Developed: December 2011Most recent update: January 2014

Kathy Wonderly Performance Improvement Coordinator

Hospital Council of Western Pennsylvania

Hospital Outpatient Quality Reporting Requirements

IntroductionThe Hospital Outpatient Quality

Reporting (OQR) program has been developed by CMS to promote high quality care for patients receiving service in hospital outpatient settings.

The information included in this program covers outpatient encounters from January 1, 2014 through September 30, 2014.

Departments Impacted by the Current OQR Measures

1.Emergency Department2. Hospital Outpatient Surgery

3. Imaging Department- MRI, Mammography,CT,

Cardiac Imaging

4.Healthcare Worker Influenza Vaccine Compliance

Measures Reporting Median Time

Some of the outpatient measures report the median time rather than the percent of compliance.

The median time is the middle number for all the patients reported for the designated time period.

Median Value Example Patients presenting with Chest Pain are

expected to have an EKG done within 10 minutes of arrival. Rather than reporting the percent of patient that meet this measure, the results posted will be the median time. In this sample it would be 9 minutes.

Median

1 4 5 5 6 8 9 10 11 13 15 16 17 Minutes from arrival to EKG

What are the outpatient measure sets?1. Acute Myocardial Infarction ( AMI)2. Chest Pain3. Emergency Department throughput4. Pain Management for long bone fracture5. Stroke 6. Surgery Infection Prevention7. Surgical safety7. Imaging Efficiency8. Healthcare influenza vaccination

Let’s look at the measures!Some of the measures sound much like the

inpatient measures for the same diagnosis

Starting with patients admitted to the ED with chest pain or an AMI we will go through them individually .

Emergency Department Measures

All patients admitted to the ED with an AMI or chest pain are required to have:

Aspirin on arrival or documentation of allergy or other contraindication.

EKG on arrival which is reported as the median time from arrival to EKG (within10 minutes of arrival is the benchmark).

Emergency Department Measures

For AMI patients the following measures apply:

1. Fibrinolytic therapy received within 30 minutes of arrival.

2. Median time for fibrinolysis

3. Median time to transfer to another acute care facility for acute coronary intervention

Emergency Department Measures

Median time from ED arrival to ED departure for discharged ED patients.

Door to diagnostic evaluation time by a qualified medical professional.

Emergency Department Measures

The percent of patients who leave the ED without being evaluated by a physician or an institutionally credentialed provider. Depending on your facility this could be a Nurse Practitioner, CRNA, Clinical Nurse Specialist or Certified Nurse Midwife.

Emergency Department Measures

Pain Management in the ED

The median time to pain management for long bone fracture is measured in this indicator. The measurement is from the time of arrival to the time the initial oral, intranasal or parenteral pain medication is administered. If the patient receives pain medication ordered by medical command prior to arrival that would count as the initial dose.

Emergency Department Measures

Head CT or MRI scan results for ED Acute Ischemic or Hemorrhagic Stroke Patients

This indicator measures the percent of patients who arrive at the ED within 2 hours of onset of stroke symptoms and have a Head CT or MRI scan performed and the interpretation is available within 45 minutes of arrival.

Outpatient Surgery Measures

Prophylactic antibiotic given no more than 60 minutes before the time of the incision. Exception: patients receiving vancomycin or a fluroquinolone infusions require a longer time therefore 2 hours prior to incision is acceptable.

Surgical patients receive the appropriate prophylactic antibiotic consistent with current guidelines for each type of surgical procedure. These are listed in the next slides.

Approved Antibiotics by Procedure Type

Cardiac Pacemaker or AICDs- Cefazolin or Cefuroxime

If B-lactam allergy: Vancomycin or Clindamycin

Orthopedic/Podiatry- Cefazolin or Cefuroxime If B-lactam allergy: Vancomycin or

Clindamycin

Approved Antibiotics for Genitourinary Procedures

Prostate biopsy Quinolone

or any Cephalosporin

( oral or intramuscular alone are acceptable)or

Sulfamethoxazole/Trimethoprimor

Aminoglycoside or

Aztreonam

Approved Antibiotics for Genitourinary Procedures

Penile prosthesis insertion, removal or revision Ampicillin/Sulbactam or Ticarcillin/Clavulanate or Pipercillin/Tazobactam

or Aminoglycoside + 1st or 2nd generation

cephalosporin or Vancomycin (with physician or pharmacist

documented justification) or Clindamycin

or Azetreonam + 1st or 2nd generation

cephalosporin or Vancomycin or Clindamycin

Approved Antibiotics for Gastric/Biliary Procedures

PEG placement Any of the following: Cefazolin, Cefuroxime,

Cefoxitin, Cefotetan, Vancomycin (with physician or pharmacist documented justification) or Ampicillin/Sulbactam

Or Cefazolin or Cefuroxime + Metronidazole

If B-lactam allergy Clindamycin +Aminoglycoside or Quinolone

Or Vancomycin + Aminoglycoside or

Quinolone

Approved Antibiotics for Gynecological Procedures

Laparoscopically- assisted hysterectomy, vaginal hysterectomy

Cefazolin, Cefuroxime, Cefoxitin or Cefotetan or Ampicillin/Sulbactam

If B-lactam allergy

Metronidazole + Aminoglycoside or QuinoloneOr

Clindamycin + Aminoglycoside or Aztreonam or QuinoloneOr

Vancomycin + Aminoglycoside or Aztreonam or Quinolone

Approved Antibiotics for Gynecological Procedures

Pubovaginal sling1st or 2nd Generation Cephalosporin or

Ampicillin/Sulbactam or Quinolone

If B-lactam allergyAminoglycoside + Clindamycin or

MetronidazoleOr

Aztreonam + Clindamycin or Metronidazole

Approved Antibiotics for Surgical Procedures

Head and NeckCefazolin or Cefuroxime or

Ampicillin/Sulbactam or Vancomycin (with physician or pharmacist

documented justification)Or

Clindamycin + Aminoglycoside

Approved Antibiotics for Surgical Procedures

Neurological

Cefazolin or CefuroximeOr

Vancomycin (with physician or pharmacist documented justification)

OrClindamycin

Outpatient Surgery MeasuresSurgical Safety Checklist

Hospitals are required to use a Safe Surgery Checklist for all surgical procedures. This list must include safe practices for the period:

prior to administration of anesthesia, prior to skin incisionperiod of closure of the incisionprior to the patient leaving the operating room.

These practices may include patient identification, site marking, equipment checking, appropriate antibiotic timing, availability of essential imaging as appropriate or complete instrument and sponge count.

Outpatient Surgery Measures Starting April 1, 2014

ColonoscopyPatients having colonoscopy for polyp surveillance

should be scheduled at the current recommended follow-up intervals.For patients with normal colonoscopy results the

interval between scoping is at least 10 years.For those patients with a history of adenomatous

polyps, the recommended interval is 3 or more years.

This interval must be documented in the operative report. In either case, if the patient has other medical reasons for more frequent colonoscopy this reason must be documented in the medical record.

January 1, 2015 Start Date for Cataract Surgery Measure

Cataract Surgery

The surgeon must provide documentation that the cataract surgery patient completes both a pre-operative and post-operative visual function test to determine visual improvement within 90 days of surgery.

This measure will require the coordination between the hospital and the physician office to obtain the necessary information.

Claims Based Measures

Many of the outpatient measures are obtained from the codes found on the billing claim rather than through medical chart review.

Imaging MeasuresThese measures are all reported by percent of

compliance.1. MRI for low back pain without conservative

measures attempted first2. Follow-up of positive screening mammography

with diagnostic mammography3. Use of contrast material with Abdominal CT and

Thorax CT4. Use of Cardiac imaging for preoperative risk

assessment for non-cardiac low risk surgery5. Simultaneous use of brain and sinus CT6. Use of Brain CT in the ED for atraumatic

headache

Healthcare Personnel Influenza Vaccination

It is expected that healthcare personnel working in the outpatient setting will comply with the CDC recommendations for Influenza vaccination. The data will be collected from October 1 through March 31.

All employees who work at least one day in this time frame must be included.

Changes Beyond 2014 !

The CMS quality reporting program is an ever changing process. They are considering adding health information utilization, patient safety and care transition measures for future years.

Test your knowledge!1. All patients presenting in the ED with

cardiac chest pain or an AMI need an EKG on arrival. The benchmark is within _________ minutes of arrival.

a.2b.10c.20d.60

Test your knowledge!2. The imaging interpretation must be

available within _______ minutes of arrival for patients who arrive at the ED within 2 hours of onset of stroke symptoms and have a Head CT or MRI scan performed.

a. 45b. 60c. 100

Test your knowledge!3. Some of the outpatient results report the median

rather than the percent of compliance. Select the median value for this group of AMI patients that were transferred to another acute care facility for acute coronary intervention.

45 55 60 75 80 95 104 111 120 minutesThe median isa.75b.80c.95d.83

Test your knowledge!

4. All surgical procedures must include the use of a surgical safety checklist.

a.Trueb.False

Test your knowledge!5. The physician must document in the

operative report the recommended follow-up interval (10 years) for patients with a normal colonoscopy.

a.Trueb.False