Quality & Hospital
Acquired Conditions
 Rebecca Armbruster, DO, MS, FACOI
Medical Director Resource Management
 Patricia Heys, BS
Director of Infection Prevention & Control
 Sally Hinkle, DNP, MPA, RN
Director of Performance Improvement & Clinical Value
Institute of Medicine
Six Aims for Improving Health Care Quality
• Safe Care – Avoiding injuries to patients
• Effective Care – Providing care based on scientific
knowledge
• Patient-Centered Care – Providing respectful &
responsive care that ensures that patient values guide
clinical decisions
• Timely Care – Reducing waits for both patients &
providers of care
• Efficient Care – Avoiding waste
• Equitable Care – Providing consistent quality of care
HOSPITAL ACQUIRED
CONDITIONS
The Centers for Medicare and Medicaid Services (CMS)
has identified 11 types of medical occurrences that:
• Are Preventable
• Are high cost or high volume
• Result in additional costs to CMS
These are referred to as never events
NEVER EVENTS
•
•
•
•
•
•
•
•
Foreign Object Retain After Surgery
Air Embolism
Blood Incompatibility
Stage III and IV Pressures Ulcers
Falls and Trauma
Catheter Associated Urinary Tract Infections
Vascular Catheter Associated Blood Stream Infections
Surgical Site Infections Following Coronary Artery Bypass Graft
and Following Certain Orthopedic and Bariatric Procedures
• Certain Manifestations of Poor Control of Blood Sugar Levels
• Deep Vein Thrombosis or Pulmonary Embolism Following Total
Knee and Total Hip Replacement
ACT 52
Patients must be notified in writing of all hospital acquired
conditions in the Commonwealth of Pennsylvania
TWO AREAS TO FOCUS ON
Identify, document and code those
conditions present on admission
Prevent conditions from occurring
Case Study
What conditions were present at the time of admission?
Were there any infections that resulted from the care
delivered during the inpatient admission?
• 50 year old female with past history of
obesity, schizophrenia, and sleep apnea
(remote tracheostomy)
• Presents with Back pain and Chest Pain
• Positives on exam:
• pulse ox 91% room air, heart rate 120,
respiratory rate 20
• Oriented x 2, mild respiratory distress,
• rales at bilateral bases
• Obese, mild diffuse abdominal tenderness
• Abnormal labs/tests:
• White blood count 23.9,
Hemoglobin: 9, Sodium 130, bicarb:
10, Creatine 1.37, Glucose 540
(anion gap of 25)
• Amylase and Lipase both elevated
• Urine: + ketones, blood, protein
• Cat Scan thorax: multiple pulmonary
nodules, consistent with metastatic
disease
“50 year old with Chest
pain, shortness of breath and
cough, found to have
Diabetic ketoacidosis and
Anion Gap Metabolic
acidosis”
Day 1: Admit for 1. Diabetic Ketoacidosis(no history of Diabetes), may be secondary
to pancreatitis, rule out infection, pan
culture, start insulin drip, fluids, antibiotics.
2. Pulmonary nodules- concern for
unknown primary, check cat scan of
chest/abdomen/pelvis, 3. Pancreatitisnothing to eat, 4. Chest pain- rule out acute
coronary syndrome.
Day 4: Condition declines, with
worsening respiratory distress-possibly
due to Pancreatitis, continued
leukocytosis and fevers- possibly due to
Diabetic Ketoacidosis. And she was
found on the floor.
Day 7: increasing oxygen
requirements, now requiring full
ventilator support- possibly due to
Pulmonary Embolus. Check
dopplers and cat scan. And found
to have Vaginal bleeding.
Day 15: Hypotension- due to sepsis (on
multiple drips), Hypoxic respiratory
failure –due to pulmonary embolus (on
heparin), Multiorgan system failuredue to sepsis
Discharge summary: The
patient had a long and complicated
course which included being treated
for Diabetic ketoacidosis and
PNEUMONIA!
So what if …
•
White Blood Cell
Count Is 9.6
•
Urinalysis Is
Negative
•
Input / Output
Requires Foley
Catheter On
Admission
Core Measures
• Set of best practice standards proven to decrease
morbidity, mortality & readmission rates
• Process indicators tied to clinical outcomes &
improved quality
• Mandated by Centers for Medicare & Medicaid
Services (CMS) & The Joint Commission (TJC)
• Links healthcare provider performance practices
to facility reimbursement
Core Measures
Measuring the Care You Deliver
FY'11
Target
FY 2011
FY'12
Target
FY 2012
CMS/TJC AMI-1 Aspirin at arrival
100%
99.1%
100%
99.7%
100%
100.0%
98.9%
100.0%
98.8%
99.2%
CMS/TJC AMI-2 Aspirin at discharge
100%
98.7%
100%
100.0%
100%
100.0%
100.0%
100.0%
100.0%
100.0%
CMS/TJC AMI-3 ACE-I or ARB for LVSD
100%
95.1%
100%
98.8%
100%
100.0%
100.0%
100.0%
100.0%
100.0%
CMS/TJC AMI-5 Beta blocker at d/c
100%
99.3%
100%
99.7%
100%
100.0%
100.0%
100.0%
100.0%
100.0%
NA
100%
NA
NA
NA
NA
NA
Required by
Core Measures
FY'13 Target
Source
FY'13
Target
FY'12 Q4 FY'13 Q1
FY'13 Q2
FY'13 Q3 FY'13 Q4
FY 2013
To Date
Inpatient
Acute Myocardial Infarction (AMI)
HQA - Top
10%
CMS/VBP/TJC
AMI-7a Fibrinolysis w/i 30 min of arrival
100%
NA
100%
CMS/VBP/TJC
AMI-8a PCI w/i 90 min of arrival
99%
86.7%
100%
90.2%
100%
100.0%
100.0%
100.0%
100.0%
100.0%
NA
98.4%
NA
100.0%
100%
100.0%
100.0%
98.6%
100.0%
99.5%
99.8%
95.5%
99.8%
98.4%
99.9%
100.0%
98.9%
98.8%
98.9%
98.8%
99%
96.1%
100%
97.8%
100%
97.4%
97.0%
94.7%
98.3%
96.5%
100%
100.0%
100.0%
100.0%
100.0%
100.0%
100%
100.0%
99.0%
100.0%
100.0%
99.7%
97.6%
97.3%
94.9%
98.4%
96.8%
CMS/TJC AMI-10 Statin Prescribed at discharge
ACM for AMI (CMS methodology)
QIO - Top 10%
Heart Failure (HF)
CMS/VBP/TJC
HF-1 D/C instructions
HQA - Top
10%
CMS/TJC HF-2 Evaluation of LVSF
100%
99.8%
100%
100.0%
CMS/TJC HF-3 ACE-I or ARB for LVSD
100%
97.3%
100%
99.6%
99.5%
94.8%
99.8%
97.7%
QIO - Top 10%
99.9%
ACM for HF (CMS methodology)
Pneumonia (PN)
CMS/VBP/TJC
PN-3b Bld cultures prior to antibiotic
100%
97.0%
100%
98.7%
97.6%
100.0%
100.0%
100.0%
100.0%
PN-6 Antibiotic Selection ICU and non-ICU
98%
97.4%
99%
99.4%
HQA - Top
10%
100%
CMS/VBP/TJC
100%
100.0%
96.7%
100.0%
96.6%
97.7%
98.6%
93.1%
99.1%
97.6%
QIO - Top 10%
99.5%
98.5%
98.5%
100.0%
98.2%
98.8%
ACM for PN (CMS methodology)
14
CMS Hospital Value-Based
Purchasing Program (VBP)
• Required in the Affordable Care Act
• Quality incentive program built on the
Hospital Inpatient Quality Reporting
• Rewards value, patient outcomes &
innovations
• Hospitals have potential to earn more
than 1.50% based on total performance
VBP Domains, Measures &
Dimensions
Get Involved in Quality & Safety
Accountable Care
Units: Huddles,
Multidisciplinary
Rounds, Mini
RCA’s, Throughput,
Patient Satisfaction,
Core Measures,
Infection Control
Resident
Integration
Into
Quality
House Staff Quality
Council & Program
Level PI/QI
Medical Staff
Committees:
Patient Safety,
Performance
Improvement, Peer
Review
Centers for Medicare &
Medicaid Services
Health care quality is:
Getting the right care to the right patient –
every time
REMEMBER
• Always keep the patient at the center of
everything that you do
• Provide care based on nationally excepted
best practices
• Document conditions that are present on
admission
• And last but not least ...
19
WASH YOUR HANDS!
20