Quality and Patient SafetyQuality Measures and National Patient Safety Goals

Floyd’s Commitment to Quality

What are Quality Measures?Quality Measures are standardized, evidence-based treatments proven to:

Risk of Complications

Better Patient Outcomes

Readmissions

The Centers for Medicare and Medicaid Services (CMS), medical experts and researchers teamed to develop these measures which are accepted as best practices.

Inpatient and Outpatient Quality Measures• This is a partial list of the quality

measures Floyd’s Quality department reviews continually.

• Each measure has a set of requirements for us to meet. We report our compliance to CMS.

• Stroke (STK)

• Severe Sepsis and Septic Shock (SEP)

• Perinatal Care (PC)

• Heart Failure (HF)

• Hospital Based Inpatient Psychiatric Services (HBIPS) (FBH)

• Tobacco Abuse (FBH)

• Substance Abuse (FBH)

• Emergency Department (ED 1, ED 2)

• AMI/Chest Pain

• Emergency Department Throughput

Centers of Excellence and Advanced Certifications• Our Centers of Excellence (COE) and

Advanced Certifications also must follow requirements that go with certification.

• We monitored and reported on an ongoing basis.

• Bariatric Surgery

• Breast Center

• Inpatient Diabetes

• Total Knee/Hip Replacements

• Spine Surgery

• Stroke

• Heart Failure

• Atrial Fibrillation

• Chest Pain/AMI

• Hip Fracture

Did you know?There are literally thousands of pages of specifications, appendices, data dictionaries, guidelines, etc. surrounding quality measures.

4 Key Quality MeasuresNext, you will learn about four Key Quality Measures.

Sepsis Stroke

Heart Failure

PCI

There is a job aid to help guide you on GreenLink, Floyd’s Intranet site.

Sepsis

Quality Measure 1

What is Sepsis?It’s a body’s overwhelming, life-threatening response to infection. Sepsis can lead to tissue damage, organ failure and death.

Did you know?

Mortality from sepsis increases 8% every hour that treatment is delayed.

Sepsis is the leading cause of death in U.S. hospitals.

62% of people hospitalized with sepsis are re-admitted within 30 days.

As many as 80% of sepsis deaths could be prevented with rapid diagnosis and treatment.

How does sepsis start?

Sepsis begins with SIRS:

Systemic

Inflammatory

Response

Syndrome

It is a severe systemic response to a condition such as trauma (an infection or burn) that provokes an acute inflammatory reaction.

SIRS CriteriaThe patient needs to have two or more of the following:

Temperature > 101

Heart Rate > 90

Respiratory Rate > 20

White Blood Cells > 12. (4,000 or BAND) greater than 10

Sepsis: Your patient has two or more of the SIRS criteria, and an infection (suspected or confirmed).

Example:

Your patient has a temperature of 101, a heart rate of 92, and a urinary tract infection. Your patient has sepsis.

Severe Sepsis> 2 SIRS Infection (suspected or confirmed)

ORGAN DYSFUNCTION (defined as):• SBP < 90 OR MAP < 65• Acute Respiratory Failure (new need for vent or BiPap)• Cr > 2.0 OR UOP < 0.5 ml/kg/hr for two hours• Bilirubin > 2 mg/dL• Platelet Count < 100,000• INR > 1.5 OR PTT > 60• Lactate > 2 mmol/L (If > 2.0 mmol/L, repeat within 6 hours presentation)

Severe Sepsis Example:

Remember your patient who has a temperature of 101, a heart rate of 92, and a urinary tract infection?

Now, your patient is feeling worse. Lab results show Lactic Acid is 2.2. Your patient has severe sepsis.

Severe Sepsis Treatment

Initial Lactate result received within 3 hours (If 2.0 mmol/L , repeat within 6 hours of presentation) ???Blood cultures within 3 hours and PRIOR TO Abx begin time.

IV Abx given within 3 hours of presentation time.If there are 2 SABP > 90 OR MAP < 65, 6 hours prior to OR 6 hours after presentation (initial hypotension), give Crystalloid Fluid Resuscitation of 30 ml/kg at a rate of > 126 ml/hr.

Septic Shock> 2 SIRS Infection (suspected or confirmed)

ORGAN DYSFUNCTION (defined as):• SBP < 90 OR MAP < 65• Acute Respiratory Failure (new need for vent or BiPap)• Cr > 2.0 OR UOP < 0.5 ml/kg/hr for two hours• Bilirubin > 2 mg/dL• Platelet Count < 100,000• INR > 1.5 OR PTT > 60• Lactate > 2 mmol/L

2 consecutive SBP < 90 AFTER IVF Bolus complete (persistent hypotension) OR initial Lactate > 4.

Septic Shock Example:

Now, your patient is lethargic and weaker with occasional confusion. The lab work is repeated. Lactic Acid is now 4.2. Your patient is in septic shock.

This can progress rapid to death, if not treated quickly and correctly.

Septic Shock Treatment

IF INITIAL LACTATE IS > 4:Give Crystalloid fluid resuscitation of 30 ml/kg at > 126 ml/hr.(FINISH BOLUS PRIOR TO CHANGING ROUTINE IVF)Physician should do a re-assessment including 5 of the following:VS (T, P, R, BP)

Cardiopulmonary exam

Capillary refill evaluation

Skin examination

Arterial O2 saturation (Pulse Ox)

Urine output (volume not required)

Peripheral pulses

CAN DOCUMENT “REASSESSMENT COMPLETE” or “PHYSICIAN EXAM DONE”

Septic Shock Treatment

IF PERSISTENT HYPOTENSION:

Must hang vasopressor within 3 hours.

Physician should do a re-assessment including 5 of the following:VS (T, P, R, BP)

Cardiopulmonary exam

Capillary refill evaluation

Skin examination

Arterial O2 saturation (Pulse Ox)

Urine output (volume not required)

Peripheral pulses

CAN DOCUMENT “REASSESSMENT COMPLETE” or “PHYSICIAN EXAM DONE”

Congestive Heart Failure

Quality Measure 2

Heart Failure Patient RequirementsThere are several requirements affecting nurses providing care for heart failure patients. The next several slides provide a list of what needs to be completed.

Documentation of VTE prophylaxis, contraindication or ambulation by the end of day 2.

Keep in mind – admission date is day 1.

Documentation of EF (no time limit)

Echo, TEE, Cardiac Cath or physician documentation. If not a current admission, must be printed and placed in chart.

Heart Failure Patient RequirementsThere are several requirements affecting nurses providing care for heart failure patients.

Post – discharge appointment must be made

The patient must have a follow-up appointment scheduled within 7 days of discharge. This must be documented in the chart.

Documentation should include the physician’s name and date/time of the appointment.

The physician should be the one who will address the patient’s heart failure needs (PCP, Cardiologist, Heart Failure Clinic, Transitional Care Clinic).

Heart Failure Patient RequirementsThere are several requirements affecting nurses providing care for heart failure patients.

Referral to heart failure disease management AND 60 minutes of documented heart failure education.

Document the time spent on heart failure education in Iview. There MUST be 60 minutes spend on education.

NOTE: If there is at least 30 minutes documented by nursing, the other 30 minutes of education can come from a nutritionist, physical/occupational therapy or exercise specialist documentation.If referred to the Heart Failure Clinic or it is documented on Iviewthat the patient received the AHA Heart Failure interactive workbook referral, it will satisfy the requirement.

Heart Failure Patient RequirementsThere are several requirements affecting nurses providing care for heart failure patients.

If the patient has EF < 40% a Beta Blocker (EBBB) must be prescribed at discharge.

It must be an evidence-based beta blocker. Most often prescribed meds are:• Coreg (Carvedilol)• Toprol VL (Metoprolol Succinate)• Zebeta (Bisoprolol)

For a full list, refer to the Core Measures booklet at the nurses’ station.

There must be physician documentation that the patient is intolerant to ALL evidence-based beta blockers for the requirement to be waived.

Heart Failure Patient RequirementsThis is the final one.

Anticoagulation in Afib

An anticoagulant must be prescribed at discharge for all heart failure patients with atrial fibrillation/flutter.

If diabetic, must have a cholesterol reducer prescribed at discharge.

Did you know?Floyd monitors over 41 quality measure requirements on an ongoing basis.

Stroke

Quality Measure 3

Stroke RequirementsThe next several slides reveal the requirements regarding stroke patients.

VTE (blood clot prevention) Prophylaxis

All patients must have either mechanical or pharmacological prophylaxis.

NOTE: Ambulation does not meet the quality measure.

Pharmacological options include: Xarelto, Heparin, Eliquis and Lovenox.

NOTE: Thrombolytic Therapy Administered (tPA) does not pass the quality measure.

Stroke Requirements

Dysphagia Screening (Swallow Screen) prior to ANY PO

All patients need a swallow screen performed and documented prior to anything being given by mouth.

A simple bedside swallow screen will pass this measure, but it must be documented.

Stroke Requirements

Antithrombotic therapy by the end of day 2

All patients must have an antithrombotic ordered and given by the end of the day (23:59) after arrival. (Day of arrival is day 1.)

ASA, Plavix, Aggrenox, Eliquis and Coumadin will meet the quality measure.

NOTE: IF THE PATIENT DOES NOT PASS THE SWALLOW SCREEN, A RECTAL ASA MUST BE GIVEN.

This measure does not apply, if the patient was given tPA.

Stroke Requirements

Patients with Afib/flutter must receive anticoagulant therapy.

All patients with a history of, or a current diagnosis of Afib/flutter must have an anticoagulant ordered OR a reason why the anticoagulant was not given documented by the provider.

Patients must go home on this as well, or the reason must be documented by the provider.

Eliquis, Xarelto and Coumadin are examples of anticoagulant therapy.

Stroke Requirements

Thrombolytic Therapy Administered (tPA)

Continue flowsheet of vital signs and neuro checks until completed. (Most of these patients will be in the ICU for the first 24 hours.)

tPA is given for stroke. It is a clot buster.

An assessment using the NIHSS (Stroke Scale) must be documented within first 12 hours and prior to tPA.

Stroke Requirements

Smoking Cessation

Any patient who has smoked within the past 12 months needs smoking cessation counseling.

Respiratory Therapy gets a trigger upon the patient’s admission, but as the nurse, you must ensure it’s documented before discharge.

Any cessation medication (patch, gum, etc.) that’s ordered and given passes this quality measure.

Stroke Requirements

Discharged on antithrombotic therapy

All patients must have an antithrombotic prescribed at discharge OR the provider must document the reason for not ordering.

Antithrombotics include: ASA, Plavix, Aggrenox

Anticoagulants (Coumadin, Eliquis and Xarelto) will pass this quality measure as well.

Stroke Requirements

Discharged on a statin

All patients must have a lipid panel ordered. If the LDL is > 70, a high intensity statin must be ordered at discharge. If not ordered, the provider must document the reason.

Statins include Crestor, Lipitor, Simvastatin, and Pravachol. An allergy to ALL statins will exclude this quality measure. If allergic to only one statin, a different one should be ordered. If NOT ordered, the reason must be documented.

If no lipid panel is drawn, the patient must be discharged on a high intensity statin. If not, the provider must document the reason.

Stroke Requirements

Additional Requirements:

1. Requires consult and evaluation to Physical Therapy, Occupational Therapy or Speech Therapy prior to discharge. Please make sure Stroke Coordinator is consulted.

2. Education is required. Krame’s “Stroke” education covers all requirements. Document this education was given and print education for patient.

The last requirements regarding stroke patients.

Did you know?The Quality Measure requirements are subject to change on a semi-annual basis as new data is released.

Percutaneous Coronary Intervention (PCI)

Quality Measure 4

What is a Percutaneous Coronary Intervention (PCI)?It’s a procedure to unblock an artery using either a stent or balloon angioplasty.

PCI RequirementsThere are several slides outlining the requirements.

Aspirin

An ASA must be given within 24 hours of the patient’s arrival to the hospital. If contraindicated, the provider must document the reason.

If aspirin was given prior to arrival, or listed as a home medicine, it will pass the measure.

The ONLY exceptions are refusal or allergy.

Aspirin must be prescribed at discharge or the contraindication documented by the provider.

PCI Requirements

Antithrombotic

An antithrombotic must be prescribed at discharge. If not, the provider must document the contraindication.

Approved antithrombotics are Brilinta, Plavix and Effient.

Neither Aspirin nor an anticoagulant count.

Beta Blocker

Must be prescribed at discharge if the patient has a STEMI/NSTEMI. If it is not prescribed, the provider must document the contraindication.

PCI RequirementsThese are the last requirements.

Statin

Must be prescribed at discharge. If not, the provider must document the contraindication.

ACEI /ARB for LVSD

Must be prescribed at discharge, if the EF is < 40. If not prescribed, the provider must document why. The documentation may be found in MD notes or placed as an MD order.

Allergy to or documentation of a reason for not ordering one particular medicine in a class will suffice for all medications in that same class, but it is not a reason for not prescribing other classes.

There must be documentation if not prescribed an ACE or ARB.

Coming in the future:

Electronic Core Quality Measures (eCQM)

CMS will pull data directly from the documentation.

This means the Quality Clinical Coordinators will NOT be able to double check to see if the documentation criteria was met prior to reporting. It will be crucial to remember to document.

Why is this important?• Quality Measure compliance is reported to CMS and The Joint Commission.

In addition, compliance is linked to payment and reimbursement for patient care.

• The federal government reimburses the organization for Medicare and Medicaid patient care. Unfortunately, we are not reimbursed for the total cost of care. That makes it even more important to recover as much as we are able.

• Payment and reimbursement for patient care is what allows our organization to continue meeting our vision to provide access to healthcare to everyone in the areas we serve.

• Did you know that the outcomes are available online? Patients look at reviews for healthcare, just like you do for restaurants, etc. Patients are able to compare our care to any other Georgia hospital. We want them to CHOOSE Floyd.

MOST importantly, it’s the RIGHT thing to do for our patients! We must provide them with the highest quality of care possible.

2021 National Patient Safety Goals (NPSG) Overview

National Patient Safety GoalsPurpose:The National Patient Safety Goals (NPSG) seek to improve patient safety. The goals focus on healthcare safety issues and seek to resolve them.

Who creates the goals?The Patient Safety Advisory Group advises The Joint Commission on developing and updating the NPSGs. The advisory group is composed of nurses, physicians and other healthcare professions.

The Joint Commission works with the advisory group to identify emerging patient safety issues and ways to address those issues.

Next, you will review some of the goals.

Goal 1: Identify Patients Correctly

Use at least two ways to identify patients (name and date of birth) to ensure the correct patient gets the correct medicine and treatment.

1Label containers and specimens in the presence of the patient. Don’t place in your pocket with the intent of labeling later.

2Make sure the correct patient gets the correct blood when they get a blood transfusion by using a two person identification process.

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Goal 2:Improve the

Effectiveness of Communication

Among Caregivers

Communication continues to be our number one issue on every patient safety survey.

When communicating with other teammates, give complete information and ask questions to ensure they understand.

Get important test results to the right teammate on time.

Communicate critical lab and diagnostic procedure results within 30 minutes to the provider (per policy).

Document in critical result notes

Goal 3: Use Medications Safely

Before a procedure, label medicines that are not labeled (syringes, cups, basins) in the area where medicines and supplies are set up.

1Take extra care with patients who take medicine to thin their blood by providing effective patient communication and adhering to hospital protocols.

2Record and pass along information about a patient’s medicines. Find out what medicines the patient is taking; compare those to new medicines given to the patient.

3Make sure the patient knows which medications to take when they get home.

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Goal 6: Use Alarms Safely

Make improvements to ensure that alarms on medical equipment are heard and responded to promptly.

1Know established alarm system safety as a hospital priority.

2Identify the most critical alarm signals to manage.

3Know the established policies and procedures for managing alarms.

4Educate licensed, independent practitioners about the purpose and proper operation of alarm systems.

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Goal 7: Prevent Infection

Use the hand hygiene guidelines from the CDC or WHO. Set goals for improved hand hygiene.

1Use proven guidelines to prevent infections that are difficult to treat.

2Use proven guidelines to prevent infection from central lines.

3Use proven guidelines to prevent infections of the urinary tract caused by catheters.

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KNOW AND FOLLOW ALL INFECTION PREVENTION POLICIES

Goal 15: Identify Patient Safety Risks

Identify patients at risk for suicide.Identify

Conduct a risk assessment of the patient and environment that may increase or decrease the risk of suicide.Conduct

Address the patient’s immediate safety needs and the most appropriate setting for treatment.Address

Provide suicide prevention information to the patient and the patient’s family upon discharge.Provide

Prevent Mistakes in Surgery

Ensure

Ensure the correct surgery is done on the correct patient and at the correct place on the patient’s body.

Mark

Mark the correct place on the patient’s body where the surgery is to be done.

Conduct

Conduct a “time out” before the surgery to ensure a mistake is not being made.

What is your role?Quality and patient safety is everyone’s responsibility. Every day, every patient.