2005 requirements eposiqip · the iqip software (but they should continue to collect the data...

Administrative Issues

Technical Requirements

VGA color monitorInternet access with at least 56K modemMS Internet Explorer 6.0 or higher with the ability to view pop-up windowsAdobe Acrobat Reader 5.0 or higherThe ability to

download filesto send and receive e-mail attachmentsdownload and open zipped files

Internet access with T1, T3, Cable, or DSL and MS Excel spreadsheet software or similar are strongly suggested.

IQIP Web Sites

A Demonstration website is available for hospitals to familiarize themselves with the software or to train a new coordinator in a hospital. Hospital ID numbers and data on this web site are random and fictitious, meaning that you are free to enter and change data, hospital characteristics, or any other information on this web site.

http://Demo.InternationalQIP.com

IQIP Web Sites

The production or “live” server URL. This web site should only be used to enter “real” data, hospital characteristics, or other information.

http://www.InternationalQIP.com

IQIP Terminology

Health care organizations join the IQIP through a sponsoring organization in their country or region. The sponsoring organization is referred to as a system. Some systems may find it easier to manage the Project by creating smaller groups, which are referred to as sub-systems

IQIP Terminology

• A participating health care organization is referred to as facility, hospital, or participant.

System

Facility

Facility

Facility

System System

Facility

Facility

Facility Sub-System Sub-System

Facility

Facility

Facility

Facility

IQIP Terminology

The IQIP currently offers performance measures in four Indicator Sets: Acute Care, Psychiatric Care, Long Term Care, and Home CareWithin each Indicator Set are a number of indicators, which are broad categories summarizing groups of similar or related performance measures. A measure divides a numerator value by a denominator value and applies a multiplier to express a rate. Multipliers are often used to transform a quotient into a more comprehensible value.Data elements are components that make up a numerator or a denominator.

IQIP TerminologyIndicator Set: Acute Care

Measure 6.4: Vaginal Birth after C-section (VBAC)

Measure 6.5: Trial of labor success

Measure 6.1: Primary C-sections

Measure 6.2: Repeat C-sections

Measure 6.3:Total C-section frequency

Indicator 6: Management of Labor

Numerator Number of Primary C-sectionsDenominator (Number of Deliveries) - (Number of Repeat C-sections + Number of VBACs)

Data Elements

* 100

Multiplier

Parent- and Sub-measures

Sub-measures (or child measures) are those where the summation of the numerator or denominator equals 100% of the hospital’s total population. For example, neonatal mortality for direct admissions. Since the measures are broken down by weight of the neonate, a hospital is required to submit data for all of the sub-measures in this indicator (4.1 to 4.4). This ensures that the hospital’s total population of direct admission neonatal mortality is captured.

Sub-measure Group, Example

Sub-measures

Neonatal mortality for direct admissions, birth weight > 1800 grams

AC 4.4

Neonatal mortality for direct admissions, birth weight 751 to 1000 grams

AC 4.2

Neonatal mortality for direct admissions, birth weight 1001 to 1800 grams

AC 4.3

Neonatal mortality for direct admissions, birth weight < 750 grams

AC 4.1

Parent- and Sub-measures

Some sub-measures have a parent measure. For example, total perioperative mortality for all ASA classes (AC measure 5.1).

The sum of the sub-measures (AC 5.2 to 5.6 for each ASA class 1 to 5) should equal the total measure.

Parent- and Sub-measures, Example

Total perioperative mortality for patients with ASA P4AC 5.5

Total perioperative mortalityAC 5.1Parent measure




Sub-measuresTotal perioperative mortality for patients with ASA P1AC 5.2

Data Due Dates

Data are due by midnight on the last day of January, April, July, and October regardless of day of the week. On-time data are based on date and time at CPS offices in Maryland, USA. Keep in mind the time difference from your location and the CPS offices.

Data Due Dates

31 January16 November31 December1 OctoberOctober – December4

31 October16 August30 September1 JulyJuly - September3

31 July16 May30 June1 AprilApril - June2

30 April16 February31 March1 JanuaryJanuary - March1

Data Collection Due

Data Collection Begins

Quarter End Date

Quarter Start DateMonthsQuarter

IQIP Data Collection PeriodCalendar Time

Data Entry

Hospitals should enter values of zero when they have no cases or events that can be counted in the data element. Hospitals should leave empty or blank values to show that the data are incomplete or incompatible if

the data are not available orthere is no comparable term or definition.

Data Entry, Example

Zeros represent “no population” (e.g., no unscheduled inpatient or observation admissions following diagnostic endoscopies in October or November 2004)

Data Entry, Example

Blank values indicate that no data are available for December 2004.

Data Entry

Also, if a hospital does not have monthly-level data, they should not submit data into the IQIP software (but they should continue to collect the data internally!). While the hospital may have correct quarterly data, entering all the data into one month of the IQIP software can falsely skew monthly aggregate data, and falsely indicate seasonal variation when trending data.

Hospital Characteristics

Each participating hospital is required to answer the annual Hospital Characteristics Questionnaire before 1 April of the New Year. New hospitals have time until 16 April. If a question does not apply to the facility, a value of zero should be entered or an answer of “No” should be selected.If the Hospital Characteristics Questionnaire is not completed by the due date, the hospital’s access to all other pages of the IQIP software will be restricted.

Hospital Characteristics, Example

Since the hospital does not have a DEFINED catchment area, a value of 0 is entered

Since the hospital answered that it does not have a cardiac catheterization lab, question 18a regarding ownership does not apply and an answer of “No” is entered.

Password Changes

The best way to protect the integrity of the IQIP software is for users to change their passwords regularly. In the past, most users did not change their passwords regularly. Therefore, CPS institutes periodic changes every 90 days (usually after the data collection due dates but before the release of aggregate data and reports). CPS makes a systematic change to all access codes by adding a certain number of characters to the beginning or end ofeach existing access code. For example, CPS might add “ab1” to the end of every access code, so a user whose access code previously was “orange” would now have the access code “orangeab1.” All users have the same characters added to the beginning or end of their existing access code.

Standard Quarterly Reports

The quarterly report provides all hospital-specific, regional, and/or national aggregate data for each measure for which the hospital submits data in a two-page format. If translations are available, hospitals will receive the quarterly report in their native language.The first of the two pages displays the hospital’s data for the last year in tabular format and in a graphical run chart. Project-Wide data for the last year are also presented on page one in tabularformat.

Standard Quarterly Reports

There are different formats available for the second of the two pages and hospitals are free to select the comparison groups foreither layout. One layout presents data for half a year in tabular format for up to four comparison groups and the other layout presents data for one year in tabular and graphical format for up to two comparison groups.

Conformance Assessment Survey

The CAS Survey is a quarterly questionnaire where participating facilities answer questions about whether a patient or event should be included in a measure based on sample scenarios. The survey is intended to help participants assess their understanding of IQIP implementation rules and exclusion criteria.


In order to facilitate participants' awareness of the surveys' availability and due date, the CAS surveys according to the quarter in which the survey is both available on the web site and is due - e.g., CAS 1Q2005 is available in the first quarter of calendar year 2005 and is due with the first quarter 2005 data.


1.For the purposes of the QI Project®, do you define an intensive care unit (ICU) as an inpatient unit specially equipped and staffed to provide continuous care to critically ill patients? YESNO


2. For the purposes of the QI Project, do you define a progressive care unit as an inpatient unit equipped and staffed to provide an intermediate or transitional level of care which is less specialized than that provided in an ICU, but more specialized than the care provided by a general medical or surgical unit? YESNO


3.Case Study 1 : Laura McEnroe is admitted to your ICU from a skilled nursing facility with head trauma following a fall. Her condition improves and she is transferred to one of your medicalunits before being discharged back to the SNF on day 7. Two dayslater Laura is admitted to your ICU again from the SNF with severe CHF. a.Should you count Laura in the denominator of measure 9.1, unscheduled returns to ICUs?

YESNO

b.Do you count Laura in the numerator of measure 9.1, unscheduled returns to ICUs?

YESNO


4.Case Study 2 : Jerry Smith is admitted to your ICU following open-heart surgery. On day 2 he is transferred to a medical/surgical floor, but experiences uncontrolled bleeding within 24 hours and has to be taken back to the OR. From the OR he is admitted again to your ICU and is stable enough on day 5 to be transferred to the medical/surgical unit, from which he is discharged home on day 7.

a.How many times should you include Jerry in the denominator of measure 9.1, unscheduled returns to ICUs?

12

b.Should you include Jerry in the numerator of measure 9.1, unscheduled returns to ICUs?

YESNO


Reports available to each facility will include analysis based on Project-Wide responses (percentage of correct and incorrect responses for each survey question).

2005 requirements eposiqip · the iqip software (but they should continue to collect the data...

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