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
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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.