HOP QDRP Measure Compliance: Issues, Barriers, and Interventions

HOP QDRP
Measure Compliance:
Issues, Barriers, and
Interventions
October 21, 2009
Mark S. Michelman, MD, MBA
Clinical Director
FMQAI
1
Objectives
• Discuss barriers to physician documentation
noncompliance.
• Identify antibiotic selection barriers.
• Provide rational for appropriate surgical antibiotic
selection.
• Discuss methods to approach noncompliant physicians
and corrective actions if necessary.
• Identify interventions for effective quality improvement
actions.
• Address documentation noncompliance risk to
hospitals.
2
Keys to Physician Acceptance of
HOP Indicators
• Credible, compelling, evidence based
literature
• Presented by a credible
credible, respected
physician (preferably in their specialty)
• Explain that their peers endorse the
indicators
3
1
Reasons to Support and Expect
Physician Compliance
•
•
•
•
•
•
•
Right thing to do
Quality issue
Financial issue (P4P)
Liability issue
Public reporting issue
Potential impact on pt referrals
Need to hold physician accountable (only if
hospital has process in place)
4
Hospital Process in Place to Educate
Physicians
• EBM education to medical staff
• Process to help physicians with indicators
• Concurrent review to catch missed
indicators (early, late)
• Retrospective review (educational)
• Physician feedback comparative profiles
5
OP-1
Hospital Outpatient AMI
• Median time from emergency department
arrival to administration of fibrinolytic
therapy in ED patients with ST-segment
ST segment
elevation or left bundle branch block
(LBBB) on the electrocardiogram (ECG)
performed closest to ED arrival and prior
to transfer.
6
2
OP-2
Hospital Outpatient AMI
• Emergency department acute myocardial
infarction (AMI) patients receiving
fib i l ti th
fibrinolytic
therapy d
during
i tthe
h ED stay
t
and having a time from ED arrival to
fibrinolysis of 30 minutes or less.
7
OP-3
Hospital Outpatient AMI
• Median time from emergency department
arrival to time of transfer to another
facility for acute coronary intervention
8
AMI Barriers
OP-1: Median Time to Fibrinolysis (min)
OP-2: Fibrinolysis w/in 30 Min. (%)
OP-3: Median Time to Transfer (min)
•
•
•
•
•
•
•
Time to triage
Time to Dx
Time to reach cardiologist
Pending transfer for PCI
ED told not to give fibrinolytic
We transfer all cardiac pts
ED physician unable to initiate w/o cardiology
input
9
3
OP-4
Hospital Outpatient AMI
& Chest Pain
• Emergency Department acute myocardial
infarction (AMI) patients or chest pain
patients (with Probable Cardiac Chest
Pain) who received aspirin within 24
hours before ED arrival or prior to
transfer.
10
OP-4 ASA at Arrival (%) Barriers
• Hx of ulcer/gastritis years ago
• Patient on warfarin for valve, DVT/PE or
hypercoaguable state
• NPO
• Renal impairment
11
OP-4 Barriers (cont)
• Physicians don’t document the following:




Transferred for acute coronary intervention
Recent GI bleed
Hold fibrinolytic (no reason given)
Chest pain noncardiac
12
4
OP-5
Hospital Outpatient AMI
& Chest Pain
• Median time from emergency department
arrival to ECG (performed in the ED prior
to transfer) for acute myocardial
infarction (AMI) or Chest Pain patients
(with Probable Cardiac Chest Pain).
13
OP-5 Median Time to ECG (min)
Barriers
•
•
•
•
Time to triage
No fast track
Time to Dx
No ECG/tech in ED
14
HOP AMI Issues
•
•
ASA – Not given and no
documentation that pt had recent bleed
Fibrinolytic Rx
1 H
1.
Held,
ld no reason given
i
2. Held due to transfer for PCI
3. ED physician must document, sign
EKG referenced
15
5
AMI ED Interventions
•
•
•
•
•
Physician education
Fast track
Pre-printed order sets (pros and cons)
Timed chest pain ED protocol
Pre printed d/c template (progress note or
d/c summary)
• ED physician initiates thrombolysis
16
% in-patien
nt m ortality
Adherence to ACC/AHA
Guidelines and Mortality
20
15
10
5
0
30-50%
50-60%
60-70%
>70%
Peterson E, ACC 2002
17
Advantages to Standing
Preprinted Orders
•
•
•
•
Evidenced based guidelines
Prevents missed indicators
Protects patient, physician, hospital
Easier to defend case legally if bad
outcome
18
6
SCIP
19
SIP/SCIP National Expert Panel
•American Academy of Orthopedic
Surgeons
•American Association of Critical
Care Nurses
•American College of Obstetricians
& Gynecologists
•American College of Surgeons
•American Geriatrics Societyy
•American Hospital Association
•American Society of
Anesthesiologists
•American Society of Colon and
Rectal Surgeons
•American Society of Health System
Pharmacists
•APIC
•Ascension Health
•Association of PeriOperative
Registered Nurses
•HICPAC
•IDSA
•JCAHO
•Premier, Inc.
•Sanford Guide
•Society for Healthcare
Epidemiology of America
•Society of Thoracic Surgeons
•Surgical Infection Society
•The Medical Letter
•VHA, Inc.
20
OP-6
Hospital Outpatient Surgery
g
Antibiotic Timing
21
7
OP-6 ABX w/in 60 Min. to Incision
(%) Barriers
•
•
•
•
My pts don’t get infections
Never given on time when I order ABX
Hospital process ineffective
No staff to catch noncompliance
22
Surgical-Wound Infection Rates
by Antibiotic Administration Time
P < 0.05
5
Incision
Infecttion Rate (%)
6
4
3
2
1
0
>2
2
1
1
2
3
4
5
6
7
8
9
10 >10
Hourly Intervals
Classen DC, et al. NEJM. 1992 Jan 30;326(5):281-6.
23
Weight-Based Dose
Adjustment
• In a study of obese patients undergoing
gastroplasty, blood and tissue levels of Cefazolin
were consistently below the MIC for grampositive and gram
gram-negative
negative organisms in
patients who received the standard one-gram
dose preoperatively.
Forse RA. Surgery. 1989;106:750-756.
24
8
Weight-Based Dose
Adjustment (cont)
• Those patients receiving a two-gram dose
of Cefazolin had a lower incidence of
wound infection than those receiving a
one-gram
one
-gram dose
dose.
nd
• 2 Dose ABX: Procedure > 4 hours or
excess bleeding.
Forse RA. Surgery. 1989;106:750-756
25
OP-7
Hospital Outpatient Surgery
Antibiotic Selection
26
Appropriate Antibiotic Selection
• American Society of
Health System
Pharmacists
• Infectious Diseases
S i t off A
Society
America
i
• Peer reviewed journals
• Sanford Guide to
Antimicrobial Therapy
• Society of Thoracic
Surgeons
27
• Surgical Infection
Society
• The Hospital Infection
Control Practices
Ad i
Advisory
C
Committee
itt
• The Johns Hopkins
Guide
• The Medical Letter
27
9
Clindamycin for Surgical Prophylaxis
Recommended Alternative in Severe PCN
Allergy
Advantages
• Spectrum of activity
 Staph aureus
 Streptococcus species
 Anaerobes
A
b
• Infusion: 10-20 minutes
• Excellent tissue penetration
• No infusion related reactions
• Dose: 600mg IV X 1
28
Vancomycin for Surgical Prophylaxis
Used Most Commonly in PCN Allergic
Patients
Disadvantages
• Long infusion to prevent “red man syndrome”
 Infusion rate: 15 mg
g/min = 1-2 hour infusion
• Large volume to prevent phlebitis
 Concentration: 5 mg/ml
• Weight-based dosing
 Obese patients given a “standard” 1 gm dose →
sub-therapeutic tissue levels
29
Antibiotics and Antibiotic
Combinations Not Recommended
Doxycylcine (Vibramycin)
Not a SIP approved agent
Decreased Strep A/B activity
Metronidaozle (Flagyl)
Anaerobic activity only
Ampicillin
Does not cover Staph aureus
Ampicillin + Gentamicin
IE prophylaxis no longer recommended
Clindamycin + Vancomycin Inappropriate combination
Piperacillin/tazobactam
(Zosyn)
Not a SIP approved agent
Broad coverage not necessary
Overuse → resistance
Tobramycin
Reserve for Pseudomonas
Ceftriaxone (Rocephin)
Not a SIP approved agent
FDA Warning: Do not infuse with IV calcium
30
10
Fluoroquinolone Use Issues
1.
2.
3.
4.
Increased MRSA
Increased resistance
No advantage over EBM drugs
Not best choice to cover Staph (common
SSI)
5. Increased C. Difficile (St. Jude data—
50% patients with C.D had received
Levaquin)
31
OP-7
Antibiotic Selection (%) Barriers
•
•
•
•
Ampicillin, Zosyn just fine, thank you
Remember, my pts don’t get infections
Don’tt tell me how to practice medicine
Don
What is wrong with using ABX “X”
 FDA approved
 Endorsed by manufacture
32
OP-6,-7 Additional Barriers to
Compliance
• No facility mechanism to identify
noncompliant physician
• No physician
y
feedback on indicator
performance
• No process to address noncompliant
physician
• No penalty for noncompliance
33
11
HOP Issues SCIP
1.
2.
3.
4
4.
5.
6.
Prostate bx - no documentation of ABX
Anesthesia charts ABX - no time, no route
Vanco ordered - no rationale
ABX not given - no reason
Infection prior to procedure - not docum.
Physician preference inadequate for
inappropriate ABX
34
HOP Issues SCIP (cont)
• Our hospital bills for the prostate
BXs
• They
Th d
don’t
’ check
h k ffor ABX
administration
• Surgeon didn’t feel ABX necessary
35
Successful Interventions OP-6, -7
• Preprinted order sets (recommended ABX
by procedure)
• Pharmacy
y drives process
p
• OR stocks only approved ABX
• Unapproved ABX not released by
pharmacy
• Delegated individual to give ABX
36
12
SSIs
}
• Superficial incisional
• Deep incisional
2/3
}
• Organ/space
O
/
1/3
37
Impact of SSIs
•
•
•
•
•
Mortality
ICU Adm
LOS
Cost
Re-admission
Infected
7.8%
29%
11d
$57k
41%
Uninfected
3.5%
18%
6d
$4k
7%
38
SCIP-INF-6: Preoperative Hair
Removal
Method of Hair Removal
SSI Rate
Razor
9.3%
Clipper
4.6%
Timing of Hair Removal
Clipper Night Before Surgery
6.9%
Clipper Morning of Surgery
2.2%
Alexander Arch Surg. 1983; 118:347-352
39
13
Effective Action Steps to Improve
Compliance with Core Measures
• Frequent educational updates to medical
staff & perioperative teams (CME, CEU)
• Preprinted
P
i t d standing
t di orders
d
• Team meetings
 Convenient for physicians
 Right people must be present
40
Effective Action Steps (cont)
• Concurrent review with appropriate
feedback
• Senior management (c-suite) support
• Chief
Chi f off S
Surgery & OR Di
Director
t supportt
• Process for noncompliance
41
Effective Action Steps (cont)
• Physician Champions Issues
 Credible
 Knowledgeable
 Buy-in
 Education
 Counsel
 Can influence behavior
 Peer review\ListServe (SCIP, local)
• E-mails hospitals/QIOs
• Conference calls
42
14
Dealing with Noncompliant
Physicians
• Carrot vs. stick
• Education
• Physician profile (bubble
graph)
• Counseling
 Chief of Service, Chief of
Staff
 Physician Advisor
 VPMA/CMO
• Letter to support action
(evidence based)
• Meet with MEC
• Peer review
• Credentialing
• Track and trend
• Corrective action
43
MEC Action
•
•
•
•
Additional counseling
Letter of reprimand
Mandate CME (ineffective)
Mandate second opinion (mandatory
consult for ABX, DVT/PE prophylaxis)
44
Dealing with Noncompliant
Physicians
• Change surgical block time
• Possible corrective action (possible
suspension)
• Impact reappointment
45
15
Risk for Hospital
(Allowing Physicians to Be Noncompliant with
Quality Indicators)
• Poor outcome data
• Public reporting implications (state, CMS,
national,, ? impact
p
referral pattern)
p
)
• Financial implications (P4P)
• Legal implications
 Physician was noncompliant
 Hospital noncompliant (no oversight)
46
Expectations of the
Medical Staff
• Keeping up-to-date with
healthcare advances.
• Practice evidence based
medicine.
• Provide the best care
possible.
• Practice the most efficient
care possible.
• Be supportive of your facility.
• Remember, you drive the
process of health care in
yyour system.
y
• You are accountable for the
health care at
your facility.
47
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injured, contact an attorney today. Just fill out
Injuryboard.com’s on-line questionnaire and
have an attorney evaluate your case within two
business days free of charge.”
ForThePeople.com
(Morgan & Morgan)
48
16
Hospital Acquired Conditions
(Oct. 2008)
1. Foreign object retained after surgery
2. Air embolism
3. Blood incompatibility
NOTE: ABOVE ARE “NEVER EVENTS”
4. Pressure ulcers stage lll and lV
5. Falls and trauma (Fx, dislocations, intracranial injuries,
crushing injuries, burns, electric shock)
49
HAC (cont)
*6. Manifestations of poor glycemic control (ketoacidosis,
nonketotic hyperosmolar coma, hypoglycemic coma,
secondary diabetes with ketoacidosis, secondary
diabetes with hyperosmolarity) (Forget to order insulin,
monitor BS)
*7. Catheter associated UTI
*8. Vascular catheter-associated infection
50
HAC (cont)
*9. Surgical site infection following:
•
•
•
•
•
•
CABG—mediastinitis
Bariatric surgery
Laparoscopic gastric bypass
Gastroenterostomy
L
Laparoscopic
i gastric
t i restrictive
t i ti surgery
Orthopedic procedures

spine, neck, shoulder, elbow
*10. DVT/PE
•
Total knee, hip replacement
51
17
Questions ?
Thank You
Improvement Never Ends…
52
Mark S. Michelman, MD, MBA
Clinical Director
FMQAI
Ph
Phone:
813
813-865-3540
865 3540
[email protected]
53
Sources
Slide Nos. 6,7,8,10 and 13 were
reproduced from the Specifications
Manual for Hospital Outpatient
Department Quality Measures,
Measures version
2.1b.
Please Note: The Specifications Manual for Hospital Outpatient Department Quality Measures is periodically updated by the Centers for Medicare & Medicaid
Services (CMS). Users of the Specifications Manual for Hospital Outpatient Department Quality Measures must update their software and associated
documentation based on the published manual production timelines.
This material was prepared by FMQAI, the Support Center for the Hospital Outpatient Quality Data Reporting Program (HOP QDRP), under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). The contents presented do not necessarily reflect CMS
policy. FL2009SS1T111511462
54
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