Download HB 197 – 2010 Update - Ohio Association for Healthcare Quality

History
• HB. 197 signed August 2006
– Deletes SB 50 reporting requirements
– April 2007 – initial HB 197 measures submitted
HB 197 – 2010 Update
• Effective October 2009
– Expanded from 11 measures to 103 measures
• 92 calculated measures,
• 2 volume measures,
• 9 informational
Rosalie Weakland, RN, MSN, CPHQ, FACHE
Director, Quality Improvement
OAHQ Annual Education Meeting
May 21, 2010
– Initial measures – only 5 remain
– Estimated hospital costs - $11,910 - $80,000
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Children Hospital Exemptions
Adult Hospital Exemptions
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– Stroke
AMI, HF, PN, and SCIP measures
HCAHPS
IQI measures
PSI measures
NHSN measures
Stroke measures
Pregnancy Measures
• Non Stroke Centers till Jan. 2011 discharges
– HCAHPS
• Hospitals currently not collecting HCAHPS till Jan
2010 discharges
– Pregnancy (Episiotomy/Elective delivery prior
to 39 weeks)
• Jan 2010
– Surgical Pediatric Measures
• All adult hospitals that provide service till Jan 2010
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Acute Myocardial Infarction*
• All‐or‐none measure (AMI‐1, AMI‐2, AMI‐3, AMI‐4,
AMI‐5, AMI‐8a)
• AMI‐1: Aspirin at Arrival
• AMI‐2: Aspirin at Discharge
• AMI‐3: ACEI or ARB for LVSD
• AMI‐4: Smoking Cessation Counseling
• AMI‐5: Beta Blocker at Discharge
• AMI-7: Fibrinolytic therapy w/in 30 minutes
• AMI-8: Median time to Primary PCI
• AMI‐8a: Primary PCI received within 90 minutes of
hospital arrival
• Inpatient Mortality
• Mort‐30‐AMI: AMI 30‐Day Mortality
*Denotes NQF Endorsed
Heart Failure*
• All‐or‐none measure (HF‐1, HF‐2, HF‐3, HF‐4)
• HF‐1: Discharge Instructions
• HF‐2: Evaluation of left ventricular systolic
(LVS) Function
• HF‐3: ACEI or ARB for LVSD
• HF‐4: Smoking Cessation Counseling
*Denotes NQF Endorsed
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Pneumonia*
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All‐or‐none measure (PN‐2, PN‐3b, PN‐4, PN‐5c, PN‐6, PN‐7)
PN‐2: Pneumococcal Vaccination
PN-3a: Blood Cultures w/in 24h prior/24h after arrival (ICU)
PN‐3b: Blood Culture Performed in Emergency Department
Prior to Initial Antibiotic Received in Hospital
PN‐4: Smoking Cessation Counseling
PN-5: Antibiotic Timing
PN5c: Initial Antibiotic received within 6 hours of hospital
arrival
PN‐6: Initial Antibiotic Selection for Community‐ Acquired
Pneumonia in Immunocompetent Patients
PN-6a: Initial Antibiotic Selection – ICU
PN-6b: Initial Antibiotic Selection – Non-ICU
PN‐7: Influenza Vaccination
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SCIP*
• Appropriateness of care measure ( SCIP‐Inf 1, 2, 3)
• SCIP‐Inf 1a: Prophylactic Antibiotic Received Within One Hour Prior
to Surgical Incision ‐ Overall Rate
– (SCIP‐Inf 1b: CABG; SCIP‐Inf 1c: Other Cardiac Surgery; SCIP‐Inf
1d: Hip Arthroplasty; SCIP‐Inf 1e: Knee Arthroplasty; SCIP‐Inf 1f:
Colon Surgery; SCIP‐Inf 1g: Hysterectomy; SCIP‐Inf 1h: Vascular
Surgery)
• SCIP‐Inf‐2a: Prophylactic Antibiotic Selection for Surgical Patients –
Overall Rate
– (SCIP‐Inf‐2b: CABG; SCIP‐Inf‐2c: Other Cardiac Surgery; SCIP‐Inf‐2d:
Hip Arthroplasty; SCIP‐Inf‐2e: Knee Arthroplasty; SCIP‐Inf‐2f: Colon
Surgery; SCIP‐Inf‐2g: Hysterectomy; SCIP‐Inf‐2h: Vascular Surgery)
• SCIP‐Inf‐3a: Prophylactic Antibiotics Discontinued within 24 Hours
after Surgery End Time – Overall Rate
– (SCIP‐Inf‐3b: CABG; SCIP‐Inf‐3c: Other Cardiac; SCIP‐Inf‐3d: Hip
Arthroplasty; SCIP‐Inf‐3e: Knee Arthroplasty; SCIP‐Inf‐3f: Colon
Surgery; SCIP‐Inf‐3g: Hysterectomy; SCIP‐Inf‐3h: Vascular Surgery)
*Denotes NQF Endorsed
*Denotes NQF Endorsed
SCIP*
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SCIP-Inf-4: cardiac Surgery 6 am Glucose
SCIP-Inf-6: Appropriate Hair Removal
SCIP-Inf-9: Urinary Catheter Removal
SCIP-Inf-9: Peri-operative Temperature Management
SCIP‐Card‐2: Surgery Patients on Beta Blocker
Therapy Prior to Admission who Received a Beta
Blocker during
• SCIP‐VTE‐1: Surgery Patients with Recommended
Venous Thromboembolism Prophylaxis Ordered
• SCIP‐VTE‐2: Surgery Patients who Received
Appropriate Venous Thromboembolism Prophylaxis
Within 24 Hours Prior to Surgery to 24 Hours after
Surgery
*Denotes NQF Endorsed
TJC Stroke Measures
• DSC/Stroke‐01: Deep Vein Thrombosis (DVT) Prophylaxis
• DSC/Stroke‐02: Discharged on Antithrombotic Therapy
• DSC/Stroke‐03: Patients with Atrial Fibrillation Receiving
Anticoagulation Therapy
• DSC/Stroke‐04: Thrombolytic Therapy Administered
• DSC/Stroke‐05: Antithrombotic Therapy by End of Hospital
Day Two
• DSC/Stroke‐06: D/C on Cholesterol Reducing Medication
• DSC/Stroke‐07: Dysphagia Screening
• DSC/Stroke‐08: Stroke Education
• DSC/Stroke‐09: Smoking Cessation /Advice/Counseling
• DSC/Stroke‐10: Assessed for Rehabilitation
HCAHPS
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Communication with Nurses
Communication with Doctors
Responsiveness of Hospital Staff
Pain Management
Communication about Medicines
Cleanliness of Hospital Environment
Quietness of Hospital Environment
Discharge Information
Overall Rating of this Hospital
Willingness to Recommend This Hospital
Initial report Oct 2011 for Non IPPS
AHRQ Other Heart Measures
• IQI‐6: Percutaneous Coronary Intervention
(Angioplasty) (PCTA) volume
• IQI‐30: Percutaneous Coronary Intervention
(Angioplasty ) (PCTA) mortality rate
• IQI‐5: Coronary Artery Bypass Graft (CABG)
volume
• IQI‐12: Coronary Artery Bypass Graft (CABG)
mortality rate
Initial report Oct 2012 – non-stroke centers
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AHRQ Patient Safety Measures
• PSI‐1: Complications of Anesthesia (Retired)
• PSI‐3: Decubitus Ulcer
• PSI‐5: Foreign Body Left During Procedure
CDC National Healthcare Safety
Network (NHSN)
• Surgical Site Infection Event
– Coronary artery bypass graft with chest
incision only *
– Cesarean Section*
– Knee Prosthesis, initial surgery only*
• Hospital‐Acquired Clostridium difficile
(C. Diff.)
• Hospital‐Acquired MRSA/MSSA
Bacteremia
*Denotes NQF Endorsed
Infection Control Information
• Hand‐washing Program
• Infection Control Staffing
Perinatal Measures
• California Maternal Quality Care
Collaborative
– Cesarean Rate for Low‐Risk First Birth
Women (NTSV CS Rate)*
– Infants Under 1500g Not Delivered at
Appropriate Level of Care*
• Providence St. Vincent’s
Hospital/CWISH
Infection Control Staffing
• Employ a qualified Infection Control
Professional (ICP)?
• ICP - board certified in infection control
(CIC)?
• A board-certified Infectious Disease
Physician either on staff or available for
consult?
Perinatal Measures
• Christiana Care Health Services/NPIC
– Incidence of Episiotomy*
• HCA‐ St Marks Perinatal Center
– Elective Delivery Prior to 39 Completed
Weeks Gestation*
Initial report Oct 2011
– Appropriate use of Antenatal Steroids*
*Denotes NQF Endorsed
*Denotes NQF Endorsed
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Health Care Provider Influenza
Vaccination Measure
TJC Children’s Asthma Care
• CAC‐1a: Systemic Corticosteroids for
Inpatient Asthma (age 2‐17) overall rate*
• CAC‐2a: Relievers for Inpatient Asthma
(age 2‐17) overall rate*
• CAC-3: Home management plan of care
• Numerator
– Number of paid inpatient employees receiving
either nasal spray or shot of Influenza vaccine
from September 1 to March 31
• Denominator
– Total number of paid inpatient hospital
employees that were employed as of March 31
Initial report Oct 2010
Future changes
Pediatric Measures
• 30 Day Mortality Measures
• Prophylactic Antibiotic Received within
One Hour Prior to Surgical Incision
• Catheter‐ Associated Bloodstream
Infection Rate for ICU Patients
• Surgical Site Infection Rate for
cardiothoracic, neurosurgical and
orthopedic procedures
– Heart Failure
– Pneumonia
• Blood Incompatibility
• Readmission
– Heart Failure
– AMI
– Pneumonia
• Employee influenza vaccination rate
Initial report Oct 2011
– From inpatient to inpatient and outpatient employees
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Under Consideration
• Staffing Ratios
• Nurse Sensitive Measures
• Hospital Based Inpatient Psychiatric
Services Measures (HBIPS)
• Outpatient Measures
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