QI ACTION Registry-Get With The Guidelines The Mission Lifeline Data Solution Kathleen O’Neill, MHA Senior Director, Quality Initiatives IL & SD American.

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ACTION Registry-Get With The Guidelines

The Mission Lifeline Data Solution

Kathleen O’Neill, MHASenior Director, Quality Initiatives

IL & SDAmerican Heart Association

9-1-09

QIAmerican Heart Association’s

Get With The Guidelines?

• Hospital performance improvement program for CAD, Heart Failure & Stroke.

• Includes a clinical decision support tool-”PMT”• Web based, real-time • Class I Level A Guidelines are imbedded in the

tool• Patient data is compared to the guidelines to

assess applicability

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Get With The Guidelinessm

We are in a new business, from development of guidelines to implementation of guidelines

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11 State AHA Midwest AffiliateGet With The Guidelines Participation

• Over 400+ contracts in place in hospitals throughout the affiliate and 1600+ nationwide

• Over 150,000+ patient records in Get With The Guidelines in the Midwest and over one million patients nationally.

QIGet With The GuidelinesSM

Patient Management Tool

• Online, web-based, real-time data collection

• De-identified patient data

• Data analysis for performance improvement

• Long term clinical outcomes registry

QI

1. Collect data on adherence to AHA guidelines with the PMT data form.

2. PMT Reporting tools allow for data analysis to identify areas for improvement.

3. Use PMT Reports to present need for change in targeted areas for improvement.

4. Hospitals implement new protocols, often using tools in the PMT.

Role of the Patient Management Tool

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AHA’s GWTG CAD Registry

+ ACC’s NCDR ACTION Registry

=

ACTION Registry® - GWTG

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ACTION Registry® - GWTGGoals

• Largest, most comprehensive AMI database• National surveillance database system for high-risk

AMI patients with STEMI/NSTEMI• Optimize care & outcomes for all acute MI patients• Assure the rights things are done right (safely &

timely)• Site level, system level & ultimately state level

outcomes & performance improvement data

QIParticipation Provides…

Weekly key measures reports and risk-adjusted quarterly benchmark reports that compare your institution’s performance with that of volume-based peer groups and the national experience

Standardized, evidence-based data elements and definitions

A complimentary online data collection tool; or a variety of certified third-party vendor software options

Complimentary access to Cardiosource®, the most authoritative and comprehensive online resource in cardiovascular medicine

A wide range of other tools to advance QI initiatives in your facility

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ACTION-GWTGWhat Are You Measuring?

• Compliance with AHA/ACC Clinical Guidelines• Adverse Event Rates• Transfer facility therapies & reperfusion

strategies• Patient demographics, provider & facility

characteristics

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ACTION-Get With The Guidelines Data Collection “Short Form”

• Demographics (10)• Admission (8)• Cardiac Status on First Medical Contact (12)• History & Risk Factors (4)• Medications (15)• Procedures & Tests (9)• Reperfusion Strategy (immediate) (4)• In-hospital clinical events (4)• Lab Results (4)• Discharge (10)• Optional Elements (AMI Core Measure Reporting Only) (2)

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Data Collection Recommendation for Primary PCI Centers

• Submit 100% of STEMI & NSTEMI cases using either full or reduced data set

• Encourage to participate in the full data set

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Data Collection Recommendation for

Non-Primary PCI Centers

• Must submit 100% of STEMI cases using either the full or reduced data set

• May choose to submit STEMI and NSTEMI cases using either the full or reduced data set

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South Dakota ACTION-Get With The Guidelines

Hospitals

• Rapid City Regional Hospital*

• Sanford USD Medical Center

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South Dakota CATH PCIHospitals

• Avera Heart Hospital

• Avera St. Lukes

• Prairie Lakes Healthcare

• Rapid City Regional*

• Sanford USD*

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ACTION-GWTGMulti-Vendor Data Collection

OptionsFree web based tool

OR

Certified third party vendor

Outcome Sciences, Inc. ($1810/yr)

Lumedx & Quantros

Additional Vendors-TBD

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Benefits of Participation• Comprehensive database & QI program to drive

better treatment of STEMI/NSTEMI patients• Measure & track risk adjusted performance

against national benchmarks• Robust reporting capabilities & quality

consultation• Network of hospitals for best practice sharing• System level aggregate data to drive Mission

Lifeline & other quality initiatives• Local & national recognition• Aligned with TJC/CMS AMI core measures

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ACTION-Get With The Guidelines Meets ABIM Diplomats MOC Recertification Requirements

• Earn up to 80 points toward evaluation of practice performance through self-directed PIM

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QIACTION-Get With The Guidelines

Data Applications

• Performance Improvement• Healthcare Systems Change• Public Reporting• Publication• Policy recommendations• Reimbursement• Data collection for M;L

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Why is this important to hospitals?

• Public reporting• Reimbursement-Pay for Quality• Decreased Length of Stay = $• Community health status• Market share• Physician & employee relations• Hospital Magnet Status• Recognition for quality care

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QISummary• Web based data collection using standardized data

elements• Embedded data elements used for TJC/CMS reporting • Quarterly comparative institutional outcome reports to

enable benchmarking with peers and nationally• Access to clinically experienced support staff• Comprehensive data quality programs that facilitate

data reliability• Additional data quality support through a national data

audit program• Participant training resources (workshops, webinars,

user group meetings)

QIQuestions ?Questions ?

Additional Information

www.ncdr.com

Sample full data set tool

Sample hospital reports

OR

www.americanheart.org/getwiththeguidelines

[email protected]

312-476-6622