QIO Update Judy Weddle, RN, BSN, MEd, CPHQ Hospital QI Specialist QSource Patient Safety Team August 2009 THA Patient Safety Center “Reducing Hospital Acquired Infections” Collaborative Regional Networking Meetings

SCIP national measure changes Stroke/VTE/ED “Core Measures” comments QSource’s CMS MRSA Project progress TeamSTEPPS training workshops HLQAT national and TN launch Informal – please ask questions throughout! Discussion Topics for Today

“The right care for every person, every time.” CMS Vision Statement For the National Healthcare Quality Improvement Program

S afe T imely E ffective Efficient Equitable P atient-centered The Institute of Medicine The “Right Care”

Available for discharges from 10/01/09 forward Remove: Inf-7 – Colorectal Surgery Patients with Immediate Postoperative Normothermia Add: Inf-10 – Surgery Patients with Perioperative Temperature Management Add: Inf-9 – Urinary Catheter Removed on Postoperative Day 1 or Postoperative Day 2, with Day of Surgery Being Day Zero SCIP Core Measures Changes

Measure Information Form (MIF) available on within the TJC/ CMS-aligned Specifications Manual –“Hospitals - Inpatient” tab –“Specifications Manual” link –“Version 3.0a” link Detailed Information on New Measures

Measure Information Form (MIF) Contents –Measure short name –Data element list –Population and sampling information –Measure-specific information (e.g., rationale, numerator/denominator statements, included/ excluded populations, selected “evidence” references from medical literature, analysis algorithm) Detailed Information, cont.

Key Points from MIF –Rationale: Postoperative patients with > 2 days duration of indwelling urinary catheters 21% more likely to develop UTI Significantly less likely to be discharged to home Significant increase in mortality at 30 days (As we all know… “catheter-associated UTI” is one of the Hospital Acquired Conditions (HAC) for which a higher-DRG payment is not allowed by CMS) SCIP Inf-9 – Urinary Catheter Removed

Key Points from MIF, cont. –Denominator: All SCIP surgery types (Appendix A, Table 5.10) Urinary catheter in place post-op Exclude patients with LOS < 2 days post-op Several exclusions related to specific urinary- type surgeries and infections prior to surgery Exclusion for patients with MD/APN/PA documentation of reason for not removing the catheter SCIP Inf-9 – Urinary Catheter Removed, cont.

Key Points from MIF, cont. –3 New Data Elements to be Abstracted See Data Dictionary in Specifications Manual “Urinary catheter” “Catheter removed” “Reasons for continuing urinary catheterization” SCIP Inf-9 – Urinary Catheter Removed, cont.

Chart audits to determine ease of collecting the 3 new data elements (simple, home-grown audit tool) Educate surgeons Educate surgery and post-op staff SCIP Inf-9 – Preparing

Update EMRs/Standing Order Sets –Examples from national SCIP List Serv: Add “catheter placed” + date documentation field Add “assess for removal” type of prompt timed to “catheter placed” field Add “catheter removed” + date documentation field Add documentation field to capture any reason for continuation SCIP Inf-9 – Preparing, cont.

IHI Improvement Map Resource –“Getting Started Kit: Prevent Catheter- Associated Urinary Tract Infections – How To Guide” –Free download (after log-in) from (you will have to “register” [free and simple] if not already a member) SCIP Inf-9 – Preparing, cont.

IHI Improvement Map Resource, cont. –Kit includes detailed information on four recommended components of care: Avoid unnecessary urinary catheters Insert urinary catheters using aseptic technique Maintain catheters based on recommended guidelines Review urinary catheter necessity daily and remove promptly SCIP Inf-9 – Preparing, cont.

Key Points from the MIF –Rationale: “Unplanned perioperative hypothermia has been correlated with impaired wound healing, adverse cardiac events, altered drug metabolism, and coagulopathies.” SSIs 3 times higher (certain SSIs are HACs) Increased chance of blood products administration, myocardial infarction, and mechanical ventilation Prolonged hospital stays and increased costs SCIP Inf-10 – Perioperative Temperature Management

Key Points from MIF, cont. –Numerator: Surgery patients for whom either active warming was used intraoperatively…or who had at least one body temperature equal to or greater than 96.8F/36C recorded within the 30 minutes immediately prior to or the 15 minutes immediately after Anesthesia End Time. SCIP Inf-10 –Perioperative Temperature Management, cont.

Key Points from MIF, cont. –Denominator: All SCIP surgery types (Appendix A, Table 5.10) All ages General or neuraxial anesthesia greater than or equal to 60 minutes duration Exclusion for patients with MD/APN/PA documentation of intentional hypothermia for the procedure SCIP Inf-10 – Perioperative Temperature Management, cont.

Key Points from MIF, cont. –2 New Data Elements to be Abstracted See Data Dictionary in Specifications Manual “Intentional hypothermia” (no specific inclusion words for surgery involving cardiopulmonary bypass) “Temperature” SCIP Inf-10 – Perioperative Temperature Management, cont.

Conduct chart audits to determine ease of collecting the 2 new data elements (simple, home-grown audit tool) Discuss with surgical team members who participated in the process improvements related to the previous normothermia measure Educate surgeons/anesthesia staff Educate surgical staff Update EMRs/Standing Order Sets/Anesthesia Records SCIP Inf-10 – Preparing

July 31, 2009 – CMS IPPS Final Rule –Both measures finalized for the FY 2011 RHQDAPU payment determination –Submission to the QIO Clinical Warehouse required beginning with 1 st quarter 2010 discharges Highly recommend taking advantage of the 4 th quarter 2009 discharges submission period to “get ready” – talk to your vendor! SCIP Inf-9 and Inf-10 CMS Requirements

Accepted by The Joint Commission only - for discharges Oct-Dec 2009 and forward “Informational” for CMS - not accepted into the QIO Clinical Warehouse at this time July 31, 2009 RHQDAPU Final Rule: CMS received public support and will likely propose these measures for the FY 2012 payment determination Full MIFs available on If interested, contact your vendor to see if they will offer data abstraction fields for these measures Stroke and VTE “Core Measures”

Informational only Not accepted by The Joint Commission or CMS at this time July 31, 2009 RHQDAPU Final Rule: CMS received public support and will likely propose these measures for the FY 2012 payment determination Full MIFs available on If interested, contact your vendor to see if they will offer data abstraction fields for these measures Emergency Department “Core Measures”

19 of the 29 participant hospitals successfully submitted MDRO baseline data and conferred data rights to QSource and the national QIO Support Contractor (not CMS) through NHSN If your hospital is in both MRSA projects (QSource & THA), confer data rights to TDOH (Dr. Kainer) also QSource’s CMS MRSA Project Progress to Date

A TN hospital and QSource worked together to identify a “glitch” in the new MDRO module system and submitted it to the CDC/NHSN Help Desk for resolution Continue to submit data monthly! Due by the end of the following month THANK YOU for your patience and perseverance!!! QSource’s CMS MRSA Project Progress to Date, cont.

Developed by the Department of Defense (DoD) and the Agency for Healthcare Research and Quality (AHRQ) –Focus: patient safety –Teamwork and communication skills CMS provided Train-the-Trainer education for all QIOs In turn, QIOs provide TeamSTEPPS training QSource TeamSTEPPS Training

Upcoming QSource regional training workshops: –Attendance required for all QSource CMS SCIP/HF and MRSA project hospitals –Also open to all other TN hospitals and QSource partners and stakeholders Training focus: communication skills Target audience: Infection Preventionists, QI staff, unit managers, and frontline staff QSource TeamSTEPPS Training, cont.

Regional workshops: 1:00–3:00pm (local time) –Chattanooga, Tuesday Oct. 20 th –Knoxville, Wednesday Oct. 21 st –Tri-Cities, Thursday Oct. 22 nd –Memphis, Tuesday Nov. 10 th –Jackson, Wednesday Nov. 11 th –Nashville, Thursday Nov. 12 th Watch for registration information !!! QSource TeamSTEPPS Training, cont.

“Helps hospitals identify and improve those structures, processes, and leadership activities associated with high performance in clinical quality” Developed by a national, collaborative panel of experts Enhances and is complementary to the AHRQ Patient Safety Culture Survey tool (elicit differences in perception between leadership and frontline staff) No plans by CMS for making it mandatory or publicly reported Hospital Leadership and Quality Assessment Tool (HLQAT)

Knowledge-seeking Established goals and priorities Effective communication Collaboration Clear roles Collaborative, supportive culture Public reporting Process improvement tools and techniques Adequate resource allocation QI education Monitoring and evaluation Rewards/recognition 12 HLQAT Domains

Consists of two survey components: –Senior leadership (includes boards/trustees) –Clinical management Minimum # of responses required: –3 board members –4 members of executive team (CEO, CMO, CNO, and CFO) –6-10 clinical managers HLQAT Details

Free to all hospitals Survey information is “the property of the hospital” No individual survey-respondent information will be made available to the hospital Online access to surveys – approx 30 min. to complete HLQAT Details, cont.

Online access to hospital and comparative reports –Only the hospital can share its results Online access to “Resources for Leadership Interventions” (RLIs) for each of the 12 Domains: Website links Evidence-based literature Tools (templates, workbooks, toolkits) HLQAT Details, cont.

Required activity for hospitals participating in the QSource/CMS SCIP/HF and MRSA projects –See next slide on “Getting Started” –Your QSource project contact will also provide you with specific support as needed Recommended activity for all hospitals (be a top performer when P4P is implemented!) HLQAT Details, cont.

Register: send an to with the subject line HLQAT Participant Receive a “Welcome Packet” and your hospital’s “Unique Identifier Codes” for respondents Visit –FAQs and support documents –Survey tool copies/take the survey –Reports –Intervention resources HLQAT – Getting Started

Judy Weddle Thank You! This presentation and related materials were developed by QSource, the Medicare Quality Improvement Organization for Tennessee, under contract with the Centers for Medicare & Medicaid Services (CMS), a division of the Department of Health and Human Services. Contents do not necessarily reflect CMS policy. QSOURCE-TN