Indiana Association for
Healthcare Quality
May 8, 2014
To promote and provide essential public health
services
Patient Safety Initiative: Assessing Quality
Through the Survey Process Using the Three
CoP Worksheets
Randy Snyder, PT, MBA
Division Director, Acute Care
Indiana State Department of Health
Objectives:
Gain an understanding of the key
measures used to assess quality
through the use of three survey
worksheets implemented within the
survey process.
Identify two primary goals associated
with the patient safety initiative.
Objectives:
Apply non-surveyor use of the
worksheets to their respective
facilities to assess quality.
Identify the key differences between
state licensure surveys and federal
certification surveys.
In the Beginning…..
The Administration and Congress created
the Health Care and Education
Reconciliation Act of 2010
AKA: Patient Protection and Affordable Care Act
AKA: Affordable Care Act
AKA: Obamacare
ACA: Section 3011
Improve research and dissemination of
strategies and best practices to
improve patient safety and reduce
medical errors, preventable
admissions and readmissions, and
health care-associated infections;
ACA Section 3021
CENTER FOR MEDICARE AND MEDICAID
INNOVATION ESTABLISHED
http://dhhs.nv.gov/HealthCare/Docs/reimbursement/ACA3021InnovationCenter.pdf
CMS Innovation Center:
The Partnership for Patients initiative is a
public-private partnership working to
improve the quality, safety and
affordability of health care for all
Americans. Physicians, nurses, hospitals,
employers, patients and their advocates,
and the federal and State governments
have joined together to form the
Partnership for Patients.
http://innovation.cms.gov/initiatives/partnership-for-patients/index.html
PfP Primary Goals:
Making Care Safer. By the end of 2013,
preventable hospital-acquired conditions
would decrease by 40% compared to 2010.
Improving Care Transitions. By the end of
2013, preventable complications during
transition from one care setting to another
would be decreased so that all hospital
readmissions would be reduced by 20%
compared to 2010.
Patient Safety Initiative
HHS announces a $1 Billion Patient
Safety Initiative
Survey and Certification’s Role:
CMS develops and issues Hospital
Patient Safety Initiative Worksheets.
Implementation
FFY 11: Piloted by several states.
FFY12: Each state used the worksheet
at least one time.
FFY13: All three used for selected
hospitals
Sample Selection
All-cause risk-adjusted readmission data
Results FFY11-12
186 Total Worksheets
QAPI: 60
Infection Control: 65
Discharge Planning: 61
Hospitals cited at Standard Level
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 QAPI
Individual questions:
 Assessment
of each contracted
service: 14.5% negative
 New
interventions developed for
those unsuccessful: 12.9% negative
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 QAPI
 Data
collection consistent when staff
involved: 12.5% negative
 Aggregate
data in subsets to allow
comparison: 12.5% negative
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 QAPI
Tags likely to be cited:



A0273 Data Collection and Analysis.
A0286 Patient Safety, Medical Errors
& Adverse Events.
A0308 Standard Tag for Condition
Statement.
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 QAPI
Themes:
 Program Data Collection and
Analysis
 Documented Evidence of QAPI
Program
 Executive Responsibilities
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 Infection
Control
Individual Questions:
 Disconnecting
catheter tubing: 47.4%
negative
 Antibiotic
orders with indication for
use: 42.6% [not required]
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 Infection
Control
 Review
need for antibiotics after 72
hours: 27.7% negative [not required]
 Hand
Hygiene: 19.2% negative
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 Infection
Control
Sections with lowest results:
 Systems to prevent transmission of
MRDO and promote antibiotic
stewardship [not required but…]
 Surgical
procedure tracer: 47.8%
negative
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 Infection
Control
 Ventilator/respiratory
tracer: 42.55%
negative
 Isolation:
Contact precautions:
42.55% negative
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 Infection
Control
“Best Practices” commonly found:

Need for central venous catheters review
daily
 Oral hygiene for high risk patients
 HOB elevated for patients at high risk for
aspiration
 Spontaneous breathing trials for vent
patients
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 Discharge
Planning
Individual Questions:
 Evaluate
if readmissions were
preventable: 18.9% preventable
 Changed
discharge planning process
if cause of readmissions: 16.7%
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 Discharge
Planning
 Update
discharge plan to reflect
changes in patient condition: 13.7%
negative
 Following
P&P: 13.3% negative
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 Discharge
Planning
Tags most likely cited:
A0820 Initial implementation
A0819 Physician request for
evaluation
A0906 Comprehensive evaluation
A0817 Plan matches evaluation
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 Discharge
Planning
“Best Practices” commonly found:
Scheduling follow up appointments
Pharmacist review of discharge med
orders
Filling prescriptions
DC plan for all inpatients (+66.7%)
DC plan for some outpatients (+78.3%)
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY13
o
o
o
o
o
o
Not yet released by CMS
QAPI results look similar
Infection control: MDRO, point of
care devices, and hand hygiene
Discharge Planning results look
similar
No citations
159 worksheets completed
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
FFY14 (Current year):
Sample selection based on citation
data
 No citations (non-punitive)
 Use as risk management assessment
tool at exit
 Worksheets publically available
 Using revised worksheets

Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
FFY15:
Additional revisions? (still draft)
 Continued data collection/analysis
 Required for all surveys?
 Additional CoPs?
 Contingent upon funding

Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
State Licensure/Federal
Certification
PSI worksheets are a federal requirement completed
by a federally defined process and conducted by
the State Agency during recertification surveys.
State licensure surveys are independent of federal
surveys.
State Agency is the contractor for Federal surveys.
Helpful sites:
The “Discharge Planning” Booklet (ICN
908184)
Partnership for Patients
http://innovation.cms.gov/initiatives/partnership-forpatients/index.html
Patient Protection and Affordable Care
Act
http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf
Objectives:
Gain an understanding of the key
measures used to assess quality
through the use of three survey
worksheets implemented within the
survey process.
Identify two primary goals associated
with the patient safety initiative.
Objectives:
Apply non-surveyor use of the
worksheets to their respective
facilities to assess quality.
Identify the key differences between
state licensure surveys and federal
certification surveys.
QUESTIONS
Thank You !
Have a great conference