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Cardiac Centers of Excellence
Cardiac Centers of Excellence
Cardiac Centers of Excellence
Cardiac Centers of Excellence
Cardiac Centers of Excellence
Cardiac Centers of Excellence
Cardiac Centers of Excellence
Cardiac Centers of Excellence
Cardiac Centers of Excellence
Cardiac Centers of Excellence
Cardiac Centers of Excellence
Cardiac Centers of Excellence
Cardiac Centers of Excellence
Cardiac Centers of Excellence
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Cardiac Centers of Excellence

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  • 1. BLUE CROSS AND BLUE SHIELD ASSOCIATION THE BLUE DISTINCTION CENTERS FOR CARDIAC CARESM REQUEST FOR INFORMATION FOR 2008/2009 DESIGNATIONSGeneral Information1. Does your facility participate in the Institute for Healthcare Improvement’s (IHI) 5 Million Lives Campaign? YES NO (YES to 1, 1a appears and must have at least one part of 1a checked) 1a. If yes, which of the following interventions does your facility participate in? (Must check at least one or more boxes.) Deploy Rapid Response Teams Prevent Central Line-Associated Bloodstream Infection Improved Care for Acute Myocardial Infarction Prevent Surgical Site Infection Prevent Adverse Drug Events (ADE) Prevent Ventilator-Associated Pneumonia Prevent Harm from High-Alert Medications Reduce Surgical Complications Prevent Pressure Ulcers Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) infection Deliver Reliable, Evidence-Based Care for Congestive Heart Failure Get Boards on Board2. Does your facility publicly report on The Leapfrog Group’s Web site via The Leapfrog Group Quality andSafety Hospital Survey? (Yes to 2, 2a appears and must have at least one part of 2a checked.) YES NO 2a. Please mark your facility’s Leapfrog Hospital Survey status for each of the following Leaps? Leap 1 Computerized Physician Order Entry (CPOE) Not Reporting In Progress Fully Implemented Leap 2 Intensive care unit managed by intensivists (IPS) Not Reporting In Progress Fully ImplementedBlueDistinctionCardiac/FullSurvey/rev.6/20/08 (mrf) 1
  • 2. Leap 3 High Risk Treatments Coronary Artery Bypass Graft (CABG) Not Reporting In Progress Fully Implemented Percutaneous Coronary Intervention (PCI) Not Reporting In Progress Fully Implemented Leap 4 Safe Practice Score Not Reporting In Progress Fully Implemented3. If your facility does not publicly report to Leapfrog, indicate which of the following initiatives your facilityparticipates in. This initiative should be one which encourages the sharing of best practices, incorporates datafeedback for objective analysis, and promotes collaborative improvement of your facility and its processes. Not Applicable, reporting to Leapfrog Alabama Hospital Quality Initiative (AHQI) Clinical Outcomes Assessment Program (COAP) Coronary Council Meeting of the Midwest Northern New England Cardiovascular Disease Study Group Pittsburgh Regional Healthcare Initiative (PRHI) Other (If other checked 3a to appear) 3a. Name of your facility’s other quality, safety, and affordability initiatives? Add attachmentBlueDistinctionCardiac/FullSurvey/rev.6/20/08 (mrf) 2
  • 3. 4. Which of the following healthcare informatics applications does your facility use?University Health System Consortium (UHC)Premier Clinical AdvisorNoneOther (If other checked 4a to appear) 4a. Other application (Please specify)5. Estimate the proportion of your provider groups that have current contracts with the local BlueCross and/orBlueShield Plan. Indicate which category most closely fits by placing an “X” for each Provider Type in the tablebelow. Provider Type None Some All Anesthesiology Cardiac Surgery Cardiology Diagnostic Radiology Interventional Cardiology Pathology6. Does your facility participate in the American Heart Association (AHA)’s Get With The Guidelines (GWTG)Coronary Artery Disease (CAD) and/or Congestive Heart Failure (CHF) Program? (Facility may check morethan one checkbox) (If Yes, we participate in GWTG CAD, Yes we participate in GWTG CHF, or Both, 6a toappear. Must have at least one part checked for 6a.) Yes, we participate Yes, we participate No, my facility does not participate in in the GWTG CAD program. in the GWTG CHF program. these programs. 6a. Please mark your facility’s current level of recognition that has been achieved. (One corresponding part in 6a must be checked if answering Yes to 6) CAD CHF Participating Facility Initial Performance Achievement Award Annual Performance Achievement Award Sustained Performance Achievement AwardBlueDistinctionCardiac/FullSurvey/rev.6/20/08 (mrf) 3
  • 4. 7. Does your facility have a formal continuous quality improvement (CQI) program in place for CARDIACservices? YES NO Please note: You may be required to provide documentation of your process upon request. (If Yes, 7a to appear) 7a. Please mark your facility’s CQI program components Written Plan YES NO Specific to cardiology/cardiac surgery YES NO Multidisciplinary team YES NO Quarterly team meetings with minutes YES NO Indicators for the improvement of YES NO processes for treatment of emergent patients8. Does your facility maintain a summary report of Quality Improvement (QI) initiatives including documentationof outcomes, e.g., dashboard? YES NO9. Does your facility obtain and evaluate overall patient satisfaction? YES NO10. Does your facility obtain and evaluate patient satisfaction specific to CARDIAC CARE with the resultsreported to the cardiac team? YES NO11. Does your facility, or the facility you refer cardiac rehab patients to, have the American Association ofCardiovascular and Pulmonary Rehabilitation (AACVPR) Cardiac Rehabilitation Program Certification? YES NO12. Does your facility track transitions of care for patients discharged from an inpatient setting to anothersetting, (e.g., home, cardiac rehab facility) using a formal method? (e.g., NQF 3-Item Care Transition Measure[CTM-3]) YES NOBlueDistinctionCardiac/FullSurvey/rev.6/20/08 (mrf) 4
  • 5. 13. Does your facility accept the Association of American Medical Colleges’ (AAMC) principles for ALL clinicaltrials? Information can be found at the Association of American Medical Colleges (AAMC)’s Web sitehttp://www.aamc.org/research/clinicaltrialsreporting/start.htm. YES NO(Yes to 13 requires at least one response in 13a to be checked.) 13a. Which of the following consensus principles for clinical trials does your facility follow? Publication and Public Availability of Research Results Registration of Clinical Trials Have a lead investigator and steering committee to represent the full body of investigators Establish a publication and analysis committee Follow AAMC guidelines for individual publication Follow AAMC guidelines for authorship14. Does your facility participate in the NCDR™ ACTION Registry™? YES NO15. Are implantable cardioverter defibrillators (ICDs) being placed at your facility? YES NO16. Does your facility participate in the NCDR™ ICD Registry™ for ALL patients that receive implantablecardioverter defibrillators? YES NO17. Does your facility use a formal credentialing process for ICD implantation privileges based on generallyaccepted credentialing criteria from a credible expert or national organization? (e.g., Heart Rhythm Society2004 Clinical Competency Statement: Training Pathways for Implantation of Cardioverter Defibrillators (ICD)and Cardiac Resynchronization (CRT) Devices) YES NOBlueDistinctionCardiac/FullSurvey/rev.6/20/08 (mrf) 5
  • 6. 18. Please complete the following table by physician type with the number of physicians performing ICDimplantations at your facility and the volume of ICD procedures performed by each physician type for thetimeframe of January 1, 2007 through December 31, 2007. Physicians should be entered only once within thistable. Enter “0” for any physician types that do not perform ICD implantations. Enter “Unknown” in each dataentry field if physician types who perform ICDs are not known and proceed to question 19. Physicians with Physicians Physicians Total for facility subspecialty with without training in subspecialty formal Electrophysiology training in training Thoracic or cardiothoracic SurgeryTotal number of physicians bycategoryTotal volume of proceduresperformed by physician categoryfor timeframe of January 1, 2007through December 31, 200719. If you provided numerical values for question 18, please enter N/A in the fields below. If you entered“Unknown” for any part of question 18, then please complete the following table with the TOTAL number ofphysicians performing ICD implantations at your facility and the TOTAL volume of ICD procedures performedfor the timeframe of January 1, 2007 through December 31, 2007. Total for FacilityTotal number of physiciansperforming ICD implantationsTotal volume of ICD proceduresperformed for timeframe ofJanuary 1, 2007 throughDecember 31, 2007BlueDistinctionCardiac/FullSurvey/rev.6/20/08 (mrf) 6
  • 7. 20. Provide your facility’s volume for the timeframe of January 1, 2007 through December 31, 2007 for thefollowing procedures: If this procedure is not performed, enter “0” in each data entry field. Diagnostic cardiac catheterizations Electrophysiology diagnostic studies Electrophysiology therapeutic procedures Ventricular Assist Devices (VADs) Heart Transplantation Cardiac MedicalComplete questions 21-27 regarding your Acute Myocardial Infarction (AMI) patients.21. Does your facility have or refer patients to a STRUCTURED PROGRAM on Smoking Cessation for patientsdiagnosed with AMI? (e.g., Nicotine Anonymous, North American Quitline Consortium, American CancerSociety’s Quitline®, http://www.smokefree.gov, National Network of Tobacco Cessation Quitlines, AmericanLegacy Foundations Great Start) YES NO22. What is your facilitys current 30 day Risk-Adjusted AMI Mortality rate as reported by your QualityImprovement Organization (QIO) for the Centers for Medicare and Medicaid Services (CMS) (e.g., The JointCommission, QualityNet, and Hospital Compare)?_______________ (e.g., 16.0%)Data provided in questions 23-27 are based on Acute Myocardial Infarction (AMI) patients’ included within theNational Hospital Quality Measures as described on CMS’ Web site Hospital Compare.23. Report the number of AMI patients who received aspirin within 24 hours before or after facility ARRIVALfor all patients discharged from October 2006 through September 2007 (AMI-1). Number of AMI patients who received aspirin on ARRIVAL ______ Total number of AMI patients _____BlueDistinctionCardiac/FullSurvey/rev.6/20/08 (mrf) 7
  • 8. 24. Report the number of AMI patients who received aspirin within 24 hours before or after facilityDISCHARGE for all patients discharged from October 2006 through September 2007 (AMI-2). Number of AMI patients who received aspirin on DISCHARGE ______ Total number of AMI patients _____25. Report the number of AMI patients prescribed Angiotensin-Converting Enzyme (ACEI) or Angiotensin-Receptor Blockers (ARB) at facility DISCHARGE for all patients discharged from October 2006 throughSeptember 2007 (AMI-3) Number of AMI patients prescribed ACEI or ARB at DISCHARGE _______ Total number of AMI patients with left ventricular systolic dysfunction (LVSD) ______26. Report the number of AMI patients who received a Beta Blocker within 24 hours after facility ARRIVAL forall patients discharged from October 2006 through September 2007 (AMI-6) Number of AMI patients receiving Beta Blocker on ARRIVAL _______ Total number of AMI patients _______27. Report the number of AMI patients who received a Beta Blocker within 24 hours after facility DISCHARGEfor all patients discharged from October 2006 through September 2007 (AMI-5) Number of AMI patients receiving Beta Blocker at DISCHARGE _______ Total number of AMI patients _______Complete questions 28-32 regarding your Heart Failure (HF) patients.28. Does your facility have or refer patients to a STRUCTURED PROGRAM on Smoking Cessation for patientsdiagnosed with Heart Failure? (e.g., Nicotine Anonymous, North American Quitline Consortium, AmericanCancer Society’s Quitline® ,http://www.smokefree.gov, National Network of Tobacco Cessation Quitlines,American Legacy Foundations Great Start) YES NOBlueDistinctionCardiac/FullSurvey/rev.6/20/08 (mrf) 8
  • 9. 29. What is your facility’s current 30 day Risk-Adjusted Heart Failure Mortality rate as reported by your QualityImprovement Organization (QIO) for CMS (e.g., The Joint Commission, QualityNet, and Hospital Compare)?_______________ (e.g., 5.0%)Data provided in questions 30-32 will be based on Heart Failure (HF) patients’ National Hospital QualityMeasures as described on CMS’ Web site Hospital Compare30. Report the number of HF patients prescribed ACEI or ARB for Left Ventricular Systolic Dysfunction atfacility DISCHARGE for all patients discharged from October 2006 through September 2007 (HF-3). Number of HF patients prescribed ACEI or ARB at DISCHARGE ______ Total number of HF patients with LVSD ______31. Report the number of HF patients with documentation in the facility record that Left Ventricular Systolic(LVS) Function was evaluated before arrival, during hospitalization, or is planned for after discharge for allpatients discharged from October 2006 through September 2007 (HF-2). Number of HF patients with documented assessed LVS function _______ Total number of HF patients ______32. Report the number of HF patients with documentation that they or their caregivers were given writtendischarge instructions or other educational material addressing ALL of the following: a. Activity level b. dietc. discharge medications d. follow-up appointment e. weight monitoring f. what to do if symptoms worsenfor all patients discharged October 2006 through September 2007 (HF-1). Number of HF patients with documented discharge instructions ______ Total number of HF patients discharged to home or home care ______BlueDistinctionCardiac/FullSurvey/rev.6/20/08 (mrf) 9
  • 10. Cardiac Catheterization Services33. Does your facility participate in the American College of Cardiology’s (ACC) D2B (Door to Balloon)Alliance ™ YES NO34. Does your facility track and trend rates of normal or insignificant CAD (i.e., <50% stenosis) results ondiagnostic cardiac catheterizations for each physician? YES NO35. What is the proportion of patients having a left heart catheterization (including only patients with theindications of rule out CAD and /or arrhythmia) where all coronary branches have < 50% stenosis? (Note: if avessel is not assessed, its stenosis is assumed as 0). ATTENTION MICHIGAN FACILITIES: PLEASE DO NOTSELECT THE OPTION: My facility reports all diagnostic catheterization procedures to the NCDR, EVEN IFYOU DO. INSTEAD, CHOOSE ONE OF THE OTHER OPTIONS: my facility does not track this data, NA; ormy facility tracks this data in our own system. My facility reports all diagnostic catheterization procedures to the NCDR My facility does not track this data, N/A. My facility tracks this data in our own system. (Question 35a appears) 35 a. Provide the proportion of non-obstructive CAD at your facility. Sum of all vessels with percentage of stenosis < 50% ________ Sum of Diagnostic Catheterization procedures with Left Heart Caths ______ Proportion of patients having a left heart catheterization where all coronary branches have < 50% stenosis ___________%BlueDistinctionCardiac/FullSurvey/rev.6/20/08 (mrf) 10
  • 11. 36. What is the proportion of patients having a diagnostic catheterization procedure with at least one vascularcomplication, (Bleeding, retroperitoneal bleeding, access site occlusion, peripheral embolization, dissectionpseudoaneurysm and AV fistula)? ATTENTION MICHIGAN FACILITIES: PLEASE DO NOT SELECT THEOPTION: My facility reports all diagnostic catheterization procedures to the NCDR, EVEN IF YOU DO.INSTEAD, CHOOSE ONE OF THE OTHER OPTIONS: my facility does not track this data, NA; or my facilitytracks this data in our own system. My facility reports all diagnostic catheterization procedures to the NCDR. My facility does not track this data, N/A. My facility tracks this data in our own system. (Question 36a appears) 36a. Provide the proportion of vascular complications at your facility. Sum of any Vascular Complication ______________ Sum of Diagnostic Catheterization procedures (excluding PCI) with Left Heart Caths __________ Proportion of patients having a diagnostic catheterization procedure with at least one vascular complication ________%37. Does your facility have a policy which provides 24/7 primary PCI staff coverage? YES NO (Yes to 37 requires a response to 37a) 37a. What is the stated response time in your facility’s policy for the 24/7 on-call surgical team to provide PCI staff coverage? Response time 30 minutes or less Response time 31 to 60 minutes Response time ≥ 61 minutes38. Report number of cardiologists at your facility that are currently performing PCI, who are board certified ininterventional cardiology Number of cardiologists certified in interventional cardiology ______ Total number of cardiologists currently performing PCI’s _______BlueDistinctionCardiac/FullSurvey/rev.6/20/08 (mrf) 11
  • 12. 39. Report number of cardiologist at your facility that are currently performing at least 75 PCI procedures peryear (may count PCI’s performed outside our facility) Number of Cardiologist performing > 75 PCI’s/year________ Total number of cardiologists currently performing PCI’s _________40. Report total number of readmissions within 30 days on patients that have received a PCI from January2007 through December 2007. Example: A patient who received a PCI on January 1, 2007 and whosubsequently was admitted on January 5, 2007, January 10, 2007, and January 15, 2007 for any reason wouldbe calculated as 3 readmissions for 1 patient that had a PCI Number of PCI readmissions within 30 days_________ Total number of patients receiving PCI _________Cardiac Surgical Services41. Report the number of surgeons at your facility that are currently performing a minimum of 75 cardiacsurgical procedures a year (May count cardiac surgeries performed outside your facility) Number of surgeons performing minimum 75 cardiac surgeries/year _________ Total number of surgeons that are currently performing cardiac surgeries ______42. Report the number of surgeons that are currently performing cardiac surgical procedures that are boardcertified in cardiothoracic surgery Number of surgeons certified in cardiothoracic surgery_________ Total number of surgeons that are currently performing cardiac surgeries ______43. Report the number of readmissions within 30 days on patients that have received CABG for timeframe ofJanuary 1, 2007 through December 31, 2007. Example: A patient who received a CABG on January 1, 2007and who subsequently was admitted on January 15, 2007, January 20, 2007 and January 25, 2007 for anyreason would be calculated as 3 readmissions for 1 patient who had a CABG. Number of readmissions within 30 days of CABG _____ Total number of patients receiving CABG __________BlueDistinctionCardiac/FullSurvey/rev.6/20/08 (mrf) 12
  • 13. 44. Does your facility have a policy which provides for a 24/7 on-call surgical team to perform emergencycardiac surgery (CABG)? YES NO (Yes to 44 requires a response to 44a) 44a. What is the stated response time in your facility’s policy for the 24/7 on-call surgical team toprovide emergency cardiac surgery (CABG) staff coverage? Response time of 60 min or less Response time 61 to 120 min Response time ≥ 121 min45. Do you participate in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC²) registryfor percutaneous coronary interventions (PCIs)? (If Yes, facility to attach report) Yes, our facility reports No, our facility only reports to BMC² for PCI procedures to the NCDR™CathPCI registry™. Attach Report“Yes, our facility reports to BMC² for PCI procedures” requires a response to each question in 45a.”Please describe any additional program strengths or innovative approaches to Cardiac Care services that youwould like to share with us. Utilize this space for any comment, additional information, or attachment that youwere not able to submit in the Survey.Question in 45a will be prepopulated from the NCDR™CathPCI Registry™ EXCEPT if “Yes, our facility reports exclusivelyto BMC²” is checked in q45 : 45a(STEMI pts who receive PCI within ≤ 90 min Ex Summary #1), 45a(Risk-adjustedmortality Ex Summary #2), 45a(Vascular Complications Ex Summary #3), 45a (Thienopyridine Ex Summary #4), 45a(Procedure Success Ex Summary #6), 45a (total length of stay for PCI patients Ex Summary #7), 45a (mean number ofstents Ex Summary #8) 35 (Proportion of non-obstructive CAD at your facility Ex Summary #9) 36 (Proportion of VascularComplications at your facility Ex Summary #10)45a. Report the number of primary (STEMI) PCI patients with door to balloon (D2B) time < 90 minutes for thetimeframe of January 1, 2007 through December 31, 2007. Total number of patients that had PCI _________ Percentage of primary (STEMI) PCI patients with D2B < 90 minutes. ______________%BlueDistinctionCardiac/FullSurvey/rev.6/20/08 (mrf) 13
  • 14. 45a. Report risk adjusted PCI mortality rate (elective and emergent) for the timeframe of January 1, 2007through December 31, 2007 ___________%45a. Report the number of PCI patients with at least one incidence of vascular complication for the time frameof January1, 2007 through December 31, 2007 Total number of patients receiving PCI________ Percentage of Incidence of Vascular Complications __________%45a. Report number of PCI patients who received any type of stent and had thienopyridine (such as clopidogrelor ticlopidine) prescribed at discharge for the timeframe of January 1, 2007 through December 31, 2007. Total number of PCI patients that received stents _______ Percentage of Eligible PCI patients who received any type of stent and had thienopyridine (such as clopidogrel or ticlopidine) prescribed at discharge ____________%45a. Report the number of PCI patients with angiographic success and no death, MI or emergent/salvageCABG during admission for the timeframe of January 1, 2007 through December 31, 2007. Example ofangiographic success: stented lesions with post procedure stenosis < 20%; non-stented lesions with a postprocedure stenosis of < 50%, no peri-procedural MI, and no death during hospitalization. Total number of patients that received PCI _________ Percentage of procedures with angiographic success and no death, MI or emergent/salvage CABG during admission __________%45a. For the timeframe of January 1, 2007 through December 31, 2007, what is the mean total length ofhospital stay (in days) for all patients having at least one PCI during admission? _______Days45a. For the timeframe of January 1, 2007 through December 31, 2007, what is the mean number of stents perPCI procedure at your facility? ____________stents46. What is your facility’s STS Star Rating (Composite Quality Rating) for the STS First Quarter 2008 HarvestWindow of January 1, 2007 through December 31, 2007? ______ (This value will be provided by STS)Please describe any additional program strengths or innovative approaches to Cardiac Care services that youwould like to share with us. Utilize this space for any comment, additional information, or attachment that youwere not able to submit in the Survey.BlueDistinctionCardiac/FullSurvey/rev.6/20/08 (mrf) 14

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