1. Developed: December 2011 Most recent update: January 2014 Kathy Wonderly Performance Improvement Coordinator Hospital Council of Western Pennsylvania Hospital Outpatient Quality Reporting Requirements

2. Introduction The Hospital Outpatient Quality Reporting (OQR) program has been developed by CMS to promote high quality care for patients receiving service in hospital outpatient settings. The information included in this program covers outpatient encounters from January 1, 2014 through September 30, 2014.

3. Departments Impacted by the Current OQR Measures 1.Emergency Department 2. Hospital Outpatient Surgery 3. Imaging Department- MRI, Mammography,CT, Cardiac Imaging 4.Healthcare Worker Influenza Vaccine Compliance

4. Measures Reporting Median Time Some of the outpatient measures report the median time rather than the percent of compliance. The median time is the middle number for all the patients reported for the designated time period.

5. Median Value Example Patients presenting with Chest Pain are expected to have an EKG done within 10 minutes of arrival. Rather than reporting the percent of patient that meet this measure, the results posted will be the median time. In this sample it would be 9 minutes. Median 1 4 5 5 6 8 9 10 11 13 15 16 17 Minutes from arrival to EKG

6. What are the outpatient measure sets? 1. Acute Myocardial Infarction ( AMI) 2. Chest Pain 3. Emergency Department throughput 4. Pain Management for long bone fracture 5. Stroke 6. Surgery Infection Prevention 7. Surgical safety 7. Imaging Efficiency 8. Healthcare influenza vaccination

7. Let’s look at the measures! Some of the measures sound much like the inpatient measures for the same diagnosis Starting with patients admitted to the ED with chest pain or an AMI we will go through them individually.

8. Emergency Department Measures All patients admitted to the ED with an AMI or chest pain are required to have: Aspirin on arrival or documentation of allergy or other contraindication. EKG on arrival which is reported as the median time from arrival to EKG (within10 minutes of arrival is the benchmark ).

9. Emergency Department Measures For AMI patients the following measures apply: 1. Fibrinolytic therapy received within 30 minutes of arrival. 2. Median time for fibrinolysis 3. Median time to transfer to another acute care facility for acute coronary intervention

10. Emergency Department Measures Median time from ED arrival to ED departure for discharged ED patients. Door to diagnostic evaluation time by a qualified medical professional.

11. Emergency Department Measures The percent of patients who leave the ED without being evaluated by a physician or an institutionally credentialed provider. Depending on your facility this could be a Nurse Practitioner, CRNA, Clinical Nurse Specialist or Certified Nurse Midwife.

12. Emergency Department Measures Pain Management in the ED The median time to pain management for long bone fracture is measured in this indicator. The measurement is from the time of arrival to the time the initial oral, intranasal or parenteral pain medication is administered. If the patient receives pain medication ordered by medical command prior to arrival that would count as the initial dose.

13. Emergency Department Measures Head CT or MRI scan results for ED Acute Ischemic or Hemorrhagic Stroke Patients This indicator measures the percent of patients who arrive at the ED within 2 hours of onset of stroke symptoms and have a Head CT or MRI scan performed and the interpretation is available within 45 minutes of arrival.

14. Outpatient Surgery Measures Prophylactic antibiotic given no more than 60 minutes before the time of the incision. Exception: patients receiving vancomycin or a fluroquinolone infusions require a longer time therefore 2 hours prior to incision is acceptable. Surgical patients receive the appropriate prophylactic antibiotic consistent with current guidelines for each type of surgical procedure. These are listed in the next slides.

15. Approved Antibiotics by Procedure Type Cardiac Pacemaker or AICDs- Cefazolin or Cefuroxime If B-lactam allergy: Vancomycin or Clindamycin Orthopedic/Podiatry- Cefazolin or Cefuroxime If B-lactam allergy: Vancomycin or Clindamycin

16. Approved Antibiotics for Genitourinary Procedures Prostate biopsy Quinolone or any Cephalosporin ( oral or intramuscular alone are acceptable) or Sulfamethoxazole/Trimethoprim or Aminoglycoside or Aztreonam

17. Approved Antibiotics for Genitourinary Procedures Penile prosthesis insertion, removal or revision Ampicillin/Sulbactam or Ticarcillin/Clavulanate or Pipercillin/Tazobactam or Aminoglycoside + 1st or 2nd generation cephalosporin or Vancomycin (with physician or pharmacist documented justification) or Clindamycin or Azetreonam + 1st or 2nd generation cephalosporin or Vancomycin or Clindamycin

18. Approved Antibiotics for Gastric/Biliary Procedures PEG placement Any of the following: Cefazolin, Cefuroxime, Cefoxitin, Cefotetan, Vancomycin (with physician or pharmacist documented justification) or Ampicillin/Sulbactam Or Cefazolin or Cefuroxime + Metronidazole If B-lactam allergy Clindamycin +Aminoglycoside or Quinolone Or Vancomycin + Aminoglycoside or Quinolone

19. Approved Antibiotics for Gynecological Procedures Laparoscopically- assisted hysterectomy, vaginal hysterectomy Cefazolin, Cefuroxime, Cefoxitin or Cefotetan or Ampicillin/Sulbactam If B-lactam allergy Metronidazole + Aminoglycoside or Quinolone Or Clindamycin + Aminoglycoside or Aztreonam or Quinolone Or Vancomycin + Aminoglycoside or Aztreonam or Quinolone

20. Approved Antibiotics for Gynecological Procedures Pubovaginal sling 1 st or 2 nd Generation Cephalosporin or Ampicillin/Sulbactam or Quinolone If B-lactam allergy Aminoglycoside + Clindamycin or Metronidazole Or Aztreonam + Clindamycin or Metronidazole

21. Approved Antibiotics for Surgical Procedures Head and Neck Cefazolin or Cefuroxime or Ampicillin/Sulbactam or Vancomycin (with physician or pharmacist documented justification) Or Clindamycin + Aminoglycoside

22. Approved Antibiotics for Surgical Procedures Neurological Cefazolin or Cefuroxime Or Vancomycin (with physician or pharmacist documented justification) Or Clindamycin

23. Outpatient Surgery Measures Surgical Safety Checklist Hospitals are required to use a Safe Surgery Checklist for all surgical procedures. This list must include safe practices for the period: prior to administration of anesthesia, prior to skin incision period of closure of the incision prior to the patient leaving the operating room. These practices may include patient identification, site marking, equipment checking, appropriate antibiotic timing, availability of essential imaging as appropriate or complete instrument and sponge count.

24. Outpatient Surgery Measures Starting April 1, 2014 Colonoscopy Patients having colonoscopy for polyp surveillance should be scheduled at the current recommended follow-up intervals. For patients with normal colonoscopy results the interval between scoping is at least 10 years. For those patients with a history of adenomatous polyps, the recommended interval is 3 or more years. This interval must be documented in the operative report. In either case, if the patient has other medical reasons for more frequent colonoscopy this reason must be documented in the medical record.

25. January 1, 2015 Start Date for Cataract Surgery Measure Cataract Surgery The surgeon must provide documentation that the cataract surgery patient completes both a pre-operative and post-operative visual function test to determine visual improvement within 90 days of surgery. This measure will require the coordination between the hospital and the physician office to obtain the necessary information.

26. Claims Based Measures Many of the outpatient measures are obtained from the codes found on the billing claim rather than through medical chart review.

27. Imaging Measures These measures are all reported by percent of compliance. 1. MRI for low back pain without conservative measures attempted first 2. Follow-up of positive screening mammography with diagnostic mammography 3. Use of contrast material with Abdominal CT and Thorax CT 4. Use of Cardiac imaging for preoperative risk assessment for non-cardiac low risk surgery 5. Simultaneous use of brain and sinus CT 6. Use of Brain CT in the ED for atraumatic headache

28. Healthcare Personnel Influenza Vaccination It is expected that healthcare personnel working in the outpatient setting will comply with the CDC recommendations for Influenza vaccination. The data will be collected from October 1 through March 31. All employees who work at least one day in this time frame must be included.

29. Changes Beyond 2014 ! The CMS quality reporting program is an ever changing process. They are considering adding health information utilization, patient safety and care transition measures for future years.

30. Test your knowledge! 1. All patients presenting in the ED with cardiac chest pain or an AMI need an EKG on arrival. The benchmark is within _________ minutes of arrival. a. 2 b. 10 c. 20 d. 60

31. Test your knowledge! 2. The imaging interpretation must be available within _______ minutes of arrival for patients who arrive at the ED within 2 hours of onset of stroke symptoms and have a Head CT or MRI scan performed. a. 45 b. 60 c. 100

32. Test your knowledge! 3. Some of the outpatient results report the median rather than the percent of compliance. Select the median value for this group of AMI patients that were transferred to another acute care facility for acute coronary intervention. 45 55 60 75 80 95 104 111 120 minutes The median is a. 75 b. 80 c. 95 d. 83

33. Test your knowledge! 4. All surgical procedures must include the use of a surgical safety checklist. a. True b. False

34. Test your knowledge! 5. The physician must document in the operative report the recommended follow-up interval (10 years) for patients with a normal colonoscopy. a. True b. False