Updates to Advanced Certification for Primary Stroke Centers and Advanced Certification in Heart Failure
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1 Updates to Advanced Certification for Primary Stroke Centers and Advanced Certification in Heart Failure February 9,
2 New Features of The Joint Commission / American Heart Association / American Stroke Association Enhanced Alliance Use of the new Heart-Check symbol On-line Discussion Forum CMIP Trend Reports Clearinghouse of clinical tools and best practices Future Data integration (GWTG and CMIP) 2
3 CMIP Trend Reports Primary Stroke and Advanced Certification in Heart Failure 3
4 CMIP Trend Reports Review Stroke and Heart Failure core measures, data collection and data submission requirements Explain data quality rules Introduce new CMIP Trend Reports and how to interpret for data analysis 4
5 Stroke National Hospital Inpatient Quality Measures (Core Measures) STK-1 VTE Prophylaxis STK-2 D/C on Antithrombotic Therapy STK-3 Anticoagulation for A-Fib/Flutter STK-4 Thrombolytic Therapy STK-5 Antithrombotic Therapy/Day 2 STK-6 D/C on Statin Medication STK-8 Stroke Education STK-10 Assessed for Rehabilitation 5
6 STK-1 VTE Prophylaxis Denominator: Ischemic or hemorrhagic stroke patients Numerator: Ischemic or hemorrhagic stroke patients who received VTE prophylaxis OR have documentation why no VTE prophylaxis was given: the day of or the day after hospital admission 6
7 STK-2 D/C on Antithrombotic Therapy Denominator: Ischemic stroke patients Numerator: Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge 7
8 STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter Denominator: Ischemic stroke patients with documented atrial fibrillation/ flutter Numerator: Ischemic stroke patients prescribed anticoagulation therapy at hospital discharge 8
9 STK-4 Thrombolytic Therapy Denominator: Acute ischemic stroke patients whose time of arrival is within 2 hours (less than or equal to 120 minutes) of time last known well Numerator: Acute ischemic stroke patients for whom IV thrombolytic therapy was initiated at this hospital within 3 hours (less than or equal to 180 minutes) of time last known well 9
10 STK-5 Antithrombotic Therapy / Day 2 Denominator: Ischemic stroke patients Numerator: Ischemic stroke patients who had antithrombotic therapy administered by end of hospital day 2 10
11 STK-6 D/C on Statin Medication Denominator: Ischemic stroke patients with an LDL greater than or equal to 100 mg/dl, OR LDL not measured, OR who were on a lipid-lowering medication prior to hospital arrival Numerator: Ischemic stroke patients prescribed statin medication at hospital discharge 11
12 STK-8 Stroke Education Denominator: Ischemic or hemorrhagic stroke patients discharged home Numerator: Ischemic or hemorrhagic stroke patients with documentation that they or their caregivers were given educational material addressing all of the following: 12
13 STK-8 Education Components 1) Activation of emergency medical system 2) Follow-up after discharge 3) Medications prescribed at discharge 4) Risk factors for stroke 5) Warning signs and symptoms of stroke 13
14 STK-10 Assessed for Rehabilitation Denominator: Ischemic or hemorrhagic stroke patients Numerator: Ischemic or hemorrhagic stroke patients assessed for or who received rehabilitation services 14
15 Heart Failure National Hospital Inpatient Quality Measures (Core Measures) HF-1 Discharge Instructions HF-2 Evaluation of LVS Function HF-3 ACEI or ARB for LVSD HF-4 Smoking Cessation Advice/Counseling Data collection for HF-4 retired effective January 1,
16 HF-1 Discharge Instructions Denominator: Heart failure patients discharged home Numerator: Heart failure patients with documentation that they or their caregivers were given written discharge instructions or other educational material addressing all of the following: 16
17 HF-1 D/C Instruction Components 1) Activity level 2) Diet 3) Discharge medications 4) Follow-up appointment 5) Weight monitoring 6) What to do if symptoms worsen 17
18 HF-2 Evaluation of LVS Function Denominator: Heart failure patients Numerator: Heart failure patients with documentation in the hospital record that LVS function was evaluated before arrival, during hospitalization, or is planned for after discharge 18
19 HF-3 ACEI or ARB for LVSD Denominator: Heart failure patients with LVSD Numerator: Heart failure patients who are prescribed an ACEI or ARB at hospital discharge 19
20 HF-4 Smoking Cessation Advice/Counseling Denominator: Heart failure patients with a history of smoking cigarettes anytime during the year prior to hospital arrival Numerator: Heart failure patients (cigarette smokers) who receive smoking cessation advice or counseling during the hospital stay 20
21 Core Measure Specifications Specifications Manual for National Hospital Inpatient Quality Measures Current Version 4.0c applicable to discharges 01/01/2012 through 06/30/2012 Future Version 4.1 applicable to discharges 07/01/2012 through 12/31/
22 Specifications Manual
23 Data Collection and Reporting 4 months of data required for each measure at time of initial review Certified firms must annually demonstrate ongoing performance measurement activities in order to maintain certification Performance Measure Data Report completed in CMIP for all measures prior to intra-cycle conference call and recertification visit 23
24 Data Collection and Reporting Data collected (monthly data points) and submitted quarterly for all measures in the set(s) 12 months of data (numerators & denominators) entered in CMIP (The Joint Commission Connect secure-extranet) by time of intra-cycle review 24 months of data by time of recertification Data submission within 45 days following the end of the calendar quarter (CMIP send button) 24
25 Data Quality Rules Electronic alerts (error messages) and warnings that display when numerator and denominator values entered in CMIP deviate from values expected by The Joint Commission when data is collected according to the specifications detailed in the Specifications Manual for National Hospital Inpatient Quality Measures. 25
26 Data Quality Rules 26
27 Measurement Results Reporting Statistical tools for data display & analysis should be used Types Control chart (Statistical Process Control or SPC) Cause & effect diagram Pareto chart Run chart/line graph/time series plot Bar graph Flow chart Many others 27
28 What are CMIP Trend Reports? Statistical Process Control (SPC) Charts Data analysis tools for internal quality improvement Help organizations meet DSC requirements for Primary Stroke and Advanced Certification in Heart Failure Use to visually identify trends/variances in the data collected and reported to The Joint Commission 28
29 Three Types of Reports Longitudinal Report Tracks program s own self-reported data Aggregate Report Tracks national and state overall rates Multi-State Report Tracks data for multiple states as selected by the program/health care organization 29
30 Screen Shots 30
31 CMIP Intro/Summary Page Left Navigation Bar 31
32 CMIP Reports Link Opens Reporting Splash Page 32
33 CMIP Report Link CMIP Trend Report 33
34 CMIP Report Link CMIP Trend Report Parameters 34
35 CMIP Trend Report Summary Page 35
36 CMIP Trend Report: STK-6 D/C on Statin Medication 36
37 CMIP Trend Report Summary Page 37
38 CMIP Trend Report: Discharge instructions 38
39 CMIP Report Link CMIP Multi-State Report 39
40 CMIP Multi-State Report Report Parameters 40
41 CMIP Multi-State Report STK-4 Thrombolytic Therapy 41
42 CMIP User Guide Link 42
43 CMIP User Guide Content Accessing the Reports Examples Report Format User Support Report Components Glossary of Terms and Abbreviations 43
44 Questions? Karen Kolbusz (Performance Measures) Andrea Weissenburger (CMIP Applications) Jean Range (Certification) David Eickemeyer (Certification) 44
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CMS Hospital Inpatient Quality Reporting (IQR) Program Measures for the FY 2020 Payment Update
CMS Inpatient Quality Reporting (IQR) Program Measures for the Payment Update Measures Required to Meet IQR Program APU Requirements Healthcare-Associated Infection on CAUTI National Healthcare Safety
4. Which survey program does your facility use to get your program designated by the state?
STEMI SURVEY Please complete one survey for each TCD designation you have in your facility. There would be a maximum of three surveys completed if your facility was designated as a trauma, stroke and STEMI
2016 General Practice/Family Practice Preferred Specialty Measure Set
1 0059 5 0081 41 N/A 50 N/A 65 0069, EHR 66 0002, EHR Effective Clinical Care Effective Clinical Care Effective Clinical Care Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%): Percentage of patients
2016 PQRS Recommended Measures for: General/Family Practice
Measures Groups Choose 1 Measures Group Report on a minimum of 20 eligible patients (at least 11 must be Medicare Part B FFS patients) #130: Documentation of Current Medications in the Medical Record #204:
FINANCIAL DISCLOSURE: No relevant financial relationship exists
The Value of Guideline Directed Medical Therapy in Heart Failure Steve Dentel RN BSN CPHQ National Director, Field Programs and Integration American Heart Association/American Stroke Association FINANCIAL
Creating a reminder for GSK vaccines in Allscripts Professional EHR
Vaccine reminders Ensure timely and appropriate vaccine orders and administration Keeping track of patient vaccination requirements is an important aspect in the delivery of ongoing patient care. Alerts
Consensus Core Set: Cardiovascular Measures Version 1.0
Consensus Core Set: Cardiovascular s NQF 0330 Hospital 30-day, all-cause, riskstandardized readmission rate (RSRR) following heart failure hospitalization 0229 Hospital 30-day, all-cause, riskstandardized