1. MBQIP measures Emergency Department Transfer Communication at Mercy Kelly Pashia Clinical Quality Measures Specialist

2. Discussion About Mercy’s Critical Access Structure Centralized abstraction/quality team Hospital based quality/performance improvement Mercy Aurora Background on hospital and leadership structure Mercy as a pilot participant Mercy’s ED: learning the transfer measures Opportunities for change Benefits gained Obstacles met

3. Mercy as a Ministry Covers four state region Hospitals: 46 acute care and specialty hospitals 17 Critical access hospitals Mercy clinics and physicians 700 physician offices with 2,000 physicians 40,000 coworkers across four states Outreach programs in Arkansas, Louisiana, Texas and Mississippi

4. Mercy’s Quality and Safety Center One centralized team specializing in core measures, CMS and TJC abstraction and reporting Maintains regulatory compliance Patient safety reporting and education Infection prevention reporting

5. Mercy’s involvement in MBQIP Started as pilot hospitals in Missouri and Oklahoma Stratus Health data collection tool Involved in surveys from each QIO on measures Expanded data collection to Arkansas and Kansas CAH’s

6. Mercy Aurora One of three Mercy hospitals to participate in first pilot with Stratus Health Joined Mercy in 2001, TJC accredited Community Population about 7500 Agricultural, schools and hospital largest employer Services provided Outpatient surgery, wound care, infusion, cardiac rehab, sleep lab, OB services, Mercy ambulance ED has average of 14,000 visits per year, ADC: 6 Leadership/Quality President, CNO/VP, Quality Manager: shared with two other Mercy facilities, ED Nurse manager, shared with Cassville

7. EDTC- The beginning Clarification of measures: quality and ED coworkers getting to know measures Data abstraction: documentation errors Population defined Education of providers HIM/EMR specialist engagement Issues with ever-changing EMR documentation

8. Mercy’s EDTC education Formation of Quality and ED team Includes central Quality specialists, Quality manager at CAH’s, ED nursing leaders, EMR team specializing in ED documentation Constant education of ED nurses and HIM coworkers during pilot program Development of new reports to facilitate abstraction of data as well as performance improvement reports

9. EDTC EMR Reports Acute Care Transfer Report EDTC-1 Quick look at what was sent with the patient Reason for transfer ACTR hyperlink within EMR transfer facility encounter

10. EDTC EMR Reports ED Transfer Report Developed by ED EPIC team specifically for EDTC measures Found as hyperlink within encounter Static “copy” of entire ED documentation at transferring facility

11. Example of hyperlinks to reports

12. EDTC Quality Reports

13. Opportunities and common misses EDTC-1 Constant reminder to staff to include title of transferring and accepting nurses/physicians/PA/EMT EDTC-2 No 24 hr intake coworkers, unable to get contact/insurance information into system if new patient to Mercy. (ongoing issue) EDTC-5 Provider was not completing H&P prior to transfer, so it was not included in ED report. Education to providers and nursing staff, increase in compliance starting with 3Q 2015. EDTC-6 Sensory status documentation: not routine for ED nurses. Developed smart phrase to address measure.

14. Benefits of EDTC Patients transferring between Mercy facilities now have complete ED documentation at arrival. Patients going to other facilities, such as skilled nursing facilities now have pertinent medical information. (not common practice prior to EDTC measures). Mercy ministry has better understanding of patient population in CAH. Has led to collaboration of all Mercy CAH on other measures.

15. Questions or Comments?