Opening Ceremony

 

Every four years, the world comes together to watch our greatest athletes compete for Olympic gold and for the glory of their country. It never ceases to amaze me. With all of the conflict, poverty and problems of the world, how is the International Olympic Committee able to bring these countries together year after year? The committee’s Web site says that it acts as a “catalyst for collaboration between all members of the Olympic family [to] shepherd success through a wide range of programs and projects which bring the Olympic values to life.”

 

Like the International Olympic Committee, Ohio KePRO is also a catalyst for collaboration. As the Medicare Quality Improvement Organization (QIO) for Ohio, we bring Ohio healthcare providers together in collaborative projects to share successes and best practices. We’ve found that creating a learning, sharing community is the best way to help providers achieve their goals.

 

Last month, around the same time as the 2008 Olympic opening ceremonies, the QIO program embarked on a new three-year contract with the Centers for Medicare & Medicaid Services (CMS). As a result, some of Ohio KePRO’s services for healthcare providers have changed. The 2008-2011 QIO contract offers new opportunities for healthcare providers to participate in quality improvement activities in key areas, such as patient safety, prevention and Medicare beneficiary protection. By and large, QIO program resources are concentrated on helping providers that demonstrate the greatest need and/or with the greatest opportunity for improvement on specific quality measures. To read more about the new QIO contract, go to www.cms.hhs.gov/QualityImprovementOrgs.

 

With this first edition of Spotlight on Quality, we introduce key issues that will be the focus of the CMS QIO program for the next three years. This newsletter is designed to be a quarterly resource for Ohio healthcare providers for best practices in healthcare, quality tools, tips from industry experts, key dates calendar, and updates on CMS regulations. Enjoy!

 

— Gayle Smith, RN, MBA
Vice President of Public Programs, Ohio KePRO

---

Tapping Into Your Electronic Health Record's Full Potential

 

An electronic health record is a substantial investment. In addition to monetary costs, an electronic health record system requires that all employees learn how to do their job differently. It’s a change — and change is always scary. So once your practice has implemented an electronic health record and gotten most of the bugs out of the system and processes — it’s time to make sure that your practice is making the most of its investment.

 

Eighty-five percent of physicians with a comprehensive electronic health record system reported a positive effect on the delivery of long-term and preventive care that meets guidelines, according to an article published in the July 2008 New England Journal of Medicine. However in the same study, only about half of respondents with a basic system noted the same positive effect. Is it the comprehensive system that enables these practices to deliver better care? Or could it be that practices that implemented a comprehensive system use it for more than just documentation?

 

As illustrated in the figure below, it is undeniable that most respondents felt that their electronic system helped them perform essential job functions better.

 

Rates of Positive Survey Responses on the Effect of Adoption of Electronic-Health-Records Systems

 

Healthcare is becoming increasingly focused on measurable results. Now more than ever, consumers are able to choose healthcare providers based on publicly reported information about providers’ performance.

 

Your electronic health record is a time-saving tool to proactively manage patient populations, set improvement goals and improve the health of your patients. With the right care management functions in place, your practice can create appropriate, measurable, and cost-effective intervention programs using your electronic health record. Are you using it to its fullest potential?

 

—Bonnie Hollopeter, LPN, CPHQ, CPEHR
Project Manager, bhollopeter@ohqio.sdps.org

---

Regulatory Update

 

Centralizing Medicare Claims:
The Transition from FIs to MACs by 2011

In an effort to reform the Medicare fee-for-services (FFS) system and offer a centralized resource for all Part A and B claims, Medicare is replacing the current fiscal intermediaries (FIs) and carrier contracts with Medicare Administrative Contractors (MACs) by 2011. In his 2005 report to Congress, Michael Leavitt, Secretary of Health and Human Services, estimates that this transition could save the Medicare trust fund a total of $900 million by the end of fiscal year 2010.

CMS designed 15 new MAC jurisdictions to balance the number of fee-for-service beneficiaries and providers and to be more alike in size than the existing FI jurisdictions, promoting greater efficiency in processing Medicare’s billion claims a year. To date, CMS has awarded nine out of 15 total MAC contracts. Ohio, which is in jurisdiction 15, is still awaiting the announcement of the designated MAC.

For more information, go to: www.cms.hhs.gov/MedicareContractingReform

Detecting Improper Payments:
Implementation of RAC Program by 2010

By 2010, the Centers for Medicare & Medicaid Services plans to have four Recovery Audit Contractors (RACs) in place to ensure correct payments are being made to providers and suppliers and, therefore, protect the Medicare Trust Fund. This decisions was made after a three-year RAC demonstration projects in New York, Massachusetts, Florida, South Carolina, and California ended in March 2008.

In February 2008, CMS posted “CMS RAC Status Document 2007” and in June 2008, CMS posted “CMS RAC Demonstration Evaluation Report.”.

For more information, go to: www.cms.hhs.gov/RAC

Hospital Payment Monitoring Program Discontinues Some Services, not All

In an effort to align the oversight of acute inpatient prospective payment system (IPPS) hospitals and long-term care hospitals (LTCHs), some of the QIO responsibilities under the Hospital Payment Monitoring Program (HPMP) have transitioned to the fiscal intermediaries (FIs)/Medicare Administrative Contractors (MACs) or the Comprehensive Error Rate Testing (CERT) contractors. Therefore, Medicare Fiscal Intermediaries (FIs) and Medicare Administrative Contractors (MACs) will now conduct medical review to prevent improper payment of inpatient hospital claims. Medical review is the process performed by Medicare contractors to ensure that billed items or services are covered and are reasonable and necessary as specified under section 1862(a)(1)(A) of the Act. In addition, the Comprehensive Error Rate Testing (CERT) contractor will now conduct medical review to measure inpatient hospital payment error rates. Also, QIOs will no longer provide Program for Evaluating Payment Patterns Electronic Reports (PEPPER).

The activities related to acute IPPS hospital and LTCH claims review which will continue to be performed by the QIOs are:

• Quality of care reviews due to beneficiary complaints, complaints other than from beneficiaries, and quality of care reviews for cases referred by CMS or CMS designated entities (e.g.; FIs, Carriers, MACs, SSAs, OIG)

• Utilization reviews for hospital requested higher-weighted DRGs

• Utilization reviews referred by CMS or CMS designated entities (e.g.; FIs, Carriers, MACs, SSAs, OIG.) for cases involving issues such as transfers and readmissions

• Review of Emergency Medical Treatment Active Labor Act (EMTALA) cases

• Expedited determinations

• Provider education on quality of care issues, and other issues under their purview (e.g.; hospital-requested higher weighted DRG review, etc.)

For more information go to: http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/InpatientReviewFactSheet.pdf

— Jennifer Bitterman, MBA, RHIA
Review Director, jbitterman@ohqio.sdps.org

---

---

Ten Ways To Beat The MRSA Superbug

 

The proportion of infections that are antimicrobial resistant has grown exponentially over the last 30 years, according to a 2007 report by the Centers for Disease Control and Prevention (CDC). As illustrated in Figure 1, Methicillin-resistant Staphylococcus aureus (MRSA) infections accounted for two percent of the total number of staph infections in 1974. By 1995, that number had grown to 22 percent. And in 2004, 63 percent of infections were antimicrobial resistant.

Rates of Infections that are Antimicrobial-Resistant

 

 

 

The good news is that MRSA is preventable by following standard infection control guidelines. Follow the ten practices below to prevent the transmission of infection and beat the MRSA superbug.

 

 

1. Active surveillance in critical care units, surgery suites, emergency departments or consider all admissions

2. Keep patient care environment clean; clean patient rooms and care areas regularly and properly with correct disinfectants

3. Use antimicrobials only when there is an identified infection

4. Remove all catheters as soon as possible

5. Staff education – everyone is accountable for knowing their roles and responsibilities for preventing MRSA transmission

6. Patient and family education – encourage family members to stay home if they are sick and wash their hands regularly before and after being in patient rooms

7. Use masks for coughing patients, family members and staff

8. Use standard contact precautions; be sure that contact precautions are up to date and that they are routinely reviewed with staff

9. Practice effective hand hygiene – wash hands before and after patient contact

10. Leadership involvement – promoting and supporting prevention through conversations with front-line staff about patient safety, holding staff accountable for reliable performance of basic infection control practices and providing necessary supplies and resources for staff to get the job done

— Ann Fitzsimons, RN, MBA
Quality Improvement Specialist,
afitzsimons@ohqio.sdps.org

---

Preventing Pressure Ulcers In The Acute Care Setting

 

Pressure ulcers can cause significant harm to patients. Not only are they painful, but they can also impede functional recovery and lead to infection or even death. Although pressure ulcers are preventable in most cases, they are becoming more and more prevalent. According to a 2003 article in the Journal of the American Medical Association, an estimated 2.5 million patients are treated for pressure ulcers in acute care facilities in this country each year. JAMA further reports that incidence rates vary considerably by clinical setting, ranging from 0.4 percent to 38 percent in acute care; from 2.2 percent to 23.9 percent in long-term care; and from 0 percent to 17 percent in home care.

Financial Incentives and Deficiency Patterns

Recently, the National Quality Forum and the Centers for Medicare & Medicaid Services (CMS) have placed an increased focus on hospital-acquired pressure ulcers. Beginning October 2008, CMS will discontinue the reimbursement of care for hospital-acquired pressure ulcers. This includes cases that lack documentation of a pressure ulcer within 24 hours of admission to the acute care facility.

In nursing homes, the number of healthcare deficiencies for pressure ulcer prevention and treatment is increasing, with approximately one in five nursing homes in Ohio cited for deficient practices between May 2007 and May 2008. Regulatory concerns aside, nursing homes in Ohio also have a financial incentive to reduce the number of pressure ulcers: if a facility has healthcare deficiencies, they receive less Medicaid funding.

What’s the bottom line on pressure ulcers for healthcare providers? With pressure ulcers linked to reimbursement rates, consistent and appropriate documentation of skin inspections, risk assessments and preventive interventions is more important than ever.

IHI 5 Million Lives Campaign

In an effort to protect patients from medical harm, the Institute for Healthcare Improvement (IHI) began the 5 Million Lives Campaign in December 2006. The 5 Million Lives Campaign defines medical harm as “unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment), that requires additional monitoring, treatment or hospitalization, or that results in death. Such injury is considered harm whether or not it is considered preventable, resulted from a medical error, or occurred within a hospital.”

Recognizing that many efforts have already been made by healthcare providers to prevent pressure ulcers, the IHI has attempted to uncover some of the reasons that this clinical condition remains a persistent matter. In a 2007 article that appeared in The Joint Commission Journal on Quality and Patient Safety, IHI Faculty Member Kathy Duncan noted, “For years, healthcare organizations have tried to prevent pressure ulcers, but have lacked reliable strategies as well as a long-term commitment to prioritize and design caregivers’ work so that prevention remains a priority.”

As outlined by the campaign, certain strategies have proven effective in preventing pressure ulcers. Implementing these changes throughout an entire facility requires an organizational commitment and a standardized approach. According to the IHI, pressure ulcer prevention entails two major steps: (1) identification of patients who are at risk and (2) reliable implementation of prevention strategies for all patients who are identified as being at risk.

To identify patients at risk, the IHI recommends the following:

• Conduct a pressure ulcer admission assessment for all patients

• Reassess risk for all patients daily

To implement prevention strategies, the IHI recommends the following:

• Inspect skin daily

• Manage moisture

• Optimize nutrition and hydration

• Minimize pressure

— Leasa Novak, LPN, BA Quality Improvement Specialist, Barbara Stiebling, RN, MSN, CPHQ Quality Improvement Specialist, bstiebling@ohqio.sdps.org

References

CASPER Report 0314S, Most Frequently Cited Tags, Chicago Regional Office, Ohio, 05/16/2008.

Duncan, K., Preventing Pressure Ulcers: The Goal Is Zero. The Joint Commission Journal on Quality and Patient Safety, 2007; 33(10):605-610.

Institute for Healthcare Improvement www.ihi.org

Lyder, CH., Pressure ulcer prevention and management. JAMA 2003; 289(2):223-226.

---

Reconsidering Physical Restraint Use in the Nursing Home

 

More than 108,000 nursing home residents are physically restrained in the United States every day.¹ Research and standards of practice show that the belief that restraints ensure safety is often unfounded. In practice, restraints have many negative side effects and risks that in some cases far outweigh any possible benefit that can be derived from their use.² In fact, as many as 200 deaths occur every year as a result of strangulation or suffocation from restraints, even when they are applied according to manufacturer’s instructions.³

Physical restraints can have harmful effects on nursing home residents. As caregivers and nursing professionals, it is imperative that we thoroughly understand the laws, risks, and alternatives pertaining to restraint use. The Long-Term Care Resident Assessment Instrument (RAI) User’s Manual Version 2.0 associates the following negative consequences with restraint use:

• Strangulation

• Loss of muscle tone

• Decreased bone density (with greater susceptibility for fractures)

• Pressure ulcers

• Decreased mobility

• Depression and agitation

• Loss of dignity

• Incontinence and constipation

• Death

Furthermore, indiscriminate use of restraints, such as for the convenience of the staff, not only violates residents’ rights to freedom and dignity, but has also been associated with higher rates of injury and injuries associated with falls, precisely the conditions that the restraints are intended to prevent.

Do physical restraints help reduce falls?

No. The routine use of restraints does not lower the risk of falls or fall injuries. They can actually add to the risk of fall-related injuries and deaths.⁴ Thus, they should not be used as a fall prevention strategy.⁵

Furthermore, limiting a patient’s freedom to move around leads to muscle weakness and reduces physical function.⁶

Since federal regulations took effect in 1990, nursing homes have reduced the use of physical restraints.⁷ Some nursing homes have reported an increase in falls since the regulations took effect, but most have seen a drop in fall-related injuries.⁸

— Leasa Novak, LPN, BA,
Quality Improvement Specialist, lnovak@ohqio.sdps.org
and
— Deborah Shaeffer, LPN,
Quality Improvement Specialist, dshaeffer@ohqio.sdps.org

1. CDC. Health, United States, 2004. http://www.cdc.gov/nchs/data/hus/hus06.pdf, last accessed 8/27/08.

2. CMS RAI Version 2.0 Manual Appendix C, Page C-99.

3. Guttman R, Altman RD, Karlan MS. Report of the Council on Scientific Affairs. Use of Restraints for Patients in Nursing Homes. Council on Scientific Affairs, American Medical Association. Archives of Family Medicine. 1999; 8(2): 101-5.

4. Rubenstein LZ, Josephson KR, Robbins AS. “Falls in the nursing home.” Annals of Internal Medicine 1994;121:442–51.

5. Capezuti E, Evans L, Strumpf N. Physical restraint use and falls in nursing home residents. Journal of the American Geriatrics Society 1996;44:627–33

6. Rubenstein LZ. “Preventing falls in the nursing home.” Journal of the American Medical Association 1997;278(7):595–6.

7. Rubenstein et al. 1994

8. Ejaz FK, Jones JA, Rose MS. Falls among nursing home residents: an examination of incident reports before and after restraint reduction programs. Journal of the American Geriatrics Society 1994;42(9):960–4.

---

Medicare To Refuse Payment For Preventable Occurrences In October With More To Follow

 

Beginning in October 2008, the Centers for Medicare & Medicaid Services (CMS) will refuse hospital reimbursement for additional costs associated with eight conditions or events, unless they were present on admission, including:

1. Object left in surgery

2. Air embolism

3. Blood incompatibility

4. Catheter-associated urinary tract infections

5. Pressure ulcers (decubitus ulcers)

6. Vascular catheter-associated infection

7. Surgical site infection – mediastinitis after coronary artery bypass graft surgery

8. Hospital-acquired injuries – fractures, dislocations, intracranial injury, crushing injury, burns, and other causes.

These serious preventable events or “never events” are derived from the National Quality Forum’s (NQF) list of 28 inexcusable outcomes in a healthcare setting. The NQF defines never events as “serious, largely preventable, and of concern to both the public and healthcare providers for the purpose of public accountability.”

This change in Medicare reimbursement was initiated in an October 2007 revision of the Deficit Reduction Act of 2005.

These non-reimburseable conditions mark the beginning of a new trend in the Medicare/Medicaid system to cut costs. When this new payment rule was finalized in July 2008, CMS also sent a letter to state Medicaid directors providing information about how states can adopt the same never events practices. Nearly 20 states already have or are considering methods to eliminate payment for some never events.

In 2009, the following three events are planned to be added to the non-payment list:

1. Surgical site infections following certain elective procedures, including certain orthopedic surgeries and bariatric surgery for obesity

2. Certain manifestations of poor control of blood sugar levels

3. Deep vein thrombosis of pulmonary embolism following total knee replacement and hip replacement procedures.

Again, these occurrences will not be reimbursed unless the medical record shows that they were present upon admission.

At the same time, CMS is also in the process of developing three National Coverage Determinations (NCDs) that would address Medicare coverage of certain surgical procedures and set national policy on whether Medicare will cover an item of service and under what conditions. In the absence of an NCD, coverage decisions are made by local contractors that process and pay Medicare claims. The three types of surgery under consideration are surgery on the wrong body part, surgery on the wrong patient, and wrong surgery occurrences. The Medicare NCD program is slated to begin in 2009.

Evaluating coverage of these procedures — and refusing payment for preventable occurrences — are yet two more important steps for Medicare in addressing concerns regarding never events.

— Susan Ferrante, ARM
Quality Improvement Specialist, sferrante@ohqio.sdps.org

---

Calendar/Reminders

 

Reminder of upcoming reporting, deadlines and events.

Click here to view and print.

---

Drugs To Avoid With Elderly Patients

 

Reference chart to be used as a reminder of medications that may be unsuitable for your older patients.

Click here to view and print.

---

Required Medicare Notices Of Non-Coverage At A Glance

 

Notices of non-coverage are now given routinely in all inpatient and some outpatient settings. A list of these notices follows:

The updated Fee-for-Service Expedited Review Notice (the Generic Notice), Form No. CMS-10123 (Expiration date: 07/31/2011) and the Detailed Notice, Form No. CMS-10124 (Expiration date: 07/31/2011), are now available on the BNI webpage at http://www.cms.hhs.gov/BNI/. CMS is allowing a 60-day transition period for mandatory use of the updated forms. Mandatory use of the updated forms will begin on November 1, 2008.

— Jennifer Bitterman, MBA, RHIA
Review Director, jbitterman@ohqio.sdps.org

---

---