the efficacy of the PI
    activities with a focus on continually improving
    the care provided at your hospital?
  • Does it look at indicators for both process and
    outcome?
  • Are the indicators objective, measurable, and
    based on current knowledge and experience?

74
What is the Scope of Your PI Program?
  • Threats to patient safety
  • Eg. falls, patient identification, injuries
  • Medication therapy/medication use
  • Includes medication reconciliation
  • Includes the use of dangerous abbreviations
  • Infection control system, including healthcare
    associated infections (HAI)
  • Utilization Management System
  • Patient experience or satisfaction

75
What is the Scope of Your PI Program?
  • Discrepant pathology reports
  • Unanticipated deaths, adverse and/or sentinel
    events
  • Adverse event/near miss
  • Physical Environment Management Systems
  • Operative and invasive procedures
  • Including wrong site/wrong patient/wrong
    procedure surgery
  • Anesthesia/moderate sedation
  • Blood and blood components
  • Restraint use/seclusion

76
What is the Scope of Your PI Program?
  • Effectiveness of pain management system
  • Patient flow issues, to include reporting of
    patients held in the Emergency Department in
    excess of four hours
  • Other adverse events
  • Critical and/or pertinent processes, both
    clinical and supportive
  • Medical record delinquency
  • Other aspects of performance that assess process
    of care, hospital service and operation

77
Whats in Your PI Plan?
78
(No Transcript)
79
(No Transcript)
80
Scope of Activities of the PI Plan
81
(No Transcript)
82
Scope of PI Plan and Program
83
Board is Responsible for Quality of Care
84
Role of MEC in PI Plan and Program
85
Hospital Uses PDCA and FOCUS
86
Focus on High Risk and High Volume
87
Collect Data and Monitor
88
Identify Change and Implement
89
Ongoing Program 265
  • Standard The PI program must include an ongoing
    program
  • The program must show measurable improvements in
    indicators for which there is evidence that it
    will improve health outcomes
  • Hospitals has improved patient flow and admitted
    patients now get to their bed in four hours or
    less
  • Patients get their antibiotics timely in the OR
    now
  • Patients with pneumonia now get their antibiotics
    within the six hour window

90
Identify and Reduce Medical Errors 266
  • Standard The PI program needs to identify and
    reduce medical errors
  • First, the hospital need to identify that there
    is a medical error
  • It needs to be reported into the PI system
  • Risk management and hospital staff cannot fix a
    problem they do not know exists
  • Second, the hospital evaluates it to determine
    what processes can be put in place to prevent it
    from occurring
  • RCA and FMEA are two tools that can be used

91
Identify and Reduce Medical Errors 266
  • Medical errors may be difficult to detect in
    hospitals and are under reported
  • Make sure incident reports filled out for errors
    and near misses
  • Are there any diagnostic errors, equipment
    failures, blood transfusion injuries, or
    medication errors
  • Trigger tools by IHI can assist in finding
    medical errors and opportunities for improvement
  • Classen DC, Resar R, Griffin F, et al. Global
    Trigger Tool shows that adverse events in
    hospitals may be ten times greater than
    previously measured. Health Affairs. 2011
    Apr30(4)581-589.

92
IHI Global Trigger Tool wwww.ihi.org
93
Trigger Tool for Adverse Drug Events
94
Resources
  • Griffin FA, Classen DC. Detection of adverse
    events in surgical patients using the Trigger
    Tool approach. Quality and Safety in Health Care.
    2008 Aug17(4)253-258.
  • Classen DC, Lloyd RC, Provost L, Griffin FA,
    Resar R. Development and evaluation of the
    Institute for Healthcare Improvement Global
    Trigger Tool. Journal of Patient Safety. 2008
    Sep4(3)169-177.
  • Resar RK, Rozich JD, Simmonds T, Haraden CR. A
    trigger tool to identify adverse events in the
    intensive care unit. Joint Commission Journal on
    Quality and Patient Safety. Oct
    200632(10)585-590.

95
Track Quality Indicators 267
  • Standard the hospital must measure, analyze, and
    track quality indicators, including adverse
    events
  • This includes adverse patient events
  • This includes other aspects of performance that
    assess processes of care, hospital service, and
    operation
  • Want to focus on aspects and processes that
    related to the health and safety of patient care
    services
  • Look at what could result in a sentinel event if
    not properly managed
  • TJC has a sentinel event policy and lists
    reviewable SE

96
TJC Revised Sentinel Event Policy
www.jointcommission.org/Sentinel_Event_Policy_and_
Procedures/
97
Reviewable Sentinel Events
98
(No Transcript)
99
QAPI Standards
  • Standard Program Data (Tag 273)
  • Hospital must ensure that the program data
    requirements are met
  • Standard The PI program must incorporate quality
    indicator data including patient care data (Tag
    274)
  • For example, information submitted or received
    from the QIO
  • QIO stands for Quality Improvement Organization
    and every state has one under contract by CMS

100
CMS QIO Website
www.cms.gov/Medicare/Quality-Initiatives-Patient-A
ssessment-Instruments/QualityImprovementOrgs/index
.html?redirect/qualityimprovementorgs
101
List of QIOs
http//www.qualitynet.org/dcs/ContentServer?cPage
pagenameQnetPublic2FPage2FQnetTier2cid114476
7874793
http//www.qualitynet.org/dcs/ContentServer?cPage
pagenameQnetPublic2FPage2FQnetTier2cid114476
7874793
102
Outpatient Data Collection
103
CMS Hospital CoPs QAPI
  • Hospital uses data to monitor the effectiveness
    and safety of services and quality of care (275)
  • Hospital identify opportunities for improvement
    (276)
  • Board determines frequency and detail of data
    collection (277)
  • Hospital ensures that the program activities are
    met (283)
  • Hospital sets priorities and focuses on high
    risk, high volume, or problem prone (285)
  • Considers incidence and severity of problems

104
QAPI
  • Must not only track medical errors and adverse
    events but also analyze their causes (287, 288)
  • RCA is one tool to analyze causes
  • Includes preventive actions and learning
    throughout
  • Hospital must take action based on data (289)
    and measure its success (290)
  • Example process hospitals took to get MI patient
    timely thrombolytics and timely antibiotics and
    blood culture for pneumonia patients
  • TJC has accountability measures and CMS has value
    based purchasing (VBP)

105
CMS VBP Website
www.cms.gov/Medicare/Quality-Initiatives-Patient-A
ssessment-Instruments/hospital-value-based-purchas
ing/index.html?redirect/hospital-value-based-purc
hasing/
106
VBP Fact Sheet
107
VBP Clinical Process of Care Measures
108
(No Transcript)
109
CMS Hospital Compare
www.cms.gov/Medicare/Quality-Initiatives-Patient-A
ssessment-Instruments/HospitalQualityInits/Hospita
lCompare.html
110
CMS Outcome Measure Hospital Compare
111
QAPI
  • Hospital needs to document and track performance
    to make sure improvements are sustained (291)
  • Continue to track antibiotics given timely in the
    OR before surgical procedure and prophylactic
    treatment to prevent DVT/PE in major surgery
    patients
  • Number of PI projects depends on scope and
    complexity of hospital services so large hospital
    doing CABG would measure indicators on this (298)
  • Hospital may want to develop and implement IT
    system to improve patient safety and the quality
    of care (299)

112
QAPI
  • Hospital must document what PI projects are being
    done (300) and the reason for doing them (301)
    and progress on it (302)
  • The hospital is not required to participate in
    the QIO projects but its own projects are
    required to be of comparable effort (303)
  • Board, MS, and administration are responsible for
    and accountable for ongoing program (309)
  • These 3 must make sure the following are done
  • That an ongoing program for PI is defined,
    implemented and maintained (310)

113
QAPI
  • That there is an ongoing program for patient
    safety that includes reduction of medical errors
  • Decide which are priorities and that all
    improvement actions are evaluated (312)
  • Hospital must address issues to improve patient
    safety (313)
  • Clear expectations for patient safety are
    established (314)
  • Need adequate resources for PI and patient safety
    (315, 316) and number of projects is conducted
    annually (317)

114
QAPI Patient Safety
  • This means people who can attend meetings, data
    so analysis can be made and other resources
  • Safer IV pumps, new anticoagulant program,
    implement central line bundle, sepsis, and VAP
    bundle, preventing inpatient suicides, wrong site
    surgery, retained FB, new processes for
    neuromuscular blocker agents, implement policy
    on Phenergan administration and Fentanyl patches
  • So whats in your PI and Safety Plans?

115
National Quality Forum NQF
  • NQF is an excellent resource
  • Has the ABCs of measurement
  • A list of NQF endorsed standards
  • A list of consensus projects
  • Resources
  • Can do a search of measures such as AAA repair
    mortality rate, accidental puncture or laceration
    rate, 30 day post hospital MI discharge care
    transition rate, stroke mortality rate, adherence
    to medication for diabetic patients, etc.

116
AHRQ Has Excellent Resources
117
Quality Indicator Toolkit
www.ahrq.gov/legacy/qual/qitoolkit/
118
Patient Safety Indicators
119
Types of Indicators Inpatient, PS, Peds,
120
List of NQF Measures
121
National Quality Forum NQF
www.qualityforum.org/Home.aspx
122
TJC Performance Measurement
http//www.jointcommission.org/performance_measure
ment.aspx
http//www.jointcommission.org/performance_measure
ment.aspx
www.jointcommission.org/performance_measurement.as
px
www.jointcommission.org/performance_measurement.as
px
www.jointcommission.org/performance_measurement.as
px
123
Hospital Quality Alliance
www.hospitalqualityalliance.org/hospitalqualityall
iance/index.html
124
The End! Questions??
  • Sue Dill Calloway RN, Esq. CPHRM, CCMSCP
  • AD, BA, BSN, MSN, JD
  • President of Patient Safety and Education
    Consulting
  • Board Member Emergency
    Medicine Patient Safety Foundation at
    www.empsf.org
  • 614 791-1468
  • sdill1_at_columbus.rr.com
  • Call with questions, No emails, Thanks

124
124
About PowerShow.com