1. Indiana Association for Healthcare Quality May 8, 2014 To promote and provide essential public health services

2. Patient Safety Initiative: Assessing Quality Through the Survey Process Using the Three CoP Worksheets Randy Snyder, PT, MBA Division Director, Acute Care Indiana State Department of Health

3. Objectives: Gain an understanding of the key measures used to assess quality through the use of three survey worksheets implemented within the survey process. Identify two primary goals associated with the patient safety initiative.

4. Objectives: Apply non-surveyor use of the worksheets to their respective facilities to assess quality. Identify the key differences between state licensure surveys and federal certification surveys.

5. In the Beginning….. The Administration and Congress created the Health Care and Education Reconciliation Act of 2010 AKA: Patient Protection and Affordable Care Act AKA: Affordable Care Act AKA: Obamacare

6. ACA: Section 3011 Improve research and dissemination of strategies and best practices to improve patient safety and reduce medical errors, preventable admissions and readmissions, and health care-associated infections;

7. ACA Section 3021 http://dhhs.nv.gov/HealthCare/Docs/reimbursement/ACA3021InnovationCenter.pdf CENTER FOR MEDICARE AND MEDICAID INNOVATION ESTABLISHED

8. CMS Innovation Center: The Partnership for Patients initiative is a public-private partnership working to improve the quality, safety and affordability of health care for all Americans. Physicians, nurses, hospitals, employers, patients and their advocates, and the federal and State governments have joined together to form the Partnership for Patients. http://innovation.cms.gov/initiatives/partnership-for-patients/index.html

9. PfP Primary Goals: Making Care Safer. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010. Improving Care Transitions. By the end of 2013, preventable complications during transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010.

10. Patient Safety Initiative HHS announces a $1 Billion Patient Safety Initiative

11. Survey and Certification’s Role: CMS develops and issues Hospital Patient Safety Initiative Worksheets.

12. Implementation FFY 11: Piloted by several states. FFY12: Each state used the worksheet at least one time. FFY13: All three used for selected hospitals

13. Sample Selection All-cause risk-adjusted readmission data

14. Results FFY11-12 186 Total Worksheets QAPI: 60 Infection Control: 65 Discharge Planning: 61 Hospitals cited at Standard Level Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI

15. Results FFY11-12 QAPI Individual questions:  Assessment of each contracted service: 14.5% negative  New interventions developed for those unsuccessful: 12.9% negative Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI

16. Results FFY11-12 QAPI  Data collection consistent when staff involved: 12.5% negative  Aggregate data in subsets to allow comparison: 12.5% negative Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI

17. Results FFY11-12 QAPI Tags likely to be cited:  A0273 Data Collection and Analysis.  A0286 Patient Safety, Medical Errors & Adverse Events.  A0308 Standard Tag for Condition Statement. Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI

18. Results FFY11-12 QAPI Themes: Program Data Collection and Analysis Documented Evidence of QAPI Program Executive Responsibilities Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI

19. Results FFY11-12 Infection Control Individual Questions:  Disconnecting catheter tubing: 47.4% negative  Antibiotic orders with indication for use: 42.6% [not required] Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI

20. Results FFY11-12 Infection Control  Review need for antibiotics after 72 hours: 27.7% negative [not required]  Hand Hygiene: 19.2% negative Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI

21. Results FFY11-12 Infection Control Sections with lowest results:  Systems to prevent transmission of MRDO and promote antibiotic stewardship [not required but…]  Surgical procedure tracer: 47.8% negative Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI

22. Results FFY11-12 Infection Control  Ventilator/respiratory tracer: 42.55% negative  Isolation: Contact precautions: 42.55% negative Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI

23. Results FFY11-12 Infection Control “Best Practices” commonly found: Need for central venous catheters review daily Oral hygiene for high risk patients HOB elevated for patients at high risk for aspiration Spontaneous breathing trials for vent patients Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI

24. Results FFY11-12 Discharge Planning Individual Questions:  Evaluate if readmissions were preventable: 18.9% preventable  Changed discharge planning process if cause of readmissions: 16.7% Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI

25. Results FFY11-12 Discharge Planning  Update discharge plan to reflect changes in patient condition: 13.7% negative  Following P&P: 13.3% negative Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI

26. Results FFY11-12 Discharge Planning Tags most likely cited: A0820 Initial implementation A0819 Physician request for evaluation A0906 Comprehensive evaluation A0817 Plan matches evaluation Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI

27. Results FFY11-12 Discharge Planning “Best Practices” commonly found: Scheduling follow up appointments Pharmacist review of discharge med orders Filling prescriptions DC plan for all inpatients (+66.7%) DC plan for some outpatients (+78.3%) Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI

28. Results FFY13 o Not yet released by CMS o QAPI results look similar o Infection control: MDRO, point of care devices, and hand hygiene o Discharge Planning results look similar o No citations o 159 worksheets completed Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI

29. FFY14 (Current year): Sample selection based on citation data No citations (non-punitive) Use as risk management assessment tool at exit Worksheets publically available Using revised worksheets Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI

30. FFY15: Additional revisions? (still draft) Continued data collection/analysis Required for all surveys? Additional CoPs? Contingent upon funding Update: CMS Survey & Certification Hospital Patient Safety Initiative, 2014 SETI

31. State Licensure/Federal Certification PSI worksheets are a federal requirement completed by a federally defined process and conducted by the State Agency during recertification surveys. State licensure surveys are independent of federal surveys. State Agency is the contractor for Federal surveys.

32. Helpful sites: The “Discharge Planning” Booklet (ICN 908184) Partnership for Patients http://innovation.cms.gov/initiatives/partnership-for- patients/index.html Patient Protection and Affordable Care Act http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf

33. Objectives: Gain an understanding of the key measures used to assess quality through the use of three survey worksheets implemented within the survey process. Identify two primary goals associated with the patient safety initiative.

34. Objectives: Apply non-surveyor use of the worksheets to their respective facilities to assess quality. Identify the key differences between state licensure surveys and federal certification surveys.

35. QUESTIONS

36. Thank You ! Have a great conference