Medicare Beneficiary Quality Improvement Project (MBQIP ) ED Transfer Communication

1. Medicare Beneficiary Quality Improvement Project (MBQIP)ED Transfer Communication Abstraction Training July 2014

2. Background The Office of Rural Health Policy (ORHP) created the Medicare Beneficiary Quality Improvement Project (MBQIP) as a Flex Grant Program activity within the core area of quality improvement. • The primary goal of this project is for CAHs to implement quality improvement initiatives to improve their patient care and operations. • MBQIP provides Flex funding to support Critical Access Hospitals (CAH) with technical assistance and national benchmarks to improve health care outcomes. • CAHs opting to participate are requested to report a specific set of annual measures determined by ORHP timeline and measures and engage in quality improvement projects to benefit patient care.

3. Accountable Care This initiative takes a proactive and visionary approach to ensure CAHs are well-equipped and prepared to meet future quality legislation. • Additionally, MBQIP fulfills the Flex grant Quality Improvement (QI) objectives regarding Hospital Compare reporting, and supporting participation in various multi-hospital QI initiatives. • The main emphasis of this project is putting patients first by focusing on improving health care services, processes and administration.

4. MBQIP Goal: To implement informed quality improvement projects to improve patient care and CAH;s through data collection, leadership and support “We improve what we measure”

5. Seamless Care: Safe patient transitions between facilities Ensuring appropriate and timely care beyond organizational silos is essential to transforming health care.

6. Avoiding transition of care errors • Information silos and poor communication between settings • Confusion about care management; coordination across settings • Medications Errors can occur during times of transition: upon admission, transfer, or discharge of a patient.

7. Avoiding transition of care errors Communication means more than person to person, although this is of course an enormously important. Communication also means access by all the players to mission critical clinical information. In our highly fragmented or “siloed” healthcare delivery system, this is most often the greatest barrier to effective transitions of care.

8. ED Transfer Communication Measures: – Administrative communication – Patient information – Vital signs – Medication information – Physician information – Nurse information – Procedures and tests

9. Resources

10. Population and sampling

11. Population and sampling

12. Abstraction tool

13. EDTC-1: (NQF # 291) Administrative Communication Does the medical record (MR) documentation indicate that administrative information was communicated to the receiving facility PRIOR TO departure? • Numerator: # of patients who have a yes or NA for both measures: nurse to nurse communication and physician to physician communication • Denominator: # All transfers from ED to another health care facility

14. Abstraction tool

15. EDTC-2 (NQF#294) Patient Information Does the medical record (MR) documentation indicate that the patient information was communicated to the receiving facility within 60 min of departure? • Numerator: # of patients who have a yes or NA for all measures: name, address, age, gender, contact, insurance • Denominator: # All transfers from ED to another healthcare facility

16. Abstraction tool

17. EDTC-3 (NQF #292) Vital Signs Does the medical record (MR) documentation indicate that the ENTIRE vital signs record was communicated to the receiving facility within 60 min of departure? • Numerator: # of patients who have a yes or NA for all measures: pulse, respiration, blood pressure, oxygen saturation, temperature and neurological assessment • Denominator: All transfers from ED to another healthcare facility

18. Abstraction tool

19. EDTC- 4 (NQF# 293) Medication Information Does the medical record (MR) documentation indicate that medication information was communicated to the receiving facility within 60 min of departure? • Numerator: # of patients who have a yes or NA for all measures: Medications administered in ED, allergies and home medications • Denominator: All transfers from ED to another healthcare facility

20. Abstraction tool

21. EDTC- 5 (NQF # 295) Physician Information Does the medical record (MR) documentation indicate that physician information was communicated to the receiving facility within 60 min of departure? • Numerator: # of patients who have a yes for all measures: history and physical and reason for transfer and/or plan of care • Denominator: All transfers from ED to another healthcare facility

22. Abstraction tool

23. EDTC – 6 (NQF # 296)Nursing Information Does the medical record (MR) documentation indicate nursing information communicated to the receiving facility within 60 min of departure? • Numerator: # of patients who have a yes or NA for all measures: assessments/interventions/response, impairments, catheter, immobilization, respiratory support, oral limitations • Denominator: All transfers from ED to another healthcare facility

24. Abstraction tool

25. EDTC – 7 (NQF # 297)Procedures and Tests Information Does the medical record (MR) documentation indicate that procedures and tests information was communicated to the receiving facility within 60 min of departure? • Numerator: # of patients who have a yes or NA for all measures: test and procedures done and test and procedure results sent • Denominator: All transfers from ED to another healthcare facility

26. Data Submission via Novi survey

27. Questions

28. GHA Contact Information Kathy McGowan, Vice President of Quality & Safety kmcgowan@gha.org 770-249-4519 Joyce Reid, Vice President of Community Health Connections jreid@gha.org 770-249-4545 Lisa Carhuff, Quality Improvement/Patient Safety Specialist lcarhuff@gha.org 770-249-4553