QI ACTION Registry-Get With The Guidelines The Mission Lifeline Data Solution Kathleen O’Neill, MHA Senior Director, Quality Initiatives IL & SD American Heart Association

QI American Heart Association’s Get With The Guidelines? Hospital performance improvement program for CAD, Heart Failure & Stroke. Includes a clinical decision support tool-”PMT” Web based, real-time Class I Level A Guidelines are imbedded in the tool Patient data is compared to the guidelines to assess applicability

QI Get With The Guidelines sm We are in a new business, from development of guidelines to implementation of guidelines

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11 State AHA Midwest Affiliate Get With The Guidelines Participation Over 400+ contracts in place in hospitals throughout the affiliate and nationwide Over 150,000+ patient records in Get With The Guidelines in the Midwest and over one million patients nationally.

QI Get With The Guidelines SM Patient Management Tool Online, web-based, real-time data collection De-identified patient data Data analysis for performance improvement Long term clinical outcomes registry

QI 1.Collect data on adherence to AHA guidelines with the PMT data form. 2.PMT Reporting tools allow for data analysis to identify areas for improvement. 3.Use PMT Reports to present need for change in targeted areas for improvement. 4.Hospitals implement new protocols, often using tools in the PMT. Role of the Patient Management Tool

QI AHA’s GWTG CAD Registry + ACC’s NCDR ACTION Registry = ACTION Registry® - GWTG

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ACTION Registry® - GWTG Goals Largest, most comprehensive AMI database National surveillance database system for high-risk AMI patients with STEMI/NSTEMI Optimize care & outcomes for all acute MI patients Assure the rights things are done right (safely & timely) Site level, system level & ultimately state level outcomes & performance improvement data

QI Participation Provides… Weekly key measures reports and risk-adjusted quarterly benchmark reports that compare your institution’s performance with that of volume- based peer groups and the national experience Standardized, evidence-based data elements and definitions A complimentary online data collection tool; or a variety of certified third- party vendor software options Complimentary access to Cardiosource®, the most authoritative and comprehensive online resource in cardiovascular medicineCardiosource A wide range of other tools to advance QI initiatives in your facility

QI ACTION-GWTG What Are You Measuring? Compliance with AHA/ACC Clinical Guidelines Adverse Event Rates Transfer facility therapies & reperfusion strategies Patient demographics, provider & facility characteristics

QI ACTION-Get With The Guidelines Data Collection “Short Form” Demographics (10) Admission (8) Cardiac Status on First Medical Contact (12) History & Risk Factors (4) Medications (15) Procedures & Tests (9) Reperfusion Strategy (immediate) (4) In-hospital clinical events (4) Lab Results (4) Discharge (10) Optional Elements (AMI Core Measure Reporting Only) (2)

QI Data Collection Recommendation for Primary PCI Centers Submit 100% of STEMI & NSTEMI cases using either full or reduced data set Encourage to participate in the full data set

QI Data Collection Recommendation for Non-Primary PCI Centers Must submit 100% of STEMI cases using either the full or reduced data set May choose to submit STEMI and NSTEMI cases using either the full or reduced data set

QI South Dakota ACTION-Get With The Guidelines Hospitals Rapid City Regional Hospital* Sanford USD Medical Center

QI South Dakota CATH PCI Hospitals Avera Heart Hospital Avera St. Lukes Prairie Lakes Healthcare Rapid City Regional* Sanford USD*

QI ACTION-GWTG Multi-Vendor Data Collection Options Free web based tool OR Certified third party vendor Outcome Sciences, Inc. ($1810/yr) Lumedx & Quantros Additional Vendors-TBD

QI Benefits of Participation Comprehensive database & QI program to drive better treatment of STEMI/NSTEMI patients Measure & track risk adjusted performance against national benchmarks Robust reporting capabilities & quality consultation Network of hospitals for best practice sharing System level aggregate data to drive Mission Lifeline & other quality initiatives Local & national recognition Aligned with TJC/CMS AMI core measures

QI ACTION-Get With The Guidelines Meets ABIM Diplomats MOC Recertification Requirements Earn up to 80 points toward evaluation of practice performance through self-directed PIM

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ACTION-Get With The Guidelines Data Applications Performance Improvement Healthcare Systems Change Public Reporting Publication Policy recommendations Reimbursement Data collection for M;L

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Why is this important to hospitals? Public reporting Reimbursement-Pay for Quality Decreased Length of Stay = $ Community health status Market share Physician & employee relations Hospital Magnet Status Recognition for quality care

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Summary Web based data collection using standardized data elements Embedded data elements used for TJC/CMS reporting Quarterly comparative institutional outcome reports to enable benchmarking with peers and nationally Access to clinically experienced support staff Comprehensive data quality programs that facilitate data reliability Additional data quality support through a national data audit program Participant training resources (workshops, webinars, user group meetings)

QI Questions ? Additional Information Sample full data set tool Sample hospital reports OR