2. What is the Role of the QM Dept?
• Establish structure throughout the organization to
support the mission, vision & goals.
1. Coordinate PI activities
2. Serve as centralized area for data collection
3. Collect & maintain Quality Data on Physicians/Allied Health
4. Analyze Data
5. Communicate results to Hospital Board, Leadership and Staff
6. Train staff on PI methodologies
3. What is the Role of the QM Dept. con’t
7. Ensure compliance with applicable laws,
regulations and accreditation requirements.
-CMS (Center for Medicare & Medicaid Services)
-TJC (The Joint Commission)
-OSHA
-State Licensing Boards
4. What is NAMC trying to accomplish through the quality
program ?
• Mission: Make Communities Healthier®
• Vision: Create places where people choose to come for healthcare, physicians
want to practice and employees want to work.
• Core Values: Honesty, Integrity and Trustworthiness, Inclusion, Compassion, Legal
and Ethical Compliance
• Guiding Principles:
• Delivering high quality patient care.
• Supporting Physicians
• Creating excellent workplaces for our employees
• Taking leadership role in our communities
• Ensuring fiscal responsibility.
5. Why do I need to know about quality?
• The patient is the most important reason!
• Quality care takes TEAMWORK!
• Gives NAMC the opportunity to show the service area that we
provide quality care.
• Quality scores affect our reputation: customers can now view
our results & compare us to others. www.hospitalcompare.gov
• Hospitals that have higher Quality Scores avoid financial
penalties and may receive higher reimbursement from M’care
& other payers.
7. QBPR Programs
• Mandated by the Affordable Care Act of 2010.
• Most acute care hospitals must participate.
• Hospital payment is adjusted based on performance compared to
national standards.
1. Inpatient Quality Reporting (formerly called Value Based Purchasing)-
2% penalty
2. Readmission Reduction Program-3% penalty
3. HAC (Hospital Acquired Condition) Reduction Program-1% penalty
8. IQR/Value Based Purchasing Background
• Incentive program built on measuring the ‘quality’ of care provided
to inpatients in acute care settings. The only Medicare program
which is redistributive (winners and losers). The only program that
recognizes improvement as well as achievement.
In a Nutshell: Rewarding hospitals for providing
quality care and penalizing hospitals that are not.
• Funded by reduction in payment.
• Financial risks increase every year
2013 2014 2015 2016 2017
1.00% 1.25% 1.50% 1.75% 2.00%
9. IQR/Value Based Purchasing
• Programs components and weights generally change every year.
25%
25%
25%
25%
2021 Performance Domains
Patient Experience
Clinical Care
Efficiency
Safety
10. IQR Domains
Patient Experience (25%) Clinical Care (25%)
-Communication with Nurses 30-day Mortality: AMI
-Communication with Doctors 30-day Mortality: HF
-Responsiveness of Hospital Staff 30-day Mortality: Pneumonia
-Communication about Medications 30-day Mortality: COPD
-Cleanliness and Quietness 30-day Mortality: CABG
-Discharge Information THR/THA Complication Rate
-Overall Rating of Hospital
-Transitions of Care Measure
11. Value Based Purchasing Domains cont’
Safety (25%)
-Healthcare-Associated Infections
Central Line Blood Stream
Catheter Assoc. UTI
Surgical Site Infection
C. Diff
MRSA
Efficiency (25%)
-Medicare Spending per
Beneficiary
13. How do we know we are providing quality care?
• Customer surveys
-Patient
-Employee
-Physician
• External Surveys
-NHSN
-TJC
-Press Ganey®
-CMS
-Third Party Payors (BCBS)
-Leapfrog
14. How can I make an impact?
• Identify complications which may be present on admission.
1. Collect urine for C&S if patient presents to the hospital with a foley catheter.
2. Collect a stool specimen by Day 2 if a patient presents with diarrhea.
3. Obtain blood cultures from patients who present with central lines.
4. Inspect and document skin breakdown or changes indicating pressure ulcers.
5. Document thorough assessments, especially initial assessments. (Example: Was the patient
coughing or short of breath on admission, complaining of leg pain etc.?)
• Provide good nursing care and follow accepted standards of practice.
1. Use external catheters when possible. When foleys must be utilized, reassess daily for
ablility to remove.
2. Provide foley care and daily hygiene.
3. Daily CHG baths for patients with central lines. Avoid use of PICC and CVL when a
peripheral or midline is appropriate.
4. Leave Staging of wounds to trained wound care nurse. Describe wounds and discolored
skin conditions.
5. Assess skin in BSSR and implement preventative strategies for patients at risk.
15.
16. TJC Primary Stroke Center Tips for Success
Admission Guidelines
• Use Stroke Order Set
• Date/Time patient last known well or baseline state of health
• Date/Time discovery of stroke symptoms
• NIHSS documented (by physician or order for nurse to complete)
• tPA within 60 minutes of arrival when indicated
• tPA documentation to contain: Inclusions/Exclusions, patient/family discussion, document reason
if not a candidate for tPA, and if tPA administered > 60 minutes after arrival to hospital, document
medical reason for delay.
• Keep patient NPO until dysphagia screening is passed.
• Order Swallow Study for patient failed dysphagia screening.
• Give ASA (or other anti-thrombotic med) if tPA was not given. Order rectally if NPO.
Inpatient Guidelines
• Lipid Panel in am.
• VTE prophylaxis by Day 2 (mechanical or pharmacological)
• Rehab Assessment to include PT, ST or Rehab Facility placement, must document reason if not
indicated (example: back to baseline, no rehab needed)
Discharge Guidelines
• Statin medication at discharge for LDLc >70 or reason for not prescribing if indicated.
• Anti-thrombotic medication at discharge or reason for not prescribing contraindicated.
• Anti-coagulant medication if persistent Atrial fibrillation or reason for not prescribing.
• Stroke education and follow-up plans.
