IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD % Perfection Worksite Safety Indicators Blood Borne Pathogen Exposures--Sharps0? 3.85 (6) 1.20.

Slides:

Advertisements

Similar presentations

Adverse Patient Safety Events: Costs of Readmissions and Patient Outcomes Following Discharge Didem M. Bernard, Ph.D. William E. Encinosa, Ph.D.

Advertisements

CMS’ HOSPITAL ACQUIRED CONDITIONS

Presented by: Richard Schirmer, MBA, FACHE July 2012 Quality Reporting: Initiatives at the Federal and State Level.

Healthcare Quality: DHHS Don Wright, MD MPH Deputy Assistant Secretary for Healthcare Quality Office of Healthcare Quality Office of the Assistant Secretary.

Safety  Quality  Service  Relationships  Performance SOMC Performance Dashboard – FY 13 SOMC Performance Dashboard – FY 13 Patient-Centered Perfection.

Session 3C: Overview of the AHRQ Quality Indicators Thursday, September 27, :30 pm to 5:00 pm ET.

CMS Update FY’14 Frank Briggs, Pharm.D., M.P.H. Vice President, Quality and Patient Safety West Virginia University Healthcare.

SOMCQuality Dashboard - FY 12 Patient-Centered Perfection is the Goal Safety  Quality  Service  Relationships  Performance IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD.

Fundamentals of Healthcare Reform Walter Coleman WV/PA HFMA September 25, 2014.

June 20, 2013 Infection Prevention Power Hour. IPPS/LTCH PPS Proposed Rule Summary Includes proposals for seven different quality reporting and payment.

CONTINUOUS QUALITY IMPROVEMENT Continuous Quality Stony Brook Medicine.

Annual Review of Nursing Services Staffing Plan Sample Outcome Metrics NH Nurse Staffing Toolkit 2010.

Washington State Hospital Association Partnership for Patients Safe Table Reducing Hospital Acquired Infections July 31, 2013 Amber Theel, Director Patient.

Option Year 1 Metrics January 14, E. Grand Ave., Ste. 360 Des Moines, IA Office: Fax:

Issues, trends, and resources for combating the problem. Nancy Hudecek RN, BSN, MS Director, Risk Management, Patient Safety, and Quality Improvement Today’s.

Understanding the Impact of HACs/POAs and Never Events/Adverse Events Nadyne Hagmeier, RN Hospital Project Manager.

Indun Whetsell March 6, ContributedPotential Gain/At Risk VBP $408,893$1,054,593* RRP $817,786$817,786** HAC $272,595$272,595** BCBS $1.2 million*

DIVISION OF HEALTH CARE FINANCING & POLICY Patient Protection and Affordable Care Act Provider-Preventable Conditions.

1 Overview of Organization & Comparative Quality Data Ron Spingarn, Deputy Director Healthcare Information Division Phone:

DIVISION OF HEALTH CARE FINANCING & POLICY Patient Protection and Affordable Care Act Provider-Preventable Conditions.

Safety  Quality  Service  Relationships  Performance SOMCService Dashboard – FY 12 SOMCService Dashboard – FY 12 Patient-Centered Perfection is the.

Safety  Quality  Service  Relationships  Performance SOMCService Dashboard – FY 13 SOMCService Dashboard – FY 13 Patient-Centered Perfection is the.

Overview of Never Events and Hospital Acquired Conditions in Medicare and Medicaid Barbara Dailey, Director Division of Quality, Evaluation, and Health.

Agency For Healthcare Quality and Research Quality Indicators NH Health Care QA Commission AHRQ Subcommittee Report July 31, 2009.

IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD Worksite Safety Indicators Total Recordable Injury Incident Rate Never Occurring 100%?

Linking Quality To Payment 17 th Annual Rural Health Conference Timothy Burrell, MD, MBA Medical Director.

Reporting hospital quality Ben Yandell, PhD, CQE System Associate Vice President Clinical Information Analysis (CIA) Norton Healthcare.

Core Measures Evidence-Based Performance Measurement Lynne Hall, RN, BSN Green Belt Six Sigma Updated: 06/16/2011.

Safety  Quality  Service  Relationships  Performance SOMC Performance Dashboard – FY 12 SOMC Performance Dashboard – FY 12 Patient-Centered Perfection.

CMS Future HAC Plans? HAI Cost Impact on Hospitals? Rick Sites General Counsel & Senior Health Policy Director October 1, 2008.

SOMCRelationships Dashboard – FY 12 SOMCRelationships Dashboard – FY 12 Patient-Centered Perfection is the Goal Safety  Quality  Service  Relationships.

SOMCRelationships Dashboard – FY 13 SOMCRelationships Dashboard – FY 13 Patient-Centered Perfection is the Goal Safety  Quality  Service  Relationships.

How to facilitate supervision? How to improve quality? How to improve transparency? Dutch hospitals.

Hospital Acquired Conditions: Present on Admission APIC Chapter 26 Carol Jacobson, RN October 1, 2008.

Hospital Association of Rhode Island. Heart Attack or Chest Pain Heart FailurePneumonia Surgical Care Improvement ScoreRankScoreRankScoreRankScoreRank.

Hospital Value-Based Purchasing Update Jim Poyer Director, OCSQ/QIG/DQIPAC April 27, 2011.

“Never Events” in Surgery Stephen D. Cassivi, MD MSc FRCSC FACS Professor of Surgery Vice Chair – Department of Surgery

In Hospital Hip Fracture Mortality Colleen McLaughlin, MPH, PhD Division of Quality and Patient Safety.

Comparative Rankings of Hospital Quality – Does the Data Source Matter? Anne Elixhauser, Ph.D. Bernard Friedman, Ph.D. June 26, 2005 AcademyHealth Research.

MAHP-MHA Proposed Tiering Measures 1. Purpose & Scope Purpose Recommend quality measures to include in a common measure set for health plans to select.

What is Clinical Documentation Integrity? A daily scavenger hunt.

1 1 Survey of Patient Safety Culture in U.S. Hospitals: External Validity Analyses Russ Mardon, Ph.D. Westat 2008 AHRQ Annual Conference Westat 1650 Research.

Fundamentals of Reform/ HFMA Update

Perioperative Enterprise Committee Surgical Site Infection Report

Hospital-Acquired VTE: What We Have Learned Martha J. Radford, MD Chief Quality Officer NYU Langone Medical Center September 2009.

Going Public Ben Yandell, PhD, CQE Clinical Information Analysis Norton Healthcare, Louisville, KY

AHRQ PSIs and IQIs in National Pay for Reporting September 14, 2009 AHRQ QI Conference Shaheen Halim, Ph.D. Centers for Medicare & Medicaid Services.

AHRQ Quality Indicators NQF Update Marybeth Farquhar, PhD, MSN, RN QI Users Meeting AHRQ 2 nd Annual Conference Rockville, MD September 10, 2008.

Panel Reviews of the AHRQ QIs: AHRQ and NQF panels Sheryl Davies, MA Stanford University.

The role of nurses in new incentive-based hospital payment models

Hospital Measures Reporting in Ohio Michele Shipp, MD, DrPH AHRQ QUALITY INDICATORS USERS MEETING Wednesday September 9, 2008 AHRQ ANNUAL CONFERENCE 2008.

Hospital Acquired Conditions (HACs). Overview The Deficit Reduction Act of 2005 (DRA) requires a quality adjustment in Medicare Severity Diagnosis Related.

Common causes of Perioperative Cardiac arrest Sepsis and multiple organ failure Trauma, motor vehicle, gun shot wound, and stabbing Exsanguination, hemorrhage.

1 Quality of Care and Patient Safety: Impact on Healthcare January 22, 2009 Presenter: F. Lisa Murtha, Practice Leader and Managing Director, Huron Consulting.

Minnesota Statewide Quality Reporting and Measurement System Chartbook Section 9.

Tennessee Center for Patient Safety. Center Staff Chris Clarke, Sr. VP, Clinical and Professional Practices Patrice Mayo, VP, Operations Director Darlene.

Performance Measures: CMS Hospital Inpatient Quality Reporting Program (IQR)Update As of November 2012.

Florida Hospital Association Hospital Engagement Network (HEN) Office Hours Tuesday, August 20, – 10 a.m. EDT Audio for today’s presentation is.

How To Improve Performance on the AHRQ Inpatient Quality and Patient Safety Indicators: Introducing a Toolkit for Hospitals Webinar February 15, :30-4:00.

3 rd Annual Association of Clinical Documentation Improvement Specialists Conference.

AHRQ QI Guide to Comparative Reporting AHRQ Annual Conference September 10, 2008 Bethesda, MD Presented by Sheryl Davies.

The Department of Quality and Risk Management

Managing Hospital Safety: Common Safety Concerns

PATIENT SAFETY AND DOCUMENTATION: Connecting the Dots

The Agency for Healthcare Research and Quality Inpatient Quality Indicator #11 overall mortality rate does not accurately assess mortality risk after.

Quality How is this LOM Metric measured in the LEM?

Inpatient Quality Coding It’s Not Just About What you Get Paid

Severity of chronic obstructive pulmonary disease is associated with adverse outcomes in patients undergoing elective abdominal aortic aneurysm repair

Quality….. The True Sustainable Strategy To Ensure Viability

The Agency for Healthcare Research and Quality Inpatient Quality Indicator #11 overall mortality rate does not accurately assess mortality risk after.

Presentation transcript:

IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD % Perfection Worksite Safety Indicators Blood Borne Pathogen Exposures--Sharps0? 3.85 (6) 1.20 (2) 2.35 (4) 0.60 (1) 1.79 (3) 1.18 (2) 1.16 (2) 1.70 (3) 1.78 (3) 2.27 (4) 2.99 (5) 3.03 (5) 1.98 (40) 53.2 Patient Safety Indicators (PSI) PSI Composite Score for Patient SafetyB.L.HC? B.L. PSI 04 Death Among Surgical Inpatients With Serious Treatable Complications 0HC? PSI 06 Iatrogenic Pneumothorax, Adult0HC? (1) (2) 0.13 (1) (1) 0.09 (8) 99.9 PSI 11 Post-op Respiratory Failure0HC? 0.13 (1) (1) 99.9 PSI 12 Post-op Pulmonary Embolism/DVT0HC? (2) (1) (1) 2.01 (3) (8) 99.5 PSI 14 Percent of Postoperative Wound Dehiscence 0HC? PSI 15 Accidental Puncture or Laceration0HC? (1) 0.13 (1) 0.12 (1) 0.13 (1) (2) (7) 99.9 Safety  Quality  Service  Relationships  Performance Task List Task List Goal = Perfection ? = Explanation/Calculation HC = Hospital Compare SOMCSafety Dashboard – FY 13 Patient-Centered Perfection is the Goal

IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD % Perfection Inpatient Quality Indicators (IQI) Mortality Measures IQI Composite Score for Mortality for Selected Medical Conditions B.L.HC? B.L. IQI 11 Abdominal Aortic Aneurysm (AAA) Repair Mortality 0?N/A IQI 19 Mortality Hip Fracture0HC? 7.69 (1) (2) (3) 96 AMI 30 day Non-Risk Standardized Mortality Rate – SOMC Internal Report 0HC? (1) (2) (1) (1) (5) 96.4 HF 30 day Non-Risk Standardized Mortality Rate –SOMC Internal Report 0HC? (2) (2) (2) 5.88 (1) (1) 6.67 (1) (1) (5) 4.55 (1) 8.33 (1) 8.85 (17) 90.8 PN 30 day Non-Risk Standardized Mortality Rate – SOMC Internal Report 0HC? (2) (1) 8.33 (1) (1) (3) 4.00 (1) (1) (2) 6.67 (1) 5.00 (1) 7.65 (14) 91.8 Safety  Quality  Service  Relationships  Performance SOMCSafety Dashboard – FY 13 Patient-Centered Perfection is the Goal Task List Task List Goal = Perfection ? = Explanation/Calculation HC = Hospital Compare

Safety  Quality  Service  Relationships  Performance Tasklist Tasklist Goal = Perfection ? = Explanation/Calculation HC = Hospital Compare SOMCSafety Dashboard – FY 13 Patient-Centered Perfection is the Goal IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD % Perfection Readmission Rate Indicators AMI 30 day Non-Risk Standardized Readmission Rate - SOMC Internal Report 0HC 44.4 (4) (1) (2) (3) (2) (5) (2) (3) (6) (4) 8.33 (1) (3) (36) 72.2 HF 30 day Non-Risk Standardized Readmission Rate - SOMC Internal Report 0HC 12.5 (1) 25.0 (4) (2) (5) (6) (4) (6) 9.09 (1) (5) (2) (4) 6.67 (1) (41) 82.2 PN 30 day Non-Risk Standardized Readmission Rate - SOMC Internal Report 0HC 28.6 (2) 10.0 (1) 7.14 (1) (4) (8) 7.41 (2) (1) (3) (3) (4) (33) 84.5 Hospital –Wide All –Cause Unplanned Readmission Measure (HWR) B.L.? (43) (41) (36) (35) (47) (52) (36) (46) (47) (49) (58) (31) ( Hospital-Level 30-Day All-Cause Risk- Standardized Readmission Rate Following Elective Primary Total Hip Arthroplasty (THA) and/or Total knee Arthroplasty (TKA) B.L.? (3) (2) (1) (1) (1) (1) (1) (10) 89.6 Patient Safety Outpatient Imaging Efficiency Indicators MRI Lumber Spine for Low Back Pain0HC? Mammography Follow-up Rates8-14%HC? Abdomen CT – Use of Contrast Material 0HC? Thorax CT Use of Contrast Material0HC? Simultaneous use of Brain CT and Sinus CT 0HC?

IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD % Perfection Patient Safety Outpatient Imaging Efficiency Indicators Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac Low-Risk Surgery 0HC? 3.85 (2) 1.64 (1) (2) 2.94 (2) 1.61 (1) 3.70 (2) 3.00 (3) 4.69 (3) 2.67 (2) 1.35 (1) 2.74 (2) 2.61 (21) 97.3 ED Outpatient Measure Left Without Being Seen0? Patient Safety Hospital Acquired Infection Indicators Catheter-Associated Vascular Infection * 0HC? (1) (1) (1) (3) 75.0 Catheter-Associated UTI *0HC? (2) (3) 0.77 (1) (6) 75.0 Ventilator Associated Pneumonia0? Mediastinitis After CABG *0? SSI In Deep Open Heart Patients * (Non-risk Adjusted) Expected Rate 0? SSI in Colon Surgeries0HC? SSI in Total Abdominal Hysterectomy (TAH) Surgeries) 0HC? (1) 0.58 (1) 91.7 Safety  Quality  Service  Relationships  Performance SOMCSafety Dashboard – FY 13 Patient-Centered Perfection is the Goal Tasklist Tasklist Goal = Perfection ? = Explanation/Calculation HC = Hospital Compare *Hospital-Acquired Conditions

Safety  Quality  Service  Relationships  Performance IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD % Perfection SSI in Deep C-Section Patients *0? (1) (1) 91.7 SSI Deep in Knee Replacements *0? (2) (1) (1) (4) 75.0 C.Diff Acquired While in Hospital *0? 0.21 (1) (1) 0.16 (1).40 (2) 0.19 (1) 0.41 (2) 0.38 (2) (3) 0.40 (2) 0.25 (16) 92.0 MRSA Blood Stream Infection Acquired While in Hospital * 0? MSSA Blood Stream Infection Acquired While in Hospital * 0? MRSA & MSSA Blood Stream Infection Acquired While in Hospital * 0? CMS Hospital Acquired Conditions Patient Retention of Foreign Object After Surgery or Death * 0HC? Hemolytic /Reaction due to Incompatible Blood Product * 0HC? Falls & Trauma *0HC? 0.21 (1) 0.20 (1) 0.19 (1) 0.58 (3) (1) (2) 0.16 (10) 98 SOMCSafety Dashboard – FY 13 Patient-Centered Perfection is the Goal Tasklist Tasklist Goal = Perfection ? = Explanation/Calculation HC = Hospital Compare *Hospital-Acquired Conditions

Safety  Quality  Service  Relationships  Performance IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD % Perfection Stage 3 & 4 Pressure Ulcers0HC? 0.21 (1) (1) (2) 88.9 Air Embolus *0HC? Manifestations of Poor Glycemic Control 0HC? Non-Risk Adjusted Complication Rate Following Elective Primary Total Hip Arthroplasty (THA) and/or Total knee Arthroplasty (TKA) within 7, 30, and 90 Days (SOMC Internal Report) 0? (1) (2) (1) (1) (1) (6) 73.0 National Quality Forum (NQF) Never Events Serious Safety Events (SSE)0? (10) 33 Never Events (Rollup)0? Leapfrog Safety Score Hospital Safety Score 100% “A” ? 3.21 “A” % Rate of Perfection:100%90.0% SOMCSafety Dashboard – FY 13 Patient-Centered Perfection is the Goal Tasklist Tasklist Goal = Perfection ? = Explanation/Calculation HC = Hospital Compare * Hospital-Acquired Conditions

S a f e t y  Q u a l i t y  S e r v i c e  R e l a t i o n s h i p s  P e r f o r m a n c e What questions do you have?