Franciscan St. Anthony Health
Michigan City, IN
Franciscan Health Services, Inc.
St. Margaret Health
Hammond
St. Anthony Health
Michigan City
Franciscan Alliance Corporate Office
St. James Health
Olympia Fields
Mishawaka
80
90
80
90
90
St. James Health
Chicago Heights
St. Margaret Health
Dyer
St. Anthony Health
Crown Point
65
St. Elizabeth Health
Lafayette
St. Elizabeth Health
Crawfordsville
St. Francis Health
Mooresville
St. Francis Health
Beech Grove
St. Francis Health
Indianapolis
65
Franciscan Alliance
Mission Driven Quality Goals
• Adherence to the CMS Core Measures is rooted in the
Franciscan Alliance culture at the facility, regional, and
corporate level which is accomplished through
continuous process improvement and focus on CMS
best practice standards with robust communication at all
levels, as well as through results reporting on the
Franciscan Alliance Corporate Report. The color green
on this report is associated with achieving results in line
with the top 10% of hospitals in the nation. FSAH used
this cultural norm to launch the Quality Rounding
Program with the slogan:
It Takes a Team to Go Green!
Purpose and Goal
Purpose:
• Assist the facility in compliance with the CMS quality initiatives,
and to move our results on the Franciscan Alliance Corporate
Report from red or yellow to green.
• Prepare FSAH to compete as healthcare reimbursement moves to
Value-Based Purchasing.
Goal:
• The broad goal of the Quality Rounding Program is to assist FSAH
in elevating the quality and consistency of patient care delivery
through improvement with compliance to the CMS Core Measure
Standards through a collective experience of teamwork,
communication and accountability.
Franciscan Alliance Corporate Report – CMS Quality Measures
Action Plan
Caution Zone
Way to Go!
Value-Based Purchasing (VBP)
• In 2010 VBP became required by the Affordable Care Act to provide
value-based incentive payments to hospitals beginning in FY 2013 for
two domains: Clinical Process Measures and HCAHPS.
• CMS has outlined proposals for the VBP Program and views it a vital
link to moving increasingly toward rewarding better value, outcomes
and innovations instead of volume.
• FY 2013 payment determination will be based upon comparing a
hospital’s performance of the chosen measures during a performance
period (7/1/2011 – 3/31/2012) to a baseline period (7/1/2009 – 3/31/
2010).
• FY 2014 payment determination will include mortality measures, as
well as certain hospital-acquired conditions and patient safety/inpatient
quality indicators.
• At risk is a 1% reduction of FY 2013 base operating DRG payments,
with a .25% added reduction per year.
VBP Scoring
•
Total Performance Score:
– 70% Clinical Process Measures
– 30% HCAHPS
•
Two scores will be awarded for each measure: Achievement and
Improvement, with the higher score used
– Attainment
• 0 to 10 points awarded for achievement based on where the hospital’s
performance for the measure falls relative to an achievement threshold
(proposed to be at the 50th percentile during the baseline period) and the
benchmark (proposed to be at the mean of the top decile).
– Improvement
• 0 to 9 points scored relative to a hospital’s performance during the
performance period compared to its own performance during the baseline
period.
•
For HCAPHS, up to an additional 20 consistency points are possible to
obtained
• CMS feels that consistency points encourage hospitals to meet or exceed
the achievement threshold.
• If all HCAHPS scores are > the achievement threshold than all 20 points will
be awarded.
Value-Based Purchasing
HCAHPS
30%
CMS Core
Measures
70%
Achieving and sustaining top box scores will be vital to survival!
Goal Attainment Through Focused Objectives
•
During Quality Rounding the Quality Services
team focuses on the following objectives:
–
–
–
–
–
Performing concurrent review and abstraction
Capturing CMS documentation compliance prior to
discharge
Providing “just-in-time” education and support for
staff and physicians
Ensuring timely feedback of results for
accountability
Identifying and improving processes to eliminate
barriers to compliance through teamwork
Key to Success:
Multidisciplinary Approach
Quality
Services
Pharmacy
Staff
Medical Staff
Patient
Patient Care
Staff
Documentation
Specialist
Case
Management
Informatics
Staff
Quality Rounding Process Flow
Obtain Reports
Census Report
Surgery Schedule
Pneumo/Flu Status Reports
Review Portal
Test Results
Admission Hx
Home Med List
H&P/Dicated Consults
Round on Floors
Read MD Notes
Talk w/ MD/Nursing Staff
Leave Rounding Notes
Follow Up
RN
Documentation
Issue
NO
NO
Yes
NO
MD
Documentation
Issue
Yes
Discuss w/ RN
or Leave Note
on Chart
Discuss w/ MD
or Leave Note
on Chart
Issue
Resolved
Issue
Resolved
Yes
Yes
Record Information
on Abstraction Tool
Abstract Record
as Usual
NO
Day in the Life of a Quality Rounder
•
Run daily census report and surgery schedule
•
Log onto physician portal and review:
– Test results
•
•
•
•
•
Labs (cardiac enzymes, BNP level, blood cultures & lipid panel performed)
Chest Xray/CT (congestion, edema, infiltrates, consolidation, etc.)
Abdominal Xray/CT (obstruction, free air, ileus, infarcted bowel, perforation, etc.)
Other Xray/CT/Angiography (fractures, occlusion, aneurysm, etc.)
EKGs, Stress Tests, Echocardiograms
– Admission History
• Current smoker or quit within last 12 months
• Vaccination status
• Past medical history (i.e., CHF)
– Home medication list
• Close attention to ACE/ARB, Beta-Blocker, Coumadin, Aspirin, Statin,
Antiboitics, Immunosuppressives
– Dictated H&Ps/Consults/Operative Reports
– Electronic Nursing Charting
• Pre-op/Intraop/PACU charting
• Narrative notes
• Clinical documentation (I&O, ADLs, etc)
Day in the Life of a Quality Rounder
• Round on Units - Interventions Include:
– Review Emergency Department documentation
– Read physician progress notes/physicians orders
– Confer with documentation specialist
– If patient has a history of HF, an automatic education
referral will be ordered
– Talk one-to-one with physicians and/or nurses
– Leave rounding notes on chart for physicians and/or
nurses
– Follow up on previous day’s active patient records
Core Measure Focus
•
Heart Failure Measures
–
LV Assessment:
? Appropriate testing ordered
? LV function/EF documentation within physician documentation
? Reason for not assessing documented
–
ACE/ARB for LVSD
? ACE/ARB ordered
? Contraindication documented within physician documentation
If the answer is always no, note left for physician to ensure measure compliance
–
Smoking Cessation
? Current smoker and/or quit within last 12 months
? Education refusal documented / Smoking cessation education ordered
? Education completed
If near discharge and the education not completed, contact Cardiac Services and/or inform patient’s nurse that
education has not been done
–
HF Discharge Instructions
?
?
?
?
Admission origin
HF discharge education ordered
Education completed
Discharge medications & Discharge summary match
If near discharge and the education not completed, contact Cardiac Services and/or inform patient’s nurse
that education has not been done
If discharge summary is missing a medication that physician ordered/patient went home on, meet with physician
to review case. Physician can dictate an addendum within 30 days, if appropriate.
Core Measure Focus
• AMI Measures
– Aspirin on arrival
? Aspirin given within 24 hours prior to arrival or administer within 24
hours after arrival
? Contraindication documented within physician documentation
– EKG positive & Angioplasty performed
? Balloon/Stent inflated/deployed within 90 minutes
? Reason for delay documented
– ACE/ARB for LVSD ordered
? ACE/ARB ordered
? Contraindication documented within physician documentation
– Aspirin at discharge
? Aspirin ordered
? Contraindication documented within physician documentation
If the answer is always no, note left for physician to ensure
measure compliance
Core Measure Focus
• AMI Measures (cont)
– Beta-Blocker at discharge
? Beta-Blocker ordered
? Contraindication documented within physician documentation
– Statin at discharge
? Statin ordered
? Contraindication documented within physician documentation
If the answer is always no, note left for physician to ensure
measure compliance
– Smoking Cessation
? Current smoker and/or quit within last 12 months
? Education refusal documented / Smoking cessation education ordered
? Education completed
If near discharge and the education not completed, contact Cardiac Services
and/or inform patient’s nurse that education has not been done
Core Measure Focus
• Pneumonia Measures
– Antibiotic given within 6 hours of arrival
– Appropriate antibiotic given
– Blood Culture collected before antibiotic
The above measures do not allow for a yes/no answer…it is what it is!
– Smoking Cessation
? Current smoker and/or quit within last 12 months
? Education refusal documented / Smoking cessation education ordered
? Education completed
If near discharge and the education not completed, contact Cardiac Services and/or inform patient’s nurse
that education has not been done
– Pneumococcal / Influenza vaccinations
? Patient up-to-date with vaccines
? Contraindication documented
? Vaccine administered
Note left for nursing staff on patient’s Kardex as a reminder that patient qualifies and vaccine(s) need to
be given before discharge or document contraindication…daily re-checks and calls to nurse until vaccine given
Core Measure Focus
• SCIP Measures
– Beta-Blocker within appropriate timeframe
? Beta-Blocker given / taken prior to surgery
? Contraindication documented within physician documentation
If the answer is always no, note left for physician to ensure measure compliance
If patient’s nurse failed to document date & time of last home dose, the nurse to reinterview patient to obtain information.
– VTE prophylaxis ordered
? Appropriate mechanical/pharmacological VTE prophylaxis ordered
? Contraindication documented within physician documentation
– Foley discontinued by POD 2
• Foley discontinued
• ICU patient and receiving IV Lasix
• Reason to keep documented
– Antibiotic stopped within 24 hours of anesthesia end time
? Appropriate post-op antibiotics ordered (Q8 X 2 doses, Q12 X 1 dose)
? Post-op infection documented
If the answer is always no, note left for physician to ensure measure compliance
Core Measure Focus
• SCIP Measures (cont)
– VTE prophylaxis given / on
? Ordered VTE prophylaxis given / status documented
Nurse contacted and reminded that the medication needs to be given
by X time and/or mechanical prophylaxis needs to be documented on.
– Antibiotic prior to incision
? Pre-op infection
? Pre-op antibiotic given and documented
Contact Anesthesia Medical Director to review and follow up
– Perioperative temperature management
? Forced air warming unit documented as on patient during surgery
? 1st post-op temperature documented
– Hair Removal
? Hair removal method documented
Contact Surgery / PACU Manager to review and follow up
Measure Awareness
CMS QUALITY INITIATIVES
REVISED 9/22/2010
HOSPITAL QUALITY ALLIANCE (INPATIENT)
• Ensuring that all
are aware of the
CMS measures,
this document is
laminated on bright
yellow paper and
placed in nursing
staff and physician
areas of the
hospital (i.e., break
rooms, lounges).
Acute Myocardial Infarction Patients
• Aspirin on arrival
• Aspirin prescribed at discharge
• ACE-I or ARB for LVSD
• Adult smoking cessation advise/counseling
• Beta blocker prescribed at discharge
• Thrombolytic Agent within 30 minutes of hospital arrival
• PCI received within 90 minutes of hospital arrival
• Statin at discharge (beginning 1/1/2011)
Heart Failure Patients
• Discharge instructions
• LV function assessment
• ACE-I or ARB for LVSD
• Adult smoking cessation advice/counseling
Pneumonia Patients
• Pneumococcal vaccination
• Blood cultures performed in the Emergency Department prior to initial antibiotic received in hospital
• Blood cultures within 24 hrs prior to or 24 hrs after arrival for patients transferred or admitted to ICU within 24 hrs of arrival
• Adult smoking cessation advice/counseling
• Initial antibiotic received within 6 hrs (360 min) of hospital arrival
• Initial antibiotic selection for Community-Acquired Pneumonia (CAP) in Immunocompetent patient
• Influenza vaccination
Surgical Patients (SCIP)
• Prophylactic antibiotic received within 1 hour prior to surgical incision
• Prophylactic antibiotic selection for surgical patients
• Prophylactic antibiotic discontinued within 24 hrs after surgery end time
• Cardiac Surgery patients with controlled post-operative serum glucose (POD 1 & 2)
• Surgery patients with appropriate hair removal
• Surgery patients on a beta-blocker prior to arrival who received a beta-blocker during the perioperative period
• Surgery patients with recommended VTE prophylaxis ordered
• Surgery patients who received appropriate VTE prophylaxis within 24 hrs prior to surgery to 24 hrs after surgery
• Urinary catheter removed on post-op day 1 or 2
• Surgery patients with perioperative temperature management
Pediatric Asthma Patients
• Relievers for inpatient asthma
• Systemic Corticosteroids for inpatient asthma
• Home Management Plan of Care
HOSPITAL OUTPATIENT PROGRAM
Acute Myocardial Infarction & Chest Pain
(patients seen in the ED and discharged/transferred to a shortterm acute care hospital for inpatient care)
• Median time to fibrinolysis
• Fibrinolytic therapy received within 30 minutes
• Median time to transfer to another facility for acute coronary
intervention
• Aspirin at arrival
• Median time to ECG
Outpatient Surgery
• Antibiotic timing
• Antibiotic selection
Imaging Efficiency
• MRI Lumbar Spine for Low Back Pain
• Mammography Follow-up Rates
• Abdomen CT - Use of Contrast Material
• Thorax CT - Use of Contrast Material
PRESENT ON ARRIVAL (POA) MEASURES
• Object left in surgery
• Air embolism
• Blood incompatibility
• Catheter-Associated urinary tract infections
• Pressure ulcers (decubitis ulcers) stages III and IV
• Vascular catheter-associated infection
• Surgical site infection – mediastinitis after CABG surgery
• Hospital acquired injuries – fractures, dislocations,
intracranial injury, crushing injury, burn, etc.
• Manifestations of poor glycemic control
CMS Tri-fold Pocket Guide
•
•
In keeping with our facility motto…It takes a Team to go GREEN, a pocket sized
education tool was developed.
These guides will be provided to our physicians and nursing staff
–
A small but great reminder of SAM’s commitment to the CMS quality measures
Educational Tools
Appropriate antibiotic selection tables posted in the physician dictation areas within
Surgery, Outpatient Surgery, ICU and the medical/surgical inpatient units.
Request for Documentation
• Below is the documentation request that is left for
the physicians when there is a potential measure
non-compliance.
• Contact with the individual physician/surgeon
occurs when note is not addressed.
Variances
• When a variance is identified, the Quality
Rounders update a spreadsheet and issue a letter
of non-compliance.
• Real-time information is available to department
director and vice president.
PN Variances - 2010
Measure
Antibiotic Selection
January
February
March
April
May
June
July
August
Variances
100% compliant
100% compliant
100% compliant
100% compliant
100% compliant
100% compliant
100% compliant
1 = only one appropriate abx (Rocephin) ordered in the ED / EBOS not used, guideline recommends tw o (Rocephin & Zithromax)
Improvement in ACM Scores
Appropriate Care Measure (ACM)
Set
Total Year (before QR)
(2008)
Total Year
(2009)
Year To Date
(2010)
Acute Myocardial Infarction (AMI)
86.6%
89.4%
97.7%
Heart Failure (HF)
90.0%
95.7%
98.8%
Pneumonia (PN)
68.2%
91.5%
93%
Surgical Care Improvement
Program (SCIP)
78.3%
85.5%
94.1%
•
Source: SSFHS Quality Improvement CMS BIS Report-AMC Scores. Retrieved: 4/18/2011
CMS Quality Measures
It takes a Team to go GREEN!
2010
AMI (Acute MI)
Top 10%
Aspirin on arrival
Betw een
2011
National Mean
1st Q
2nd Q
3rd Q
4th Q Jan-11 Feb-11 Mar-11
100%
94%
97%
100%
100%
100%
100%
100%
100%
Aspirin prescribed at discharge
100%
91%
100%
100%
95%
100%
100%
100%
100%
ACEI or ARB for LVSD
Beta blocker prescribed at
discharge
Fibrinolytic therapy received
w ithin 30 minutes of hospital
Primary PCI received w ithin 90
min. of hospital arrival
100%
89%
100%
100%
100%
100%
N/A
100%
100%
100%
92%
100%
100%
100%
100%
100%
100%
100%
100%
82%
N/A
N/A
N/A
N/A
N/A
N/A
N/A
97%
82%
100%
100%
100%
100%
100%
100%
100%
Celebrate the Green!!
2010
HF (Heart Failure)
Top 10%
Betw een
2011
National Mean
1st Q
2nd Q
3rd Q
4th Q Jan-11 Feb-11 Mar-11
Evaluation of LVS function
100%
87%
100%
100%
100%
100%
95%
100%
100%
ACEI or ARB LVSD
Adult smoking cessation
advise/counseling
Discharge instructions
100%
88%
100%
100%
96%
100%
100%
100%
100%
100%
90%
100%
100%
100%
100%
100%
100%
100%
97%
71%
98%
100%
98%
98%
100%
100%
100%
CMS Quality Measures
It takes a Team to go GREEN!
PN (Pneum onia)
Top 10%
Betw een
National Mean
1st Q
2nd Q
3rd Q
4th Q
100%
96%
100%
100%
100%
100%
98%
100%
100%
100%
Jan-11 Feb-11 Mar-11
Pneumococcal vaccination
97%
82%
92%
Influenza vaccination
Initial blood cultures collected in
the ED prior to antibiotic
Adult smoking cessation
advise/counseling
Initial antibiotic received w ithin 6
hours (360 min) of hospital arrival
Initial antibiotic selection for
Community-Acquired Pneumonia
(CAP) in Immunocompetent patient
97%
82%
94%
99%
90%
96%
100%
97%
100%
90%
100%
100%
100%
87%
100%
100%
100%
100%
100%
100%
100%
100%
93%
100%
96%
100%
97%
100%
100%
100%
97%
87%
100%
100%
95%
96%
100%
100%
100%
Continually work on opportunities
2010
SCIP (Sur gical Car e
Im pr ove m e nt Pr oje ct)
Prophylatic antibiotic received
w ithin 1 hour prior to surgical
incision
Prophylatic antibiotic selection f or
surgical patients
Prophylatic antibiotic discontinued
w ithin 24 hours af ter surgery end
time
Cardiac surgery patients w ith
controlled blood Glucose in days
right af ter surgery
A ppropriate hair removal
A ppropriate V TE prophylaxis
ordered
Receive appropriate V TE
prophylaxis w ithin 24 hours prior
to surgery to 24 hours af ter
surgery
Urinary catheter removed w itin
tw o days of surgery
Surgery pateints w ith
perioperative temperature
management
Top 10%
Betw een
2011
National Mean
1st Q
2nd Q
3rd Q
4th Q
Jan-11
Feb-11
Mar-11
98%
85%
96%
97%
100%
97%
100%
100%
94%
99%
92%
97%
99%
97%
99%
100%
100%
100%
98%
83%
100%
96%
98%
97%
96%
100%
94%
100%
86%
100%
100%
100%
83%
100%
N/A
100%
100%
95%
100%
100%
100%
100%
100%
100%
100%
97%
82%
100%
98%
100%
98%
100%
92%
92%
96%
82%
100%
98%
100%
98%
100%
92%
92%
97%
82%
98%
95%
100%
99%
100%
100%
100%
100%
99%
100%
100%
100%
100%
100%
Data Not Pub lished
Continuous Improvement
Prophylactic antibiotic received within 1 hour prior to surgical incision
SAM Monthly Data
Top 10% Scoring Hospitals
National Average
State Average
100%
24/25
95%
30/32
30/31
19/20
16/17
17/18
90%
85%
80%
March 2010
Emergent ruptured AAAs - Quality educated physicians on requirement for 1hr abx
to include even emergent cases
April & May 2010
New CRNAs began
October 2011
OR at 1044 and abx given at 0910
December 2011
OPS RN gave abx at 0820 but OR did start until 1257 - CRNA didn't redose abx.
March 2011
Abx given at 0920 and incision occurred at 1038, 18 mintues too late
75%
70%
65%
60%
55%
Fe
b11
M
ar
-1
1
Ja
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ec
-1
0
D
ov
-1
0
N
ct
-1
0
O
Ju
l-1
0
Au
g10
Se
p10
Fe
b10
M
ar
-1
0
Ap
r10
M
ay
-1
0
Ju
n10
Ja
n10
ec
-0
9
D
ov
-0
9
N
ct
-0
9
O
Ju
l-0
9
Au
g09
Se
p09
09
M
ay
-0
9
Ju
n09
Ap
r-
Fe
b09
M
ar
-0
9
Ja
n09
50%
Continuous Improvement
Primary PCI received within 90 minutes of arrival - AMI patients
(breaks in data = no population)
SAM Monthly Data
Top 10% Scoring Hospitals
National Average
State Average
100%
95%
90%
85%
80%
75%
Quality Rounders work
with physicians to
educate regarding
thorough documentation
for compliance
70%
2/3
65%
60%
55%
50%
1/2
45%
Fe
b11
M
ar
-1
1
Ja
n11
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-1
0
D
ov
-1
0
N
ct
-1
0
O
Ju
l-1
0
Au
g10
Se
p10
Fe
b10
M
ar
-1
0
Ap
r10
M
ay
-1
0
Ju
n10
Ja
n10
ec
-0
9
D
ov
-0
9
N
ct
-0
9
O
Ju
l-0
9
Au
g09
Se
p09
09
M
ay
-0
9
Ju
n09
Ap
r-
Fe
b09
M
ar
-0
9
Ja
n09
40%
Continuous Improvement
Surgery patients on a beta-blocker prior to arrival who received a
beta-blocker during the perioperative period
Top 10% Scoring Hospitals
SAM Monthly Data
National Average
State Average
100%
95%
90%
85%
Action:
Quality Rounding continually educated Nursing
staff on documenting date & time of patient’s last
home dose.
80%
75%
70%
Attended Nursing and Physician Department
meetings to review measure and results.
65%
Anesthesia pre-op assessment form revised to
ensure compliance.
60%
55%
Fe
b11
M
ar
-1
1
Ja
n11
ec
-1
0
D
ov
-1
0
N
Ju
l-1
0
Au
g10
Se
p10
O
ct
-1
0
Fe
b10
M
ar
-1
0
Ap
r10
M
ay
-1
0
Ju
n10
Ja
n10
ec
-0
9
D
ov
-0
9
N
Ju
l-0
9
Au
g09
Se
p09
O
ct
-0
9
09
Ju
n09
M
ay
-
Fe
b09
M
ar
-0
9
Ap
r09
Ja
n09
50%
Continuous Improvement
CHF Discharge Instructions - HF Patients
SAM Monthly Data
Top 10% Scoring Hospitals
National Average
State Average
100%
95%
19/20
90%
19/20
13/14
85%
80%
75%
70%
65%
60%
55%
July 2010
MD ordered med on d/c but it was not put on pts med list for home
October 2010
Discharge medications did not match. Discharge summary did not list all
medications patient went home on. MD dictated addendum but was over 30 from
discharge.
January 2011
Discharge medication did not match. Discharge summary did not list all
medications patient went home on.
Ja
n09
Fe
b09
M
ar
-0
9
Ap
r- 0
M 9
ay
-0
9
Ju
n09
Ju
l-0
Au 9
g0
Se 9
p09
O
ct
-0
9
No
v0
De 9
c09
Ja
n10
Fe
b1
M 0
ar
-1
0
Ap
r- 1
M 0
ay
-1
0
Ju
n10
Ju
l-1
Au 0
g1
Se 0
p10
O
ct
-1
0
No
v1
De 0
c10
Ja
n11
Fe
b11
M
ar
-1
1
50%
Continuous Improvement
Pneumococcal Vaccination Administered prior to Discharge - PN Patients
SAM Monthly Data
Top 10% Scoring Hospitals
National Average
State Average
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
-1
1
ar
1
-1
1
M
Fe
b
10
n1
Ja
10
ec
D
ov
-
0
-1
0
N
O
ct
0
Se
p1
l-1
g1
0
Au
0
Ju
n1
-1
0
Ju
ay
M
r-1
0
Ap
-1
0
ar
0
-1
0
M
Fe
b
09
n1
Ja
09
ec
D
ov
-
9
-0
9
N
O
ct
9
Se
p0
l-0
g0
9
Au
9
Ju
n0
-0
9
Ju
ay
r-0
9
M
Ap
-0
9
ar
-0
9
M
Fe
b
Ja
n0
9
50%
Continuous Improvement
Ultrasound Guided Biopsies
Pre-operative Antibiotic Documented
(breaks in data = no patients)
100%
90%
80%
Action:
July 2009 - changed vendors for CMS
data submission.
70%
60%
60%
October 2009 - Began abstraction of
3Q2009 data.
50%
Previous vendor did not capture
ultrasound guided biopsies in patient
population. Abstracted missing
population and resubmitted cases.
During abstraction of these cases
identified issue with no documentation of
pre operative antibiotic.
40%
30%
20%
11%
10%
n11
Ja
D
ec
-
10
10
ov
N
-1
0
O
ct
0
p1
Se
Au
g1
0
0
l-1
Ju
n10
Ju
-1
0
M
ay
r-1
0
Ap
-1
0
M
ar
b10
Fe
n10
Ja
D
ec
-
09
09
ov
N
-0
9
O
ct
Se
p0
9
0%
Continuous Improvement
Pacemaker Procedures
Appropriate Antibiotic Selection
(breaks in data = no patients)
100%
90%
80%
80%
80%
75%
70%
60%
50%
40%
30%
Action:
Change in practice identified w ith particular practitioner.
Quality Services, along w ith Infection Control, m et w ith
practitioner to explain m easure guidelines.
20%
10%
Pre-printed pre and post operative order set changed
to include guidelines, w hich w ill ensure com pliance.
11
M
ar
-
Fe
b11
Ja
n11
ec
-1
0
D
ov
-1
0
N
ct
-1
0
O
Se
p10
Au
g10
Ju
l-1
0
Ju
n10
10
M
ay
-
10
Ap
r-
10
M
ar
-
Fe
b10
Ja
n10
ec
-0
9
D
ov
-0
9
N
ct
-0
9
O
Se
p09
Au
g09
Ju
l-0
9
0%
Quality Rounding (QR)
• Highlights of our teamwork…
2E
ACEI/ARB for
LVSD
Per cardiology consult pt had moderate decrease in LV function.
However, no ACEI was prescribed during stay or on discharge. Situation
identified during QR, and QR spoke with MD who then dictated the
reason for not prescribing in the discharge summary. Contraindication
dictated in discharge summary – record excluded.
ICU
Beta-Blocker
Beta-Blocker ordered on admission MAR but was not on medication list.
QR re-faxed paperwork to Pharmacy during rounding. Medication now
on current MAR – measure passed.
ICU
ACEI/ARB for
LVSD
No documented reason why patient was not prescribed an ACE/ARB for
LVSD. Quality Services spoke with Cardiologist. Cardiologist stated
patient is allergic to ACE and ARB. Allergy order documented within
chart – measure passed.
3S
HF Education
QR left per protocol order in chart for HUC to order. Called Cardiac
Services 5/11/2010 because referral not completed and patient getting
ready for discharge. QR spoke with Cardiac Services RN. Education
completed – measure passed.
2S
Continued postop abx
MD ordered one dose of Ancef past 24 hr timeframe which would result
in noncompliance. During rounding, QR paged MD and explained criteria
for ordering post op ABX. MD then cancelled the order for Ancef as
criteria not met – measure passed.
Rounding Successes
Variances Corrected Prior to Discharge
Measure
1Q2009
2Q2009
3Q2009
4Q2009
1Q2010
2Q2010
Pneumococcal
Vaccines
0 issues
2 issues corrected
w/o corrections =
91%
Actual = 96%
3 issues corrected
w/o corrections =
86%
Actual = 96%
0 issues
0 issues
3 issues corrected
w/o corrections =
88%
Actual = 100%
Pre-operative
Antibiotics
2 issues corrected
w/o corrections =
78%
Actual = 82%
5 issues corrected
w/o corrections =
91%
Actual = 99%
5 issues corrected
w/o corrections =
88%
Actual = 95%
2 issues corrected
w/o corrections =
94%
Actual = 98%
5 issues corrected
w/o corrections =
86%
Actual = 96%
7 issues corrected
w/o corrections =
88%
Actual = 97%
LV Assessments
1 issue corrected
w/o corrections =
97%
Actual = 99%
3 issues corrected
w/o corrections =
96%
Actual = 100%
2 issues corrected
w/o corrections =
97%
Actual = 100%
3 issues corrected
w/o corrections =
94%
Actual = 100%
3 issues corrected
w/o corrections =
95%
Actual = 100%
3 issues corrected
w/o corrections =
94%
Actual = 100%
VTE Documented
Timely
0 issues
4 issues corrected
w/o corrections =
85%
Actual = 100%
0 issues
0 issues
2 issues corrected
w/o corrections =
95%
Actual = 100%
2 issues corrected
w/o corrections =
94%
Actual = 98%
Objectives Met:
• Performing concurrent review and abstraction
– QR uses the daily census report and surgery schedule
– Specific admission reports
– Daily discussions w/ charge nurse, and the clinical
documentation specialist for identification for chart review.
Objectives Met:
• Capturing CMS documentation compliance
prior to discharge
– QR identifies standard compliance opportunities and
discusses individual cases w/ nurses and MD’s
– Calls MD’s directly, or leaves rounding notes
– Emails clinical mgrs and supervisors w/ open cases
– The QR team also works with the EBOS Facilitator to
ensure CMS compliance
Objectives Met:
• Providing “just-in-time” education and support
for staff and physicians
– The success of this program is relationship driven
– QR has developed a good report with physicians and staff
through continual communication offering daily support
while rounding on the units
– The QR team has developed a one page Core Measure
Fact Sheet and CMS Pocket Guide
– Quality Services page on the Intranet which includes
CMS data definitions.
Objectives Met:
• Ensuring timely feedback of results for
accountability
– Provides daily feedback via:
•
•
•
•
rounding
staff meetings
email alerts
variance reporting through letters to physicians and
clinical managers
• reporting variances at medical staff meetings
Objectives Met:
• Identifying and improve processes to
eliminate barriers to compliance
– When trends are identified while rounding, the QR team
brings stakeholders together more timely to work on
processes.
Overall Impact:
Improved teamwork, awareness, and
accountability through relationship building
and ongoing and timely communication
among Quality Services, Medical Staff,
Nursing and Ancillary Staff resulting in
increased quality of care delivery,
consistency in practice and compliance to
standards as evidenced by our results!
Amy Baker, AD
CMS Data Analyst
amy.baker@franciscanalliance.org
Deborah Kelley, LPN
Clinical Data Coordinator
deborah.kelley@franciscanalliance.org
Genevieve Koehler, RN, CPHQ
Director of Quality
genevieve.koehler@franciscanalliance.org