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Public Reporting for CAHs


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  • 1. The Quality Reporting Landscape for CAHs
    Andrei Kuznetsov, MA
    May 25, 2010
    MO-10-05-Gen Hosp May 2010This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy
  • 2. Topics to be covered
    Pay-for-reporting and pay-for-performance
    Trends in measurement of quality of care
    Inpatient and outpatient measures
  • 3. Public Reporting
    Dept of Health and Human Services
    The Joint Commission
  • 4. Why report?
    Public interest: Promote accountability/public disclosure
    • Empower consumers to make informed decisions
    • 5. Encourage competition among providers
    Provider interest:
    • Pay-for-reporting for IPPS hospitals
    • 6. No payment incentives for CAHs
  • Pay-for-Performance?
    Value-Based Purchasing for Medicare
    CMS submitted report to Congress in 2007
    • Weighting of individual metrics
    • 7. Reimbursement based on achievement and/or improvement
    Premier P4P demonstration project – ongoing
    No payment for HACs – Hospital Acquired Conditions
  • 8. The Tale of Two Agencies
    The Joint Commission (JCAHO)
    • Accreditation +
    • 9. Before 1999, measured quality by using healthcare administrative data
    • 10. Also, American Osteopathic Association (AOA)
    CMS (Centers for Medicare & Medicaid Services)
    • Payment => concern with cost and efficiency
    • 11. Medical record review to measure quality since 1994
  • Core Measure Pilot
    Conducted by TJC in 1999 – 2001
    • Medical record review
    Clinical richness and relevance from medical records
    • Not available from administrative data
    • 12. Through a labor intensive process
    Standardized process of measurement
    • The “Core” in Core Measures
  • Public Reporting Timeline
    Voluntary hospital reporting in 2002
    Ten “starter set” measures (5 AMI, 2 HF and 3 PN)
    • Required with Nov-2003 discharges
    • 13. 21 process of care measures with Jul-2006 discharges
    • 14. 26: Jan-2007 discharges: 3 SCIP measures + AMI/HF mortality rates
    • 15. 27: Jul-2007 discharges - add Pt experience of care (HCAHPS)
    • 16. 30: Jan 2008 SCIP Inf 3 & 6 + PN 30-day standardized mortality rate
    Added Outpatient measures for surgical and chest pain pts
  • 17. Public Reporting Timeline: Jan-2009
    44 measures in Jan-2009
    • Added SCIP Beta Blocker measure
    • 18. Dropped PN-1 Oxygenation Assessment
    • 19. Changed PN-5 – Abx from 4 hrs to 6 hrs from arrival
    • 20. Added AMI, HF, PN 30-day standardized readmission rates
    • 21. Added 9 AHRQ Pt safety/Inpatient Quality indicators
    • 22. Added one nursing sensitive measure
    • 23. Added one structural measure: Participation in Cardiac Surgery DB
  • Public Reporting Timeline: Jan-2010
    46 measures
    • Added SCIP Infection 9 and 10
    • 24. Dropped AMI-6 Beta Blocker on Arrival
    • 25. Added two structural measures: participation in
    • 26. Stroke Database
    • 27. Nursing Sensitive Care Database
    • 28. Merged one AHRQ indicator with Nursing Sensitive measure
  • Proposed Changes to Start Jan-2011
    AMI: Statin at discharge
    Drop one AHRQ measure
    Add 10 Hospital Acquired Condition metrics:
    Foreign object retained after surgery
    Air embolism
    Blood incompatibility
    Pressure ulcers stages 3 and 4
    Falls and trauma
  • 29. Measures in the Pipeline
    ED throughput
    Global measures for flu and PN immunizations
    Hospital Acquired Infections per CDC specs:
    Central Line Associated Bloodstream Infections
    Surgical Site Infections
  • 30. More Measures in the Pipeline
    Registry-based measures, choose one of four sets:
    ICD complications registry measures
    Stroke registry measures
    Cardiac Surgery Registry measures
    Nursing sensitive care registry measures
  • 31. Beyond the Medical Record Abstraction
    Minimize reliance on medical record abstraction
    Use administrative data
    Use existing data sources
    • Patient registries
    • 32. Electronic Medical Records
    • 33. Explore Stroke/VTE data submission from EMR
  • Beyond the Process of Care
    Keep process of care measures
    Augment reporting with:
    • Outcome measures
    • 34. Efficiency measures
    • 35. Cost of care measures
  • Meanwhile, on the TJC side…
    Pregnancy and Related Conditions  Perinatal Care
    Children’s Asthma Care
    Emergency Department (Informational => Voluntary for CMS)
    Venous Thromboembolism
    Hospital Based Inpatient Psychiatric Services
    Nursing Sensitive Measures
    Osteoporosis Management; Blood Management
  • 36. Outpatient Reporting – Voluntary for CAHs
    Outpatient Chest Pain and surgery cases
    Process measures requiring med record review
    Imaging Efficiency Measures – from Medicare claims
    MRI Lumbar Spine for Low Back Pain
    Mammography Follow Up Rates
    Abdomen CT Use of Contrast Material
    Thorax CT Use of Contrast Material
  • 37. Support Infrastructure
    CMS supplies:
    CMS Abstraction and Reporting Tool – CART
    Toll-free Helpdesk for CART and data submission issues
    Pre-recorded Online Training Sessions
    QIO to help with abstraction questions
    You supply:
    Staff time to identify cases for reporting
    Staff time to review records, record and submit results
    May engage a private vendor
  • 38. How to Volunteer
    Hospitals – Inpatient Hospital Quality Alliance Pledge of Participation
    Hospitals – Outpatient Registration HOP QDRP Participation HOP QDRP Pledge
    At a minimum, one staff member will need to be registered as QualityNet Admin at all times
  • 39. Questions?
    Contact Andrei Kuznetsov: