1. NEW STUDY LAUNCH WEBINAR FEBRUARY 28, 2013 PIN Clinical Improvement Studies

2. Feedback from the Field Minimize data collection and reporting burden Avoid duplication Collaborate with other data collection projects Consistent data definitions with national projects Consistent report formats between projects when possible

3. Overlap/Alignment/Similarities = COLLABORATION

5. The PIN “OP 4,5” Study Data collected using the CMS CART tool  No new tool for the PIN project Data definitions consistent with those in CART tool One data submission works toward 3 initiatives:  Regulatory compliance; MBQIP; CMS-OQR Consistent reporting: we’re working on that…..

6. What is “OP 4,5” ?! OP = outpatient measures  Included in the MBQIP Phase 2 measure set  Originally defined as part of the CMS Outpatient Quality Reporting (OQR) project some years ago OP 4 and OP 5 = numbers CMS has assigned to specific measures within their OQR project  there are several other measures in their set Study name reflects that this PIN project will focus on two of the OQR- OP measures: number 4 and number 5

7. Clinical Improvement Studies Format Announcement and trainingtoday Baseline data collectionMarch 29 Reports back to facilitiesApril - May Support Facility PI CyclesApril - Sept Re-measure performanceOct 2013 Reports back to facilitiesNov 2013 In General For this study

8. Clinical Improvement Studies Format Announcement and trainingtoday Baseline data collectionMarch 29 Reports back to facilitiesApril - May Support Facility PI CyclesApril - Sept Re-measure performanceOctober Reports back to facilitiesNov - Dec In General For this study

9. OP 4,5 Measure Definitions OP 4Aspirin On Arrival Numerator: Emergency Department AMI or Chest Pain patients (with Probable Cardiac Chest Pain) who received aspirin within 24 hours before ED arrival or prior to transfer. Denominator: Emergency Department AMI or Chest Pain patients (with Probable Cardiac Chest Pain). Source: http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FSpecsMa nualTemplate&cid=1228772438492 http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FSpecsMa nualTemplate&cid=1228772438492

10. OP 4,5 Measure Definitions OP 5Median Time to EKG Description: Median time from ED arrival to ECG (performed in the ED prior to transfer) for acute myocardial infarction (AMI) or Chest Pain patients (with Probable Cardiac Chest Pain). Source: http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FSpecsMa nualTemplate&cid=1228772438492 http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FSpecsMa nualTemplate&cid=1228772438492

11. Baseline Data Collection: Due Mar 29 Emergency Room Cases only AMI population Chest Pain, Probably Cardiac Chest Pain, population Cases between Jan 1, 2012 and Sept 30, 2012 No more than 30 cases Tool: OQR - CART tool

12. Re-measurement Data Collection Emergency Room Cases only AMI population Chest Pain, Probably Cardiac Chest Pain, population Cases between April 1, 2013 and Sept 30, 2013 No more than 30 cases Tool: OQR - CART tool

13. Performance Improvement Support Time to ECG Aspirin administration Thrombolytics administration DPHHS Cardiac Program resources PIN AMI Tool Kit Coding and/or Abstraction Accuracy needs

14. Using CART to Enter Data for the OP 4 and OP 5 Shanelle, you are up! CART Demonstration!

15. Questions? Kathy Wilcox Rural Hospital Quality Coordinator MHA/MHREF kathy@mtha.orgkathy@mtha.org; 406.461.6186 Shanelle VanDyke Quality Improvement & Reporting Project Manager Mountain-Pacific Quality Health svandyke@mtqio.sdps.org; 406.457.5896svandyke@mtqio.sdps.org