National Patient Safety Goals & Quality Measures CY 2019

2019 August

General Clinical Orientation

Objectives / Key Points » Review and Discuss National Patient Safety Goals » Review and Discuss Current Quality Reporting Programs

National Patient Safety Goals

1. Identify Patients Correctly 2. Improve Staff Communication 3. Use Medications Safely 4. Use Alarms Safely 5. Reduce the Risk of Health Care-

Associated Infections 6. Identify Patient Safety Risks 7. Prevent Mistakes in Surgery

Identify Patients Correctly »Use at least two patient identifiers (Policy S-8)

»Eliminate transfusion errors related to patient misidentification

(Policy M-96)

Improve Staff Communication »Improve effectiveness of communication among caregivers: SBAR (Policy M-128)

»Report critical results of tests and diagnostic procedures on a timely basis: Readback

Use Medications Safely: (Policy M-55) »The 5 Rights of Medication Administration »Medication Reconciliation »Label all medications, medication containers and other

solutions on and off a sterile field in perioperative settings

Reduce Patient Harm From Anticoagulation Therapy »Warfarin, Heparin, and Low Molecular Weight Heparin »Protocols, monitoring, dietary interactions »Staff and Patient/Family education

Use Alarms Safely » Ensure alarms are heard and responded to timely (Policy M-143)

Reduce the Risk of Health Care Associated Infections »Use proven guidelines to prevent infections that are difficult to treat

»Use proven guidelines to prevent infection of the blood from central lines (CLABSI)

»Use proven guidelines to prevent infection after surgery

Reduce the Risk of Health Care Associated Infections »Use proven guidelines to prevent infections of the urinary tract caused by catheters (CAUTI)

What is the Best Way of Reducing the Risk of Health Care Associated Infections?

Policy I-83

Identify Patient Safety Risks » Identify Patients at Risk for Suicide (Policy M-47)

Prevent Mistakes in Surgery »Prevent Wrong Site, Wrong Procedure and Wrong Person Surgery »Conduct a Pre-procedure Verification Process (Policy M-123)

»Mark the Procedure Site »Perform a Time-Out Before the Procedure

How to Call a CODE » Adult: Code Blue, Dial 77777 » Pediatric: Code White, Dial 55555 » Outside the Hospital: Dial 911 » Rapid Response: Dial 77888 » Answer All questions from the Operator » Give Detailed Information: Unit/Department and Room

Number

Code Policy References » Inpatient- Policy M-35 » Outpatient- Policy M-127 » Visitors- Policy S-5

What are Quality Measures?

»Medical information from patient records converted into a rate or percentage that shows how well hospitals care for their patients in certain categories.

» Each measure is an evidence-based, scientifically-researched standard of care which has been shown to result in improved clinical outcomes.

Development of Quality Measures is Based on Following Criteria:

»High impact disease (cost, morbidity, mortality, quality of life)

»Guidelines that provide best practices that can be measured

»Gaps in care (opportunities for improvement)

CMS Quality Reporting Programs

Hospital Readmission Reduction Program

Hospital Outpatient Quality Reporting

Hospital Inpatient Quality Reporting

Program

Hospital Acquired Conditions Reduction

Program

Value-Based Purchasing Program

Inpatient Quality Reporting

» Examples of these measures include Sepsis

»Inpatient Quality Reporting Metrics do not directly impact hospital reimbursement

» Most hospital results are posted on Hospital Compare Website

Outpatient Quality Reporting » ED Measures » Colonoscopy

How Quality Measures Impact Reimbursement

» “Pay for Performance” » Quality Measure data submitted this year impact our reimbursement for 2021

Value Based Purchasing (VBP) »Quality incentive program that requires hospitals to contribute a percentage of their Medicare reimbursement into a pool

»Hospitals have the “opportunity” to earn back their full contribution and the potential of earning additional monies based on their national performance ranking

»Current withholding rate FY 2021 is 2.00% of Medicare base rate

Hospital Readmission Reduction Program

»Reduces payments to hospitals with excess readmissions

»Readmission defined as an admission to acute care hospital within 30 days of discharge from the same or another acute care hospital

»Unlike Value Based Purchasing (VBP) Program this is a reimbursement penalty program. Penalty reduction in Medicare payment is 3% of base rate.

Hospital Readmission Program Effective Program FY 2021

Readmission Rates

Acute MI 30 Day Readmission Rate

Heart Failure 30 Day Readmission Rate Total Hip/Knee Arthroplasty 30 Day Readmission Rate

Acute Exacerbation of COPD 30 Day Readmission Rate CABG 30 Day Readmission Rate

Pneumonia 30 Day Readmission Rate: cohort expanded

Hospital Acquired Condition (HAC) Program

»Defined as a condition that patients acquire while receiving treatment for another condition in an acute care setting

»Hospital performance determined on hospital’s total HAC score which can range from 1-10

»The higher the score the poorer the hospital performance.

Hospital Acquired Condition (HAC) Program

»HAC reduction scores are being posted on the Hospital Compare website.

This is a QUIZ………………

Questions? »Who created National Patient Safety Goals?

»We recommend using patient name and room number to identify a patient?

»What is a Code White? What phone number do you call?

»Where can I look to get information on Core Measures?

Questions

»Only nursing staff need to worry about Quality Measures? »Quality Measures are published on Hospital Compare website?

»Quality Measures stay the same from year to year?

»Hospital Readmission Reduction Program is a reimbursement incentive program?

Questions?