| AZ Annual Medical Services Review Report | |
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Winter 2011 Arizona Edition: Volume 1, Issue 4 |
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 Successful Collaboration Unties 146 Arizona Nursing
Home Residents
HSAG’s successful collaboration to reduce physical restraint use with 11 Centers for Medicare & Medicaid Services (CMS) targeted-for-improvement nursing homes is detailed in an article published in the October 2010 Arizona Geriatrics Society Journal. The article, titled "Reducing Physical Restraints in Arizona Nursing Homes," describes effective efforts those nursing homes made to safely decrease their use of physical restraints. Collectively, the nursing homes reduced their restraint use by a relative improvement rate of 84.7 percent without an increase in resident falls or falls with fractures. Given this change, approximately 146 nursing home residents were freed from physical restraints because of the implementation of this project. To read the entire article, visit http://data.memberclicks.com/site/ags/2010 Fall Journal.pdf.
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DHHS Secretary: Health Reform Law to Boost Health Care Quality
On December 21, American Medical News reported that the Department of Health and Human Services (DHHS) Secretary Kathleen Sebelius told about 6,000 health professionals and executives at the Institute for Healthcare Improvement’s annual meeting that the Patient Protection and Affordable Care Act (PPACA) enacted in March will place a greater emphasis on improving the quality and safety of medical care in America. The health care reform law has made it easier for DHHS and the Centers for Medicare & Medicaid Services (CMS) to study health care delivery innovations and make changes based on the results. According to George Halvorson, chief executive officer of Kaiser Permanente, the appointment of Donald M. Berwick, MD (former chief executive officer of the Institute for Healthcare Improvement), as CMS administrator sent a clear message about how quality will soon take center stage in health policy discussions. Read more: http://tinyurl.com/3yrlyag.
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Beatitudes Featured in New York Times Alzheimer’s Article
The New York Times recently featured an article on successful efforts at The Beatitudes Campus in caring for residents with Alzheimer’s and dementia. The article, titled "Giving Alzheimer’s Patients Their Way, Even Chocolate," discusses Beatitudes’ commitment to honoring resident preferences and allowing them practically anything that brings comfort—even chocolate. Beatitudes’ efforts support some of the latest research that suggests that creating positive emotional experiences for Alzheimer’s patients diminishes distress and behavior problems. Click here to read the entire article.
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 OR Communication Tools
OR Nurse conducted an online survey from April–June 2010 to determine how familiar perioperative nurses were with several standardized communication tools, including Situation-Background-Assessment-Recommendation (SBAR), preoperative briefing, the World Health Organization checklist, and the Universal Protocol. The survey also focused on how often these tools were used, their ease of use, and their effectiveness. To read the article, which highlights the survey findings, click here.
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NHSN Training Series Posted on HSAG Web Site
Data collection for Central Line-Associated Bloodstream Infections (CLABSI) is now part of the CMS Hospital Inpatient Quality Reporting Program (formerly known as the Reporting Hospital Quality Data for Annual Payment Update—RHQDAPU). CLABSI data for first quarter 2011 (January–March 2011) must be submitted and accepted in the CDC National Healthcare Safety Network (NHSN) by August 15, 2011. HSAG has posted NHSN Training Series materials, including recorded WebEx events, at http://www.hsag.com/azhospitals/mrsa/events.aspx.
For the latest information on this initiative, visit CMS QualityNet: Reporting for Healthcare Associated Infections and CDC: NHSN Training and Enrollment Requirements.
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The Future of Nursing
The Institute of Medicine (IoM) has released a report on the future of nursing. The report explores how nurses' roles, responsibilities, and education should change significantly to meet the increased demand for care that will be created by health care reform and advance improvements in America's increasingly complex health system. The executive summary is free to download—the book is available for purchase. The summary can be found at http://www.nap.edu/catalog.php?record_id=12956#description.
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Inpatient ED Measures
The Centers for Medicare & Medicaid Services (CMS) has made the decision to change the inpatient emergency department (ED) measures to voluntary in order to allow hospitals to begin submitting data for this measure set. The inpatient ED measures were first published as "Information Only" in the Specifications Manual for National Hospital Inpatient Quality Measures. The Specifications Manual Version 3.2b for discharges beginning 10/01/2010 and CART include the ED measures for "CMS Voluntary Only." Hospitals can begin voluntarily reporting the ED measures beginning with 10/01/2010 discharges, and the QIO Clinical Warehouse will accept the data. This is an excellent way for hospitals to gain experience with the measures prior to required submission. If you do not use CART to submit data, contact your vendor.
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Hospital Events and Resources
NHSN Training Series
Getting to Know NHSN—Don't Let it Bug You!
Materials and WebEx recordings for this training series are available at http://www.hsag.com/azhospitals/mrsa/events.aspx.
Important Dates for Hospital Inpatient Public Reporting
- Reporting CLABSI via NHSN begins with January 1, 2011, discharges.
- Hospital Compare was refreshed December 11, 2010.
- Preview Reports for March 2011 Hospital Compare are available January 11, 2011, to February 9, 2011.
- Q2 2010 Validation Records were due to CDAC by January 18, 2011
(selected hospitals only).
- Q3 2010 HCAHPS Data Submission was due January 18, 2011.
- Q3 2010 Population and Sampling is due February 1, 2011.
- Q3 2010 Inpatient Clinical Data Submission is due February 15, 2011.
HSAG provides all Arizona hospitals with notifications and reminders—with detailed instructions—for each of these CMS requirements. For questions or assistance, please contact Suzette Gerhart at sgerhart@azqio.sdps.org or at 602.801.6915.
For more information on HSAG's hospital initiatives, visit:
http://www.hsag.com/azhospitals/default.aspx. | |
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 Picker Institute’s Long Term Care Improvement Guide
The Long Term Care Improvement Guide, developed by Planetree and in partnership with Picker Institute, is a compendium of best practices in long term care that supplies providers with tools, data, and practical resources so they can make informed decisions as they consider implementing quality improvement and culture change initiatives in order to deliver person-centered care. Although this guide is acute-care focused, it is a valuable tool to assist nursing homes with person-centered care efforts with short-term rehabilitation residents. To view the Guide, visit http://pickerinstitute.org/wp-content/uploads/2010/10/LTC_Improvement_Guide.pdf.
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Nursing Homes: New Partners in the Fight Against HAIs
On the Centers for Disease Control and Prevention’s (CDC’s) Safe Healthcare Blog, medical epidemiologist Dr. Nimalie Stone explains the “extreme make-over” nursing homes have undergone in recent years and the impact healthcare-associated infections (HAIs) have on patients in these settings. Visit http://blogs.cdc.gov/safehealthcare/?p=1064 to read more.
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 CMS Launches "Physician Compare" Web Site
The Centers for Medicare & Medicaid Services (CMS) has expanded its online Physician Directory tool at www.medicare.gov to include new information mandated by the Affordable Care Act. Renamed Physician Compare, the site now includes information as to whether or not physicians and other health care workers enrolled in the Medicare program report specific quality data to CMS. In a second-phase update expected to be completed later in 2011, the site will show whether or not listed physicians are prescribing electronically. The Affordable Care act also requires CMS to develop a plan by 2013 to have Physician Compare include data about the quality of care Medicare patients received from listed medical providers
The Physician Compare site falls in line with the other Compare sites that CMS has made available to consumers since the launch of Nursing Home Compare in 2002. Other Compare sites that allow consumers to view and compare provider quality measure outcomes include Hospital Compare, Home Health Compare, and Dialysis Facility Compare. To view the CMS press release, click here.
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Meaningful Use FAQs on Web
The CMS Electronic Health Record (EHR) Incentive Program Web site contains a new FAQs page with answers to more than 100 questions. If you can’t find what you are looking for, you can submit your question to the appropriate Regional Office. For additional information, visit https://www.cms.gov/EHRIncentivePrograms.
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More Meaningful-Use Certified EHRs
The Certified HIT Product List (CHPL) provides the authoritative, comprehensive listing of complete EHRs and EHR modules that have been tested and certified under the Temporary Certification Program maintained by the Office of the National Coordinator for Health IT (ONC). Each complete EHR and EHR module listed on the Web site has been certified by an ONC-Authorized Testing and Certification Body (ONC-ATCB) and reported to ONC. Only the product versions that are included on the CHPL are certified under the ONC Temporary Certification Program. Please note that the CHPL is a “snapshot” of the current list of certified products. The CHPL is updated frequently as newly certified products are reported to ONC. For an up-to-date list of certified products, please visit http://onc-chpl.force.com/ehrcert.
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New Colorectal Cancer Screening Tools Highlighted
Novel colorectal cancer screening tools and markers, as well as a new treatment, were presented at the American Association for Cancer Research (AACR) special conference, Colorectal Cancer: Biology to Therapy, in October 2010. For more information, please click here.
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CMS to Develop Specifications for EHR Quality Measures
On November 3, 2010, Government Health IT reported that CMS plans to digitalize clinical quality measures so health care providers can send them to CMS directly from their EHR systems. The new system will help streamline the electronic sharing process and help providers meet meaningful use and other performance-based incentive program requirements. CMS also plans to offer electronic specifications to guide health care providers in including the Continuity Assessment Record and Evaluation (CARE) standard in inpatient EHRs. CARE is a tool designed to portray a patient’s health and functional assessment. To read more, visit http://www.govhealthit.com/newsitem.aspx?nid=75023.
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 Hospital Discharge Appeal Notices
The latest versions of the "Important Message from Medicare" (Form CMS-R-193) and the "Detailed Notice of Discharge" (Form CMS-10066), updated as of July 20, 2010, are posted on the Centers for Medicare & Medicaid Services (CMS) Beneficiary Notices Initiative (BNI) Web site (http://www.cms.gov/BNI). Manual instructions are also posted. Please note that the latest version of the "Important Message from Medicare" requires hospitals to note the time of delivery. Hospitals and Medicare Advantage Organizations (MAOs) may use these versions immediately, but use is not required until April 1, 2011. After that date, the forms with approval dates of May 2007 will no longer be valid.
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What Difference Can the Quality Improvement Process Make?
The objective of quality improvement activities (QIA) stemming from a medical record review is to assist a provider/practitioner in identifying the root cause of a confirmed concern and developing interventions to address the concern. The overall process can then be improved, ultimately resulting in the improvement of care for all patients. QIAs are based upon the degree of improvement required for each confirmed concern. A QIA can be as simple as providing a revised policy and procedure to as intense as developing a root cause analysis (RCA), establishing a baseline of data, establishing numerators and denominators for monthly auditing, and reporting data on a quarterly basis to the Quality Improvement Organization (QIO—HSAG is the QIO for Arizona). Once the QIA is received and reviewed, technical assistance may be provided back to the health care provider/practitioner in order to strengthen the QIA.
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Revised Notice of Non-Coverage Posted on CMS Web Site
CMS recently posted a revised Notice of Non-Coverage form to its Web site (expiration date: October 31, 2013). The primary differences between the "old" and "new" form are as follows:
- The Paperwork Reduction Act verbage is gone.
- The OMB Approval number is found on the bottom-right corner of page 1, instead of on the top-right corner.
- The Plan's contact information must now be located in the Additional Information Section.
Pending further direction from CMS and based upon what has been posted to the BNI Web site, the QIO will accept both notices (provided the notices include all required elements) until February 28, 2011. After that date, the QIO will only accept the "new" form. |
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 ISMP Web Resources
The Institute for Safe Medication Practices (ISMP), a nonprofit organization educating the health care community and consumers about safe medication practices, provides important information on various aspects of medication safety. Resources include education and awareness, safety tools, resource kits, newsletters, and educational programs. Below are a few of the available resources:
Visit http://www.ismp.org for more information.
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HSAG Contacts
Hospitals and Drug Safety:
Charlie Chapin, MS, CHCA, Director, Decision Support, 602.801.6940
Nursing Homes:
Joe Bestic, NHA, BA, Director, Nursing Home, 602.801.6930
Physician Offices:
Hector Cariello, MPH, Physician Office Project Manager, 602.801.6963
Case Review:
Suzanne Powell, RN, MBA, CPHQ, CCM, Director, Quality Improvement, 602.801.6902
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We welcome your feedback! Please e-mail: lcooper@hsag.com
This material was prepared by Health Services Advisory Group, Inc., the Medicare Quality Improvement Organization for Arizona, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. AZ-9SOW-XC-011111-01.
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