QUALITY DATA FOCUSED REVIEW RICHARD GRZYB 1 Abstraction The Good The Bad The Confusing 2 IT ALL RESTS ON THE ABSTRACTOR!! QUALITY NET, APU, VPB, HOSPITAL COMPARE ORYX MEASURES, MASSHEALTH PUBLICLY REPORTED MEASURES REIMBURSEMENT QUALITY COMMITTEE HOSPITAL STATS ABSTRACTOR 3 One Small Abstraction Error Could Result in Large Consequences!!!      “For want of a nail the shoe was lost” “For want of a shoe the horse was lost” “For want of a horse the rider was lost” “For want of a rider the battle was lost” “For want of the battle the kingdom was lost” 4 Sample VBP Worksheet 5 HOW ONE FAILURE CAN AFFECT THE BOTTOM LINE Scip abx Within 1 Hour of Incision Num Den Achievement Points Improvement Points TOTAL POINTS TOTAL PERFORMANCE SCORE (adding Process, HCAHPS, Outcomes scores) 96 96 10 9 10 44.02 95 96 5 2 5 41.77 6 PLAY BY THE RULES!  Follow the Specifications Manual Rules  Do Not ASSUME Anything  Don’t be Swayed by a Clinician Stating that “It is Assumed”….  Validators Do Not Make any Assumptions 7 THE RULES CAN CHANGE  Understand the rules  Check yearly updates to see if abstracting rules have changes!!!!!  The Strange Case of Avascular Necrosis  For years it was a Pre-Op Infection  Now it is not!  NEVER ASSUME 8 QUEST IT  WHEN IN DOUBT QUEST IT –  KEEP THE QUESTION SIMPLE! FRAME IT SO THAT THEY UNDERSTAND  KEEP A LOG OF ALL ANSWERS  KEEP NOTES ON YOUR ABSTRACTION FORMS  DISCUSS WITH OTHER ABSTRACTORS 9 FREQUENTLY ASKED ABSTRACTION QUESTIONS OCTOBER 2013 Infection Prior to Anesthesia Discharge Instructions Reason for No VTE Prophylaxis - Hospital Pneumonia Diagnosis: ED/Direct Admit VTE Prophylaxis Comfort Measures Only Initial ECG Interpretation Reasons to Extend Antibiotics Antibiotic Administration Reason for No VTE Prophylaxis VTE Confirmed Reason for Discontinuation of Parental Last Known Well Date/Time Decision to Admit Date/Time General Abstraction Guidelines Continuing Urinary Catheterization Beta-Blocker Current Pregnancy Peri-op Another Source of Infection VTE Present at Admission Healthcare Associated PN Pneumococcal Vaccination (PPV23) Status Influenza Vaccination Status Reason For No Beta-Blocker Perioperative Chest X-Ray Reason for No ACEI/ARB at Discharge Admission Date Education Addresses All ICU Admission or Transfer LVSD VTE Diagnostic Test Catheter Removed Overlap Therapy 312 275 247 241 228 222 213 181 173 168 164 136 132 124 98 90 80 78 78 77 74 69 68 67 62 61 61 61 61 61 59 5 10 Outpatient Abstraction Updates and Common Errors From CDAC and CMS Educational Reviews 11 Hospital Outpatient Quality Reporting Program Educational Reviews Pain Management Review entire ED record for documentation of pain meds received prior to arrival Age 17 and under are eligible to get either Oral Parenteral (IM,IV, etc) if it is the first administration of pain med 12 Hospital Outpatient Quality Reporting Program Educational Reviews Stroke Last known well- need specific date and time Can use time range if it documented as specific number of hours 13 Hospital Outpatient Quality Reporting Program Educational Reviews Surgery All antibiotic elements must be collected from a single source Clinical trial – must be relevant to measure abstracted to answer yes 14 Hospital Outpatient Quality Reporting Program Educational Reviews Chest Pain Cardiac vs. atypical chest pain An exclusion overrides an inclusion 15 Hospital Outpatient Quality Reporting Program Educational Reviews Acute Myocardial Infarction Follow the rules for determining STEMI Take your time, find the first EKG, review line by line. 16 Hospital Outpatient Quality Reporting Program Educational Reviews Provider time needs to be clearly documented May have to change ED form to comply 17 2014 UPDATES/CHANGES OUTPATIENT         Pain-Intranasal is Now Allowed(age 2-17) Suspended OP 19-ED Transition Record Suspended OP 24-Cardiac Rehab OP 27-Flu Vaccines OP 29-Colonoscopy Follow Up OP 30-Colonoscopy with Polyps OP 31-Cataract-Improvement in Vision OP 16-Troponin Removed 18 2014 UPDATES/CHANGES INPATIENT CMS ELIMINATING MEASURES HOWEVER, THE JOINT COMMISSION IS KEEPING MOST MEASURES AS THEY ARE REFERRED TO NOW AS, ACCOUNTABILITY MEASURES 19 2014 UPDATES/CHANGES INPATIENT ~ RETIRED MEASURES ~ HF-1 DISCHARGE INSTRUCTIONS ~ PN-3b- BLOOD CULTURES IN THE ED ~ SCIP- 10 PERIOP TEMP MANAGEMENT ~ IMM-1 – PNEUMOCOCCAL IMMUNIZATION (ON HOLD) 20 2014 UPDATES/CHANGES INPATIENT PNA- Compromised and HCAP Merging into New Data Element: Reason for Alternative Empiric Antibiotic Therapy Based on 2 concepts: 1. Patient has condition that could cause an impaired immune system 2. Patient has condition that justifies an alternative antibiotic regimen 21 2014 UPDATES/CHANGES INPATIENT SCIP 4- Blood Sugar Post-Op for Cardiac Surgery - New Timeframe: 18-24 Hours - Glucose level now less than 180 22 2014 UPDATES/CHANGES INPATIENT SCIP VTE- Aspirin added for Elective Ortho -Total Hip -Total Knee -Fractured Hip Surgery 23 2014 UPDATES/CHANGES INPATIENT  ED- Observation Strata Folded into Reporting Measure  VTE- Oral Factor Xa is a reason for: 1. No VTE Prophylaxis 2. No Overlap Therapy 3. Discontinuation of Parenteral Therapy 24 ABSTRACTION ISSUES  MI- Follow Step by Step to Determine if the First EKG Shows a STEMI  CMO  PNA  Look at Final Diagnosis  If MD just Re-stating X-ray Report that Patient has PNA this would NOT count as PNA in the ED 25 TAKE HOME POINTS  Core Measures Abstraction is Important  “In God we Trust”- for the Rest Quest!  View and Listen to all the Webinars/Updates and Make Notations on Abstraction Forms 26 QUESTIONS 27