SUMMER 2009 : VOL. 7 NO. 3 : WWW.OHIOKEPRO.COM
SPECIAL 10TH ANNIVERSARY EDITION
Change – it is the one constant in our lives, and so it is in the life of a Quality Improvement Organization (QIO). As Ohio KePRO celebrates its 10th anniversary as a QIO we not only welcome, but strive to lead the metamorphosis of the Medicare quality improvement program. The evolution has been from Professional Standards Review Organizations (PSROs) to Peer Review Organizations (PROs), to Quality Improvement Organizations (QIOs). As the names imply, the focus of the work has consistently changed and evolved over time. The movement has been from judging individual cases retrospectively with a punitive approach to identifying underlying processes of care that can be improved, fundamentally changing how care is delivered thereby improving the outcomes of all Medicare beneficiaries.
Relationships with the provider community are much more positive today than they were 10 years ago. The complete transformation from single case-based reviews that often found fault and ascribed blame, to evaluations of systems and processes that promote patient safety and high quality care has helped foster collaboration with the provider community. We are committed to building strong collaborative relationships with providers as we all work to improve care and outcomes for all Medicare beneficiaries.
Our current emphasis on Patient Safety and Preventive Services, with particular attention to eliminating disparities in healthcare and promoting health information technology (HIT), forms the basis for our close relationship with the provider community. Now in the 9th Scope of Work (SOW), we have strong ties with 142 nursing home and hospital facilities and nearly 100 primary care practices, as well as relationships with such organizations as the Institute for Healthcare Improvement (IHI), the Centers for Disease Control and Prevention (CDC), and the Ohio Hospital Association (OHA). Using a collaborative approach based on the consultative model, we work with providers to develop and implement quality improvement efforts utilizing the knowledge and expertise of our staff in a wide range of methodologies—including TeamSTEPPSTM, root cause analysis, process mapping, and Appreciative Inquiry.
Whereas our case review responsibilities remain intact, to protect the Medicare beneficiary and the Medicare Trust Fund, our Review Department has embraced the evolution from individual emphasis to process analysis. Formerly, case reviews had the propensity to become adversarial. Today, we take a prospective systems-based approach. Rather than focusing on a single case and/or an individual practitioner, our goal is to identify and improve underlying processes. We work with providers to identify opportunities to facilitate system-wide changes that promote sustainable improvements in patient safety and the quality of care.
This philosophic and operational transformation has aligned all of our responsibilities to beneficiaries and our interactions with providers. Both our review coordinators and our quality improvement specialists work with providers in a mutually supportive role to identify and improve systems and processes as a means of enhancing quality care. Together we have made, and can continue to make, a real difference!
– Ronald A. Savrin, MD, MBA, FACS
Medical Director
rsavrin@ohqio.sdps.org
– Fran Hober, RHIA, MBA
Project Leader, Review Services
fhober@ohqio.sdps.org
Sustainability - Quality as a State of Mind
Our work with healthcare providers across settings over the past decade has taught us that lasting change is the true measure of success in quality improvement efforts. Single “breakthrough” improvements may come as a result of concerted efforts in the cycle of improvement, or even as the result of serendipity—but maintaining these improvements is never an accident. As Six Sigma and quality improvement gurus Niraj Goyal and Kirti Patil have noted, sustainability is a critical part of any change initiative, for which the development of a “quality mindset” is needed—a task that is far more daunting than the achievement of a single breakthrough improvement.1
Quality is, in a sense, a state of mind—one that must be integrated into the culture of your entire organization. Healthcare providers working with Ohio KePRO have been able to achieve such a mindset for sustainability by adopting principles developed by industry leaders, including the United Kingdom’s National Health Service (NHS) Institute for Innovation and Improvement, and the Primary Care Development Corporation (PCDC). The NHS Sustainability Model is based on the concept that lasting improvements occur when new processes become simply “the way things are done around here.”2 Because it is designed as a diagnostic tool to help determine the likelihood of changes being sustained within an organization, it is a useful tool for the early stages of quality improvement efforts.
This easy-to-use tool encourages discussion, and can help your organization:
- Assess against key criteria
- Plan ahead
- Identify barriers and strengths
- Monitor progress
More information about the NHS Sustainability Model, including an interactive model and user’s guide, is available at www.institute.nhs.uk/sustainability model.
In a qualitative research study on quality improvement efforts based on the Institute for Healthcare Improvement’s (IHI’s) Learning Collaborative model, PCDC offers another useful tool for promoting sustainability. By systematically examining factors that can influence the sustainability and spread of changes, PCDC identified six key components in quality improvement:
- Teamwork
- Leadership
- Processes
- Organizational culture
- Data measurement
- Education
Using these factors as its framework, the organization developed the following PCDC Principles of Sustainability and SpreadTM:
- Providing direct and visible leadership
- Deploying teams to make changes
- Testing changes with the PDSA (Plan-Do-Study-Act) process
- Using the Care Model as a framework for change
- Coaching for change
- Making the new way unavoidable
- Allocating resources
- Monitoring progress
- Creating a culture of improvement3
Adopting these principles can help your organization maximize resources and ensure long-term results. To read more about the PCDC study, visit www.pcdcny.org/resources/cmfstudy.html. Regardless of the model used, an emphasis on sustainability, including a focus on changing your organization’s “state of mind,” should be a part of all quality improvements. Sustaining effective interventions will help your facility provide safe, efficient, equitable, timely, and patient-centered care4 on a consistent basis.
– Barbara Stiebeling, RN, MSN, CPHQ
Quality Improvement Specialist
bstiebeling@ohqio.sdps.org
Ten Ways to Improve Quality in Your Facility
As we mark our first 10 years of helping improve the quality of care in Ohio, it seems only fitting for us to reflect on some of the best approaches to quality improvement. This list is far from exhaustive, but below are some methods that have proven effective for our partners and stakeholders. How many are practiced in your organization?
- Practice Person-Centered Care that takes into account individual patient/resident needs.Visit the Ohio Person-Centered Care Coalition (www.centeredcare.org) or Planetree (www.planetree.org) Web sites for more information.
- Use TeamSTEPPSTM to improve communication and teamwork skills within your organization. TeamSTEPPS resources, including a readiness assessment and training materials, are available at http://teamstepps.ahrq.gov/.
- Establish a Rapid Response Team to bring critical care expertise to patients at high risk of cardiac or respiratory arrest. Visit the Institute for Healthcare Improvement (IHI) Web site (www.ihi.org) to download IHI’s 5 Million Lives Campaign Getting Started Kit: Rapid Response Teams.
- Adopt Crew Resource Management to foster a strong team environment. Visit the Agency for Healthcare Research and Quality (AHRQ) Web site (www.ahrq.gov/clinic/ptsafety/chap44.htm) for healthcare applications of this aviation-based approach to quality improvement
- Use the SBAR Technique to facilitate communication within the healthcare environment. Read “SBAR Technique for Communication” on the IHI Web site (www.ihi.org).
- Provide Culturally and Linguistically Appropriate Care to patients and residents. Visit the Office of Minority Health Web site (www.omhrc.gov/templates/browse.aspx?lvl=1&lvlID=3) for tools and national guidelines for healthcare professionals.
- Foster a Culture of Quality at all levels of your organization. Survey assessment tools are available on the AHRQ Web site (www.ahrq.gov/qual/patientsafetyculture).
- Recruit Physician Champions and other team leaders to promote engagement in quality initiatives among medical staff. See “Engaging Senior Leadership” (www.rwjf.org/pr/product.jsp?id=30064) in Robert Wood Johnson Foundation’s Transforming Care at the Bedside Toolkit.
- Use Lean Methodology to improve workflow. Visit the Lean Enterprise Institute Web site (www.lean.org/WhatsLean/) for more information about this business system.
- Promote Staff Involvement across disciplines, including those who provide direct care to patients and residents. Visit the Health Resources and Services Administration Web site (http://bhpr.hrsa.gov/interdisciplinary/acicbl/reports/first/c4.htm) for a discussion of interdisciplinary healthcare teams.
Additional resources are available at www.ohiokepro.com.
Medication Reconciliation - A Crucial Component Of Quality Care
In recent years, Americans have become increasingly reliant on prescription and over-the-counter medications. While they can be a blessing for those who rely on them to treat their ailments, using these drugs can involve some risks, including adverse drug events such as drug-drug interactions (DDIs) and potentially inappropriate medications (PIMs). With a growing number of Americans taking multiple medications on a regular basis, and more than 100,000 Ohio seniors annually who may be at risk to become seriously ill as the result of medication-related problems1, drug safety has become an issue of paramount importance. Medication reconciliation is a crucial component of drug safety, one that can help safeguard the health of all patients.
In the process of medication reconciliation:
- Obtain complete and accurate information about each patient’s past and current medications—if necessary, verify by directly contacting the pharmacies where medications were obtained.
- Compare this information to physician orders written on admission, transfer, and discharge, and ensure that medications and doses are appropriate.
- Any changes to orders should be documented.
When interviewing patients during the reconciliation process:
- Ask open-ended questions (what/how/why/when) as well as yes/no questions.
- Use unbiased, non-leading questions.
- Ask questions in plain language.
- Pursue unclear responses until they are clarified.
- Encourage patients to ask questions.
- Remind patients of the importance of obtaining all medications from one central pharmacy/pharmacist.
- Educate patients about the importance of using a medication wallet card, and bringing their “brown bag” of medications to the hospital, physician’s office, and other healthcare-related visits.
- For all medications: Be sure to get the name, dosage form, dosage, dosing schedule, and last dose taken.
- For PRN medications: Get information that is as specific as possible.
- Prompt the patient to try and remember other types of medications, including: patches, creams, eye drops, inhalers, sample medications, shots, and all over-the-counter medications, including herbal supplements, and vitamin and mineral supplements.
- When discussing allergies, educate the patient on the difference between a side effect and a true allergy.
- Ask patients describe how and when they take their medications. (Vague responses may indicate noncompliance.)
Adapted from The Institute for Healthcare Improvement’s 100,000 Lives Campaign: Getting Started Kit: How-to Guide—Adverse Drug Events (Medication Reconciliation).
Ten Years of Quality Improvement
The world was quite a different place in 1999, when Ohio KePRO became Ohio’s Medicare Peer Review Organization (PRO) in the 6th Statement of Work (SOW). There was still talk of the healthcare industry being “recession-proof,” and we had not yet experienced 9/11, SARS, Hurricane Katrina, or H1N1. Since then, we’ve had three U.S. Presidents, each with a different perspective on the healthcare system. Ohio has had two governors, and an aging population that has expanded from 1.7 million Medicare beneficiaries to over 1.8 million.
In this changing environment, our areas of focus and approach to quality improvement have shifted with changes in the Medicare quality improvement program—including the shift from PRO to Quality Improvement Organization (QIO), an increased focus on pay-for-performance (P4P) initiatives, an emphasis on health information technology (HIT), and a move toward quality improvement across care settings. With U.S. life expectancy steadily increasing, Medicare has moved to the forefront of the healthcare discussion, making a value-driven approach more important now than ever. By working with healthcare partners and stakeholders, Ohio KePRO continues to play an active role in driving quality improvement efforts statewide.
Click here to view QIO and industry highlights from the past decade.
Immunizations - Protecting Yourself and Those You Care For
It may seem like flu season just ended, but with National Immunization Awareness Month (NIAM) in August, it’s time to start thinking about immunizations again! Immunizations are an important step in preventing serious and life-threatening infectious diseases, and are a crucial part of quality care for adults as well as children, especially among the very young and very old, as these age groups are at the highest risk.
Be sure to remind your staff and patients of the importance of immunizations, especially as flu season approaches.
- Use all patient encounters as an opportunity to assess and provide vaccinations.
- Post vaccination information in exam rooms and waiting rooms. Materials are available for electronic download from Ohio KePRO (www.ohiokepro.com) and the Immunization Action Coalition (www.immunize.org).
- Don’t forget about yourself! It’s your responsibility as a healthcare professional to safeguard your own health. Current vaccination recommendations are available from the Centers for Disease Control and Prevention (www.cdc.gov/vaccines).
Maintaining high immunization rates protects the entire community from transmission of certain disease-causing bacteria and viruses. Take the first step in ensuring that your facility is doing all it can to increase immunization rates. To aid in these efforts, we’ve created an Immunization Service Assessment form (located near the end of this newsletter) to help you assess your facility’s current practices and identify areas for improvement. This form is modeled after the Immunization Action Coalition’s “Suggestions to Improve Your Immunization Services” (available at www.immunize.org/catg.d/p2045.pdf).
Each facility is different, so we encourage you to develop an immunization education program that is customized for the unique needs of your facility. Join us in working to support the goal of delivering quality care to every person, every time. You owe it to yourself and to your patients!
– Erica Stanton, BSAS
Quality Improvement Specialist
estanton@ohqio.sdps.org
Pressure Ulcer Prevention Across Settings
With more than half a million pressure ulcer-related hospitalizations in 2006—an increase of nearly 80 percent from 19931—pressure ulcer prevention is an important patient safety topic that should be a priority at all nursing homes and hospitals. While emphasis on this topic has historically focused on care provided in the long-term care setting, pressure ulcers have the potential for significant harm across multiple settings—and, with recent changes in Medicare reimbursement, pressure ulcer prevention is finally getting more attention.
Pressure ulcer prevention is a key component of quality improvement efforts in the Centers for Medicare & Medicaid Services 9th Statement of Work (SOW) for long-term and acute care settings, and Ohio KePRO has been working with both groups on collaborative efforts to reduce pressure ulcer incidence rates. This has led to interesting insights and has helped strengthen the commitment to shared goals. This process has also highlighted the importance of effective communication and a strong spirit of cooperation between settings.
Dispelling Myths
In order to achieve collaboration, nursing home and hospital staff must dispel the pervasive myth that in transitions, the sending facility is responsible for the wound. While this may be true in some cases, the issue is very complex; patients/residents often move frequently between facilities—but they may not go back home or to the sending facility. They may also be transferred to different hospitals when acute care is needed. Regardless of where pressure ulcers originated, healthcare providers should be focused on the patient’s or resident’s health and well-being.
Setting-Specific Challenges
Nursing homes have a long history of tracking pressure ulcer incidence (both present on admission and facility-acquired). However, because of extensive turnover and staffing issues in the long-term care setting, these facilities may have limited ability to utilize this data to improve care. High turnover rates mean that staff may not have the chance to develop “familiarity” with the condition of individual residents, making it more difficult for them to identify new pressure ulcers or to recognize when they get worse.
Many hospitals are just beginning to look at skin care issues, but their primary focus is on saving lives; those admitted are critically ill and require the skill and expertise not found elsewhere. In most cases, skin care is not the first priority, but current guidelines and reimbursement changes (including CMS’ decision to stop paying hospitals for healthcare-associated pressure ulcers as of October 2008) have led to greater vigilance in skincare assessments throughout the hospital stay, especially at the time of admission. The newness of these efforts has made data collection and analysis a challenge; because most hospitals are unable to identify their pressure ulcer incidence or to trend their data, they are unable to determine such pertinent information as: where most of the in-house acquired pressure wounds are developing, how successful they are in preventing pressure ulcers from worsening, or what resources or educational needs might be helpful in improving care.
Communication/Transitions
Both the hospital and the nursing home are responsible at the point of transition. Because of the often-emergent nature of transfers, nursing homes do not always include a skin assessment for incoming residents—and, if one is included, it may be days or weeks old. On the other hand, hospitals receiving patients in transfer, most commonly in the Emergency Department (ED), may not attend to skin issues early on or even at all, unless and until the patient is admitted. Consequently, admitted patients may be assessed with a “present-on-admission” skin wound due to staying in the same position for several hours in the ED. Or, patients who are not admitted may return to the long-term care facility with a deterioration in skin integrity. In either case, the patient/resident suffers. The good news is that more and more nursing homes are beginning to understand the importance of timely skin assessments upon transfer, and an increasing number of hospitals are beginning to incorporate skincare evaluations into their ED processes.
Another challenge in transitions between settings is a seemingly basic one: at times, a patient’s paperwork may not accompany the patient from the ED to the hospital unit. This often leads to an added complication, when verbal reports from the nursing home are given only to ED staff.
Even when nursing homes and hospitals have optimized their systems for skincare data tracking, the difference in data language between care settings makes comparisons virtually impossible; while hospitals may track and report the number of individuals with pressure wounds, nursing homes track this number, as well as the total number of wounds in their facilities.
Solutions
Unfortunately, there is no one-size-fits-all solution to this challenging issue—but opening the lines of communication seems a good place to start. This goes beyond the verbal or written report given at transfer; it requires clinical and administrative leadership in both facilities coming together to problem-solve.
Other solutions currently being explored by nursing home/hospital collaboratives working with Ohio KePRO include:
- Educational modules for staff at the acute and post-acute levels
- A transfer form to ensure proper handoffs
- Proactive, ongoing communication between the facilities.
Pressure ulcer prevention across settings is a complex issue, but one well worth pursuing. With the implementation of guidelines such as those from the Institute for Healthcare Improvement and the Advancing Excellence in America’s Nursing Homes campaign, we can work together to improve the quality of care and therefore the quality of life for each Medicare beneficiary. And that’s what it’s all about.
– James Barnhart, BSH, LNHA
Quality Improvement Specialist
jbarnhart@ohqio.sdps.org
– Barbara Stiebeling, RN, MSN, CPHQ
Quality Improvement Specialist
bstiebeling@ohqio.sdps.org
Immunization Service Assessment:
How Well is Your Practice Doing?
Click here to view and print an assessment form to help your practice improve its delivery of immunization services.
Reminder of upcoming reporting, deadlines and events.
Click here to view and print.
The following are referenced in the FY 2010 IPPS Proposed Rule issued by CMS on May 1, 2009. Actual implementation will be based on the final rule, when it is published.
Retired & Discontinued Quality Measures
- AMI-6 Beta-Blocker at Arrival—effective with 2Q09 discharges
- PN-1 Oxygenation Assessment—effective with 2Q09 discharges
- PN-5b Initial Antibotic Received Within 4 Hours of Hospital Arrival—effective 1Q09
- SCIP-Inf-7 Colorectal Surgery Patient with Immediate Postoperative Normothermia*—effective 1Q10
New Quality Measures
Chart-Based Measures
- SCIP-Inf-9 Postoperative Urinary Catheter Removal on Postoperative Day 1 or 2*—effective with 1Q10 discharges
- SCIP-Inf-10 Perioperative Temperature Management*
AHRQ PSI and Nursing Sensitive Care**
- Death Among Surgical Inpatients with Serious, Treatable Complications Stroke Care
Stroke Care
- Participation in a Sytematic Clinical Database Registry for Stroke Care*
Nursing Sensitive Care
- Participation in a Systematic Clinical Database Registry for Nursing Sensitive Care*
Proposed IPPS RHQDAPU Program Procedures for the FY 2011 Payment Determination
(This process remains remains much the same as in previous years.)
- Register with QualityNet (QNet).
- Identify a QNet Security Administrator (SA). CMS recommends 2 QNet SAs per site.
- New IPPS hospitals must submit a completed Notice of Participation form no later than 180 days from the “open date” on the approved CMS Online System Certification and Reporting (OSCAR) system. Annual completion not required if already on file.
- Collect and report data for each of the chart-abstracted quality measures (AMI, HF, PN, SCIP). New hospitals must begin submitting data starting with the first day of the quarter following the hospital’s registration to participate in the program.
- Submit complete data for each quality measure in accordance with the CMS/Joint Commission sampling requirements.
- Submit to CMS on a quarterly basis aggregate population and sample size counts for Medicare and non-Medicare discharges for each of the chart-abstracted measures.
- Continuously collect and submit HCAHPS data.
- Claims-based measures will be calculated by CMS using Medicare fee-for-service claims. Time frame for the 30-Day Mortality and 30-Day Readmission Measures: July 1, 2006-Jume 30, 2009. Time frame for the AHRQ, PSI, IQI and Composite Measures: July 1, 2008-June, 30, 2009.
- Submit data to QNet on a quarterly basis for the 3 proposed structural measures, beginning 1Q10.
- Chart validation requirements:
- CDAC will continue to randomly select 5 charts each quarter from each hospital.
- Effective with 2Q09 discharges, the CDAC will request paper copies of each selected record via certified mail; the hospital will have 45 days from the date of the request to submit the requested records to the CDAC. Noncompliance within 30 days will result in a second certified request letter; failure to comply will result in a “zero” validation score that quarter.
- The hospital must pass the validation requirement of a minimum of 80% reliability using appropriate confidence intervals. Quarters included in the review: 4Q08 – 3Q09.
Ohio KePRO Celebrates 10 Years of Healthcare Quality Improvement
August 1, 2009 marks 10 years in which Ohio KePRO has worked with healthcare providers statewide to improve the quality of care for Ohio's Medicare beneficiaries. Visit www.ohiokepro.com to read about our decade of change, including landmarks in the Medicare quality improvement program, achievements in each Statement of Work, and the fluctuating healthcare environment in Ohio.
Ohio KePRO Participates in 10-State Patient Safety Project
Ohio is one of 10 states participating in a patient safety project, funded by the Agency for Healthcare Research and Quality (AHRQ) and the federal government, to reduce the national average rate of central-line associated bloodstream infections (CLABSIs) in hospitals by 80 percent. Ohio on the CUSP: Stop BSI is being coordinated by the Ohio Patient Safety Institute (OPSI), with Ohio KePRO collaborating with the Ohio Hospital Association (OIIA) to study methods to reduce CLABSIs in hospital intensive care units (ICUs). Visit www.ohiopatientsafety.org for more information.
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