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 Aggressive Marketing “If you or a family member have been 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 mmichelman@flqio.sdps.org 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 18