Indiana Association for Healthcare Quality May 8, 2014 To promote and provide essential public health services
Dec 22, 2015
Indiana Association for Healthcare Quality
May 8, 2014
To promote and provide essential public health services
Patient Safety Initiative: Assessing Quality Through the Survey Process Using the Three
CoP Worksheets
Randy Snyder, PT, MBADivision Director, Acute Care
Indiana State Department of Health
Objectives:Objectives:
Gain an understanding of the key measures used to assess quality through the use of three survey worksheets implemented within the survey process.
Identify two primary goals associated with the patient safety initiative.
Objectives:Objectives:
Apply non-surveyor use of the worksheets to their respective facilities to assess quality.
Identify the key differences between state licensure surveys and federal certification surveys.
In the Beginning…..In the Beginning…..
The Administration and Congress created the Health Care and Education Reconciliation Act of 2010
AKA: Patient Protection and Affordable Care Act
AKA: Affordable Care Act
AKA: Obamacare
ACA: Section 3011ACA: Section 3011
Improve research and dissemination of strategies and best practices to improve patient safety and reduce medical errors, preventable admissions and readmissions, and health care-associated infections;
ACA Section 3021ACA Section 3021
http://dhhs.nv.gov/HealthCare/Docs/reimbursement/ACA3021InnovationCenter.pdf
CENTER FOR MEDICARE AND MEDICAID INNOVATION ESTABLISHED
CMS Innovation Center:CMS Innovation Center:
The Partnership for Patients initiative is a public-private partnership working to improve the quality, safety and affordability of health care for all Americans. Physicians, nurses, hospitals, employers, patients and their advocates, and the federal and State governments have joined together to form the Partnership for Patients.
http://innovation.cms.gov/initiatives/partnership-for-patients/index.html
PfP Primary Goals:PfP Primary Goals:
Making Care Safer. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010.
Improving Care Transitions. By the end of 2013, preventable complications during transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010.
Patient Safety InitiativePatient Safety Initiative
HHS announces a $1 Billion Patient Safety Initiative
Survey and Certification’s Role:Survey and Certification’s Role:
CMS develops and issues Hospital Patient Safety Initiative Worksheets.
ImplementationImplementation
FFY 11: Piloted by several states.
FFY12: Each state used the worksheet at least one time.
FFY13: All three used for selected hospitals
Sample SelectionSample Selection
All-cause risk-adjusted readmission data
Results FFY11-12Results FFY11-12
186 Total Worksheets
QAPI: 60
Infection Control: 65
Discharge Planning: 61
Hospitals cited at Standard Level
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 QAPIResults FFY11-12 QAPI
Individual questions:
Assessment of each contracted service: 14.5% negative
New interventions developed for those unsuccessful: 12.9% negative
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 QAPIResults FFY11-12 QAPI
Data collection consistent when staff involved: 12.5% negative
Aggregate data in subsets to allow comparison: 12.5% negative
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 QAPIResults FFY11-12 QAPI
Tags likely to be cited:
A0273 Data Collection and Analysis. A0286 Patient Safety, Medical Errors &
Adverse Events. A0308 Standard Tag for Condition
Statement.
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 QAPIResults FFY11-12 QAPI
Themes: Program Data Collection and
Analysis Documented Evidence of QAPI
Program Executive Responsibilities
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 Infection Results FFY11-12 Infection ControlControlIndividual Questions:
Disconnecting catheter tubing: 47.4% negative
Antibiotic orders with indication for use: 42.6% [not required]
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 Infection Results FFY11-12 Infection ControlControl Review need for antibiotics after 72
hours: 27.7% negative [not required]
Hand Hygiene: 19.2% negative
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 Infection Results FFY11-12 Infection ControlControlSections with lowest results:Systems to prevent transmission of MRDO and
promote antibiotic stewardship [not required but…]
Surgical procedure tracer: 47.8% negativeUpdate: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 Infection Results FFY11-12 Infection ControlControl
Ventilator/respiratory tracer: 42.55% negative
Isolation: Contact precautions: 42.55% negative
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 Infection Results FFY11-12 Infection ControlControl“Best Practices” commonly found: Need for central venous catheters review daily Oral hygiene for high risk patients HOB elevated for patients at high risk for
aspiration Spontaneous breathing trials for vent patients
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 Discharge Results FFY11-12 Discharge PlanningPlanningIndividual Questions:
Evaluate if readmissions were preventable: 18.9% preventable
Changed discharge planning process if cause of readmissions: 16.7%
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 Discharge Results FFY11-12 Discharge PlanningPlanning Update discharge plan to reflect
changes in patient condition: 13.7% negative
Following P&P: 13.3% negative
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 Discharge Results FFY11-12 Discharge PlanningPlanningTags most likely cited:
A0820 Initial implementation
A0819 Physician request for evaluation
A0906 Comprehensive evaluation
A0817 Plan matches evaluationUpdate: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY11-12 Discharge Results FFY11-12 Discharge PlanningPlanning“Best Practices” commonly found:
Scheduling follow up appointments
Pharmacist review of discharge med orders
Filling prescriptions
DC plan for all inpatients (+66.7%)
DC plan for some outpatients (+78.3%)
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
Results FFY13Results FFY13
o Not yet released by CMSo QAPI results look similaro Infection control: MDRO, point of care
devices, and hand hygieneo Discharge Planning results look similaro No citationso 159 worksheets completedUpdate: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
FFY14 (Current year):FFY14 (Current year):
Sample selection based on citation dataNo citations (non-punitive)Use as risk management assessment
tool at exitWorksheets publically availableUsing revised worksheets
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
FFY15:FFY15:
Additional revisions? (still draft)Continued data collection/analysisRequired for all surveys?Additional CoPs?Contingent upon funding
Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI
State Licensure/Federal State Licensure/Federal CertificationCertificationPSI worksheets are a federal requirement
completed by a federally defined process and conducted by the State Agency during recertification surveys.
State licensure surveys are independent of federal surveys.
State Agency is the contractor for Federal surveys.
Helpful sites:Helpful sites:
The “Discharge Planning” Booklet (ICN 908184)
Partnership for Patientshttp://innovation.cms.gov/initiatives/partnership-for-patients/index.html
Patient Protection and Affordable Care Act
http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf
Objectives:Objectives:
Gain an understanding of the key measures used to assess quality through the use of three survey worksheets implemented within the survey process.
Identify two primary goals associated with the patient safety initiative.
Objectives:Objectives:
Apply non-surveyor use of the worksheets to their respective facilities to assess quality.
Identify the key differences between state licensure surveys and federal certification surveys.
QUESTIONS
Thank You !
Have a great conference