1. Please register your attendance using this QR code or by using an IPad located at each door

2.  The Next (NOW) Accreditation System (NAS)  Program Accreditation  Institutional Accreditation  Institutional Review  Clinical Learning Environment Review (CLER)

3.  Reminder  Provides frequent, on-site sampling of the learning environment  First CLER site visit was July 2014  Next visit between February and July 2017  Assesses the following 6 focus areas:  Patient Safety  Quality Improvement  Transitions of Care  Supervision  Duty hours oversight, fatigue management and mitigation  Professionalism

4. GME Curriculum Lisa Hutcherson Program Manager Quality Improvement/Patient Safety

5. Core Measures are something that the Quality Department handles…… Right?

6.  Introduce you to Core Measures  Ability to read Scorecard  Who to call when you have questions!

7.  Department of Health and Human Services developed the Hospital Inpatient Quality Reporting (IQR) program and released the original Core Measures November 2001.  Acute Myocardial Infarction (AMI)  Heart Failure (HF)  Pneumonia (PN),  Surgical Care Improvement Project (SCIP)

8.  Congress later authorized the hospital Value-Based Purchasing (VBP) program through the Affordable Care Act.  Built on IQR reporting structure  Uses IQR measures published on Hospital Compare for at least one year

9.  VBP program purpose  Eliminating or reducing occurrence of adverse events  Adopting evidence-based care standards and protocols that result in the best outcomes for most patients  Improve the patients experience

10.  Measures are based on published guidelines with input from practicing physicians  Reporting is the same for every hospital  If your hospital is a top performer you make money….  If your hospital is a poor performer…..

12.  Center for Medicare & Medicaid (CMS)  National Quality Forum (NQF)  Agency for Healthcare Research and Quality (AHRQ)  The Joint Commission  Others

14.  Surgical Care Improvement Project (SCIP)  Acute Myocardial Infarction (AMI)  Heart Failure (HF)  Pneumonia (PN)  Children’s Asthma (CAC)  Stroke  VTE  Global (Immunizations, ED)  Perinatal Care (mothers and newborns)

15.  SCIP (OP SCIP)  Outpatient Chest Pain  Outpatient Acute Myocardial Infarction  Outpatient Emergency Department (OP ED) – Throughput  Outpatient Stroke (OP STK)

17. 700+ hospitals will see payments docked by 1%

18. Additional Physicians Additional Staff Equipment Improving facilities

19. How do I know where my facility stands?

22. Call the hospitals Quality Department For UHS call: 358-2278 or 358- 8267 Located on the third floor just across from the cafeteria.

23. Wednesday, April 8 @ 6:30 am, 309L Friday, April 10 @ 11:00 am, 309L “Disclosing Unintended Outcomes”