Please register your attendance using this QR code or by using an IPad located at

each door

The Context

The Next (NOW) Accreditation System (NAS)Program AccreditationInstitutional Accreditation

Institutional Review Clinical Learning Environment Review (CLER)

CLER Reminder

Provides frequent, on-site sampling of the learning environment

First CLER site visit was July 2014 Next visit between February and July 2017

Assesses the following 6 focus areas: Patient Safety Quality Improvement Transitions of Care Supervision Duty hours oversight, fatigue management and

mitigation Professionalism

CORE

MEASURESGME CurriculumLisa Hutcherson

Program Manager Quality Improvement/Patient Safety

Core Measures are something

that the Quality Department

handles……

Right?

OBJECTIVES

Introduce you to Core Measures

Ability to read Scorecard Who to call when you have

questions!

History of Core Measures

Department of Health and Human Services developed the Hospital Inpatient Quality Reporting (IQR) program and released the original Core Measures November 2001. Acute Myocardial Infarction (AMI) Heart Failure (HF) Pneumonia (PN), Surgical Care Improvement Project (SCIP)

History (Continued)

Congress later authorized the hospital Value-Based Purchasing (VBP) program through the Affordable Care Act. Built on IQR reporting structure Uses IQR measures published on Hospital

Compare for at least one year

Value Based Purchasing

VBP program purpose

Eliminating or reducing occurrence of adverse events

Adopting evidence-based care standards and protocols that result in the best outcomes for most patients

Improve the patients experience

So…… Measures are based on published

guidelines with input from practicing physicians

Reporting is the same for every hospital If your hospital is a top performer you

make money….

If your hospital is a poor performer…..

Who are the players?

Center for Medicare & Medicaid (CMS) National Quality Forum (NQF) Agency for Healthcare Research and

Quality (AHRQ) The Joint Commission Others

UHS Reporting Measures

Core Measures - Inpatient

Surgical Care Improvement Project (SCIP) Acute Myocardial Infarction (AMI) Heart Failure (HF) Pneumonia (PN) Children’s Asthma (CAC) Stroke VTE Global (Immunizations, ED) Perinatal Care (mothers and newborns)

Core Measures - Outpatient

SCIP (OP SCIP) Outpatient Chest Pain Outpatient Acute Myocardial Infarction Outpatient Emergency Department (OP

ED) – Throughput Outpatient Stroke (OP STK)

Hospital Acquired Conditions (HACs)

HACs

700+ hospitals

will see

payments docked

by 1%

Additional Physicians

Additional Staff

Equipment

Improving facilities

How do I know

where my facility stands?

Let’s Look at the

Scorecard

If I have questions?

Call the hospitals Quality Department

For UHS call: 358-2278 or 358-8267

Located on the third floor just across from the cafeteria.

Next GME Curriculum

Wednesday, April 8 @ 6:30 am, 309L

Friday, April 10 @ 11:00 am, 309L

“Disclosing Unintended Outcomes”