| CA Hospital Inpatient Quality Reporting | |
| CA Annual Medical Services Review Report | |
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Winter 2011 California Edition: Volume 1, Issue 4 |
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 CMS Names HSAG of California
"QIO Quality Champion"
Health Services Advisory Group (HSAG) of California was presented with the "QIO Quality Champion" award at the recent QualityNet Conference sponsored by the Centers for Medicare & Medicaid Services (CMS). The award, given in recognition of HSAG of California’s exceptionally high performance across all segments of the current CMS Quality Improvement Organization (QIO) scope of work, was presented by Barry Straube, MD, CMS Chief Medical Officer and Director of the CMS Office of Clinical Standards and Quality. The award was accepted on behalf of the organization by HSAG of California’s Chief Executive Officer, Rick Potter, MBA, CPA, CHCA (see photo).
There is a national network of QIOs located in each of the 50 U.S. states, the District of Columbia, Puerto Rico, and the Virgin Islands (click here for more information). HSAG of California became the Medicare QIO for California in 2008. HSAG is also the Medicare QIO for the states of Arizona and Florida. The annual QualityNet Conference brings together national health care leadership from CMS, the Medicare QIO contractors, the Medicare ESRD Networks, and other public and private stakeholder organizations to discuss new directions for quality improvement work at CMS.
Improving the Health of Americans by Reducing HAIs
The U.S. Department of Health and Human Services recently launched “Healthy People 2020,” a 10-year initiative aimed at reducing health risk factors and disparities. A key focus area is healthcare-associated infections (HAIs), which have a major impact on patient care. Each year, 1.7 million HAIs occur, causing roughly 99,000 deaths at a cost of $28 billion to $45 billion to U.S. hospitals, according to the Centers for Disease Control and Prevention. To learn more about “Healthy People 2020” and the goals for reducing HAIs, visit http://www.healthypeople.gov.
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Cross-Setting Collaborations Maximize Benefit of Post-Acute Care
Coordination between acute-care hospitals and post-acute care (PAC) facilities is essential to improving health care quality while also reducing spending, according to an article in the November 10 issue of the American Hospital Association’s TrendWatch. The Affordable Care Act mandates incentives and penalties designed to encourage greater coordination of care between acute-care hospitals and PAC facilities. To learn more about ways acute-care hospitals and PAC facilities can work together to improve quality and reduce health care costs, visit http://www.aha.org/aha/trendwatch/2010/10nov-tw-postacute.pdf.
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 Reminders Cut Rates of CAUTIs in Half
Reminding hospital staff members to remove urinary catheters promptly can reduce the rate of catheter-associated urinary tract infections (CAUTIs) by more than 50 percent, according to a study published in the journal Clinical Infectious Diseases. The study authors found that reminder systems prompting hospital staff members to assess and remove catheters on a routine basis are a highly effective method for reducing the rate of CAUTIs. To learn more about the reminder systems and read a summary of the research findings, visit http://www.infectioncontroltoday.com.
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Improved Communication Leads to Better Handoffs
An estimated 80 percent of serious medical errors involve breakdowns in patient transfers and handoffs. A group of 10 leading U.S. hospitals and health care systems teamed up with the Joint Commission Center for Transforming Healthcare to address this critical issue. The Hand-off Communications Project attained impressive results: participating organizations that fully implemented the recommended solutions achieved an average 52 percent reduction in defective handoffs. The project team designed an approach called SHARE:
- Standardize critical content, including providing details of the patient's history to the receiver.
- Hardwire within your system, including developing standardized forms, tools, and methods.
- Allow opportunity to ask questions, including sharing and receiving information as an interdisciplinary team.
- Reinforce quality and measurement, including demonstrating leadership commitment to successful handoffs and holding staff members accountable.
- Educate and coach, including organizations teaching staff members what constitutes a successful handoff.
To learn more about ways to make patient handoffs and transfers safer, visit http://www.centerfortransforminghealthcare.org.
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Hospital Inpatient Quality Reporting Program
The HSAG of California Hospital Inpatient Quality Reporting Program (formerly known as the Reporting Hospital Quality Data for Annual Payment Update—RHQDAPU) Team helps California hospitals meet requirements for inpatient quality data reporting. The Hospital Inpatient Quality Reporting Program (hereafter referred to as the Reporting Program in this document) Team assists hospitals in the following areas:
- Abstraction of the National Inpatient Measure Sets (AMI, HF, Pneumonia, SCIP)
- Inpatient data reporting requirements
- Inpatient data validation
- QualityNet registrations
- The use of CART (CMS Abstraction and Reporting Tool)
The Team uses the Reporting Program E-mail List as a key resource to rapidly communicate critical information to the hospitals they support. Any hospital staff member who works with inpatient abstraction, reporting, or validation is strongly encouraged to subscribe to this list. Hospitals are not limited to the number of staff members that can subscribe. To subscribe to the Reporting Program E-mail List, visit http://www.hsag.com/caproviders/hiqr.aspx. The subscription process requires you to enter your name and e-mail address, create a password, and reply to an automated e-mail.
Pre-recorded WebEx events are produced each quarter and posted on the HSAG Web site at http://www.hsag.com/caproviders/events.aspx. Click on the “Past Hospital Inpatient Quality Reporting Events” link at the top of the page to access posted WebExs. The next pre-recorded WebEx event will be available by January 27, 2011, and will cover the new validation scoring process with lessons learned to date, administrative updates, and changes to the Specifications Manual, Version 3.3.
For more information, visit http://www.hsag.com/caproviders/events.aspx.
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Hospital Events and Resources
Southern California Patient Safety Collaborative (SCPSC)
Track I—Hospital-Acquired Infections in the ICU Setting, Sepsis, and SCIP
February 15, 2011
Contact Susan Hiyama, RN, MSN, CPHQ, for more information.
Track II—Pressure Ulcer Cross-Setting Collaborative
March 15, 2011
Contact Tom Carter, MA, MSPH, for more information.
For more information on all 2011 SCPSC events, visit
http://www.hsag.com/cahospitals/scpsc.aspx.
For more information on HSAG of California's hospital initiatives, visit http://www.hsag.com/cahospitals/default.aspx. | |
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 CMS Support Site for MDS 3.0
The Centers for Medicare & Medicaid Services (CMS) has created a Web site to support providers in implementing MDS 3.0, a standardized assessment tool designed to facilitate improved care management in nursing homes and noncritical access hospital swing beds. CMS will post frequent MDS 3.0 updates to the Web site, as well as technical information and training materials. Nursing homes and hospitals should bookmark the site and visit it often. For additional information, visit https://www.cms.gov/NursingHomeQualityInits/25_NHQIMDS30.asp.
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CDPH and CDHCS Implement New State-Developed Quality and Accountability Program
The California Department of Public Health (CDPH) and California Department of Health Care Services (CDHCS) have partnered to implement a new Quality and Accountability Program for skilled nursing facilities developed by the state of California. The program provides incentives to institutions that meet concrete indicators of quality. Performance determines payments, and higher performance results in higher payments. Indicators used to measure quality include staffing, physical restraints, facility-acquired pressure ulcers, immunizations, and patient/family satisfaction.
In the future, the state will incorporate quality measures identified by CMS for health care reform, as well as other quality measures. HSAG of California will consult on options for measuring satisfaction and identifying measures going forward. To learn more about quality measures and incentive payments, visit http://www.dhcs.ca.gov/services/medi-cal/Pages/LTCAB1629QAP.aspx.
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Picker Institute’s Long Term Care Improvement Guide
The Long Term Care Improvement Guide, developed by Planetree in partnership with Picker Institute, is a compendium of best practices in long term care. The Guide supplies providers with tools, data, and practical resources so they can make informed decisions on implementing quality improvement and culture change initiatives 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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 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 (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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PEPPER
The next Short-Term Acute Care Hospital PEPPER is scheduled for release on or about February 24, 2011. Hospitals will notice several improvements to the PEPPER format. There will be interpretive guidance included on each target area worksheet. Interventions will be suggested if the hospital is at or above the 80th percentile or at or below the 20th percentile (coding-focused target areas only). There will also be improved labeling of time periods on the target area worksheets and graphs.
Several new target areas have been added to PEPPER based on feedback from hospitals and findings from the Recovery Audit Contractor (RAC) demonstration and expansion projects. A recorded Webinar training session will be available on www.PEPPERresources.org in February to assist providers in reviewing the new format.
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What Difference Can the Quality Improvement Process Make?
The objective of quality improvement activities (QIAs) 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 determined by the QI Team at HSAG of California and are based upon the degree of improvement required for each confirmed concern. A QIA can be as simple as providing the team with a revised policy and procedure to as intense as doing 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 of California is the QIO for the state). Once the QIA is received, it is reviewed by the QI Team. Technical assistance may also be provided back to the health care provider/practitioner in order to strengthen the QIA.
Click here to read an example of a 12-month 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 verbiage 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.
For more information on appeals, visit http://www.hsag.com/caproviders/appeals.aspx. |
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 ISMP Web Resources
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:
Darla Farrell, RN, MBA, FACHE, CPHQ, Director, Hosptial Patient Safety, 818.265.4670
Elaine Krantzberg, RN, Project Director, Quality Data Reporting, 813.865.3420
Nursing Homes:
Jennifer Wieckowski, MSG, Director, Nursing Home, Patient Safety, 818.265.4640
Physician Offices:
Hector Cariello, MPH, Physician Office Project Manager, 602.801.6963
Case Review:
Marie Munch, MBA, Communication Coordinator, 813.354.9111
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We welcome your feedback! Please e-mail: arivera@hsag.com
This material was prepared by Health Services Advisory Group of California, Inc., the Medicare Quality Improvement Organization for California, 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. CA-9SOW-XC-010611-01.
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