Updates to Advanced Certification for Primary Stroke Centers and Advanced Certification in Heart Failure February 9, 2012 1
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
CMIP Trend Reports Primary Stroke and Advanced Certification in Heart Failure 3
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
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
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
STK-2 D/C on Antithrombotic Therapy Denominator: Ischemic stroke patients Numerator: Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge 7
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
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
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
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
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
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
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
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, 2012 15
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
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
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
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
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
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 12/31/2012 21
Specifications Manual
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
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
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
Data Quality Rules 26
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
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
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
Screen Shots 30
CMIP Intro/Summary Page Left Navigation Bar 31
CMIP Reports Link Opens Reporting Splash Page 32
CMIP Report Link CMIP Trend Report 33
CMIP Report Link CMIP Trend Report Parameters 34
CMIP Trend Report Summary Page 35
CMIP Trend Report: STK-6 D/C on Statin Medication 36
CMIP Trend Report Summary Page 37
CMIP Trend Report: Discharge instructions 38
CMIP Report Link CMIP Multi-State Report 39
CMIP Multi-State Report Report Parameters 40
CMIP Multi-State Report STK-4 Thrombolytic Therapy 41
CMIP User Guide Link 42
CMIP User Guide Content Accessing the Reports Examples Report Format User Support Report Components Glossary of Terms and Abbreviations 43
Questions? Karen Kolbusz (Performance Measures) kkolbusz@jointcommission.org Andrea Weissenburger (CMIP Applications) aweissenburger@jointcommission.org Jean Range (Certification) jrange@jointcommission.org David Eickemeyer (Certification) deickemeyer@jointcommission.org 44