Core Measures National Hospital Quality Measures Karen Allen, RHIT September 26, 2009

1. Core MeasuresNational Hospital Quality MeasuresKaren Allen, RHITSeptember 26, 2009

2. Core Measures Background • July 2002, JCAHO, along with CMS (Centers for Medicare and Medicaid Services) implemented a requirement that accredited hospitals collect and report data on standardized performance measures, called Core Measures.

3. These measures were a result of The National Voluntary Hospital Reporting Initiative, which was a joint effort led by the AHA, the Federation of American Hospitals, and the Association of American Medical Colleges to: • Provide useful and valid data about hospital quality to the public • Provide hospitals a sense of predictability about public reporting • To standardize data and data collection mechanisms • To foster hospital quality improvement • These measures were to be collected on inpatient records only, and for a defined population which was determined by algorithms specific to each measure.

4. There were only three initial measures to start, and had a total of 10 data elements to report. They were AMI (Acute MI), HF (Heart Failure) and Pregnancy and Related conditions (PR) • Since then the measures have continued to expand and now include PNA (Pneumonia), SCIP (Surgical Care Improvement Project), VTE (Venous Thromboembolism) and CAC (Children’s Asthma Care).

5. In addition, the Joint Commission (only) has adopted a new set of measures that will be available for hospitals to select and abstract beginning with fourth quarter 2009 discharges with regard to Stroke. These 8 measures have already been endorsed by the National Quality Forum (NQF) but are an optional measure set recommended for hospitals that have a dedicated Stroke Center.

6. Hospitals may choose their core measure sets from those currently available. No specific measure sets are currently mandated by the Joint Commission for data collection in 2009. Participation is “voluntary” and hospitals are not required to participate. However, those who choose NOT to participate will receive a reduction of 2.0 percent in their Medicare Annual Payment Update for the fiscal year. To qualify for full market basket payment, hospitals must submit complete data for each (CMS) required quality measure by the posted submission deadlines. (Inpatient and Outpatient) Core Measure Reporting

7. Each measure’s specific data can be collected either retrospectively or concurrently. Data is then submitted to JCAHO and CMS and used for quality improvement and public reporting. Core Measure Reporting

8. Data is submitted to CMS/JCAHO on a quarterly basis Validated by CDAC, CMS’s re-abstraction center. Validation must be passed by at least 75% accuracy or information publicly posted will have a “not validated” notation by it. Facilities may correct abstraction errors and resubmit to CMS. Data is then publicly reported on CMS website: Hospital Compare. Core Measure Reporting

9. Selection and Abstraction of Measure Population • Case selection and abstraction is typically done through a CMS approved vendor (whether its CMS’s CART tool or another outside vendor) • Hospital downloads heir UB data to the vendor • Cases are selected based on each indicator’s specific algorithm

10. Selection and Abstraction of Measure Population • Selection begins with principle diagnosis and/or procedure depending on the measure • From there, each measure set has it’s own specific set of criteria which will either include or exclude a case from that particular indicator • Selection continues based on whether a particular case meets that specific criteria

11. Selection and Abstraction of Measure Population Common “excludes” for each measure are: • Patients less than 18 years of age(unless the measure is specific to children as in Childhood Asthma Care) • Patients received in transfer from an acute care facility where they were an inpatient or outpatient • Patients with comfort measures only documented by a physician/advanced practice nurse/physician assistant (physician/APN/PA)

12. Selection and Abstraction of Measure Population • Once a case has satisfied all the “includes” criteria for a measure, it is populated into the vendor’s abstraction tool • This process is carried out on all patient’s submitted by the hospital until all cases are selected, downloaded and ready to be abstracted

13. Current Reportable Measures • Each year CMS and JCAHO may choose to revise these measures by the addition or retirement of certain measure elements. The current individual measures and their indicators are as follows: (Version 3.0 effective with 10/1/09 discharges)

14. Acute MI (AMI) • AMI-1 Aspirin at arrival • AMI-2 Aspirin at discharge • AMI-3 ACE or ARB for LVSD • AMI-4 Adult smoking cessation advice/counseling • AMI-5 Beta blocker at discharge • AMI-7 Median time to fibrinolysis • AMI-7a Fibrinolytic therapy received within 30 minutes of hospital arrival • AMI-8 Median time to primary PCI • AMI-8a Primary PCI received within 90 minutes of hospital arrival • AMI-9 Inpatient mortality • AMI-T1a LDL Cholesterol Assessment (optional) • AMI-T2 Lipid lowering therapy at discharge (optional)

15. Heart Failure (HF) • HF-1 Discharge instructions for Congestive Heart Failure • HF-2 Evaluation of Left Ventricular Systolic Function • HF-3 ACE or ARB for Left Ventricular Systolic Dysfunction • HF-4 Adult smoking cessation advice/counseling

16. Pneumonia (PNE) • PN-2 Pneumococcal vaccination status • PN-3a Blood cultures performed within 24 hours prior to OR 24 hours after hospital arrival for patients who were transferred or admitted to the ICU within 24 hour of hospital arrival • PN-3b Blood cultures performed in the Emergency Department prior to initial antibiotic received in hospital • PN-4 Adult smoking cessation advice/counseling • PN-5 Antibiotic timing (median)

17. Pneumonia (PNE) • PN-5c Initial antibiotic received within 6 hours of hospital arrival • PN-6 Initial Antibiotic Selection for CAP in Immunocompetent Patient • PN-6a Initial Antibiotic Selection for CAP in Immunocompetent – ICU Patient • PN-6b Initial Antibiotic Selection for CAP in Immunocompetent – Non-ICU Patient • PN-7 Influenza vaccination (reported in flu season only)

18. Surgical Care Improvement Project (SCIP) Data Elements This measure focuses on 7 specific surgical procedures: • CABG • Other Cardiac Surgery • Hip Arthroplasty • Knee Arthroplasty • Colon Surgery • Hysterectomy • Vascular Surgery

19. Surgical Care Improvement Project (SCIP) Data Elements SCIP-Inf-1 through 10 are required for all selected except where specific surgery is designated as in SCIP-Inf-4. SCIP-Inf-1 Prophylactic antibiotic received within 1 hour prior to surgical incision SCIP-Inf-2 Prophylactic antibiotic selection for surgery patients SCIP-Inf-3 Prophylactic antibiotic discontinued within 24 hours after surgery end time SCIP-Inf-4 Cardiac surgery patients with controlled 6 a.m. postoperative blood glucose *Some indicators have been "retired" accounting for missing indicator numbers

20. Surgical Care Improvement Project (SCIP) Data Elements SCIP-Inf-6 Surgery patients with appropriate hair removal SCIP-Inf-9 Urinary catheter removal on postoperative day 1 (POD 1) or postoperative day 2 (POD 2) with day of surgery being day zero SCIP-Inf10 Surgery patients with perioperative temperature management

21. Surgical Care Improvement Project (SCIP) Data Elements The following indicators are specific to the surgery referred to: SCIP-Card-2 Surgery patients on Beta Blocker therapy prior to arrival who received a Beta Blocker during the perioperative period SCIP-VTE-1 Surgery patients with recommended venous thromboembolism prophylaxis ordered SCIP-VTE-2 Surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery

22. Pregnancy and Related Conditions There are only 3 data elements for this measure. All 3 elements can be electronically populated from UB data. No manual abstraction is needed • PR-1 Vaginal birth after a C-section • PR-2 Inpatient neonatal mortality • PR-3 Vaginal delivery with a 3rd or 4th degree lacerationPR-1 Vaginal birth after a C-section

23. Specific to a Population The following 3 measures are either for a specific population and are not the most common ones chosen for abstraction: - Childhood Asthma Care - Venous Thromboembolism Data Elements (Optional) - Stroke (Optional) This is a new measure available for selection beginning with 10/1/2009 discharges and is recommended for facilities with a dedicated stroke center

24. Outpatient Quality Measures The Outpatient Prospective Payment System (OPPS) final rule was released November 1, 2007, and outlined the initial implementation of the Hospital Outpatient Quality Data Reporting Program (HOP QDRP). Under this program, hospitals also report data for services on the quality of hospital outpatient care using standardized measures of care to receive the full annual update to their OPPS payment rate, effective for payments beginning in calendar year (CY) 2009. This outpatient program is modeled on the current quality data reporting program for inpatient services.

25. Outpatient Quality Measures • There are a total of 11 quality of care measures for hospitals participating in the Hospital Outpatient Quality Data Reporting Program (HOP QDRP) • The quality of care measures include 7 clinical performance measures and four Medicare fee-for-service claims-based measures • As with the Inpatient measures, hospitals must submit complete data for each (CMS) required quality measure by the posted submission deadlines in order to qualify for full market basket payment

26. Outpatient Quality Measures OP-1 Median Time to Fibrinolysis OP-2 Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival OP-3 Median Time to Transfer to Another Facility for Acute Coronary Intervention OP-4 Aspirin at Arrival OP-5 Median Time to ECG

27. Outpatient Quality Measures OP-6 Prophylactic Antibiotic Initiated Within One Hour Prior to Surgical Incision OP-7 Prophylactic Antibiotic Selection for Surgical Patients OP-8 MRI Lumbar Spine for Low Back Pain OP-9 Mammography Follow-up Rates OP-10 Abdomen CT Use of Contrast Material OP-11 Thorax CT Use of Contrast Material

28. Data Abstraction Options Core Measures data elements can be abstracted retroactively or concurrently Because cases are selected based on principle diagnosis as well as procedure performed, the safest way to abstract is retrospectively from UB data. Once coded and billed, the principle diagnosis will not change.

29. Data Abstraction Options However, some facilities have begun to collect quality data indicators concurrently to impact quality of care provided This can be a problem because discrepancy may occur between concurrent reviewer’s choice of diagnosis and coders final choice of principal diagnosis, which can affect over picture of quality of care

30. Conclusion Whichever way you choose to collect, abstract and submit your data, it is reported publicly. People, organizations, insurance companies and anyone who wants it—it’s out there for everyone to see. Core Measures is here to stay. It is only going to expand and have more impact. It is important to work together to collect, report and improve your data where you can. Your facilities future may depend on it!