CLINICAL EFFECTIVENESS/SAFETY M CORE MEASURES 2015 See attached Results QUALITY AND SAFETY MEASURES UPDATE January 2016 Jint Cmmissin and CMS Cre Measure Dashbard updated with mst recent data available: Q3 2014 Q2 2015. Highlights f results and imprvement wrk: Strke: All measures at 100% Perinatal measures: Cntinued perfrmance n all measures better than UHC median VTE measures: ICU Prphylaxis VTE prphylaxis increased t 96%. Imprvement wrk fcused n easier access t and dcumentatin f Sequential Cmpressin Devices. Flu Immunizatin: Lwer than desired perfrmance in FY14/15 flu seasn (68%). Immunizatin team develped an A3 imprvement plan and implemented an initial technlgical slutin t imprve immunizatin screening by nurses. Implementatin f changes t the electrnic discharge pathway ccurred in late Octber 2015. Analysis f data cmparing cmpliance prir t and after implementatin f change: Cmpletin f immunizatin screening imprved frm 58% t 95% Dcumentatin f immunizatin given r reasn why nt imprved frm 64% t 86% (barriers t higher cmpliance relate t required dcumentatin in multiple systems). ED Time t Pain Management fr Lng Bne Fracture: Perfrmance better than UHC median. Emergency Dept Thrughput Median times cntinue t be lnger than UHC Median. Median time frm arrival t Diagnstic Evaluatin decreased frm 127 minutes (Q3 2014) t 46 minutes (Q2 2015). Medical prviders are nw cnducting the Medical Screening exams in the ED, decreasing wait time fr a prvider. An Emergency Dept Lean Value Stream began in Octber 2015, fcusing n imprving patient flw. Psychiatry measures: Discharged patients n mre than ne antipsychtic: Decrease nted in % f patients discharged n mre than ne antipsychtic belw UHC median. (lwer=better) Measure retired as f Q4 2015 Tbacc Use Treatment/Cunseling during stay: Current practice and dcumentatin des nt include all required elements fr cmpliance with this measure. Revisins t Salar Team Ntes templates in early 2016 will assist with imprving cmpliance. Pst Discharge Cntinuing Care Plan Created/Transmitted Measure retired as f Q4 2015 Replaced with Transitin Recrd at Discharge measure New measures 2016: Alchl Use Screening and Interventin ffered Tbacc use treatment prvided/ffered at discharge
2015 SFGH JOINT COMMISSION/CMS CORE MEASURE RESULTS Measure Measure Name Q3 2014 Q4 2014 Q1 2015 Q2 2015 UHC Median (Q1 2015) STROKE STK-1 Venus Thrmbemblism (VTE) Prphylaxis 97% 100% 100% 100% 100% STK-2 Discharged n Antithrmbtic Therapy 100% 100% 100% 100% 100% STK-3 Anticagulatin Therapy fr Atrial Fibrillatin/Flutter 100% 100% 100% 100% 100% STK-4 Thrmblytic Therapy 100% 100% 100% 100% 100% STK-5 Antithrmbtic Therapy by End f Hspital Day 2 100% 100% 100% 100% 100% STK-6 Discharged n Statin Medicatin 100% 100% 100% 100% 100% STK-8 Strke Educatin 95% 94% 100% 100% 100% STK-10 Assessed fr Rehabilitatin 100% 100% 100% 100% 100% PERINATAL CARE PC-01 Elective Delivery Prir t 39 Cmpleted Weeks Gestatin (lwer = better) 0% 0% 0% 0% 0% PC-02 Cesarean Sectin Rate (lwer = better) 17% 32% 8% 17% 25% PC-03 Antenatal Sterids Given as Apprpriate 100% 100% PC-04 Health Care-Assciated Bldstream Infectins in Newbrns (lwer = better) 0% 0% 0% 0% 0% PC-05 Exclusive Breast Milk Feeding During Hspital Stay 68% 73% 70% 79% 53% VENOUS THROMBOEMBOLISM (VTE) VTE-1 Venus Thrmbemblism Prphylaxis 86% 85% 89% 91% 94% VTE-2 Intensive Care Unit Venus Thrmbemblism Prphylaxis 95% 85% 75% 96% 100% VTE-3 Venus Thrmbemblism Patients with Anticagulatin Overlap Therapy 97% 100% 100% 97% 100% VTE-5 Venus Thrmbemblism Warfarin Therapy Discharge Instructins 94% 94% 89% 81% 100% VTE-6 IMMUNIZATION IMM-2 Hspital Acquired Ptentially-Preventable Venus Thrmbemblism Influenza Immunizatin PAIN MANAGEMENT (Minutes) 9% 7% 0% 0% 0% Nt Flu Seasn 65% 71% Nt Flu Seasn 96% OP-21 Median Time t Pain Management fr Lng Bne Fracture in the ED 64 34 50 40 57 EMERGENCY THROUGHPUT (Minutes) ED-1 ED-2 Median Time frm ED Arrival t ED Departure fr Admitted ED Patients 488 529 506 469 368 Median Time -Admit Decisin Time t ED Departure Time fr Admitted Patients 248 220 215 222 152 OP-18 Median Time frm ED Arrival t ED Departure fr Discharged ED Patients 254 263 257 229 198 OP-20 Median Time - ED Dr t Diagnstic Evaluatin by a Qualified Medical Persnnel 127 99 62 46 35 HOSPITAL BASED INPATIENT PSYCHIATRY HBIPS-1 Admissin Screening Cmpleted 92% 88% 98% HBIPS-2 Hurs f Physical Restraint Use (per 1000 patient hurs) 0.78 0.69 0.80 1.45 0.66* HBIPS-3 Hurs f Seclusin Use (per 1000 patient hurs) 4.6 4 6 6 0.3* HBIPS-4 Patients discharged n multiple antipsychtic medicatins (lwer=better) 10% 9% 15% 6% 7% HBIPS-5 Patients discharged n multiple antipsychtic medicatins with apprpriate justificatin 38% 40% 42% 40% 64% HBIPS-6 Pst discharge cntinuing care plan created 90% 90% 100% 100% 93% HBIPS-7 Pst discharge cntinuing care plan transmitted t next level f care prvider upn discharge 78% 74% 84% 52% 85% SUB-1 Alchl Use Screening 77% 84% 91% 97% 97% TOB-1 Tbacc Use Screening 95% 97% TOB-2 Tbacc Use Treatment/ Practical Cunseling Prvided r Offered IMM-2 Influenza Immunizatin (Screened/Administered if Apprpriate) * CMS Natinal Rate 0% 0% 13% Nt Flu Seasn 96%
CY2016 SFGH JOINT COMMISSION CORE MEASURE SETS - Recmmendatin Cntinued Jint Cmmissin requirement fr reprting n 6 sets f measures Perinatal Care measure set required fr hspitals with ver 300 births/year. NEW IN 2016 CMS Requirement fr electrnically submitted data Electrnic (ecqm) ecqm - Electrnic Clinical Quality Measures: clinical data elements transmitted directly frm ur electrnic systems t ur vendr withut any verificatin r crrectins based n manual medical recrd review (chart abstracted). NEW Chart Abstracted Data cllected manually thrugh review f electrnic and paper medical recrds by trained Quality Management staff. Includes ability t capture handwritten dcumentatin r data frm stand-alne systems. Allws fr crrectins prir t submitting data. In 2016, CMS will require submissin f at least 4 ecqm measures fr at least ne quarter f data (Q3 r Q4 2016). Cre Measure Optins: 1) Reprt measures as Chart Abstracted nly, 2) ecqm (Electrnic Clinical Quality Measures) nly, r 3) Cmbinatin f Chart Abstracted and ecqm. The same measure set can be selected fr bth chart abstracted and ecqm each methd will cunt tward 6 required measures sets. Example: VTE Chart Abstracted and VTE ecqm selected = 2 f the required 6 cre measure sets. RECOMMENDATION Select Optin 3 Cmbinatin f chart abstracted and ecqm measure sets (Selectin due 1/30/16) Will allw SFGH t evaluate accuracy f electrnic data befre required submissin t CMS. ecqm data will be cmpared t chart abstracted data t identify pprtunities t imprve electrnic data capture. Our current cre measure vendr, UHC, is certified t transmit ecqms t CMS UHC ffering pilt perid t submit test data befre sending required data t Jint Cmmissin and CMS.
Optin 3 Selected: Cmbinatin f Chart Abstracted¹ and ecqm² measure sets Measure Measure Name Methd Current SFGH Cre Measure PC-01 PC-02 PC-03 PC-04 PC-05 PERINATAL CARE (1 set: Chart) CHART ABSTRACTED YES Elective Delivery Prir t 39 Cmpleted Weeks Gestatin Cesarean Sectin Rate Antenatal Sterids Health Care-Assciated Bldstream Infectins in Newbrns Exclusive Breast Milk Feeding VENOUS THROMBOEMBOLISM (VTE) (2 sets: Chart & ecqm) VTE-5 Venus Thrmbemblism Warfarin Therapy Discharge Instructins CHART ABSTRACTED YES VTE-6 Hspital Acquired Ptentially-Preventable Venus Thrmbemblism CHART ABSTRACTED YES EMERGENCY THROUGHPUT (2 sets: Chart & ecqm) ED-1 Median Time frm ED Arrival t ED Departure fr Admitted ED Patients CHART ABSTRACTED YES ED-2 Admit Decisin Time t ED Departure Time fr Admitted Patients CHART ABSTRACTED YES SURGICAL CARE IMPROVEMENT (1 set: ecqm) escip-1 Prphylactic Antibitic within 1 Hur f Surgical Incisin Time ecqm NO ¹ Chart Abstracted Data cllected manually frm SFGH medical recrds, including validating and crrecting data and/r cding errrs. ² ecqm - Electrnic Clinical Quality Measures: clinical data elements transmitted directly frm ur electrnic systems t ur vendr withut any verificatin r crrectins based n chart abstractin. In 2016, CMS will require submissin f at least 4 ecqm measures fr at least ne quarter f data (Q3 r Q4 2016).
MEASURES RETAINED CMS INPATIENT/PSYCH QUALITY REPORTING PROGRAMS Measure Measure Name Methd Current SFGH Cre Measure IMMUNIZATION IMM-2 Influenza Immunizatin (Inpatient) CHART ABSTRACTED YES HOSPITAL BASED INPATIENT PSYCHIATRY CHART ABSTRACTED YES HBIPS-1 Admissin Screening fr Vilence Risk, Substance Use, Psychlgical Trauma Histry and Patient Strengths cmpleted HBIPS-2 Hurs f physical restraint use HBIPS-3 Hurs f seclusin use HBIPS-5 Patients discharged n multiple antipsychtic medicatins with apprpriate justificatin NQF0647 Transitin Recrd with specified elements received by discharged patients NQF0648 Timely transmissin f Transitin Recrd t fllw up prvider within 24 hurs f discharge SUB-1 Alchl Use Screening SUB-2/2a Alchl Use Brief Interventin Prvided r Offered TOB-1 Tbacc Use Screening TOB-2/2a Tbacc Use Treatment Practical Cunseling Prvided r Offered TOB-3/3a Tbacc Use Treatment Prvided r Offered at Discharge IMM-2 Influenza Immunizatin status dcumented/immunized/refused MEASURES RETAINED TJC STROKE CERTIFICATION PROGRAM STROKE CHART ABSTRACTED YES STK-1 Venus Thrmbemblism (VTE) Prphylaxis STK-2 Discharged n Antithrmbtic Therapy STK-3 Anticagulatin Therapy fr Atrial Fibrillatin/Flutter STK-4 Thrmblytic Therapy STK-5 Antithrmbtic Therapy by End f Hspital Day 2 STK-6 Discharged n Statin Medicatin STK-8 Strke Educatin STK-10 Assessed fr Rehabilitatin