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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 1 2 Children Hospital Exemptions Adult Hospital Exemptions • • • • • • • – 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 3 4 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 1 Pneumonia* • • • • 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 • • • • • • • 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* • • • • • 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 • • • • • • • • • • 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 2 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 3 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 22 Under Consideration • Staffing Ratios • Nurse Sensitive Measures • Hospital Based Inpatient Psychiatric Services Measures (HBIPS) • Outpatient Measures 23 4