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