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Federal Ambulatory Surgery Center Federal Ambulatory Surgery Center

Federal Ambulatory Surgery Center - PowerPoint Presentation

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Federal Ambulatory Surgery Center - PPT Presentation

Quality Reporting Program Florida State Consumer Health Information and Policy Advisory Council David Shapiro MD Federal Quality Reporting In November 2001 Health amp Human Services HHS Secretary Tommy G Thompson announced The Quality Initiative his commitment to assure quality he ID: 739891

measure asc quality patients asc measure patients quality surgery measures patient denominator hospital numerator colonoscopy reporting facility years wrong

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Slide1

FederalAmbulatory Surgery CenterQuality Reporting Program

Florida State Consumer Health Information and Policy Advisory Council

David Shapiro, M.D.Slide2

Federal Quality ReportingIn November 2001, Health & Human Services’ (HHS) Secretary Tommy G. Thompson announced The Quality Initiative, his commitment to assure quality healthcare for all Americans through published consumer information coupled with healthcare quality improvement support through Medicare’s Quality Improvement Organizations (QIOs).

The

Quality Initiative was launched nationally in 2002 as the Nursing Home Quality Initiative (NHQI) and expanded in 2003 with the Home Health Quality Initiative (HHQI) and the Hospital Quality Initiative (HQI).

These

initiatives are part of a comprehensive look at quality of care that includes hospitals, nursing homes, home health agencies, and physician offices. Slide3

Federal Quality Reporting

In

2006, the ASC community began encouraging the Centers for Medicare & Medicaid Services (CMS) to establish a uniform quality reporting system that would allow ASCs to publicly demonstrate their performance on quality measures.

CMS implemented

the Ambulatory Surgical Center Quality Reporting (ASCQR) Program on October 1, 2012.Slide4

Quality Measure Reporting

Federal Measurement Development Process:

CMS selects measures that reflect consensus among affected parties and, to the extent feasible and practicable, that these measures include measures set forth by one or more national consensus building entities (e.g. NQF).

The

ASC community formed the ASC Quality Collaboration in 2006 to initiate the process of developing standardized ASC quality measuresSlide5

ASC Quality Collaboration

Efforts

on the Regulatory and Legislative fronts

Measure

Development

process occurs over several years

The

measures

included

in

the program

have been developed using a

multi-step process

. Each has been vetted with both our internal panel of technical experts and an external

panel

of individuals and/or organizations with relevant expertise. All of the measures

have

been

pilot

tested in ASCs and assessed for validity, feasibility and reliability. Slide6

ASC Quality Reporting Program

Often referred to as the ASC QRP

The

ASC quality reporting program officially began on October 1,

2012

Data

collection

began

in CY 2012 for certain measures

Applied

to the CY 2014 payment determinationSlide7

ASC QRP Overall Structure

ASCs

that don’t submit quality measure data

incur

up to a 2.0% reduction to any annual increase provided under the payment system for

the specified year

Several mechanisms of reporting

Staggered implementation of required measures

Annual Review New Measures, Retired Measures

Many

unresolved issues remain Slide8

How Data Is Reported

Claims Based Reporting-Quality Data Codes

Web Based Reporting via QualityNet Secure Portal

www.qualitynet.org

Web Based Reporting Via Centers for Disease Control and Prevention (CDC) National Health Care Safety Network (NHSN)

www.cdc.gov/nhsn/index.html

Administrative ClaimsSlide9

Measurement 101Measures can be divided into two general categories: Outcome and Process

The

measures developed by the

ASC QC include

both

outcome measures and process measures

An

outcome measure assesses

patients for a specific result of health care

intervention

.

A process measure evaluates

a particular aspect of the care that is delivered to the

patient

.Slide10

Measurement 102Measure Type

States whether the measure is an outcome measure or a

process measure

Description

A

brief description of what is

measured

Numerator

:

Patient

population experiencing the outcome or process of

care

being measured.

Denominator

: The patient population evaluated

.

Inclusions/Exclusions

of both Numerator and Denominator

Data Sources

The documents that typically contain the information needed to

determine

the numerator and

denominator

Definitions

Specific definitions for the terms included in the numerator and

denominator

statements

Slide11

Patient BurnThis measure is used to assess the

number

of

admissions (patients)

that

experience

a burn

prior to discharge

Numerator

: Ambulatory Surgery Center ASC admissions experiencing a burn prior to

discharge

Denominator:

All ASC admissions

.

Definition:

Burn

: Unintended tissue injury caused by any of the six recognized

mechanisms

: scalds, contact, fire, chemical, electrical or radiation,

(

e.g. warming devices, prep solutions,

electrosurgical unit

or laser).Slide12

Patient FallThis

measure

is used to assess the

number of

admissions (patients)

that experience a fall within the ASC

Numerator: Ambulatory Surgery Center (ASC) admissions

experiencing

a fall within the confines of the

ASC

Denominator: All ASC

admissions

Definition:

Fall

: a sudden, uncontrolled, unintentional, downward displacement of

the

body to the ground or other object, excluding falls

resulting

from

violent

blows or other purposeful actions. (National Center for

Patient Safety)Slide13

Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong

Implant

Description:

This

measure

is used to assess the

number of

ASC admissions

(

patients)

experiencing a

wrong site, side, patient,

procedure

or

implant

Numerator

: All Ambulatory Surgery Center (ASC) admissions

experiencing

a wrong site, wrong side, wrong patient, wrong procedure or wrong

implant.

Denominator

Inclusions: All ASC

admissions

Definitions:

Admission

: completion of registration upon entry into the facility.

Wrong: not in accordance with intended site, side, patient, procedure

or implantSlide14

All Cause Hospital Transfer/Admission

Numerator: Ambulatory Surgery Center (ASC) admissions requiring a

hospital

transfer or hospital admission upon discharge from the ASC

.

Denominator: All

ASC admissions

.

Definitions:

Admission: completion of registration upon entry into the facility.

Hospital transfer/admission: any

transfer/admission

from an

ASC directly

to an acute care hospital including hospital emergency room.

Discharge: occurs when the patient leaves the confines of the ASC

While hospital

transfers

and admissions undoubtedly represent good patient care when necessary, high rates

may

be an indicator that practice patterns or patient selection guidelines are in need of review.Slide15

Influenza Vaccination Coverage Among Healthcare Personnel

Numerator:

The numerator for this measure consists of HCP in the denominator population, who during the time from when the vaccine became available (for example, August or September) through March 31 of the following year:

received an influenza vaccination administered at the healthcare facility;

or

reported

in writing (paper or electronic) or provided documentation that influenza vaccination was received elsewhere; or

were determined to have a medical contraindication/condition of severe allergic reaction to eggs or other component(s) of the vaccine, or history of Guillain-Barré Syndrome (GBS) within 6 weeks after a previous influenza vaccination; or

were offered but declined influenza vaccination; or

had an unknown vaccination status or did not otherwise meet any of the definitions of the above-mentioned

The numerator data are mutually exclusive. The sum of the numerator categories should be equal to the denominator for each HCP group. Slide16

Influenza Vaccination Coverage Among Healthcare Personnel

Denominator: The

denominator for this measure consists of HCP who are physically present in the healthcare facility for at least 1 working day between October 1 and March 31 (for example, the measure reporting period) of the following year. Denominators are to be calculated separately for three required categories of HCP and can also be calculated for a fourth optional category:

Employees

: This includes all persons who receive a direct paycheck from the reporting facility (for example, on the facility’s payroll), regardless of clinical responsibility or patient contact.

Licensed independent practitioners (LIPs): This includes physicians (MD, DO), advanced practice nurses, and physician assistants who are affiliated with the reporting facility, but are not directly employed by it (for example, they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact. Post-residency fellows are also included in this category if they are not on the facility’s payroll.

Adult students/trainees and volunteers: This includes medical, nursing, or other health professional students, interns, medical residents, or volunteers aged 18 or older who are affiliated with the healthcare facility, but are not directly employed by it (for example, they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact.

Other contract personnel (optional): Facilities may also report on individuals who are contract personnel. However, reporting for this category is optional at this time. Contract personnel are defined as persons providing care, treatment, or services at the facility through a contract who do not fall into any of the above-mentioned denominator categories. Slide17

Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy

in Average Risk Patients

Description:

Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report

Numerator Statement:

Patients who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report

Denominator Statement:

All patients aged 50 to 75 years of age receiving screening colonoscopy

without

biopsy or polypectomy

Slide18

Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use

Description:

Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior colonic polyp(s) in previous colonoscopy findings, who had a follow-up interval of 3 or more years since their last colonoscopy

Numerator Statement:

Patients who had an interval of 3 or more years since their last colonoscopy

Denominator Statement:

All patients aged 18 years and older receiving a surveillance colonoscopy with a history of a prior colonic polyp(s) in previous colonoscopy findings Slide19

Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery

Description:

Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery

Numerator Statement:

Patients who had improvement in visual function achieved within 90 days following cataract surgery, based on completing

both

a pre-operative and post-operative visual function instrument

Denominator Statement:

All patients aged 18 years and older who had cataract surgery and completed

both

a pre-operative and post-operative visual function instrument

VoluntarySlide20

Normothermia Description: This measure is used to assess the percentage of patients having surgical procedures under general or neuraxial anesthesia of 60 minutes or more in duration are normothermic within 15 minutes of arrival in PACU.

Numerator:

Surgery patients with a body temperature equal to or greater than 96.8 Fahrenheit/36 Celsius recorded within fifteen minutes of Arrival in PACU

Denominator:

All patients, regardless of age, undergoing surgical procedures under general or neuraxial anesthesia of greater than or equal to 60 minutes duration Slide21

Unplanned Anterior Vitrectomy Description

:

This measure is used to assess the percentage of cataract surgery patients who have an unplanned anterior vitrectomy.

Numerator:

All cataract surgery patients who had an unplanned anterior vitrectomy

Denominator:

All cataract surgery patients Slide22

Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy Description:

The measure estimates a facility-level rate of risk-standardized, all-cause, unplanned hospital visits within 7 days of an outpatient colonoscopy among Medicare Fee-for-Service (FFS) patients aged 65 years and older.

Rationale:

This measure will reduce adverse patient outcomes associated with preparation for colonoscopy, the procedure itself, and follow-up care by capturing and making more visible to providers and patients all unplanned hospital visits following the procedure. The measure score will assess quality and inform quality

improvmentSlide23

Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy

Numerator Statement:

This outcome measure does not have a traditional numerator and denominator like a core process measure (e.g., percentage of adult patients with diabetes aged 18-75 years receiving one or more hemoglobin A1c tests per year); thus, we are using this field to define the outcome. The calculation of the rate is defined below under Measure Calculation.

The outcome for this measure is all-cause, unplanned hospital visits within 7 days of an outpatient colonoscopy. The measure defines a hospital visit as any emergency department (ED) visit, observation stay, or unplanned inpatient admission.

Denominator Statement:

The target population for this measure includes low-risk colonoscopies performed in the outpatient setting for Medicare FFS patients aged 65 years and older. For implementation in the ASCQR Program, the measure will be calculated among ambulatory surgical centers (ASCs). Slide24

Recent DevelopmentsParticipation

Almost all — 96.9 percent — of Medicare-certified ASCs met the requirements and will receive full payment for the 2018 calendar year

.

The following measures

reported data all reflected better results in

2016 than the previous

year:

Patient

burn

Patient

fall

Wrong

site, side, patient procedure, implant

Hospital

all cause transfer/admission

Prophylactic

intravenous antibiotic timing

Safe

surgery checklist useSlide25

Recent Developments

Measures removed from ASC QRP in 2018:

Safe

Surgery Checklist Use

Prophylactic Intravenous Antibiotic

A

iming

ASC

Facility Volume Data on Selected ASC Surgical ProceduresSlide26

Future Measures Scheduled for the ASC QRP

Hospital Visit after Orthopedic Ambulatory Procedures

Hospital Visit After Urology Ambulatory Surgery Procedures

The measures are all-cause, unplanned hospital visits (Emergency Department, Observation Stays, Unplanned Inpatient Admission) within 7 days of a procedure in of either categorization

No data submission or reporting

from the

ASC is required

Data will be pulled by CMS from the Medicare Fee For Service Administrative Claims

during the CY 2020 (

January

1, 2020-December 31,

2020)Slide27

Possible Future Measures Presently Under Development

Surgical

Site Infection

After Breast Procedure In An Ambulatory Surgery Center (ASC)

Unplanned Hospital Visits

Within

7 Days

After

Selected

General

Surgery

Procedures In An Ambulatory

Surgical Center

(ASC)Slide28

OAS CAHPSFive measures are based on the use of the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS). They are:

ASC-15a:

OAS CAHPS – About Facilities and Staff

;

ASC-

15b:

OAS CAHPS – Communication About Procedure

;

ASC-15c

:

OAS CAHPS – Preparation for Discharge and Recovery

;

ASC-15d

:

OAS CAHPS – Overall Rating of

Facility

ASC-15e

:

OAS CAHPS – Recommendation of FacilitySlide29

OAS CAHPSStandardized administration protocols

Approved methodologies

Mail only

Two waves-

First: no later than 3 weeks after close of sample month.

Subsequently: approximately 3 weeks later to non respondents

Telephone only

Start no later than 3 weeks after close of sample month

Completed within 6 weeks

No more than 5 attempts

Mixed Mode- Mail survey with telephone follow up

Start no later than 3 weeks after close of sample month

Complete within 6 weeksSlide30

OAS CAHPS37 Questions in LengthRequired minimum of 300 completed surveys within 12 month period

If unable to obtain 300, ASC will need to survey all patients

Must use CMS approved vendor

List of approved vendors on OAS Chaps website

Voluntary implementation at present

Mandatory implementation date now uncertainSlide31

FederalAmbulatory Surgery Center

Quality Reporting Program

Florida State Consumer Health Information and Policy Advisory Council

David Shapiro, M.D.