NEW STUDY LAUNCH WEBINARFEBRUARY 28 , 2013

PIN Clinical Improvement Studies

Feedback from the FieldMinimize data collection and reporting burden

Avoid duplication

Collaborate with other data collection projects

Consistent data definitions with national projects

Consistent report formats between projects when possible

Overlap/Alignment/Similarities = COLLABORATION

The PIN “OP 4,5” StudyData collected using the CMS CART tool

No new tool for the PIN project

Data definitions consistent with those in CART tool

One data submission works toward 3 initiatives: Regulatory compliance; MBQIP; CMS-OQR

Consistent reporting: we’re working on that…..

What is “OP 4,5” ?!OP = outpatient measures

Included in the MBQIP Phase 2 measure set Originally defined as part of the CMS Outpatient Quality Reporting

(OQR) project some years ago

OP 4 and OP 5 = numbers CMS has assigned to specific measures within their OQR project there are several other measures in their set

Study name reflects that this PIN project will focus on two of the OQR- OP measures: number 4 and number 5

Clinical Improvement Studies Format

Announcement and training todayBaseline data collection March 29Reports back to facilities April - MaySupport Facility PI Cycles April - SeptRe-measure performance Oct 2013Reports back to facilities Nov 2013

In General For this study

Clinical Improvement Studies Format

Announcement and training todayBaseline data collection March 29Reports back to facilities April - MaySupport Facility PI Cycles April - SeptRe-measure performance OctoberReports back to facilities Nov - Dec

In General For this study

OP 4,5 Measure Definitions

OP 4 Aspirin On Arrival

Numerator: Emergency Department AMI or Chest Pain patients (with Probable Cardiac Chest Pain) who received aspirin within 24 hours before ED arrival or prior to transfer.

Denominator: Emergency Department AMI or Chest Pain patients (with Probable Cardiac Chest Pain).

Source: http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FSpecsManualTemplate&cid=1228772438492

OP 4,5 Measure Definitions

OP 5 Median Time to EKG

Description: Median time from ED arrival to ECG (performed in the ED prior to transfer) for acute myocardial infarction (AMI) or Chest Pain patients (with Probable Cardiac Chest Pain).

Source: http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FSpecsManualTemplate&cid=1228772438492

Baseline Data Collection: Due Mar 29

Emergency Room Cases onlyAMI populationChest Pain, Probably Cardiac Chest Pain,

populationCases between Jan 1, 2012 and Sept 30, 2012No more than 30 casesTool: OQR - CART tool

Re-measurement Data CollectionEmergency Room Cases onlyAMI populationChest Pain, Probably Cardiac Chest Pain,

populationCases between April 1, 2013 and Sept 30,

2013No more than 30 casesTool: OQR - CART tool

Performance Improvement SupportTime to ECGAspirin administrationThrombolytics administrationDPHHS Cardiac Program resourcesPIN AMI Tool KitCoding and/or Abstraction Accuracy needs

Using CARTto Enter Data for the OP 4 and OP 5

Shanelle, you are up!

CART Demonstration!

Questions?Kathy Wilcox

Rural Hospital Quality CoordinatorMHA/MHREFkathy@mtha.org; 406.461.6186

Shanelle VanDyke Quality Improvement & Reporting Project Manager Mountain-Pacific Quality Health svandyke@mtqio.sdps.org; 406.457.5896