hospital outpatient department quality measures national hospital quality measures team members...
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Hospital Outpatient Department Quality Measures
National Hospital Quality Measures
Team MembersAnesthesia
Surgical ServicesLabor & DeliveryNursing Education
Electrophysiology LabUrology Department
Medical RecordsEPIC
Quality Resource ManagementCenter for Clinical Effectiveness
Confidential: For Quality Improvement Purposes Only
Surgical site infections are a major complication after surgery, resulting in considerable morbidity, mortality, and resource utilization. Proper use of antibiotics-giving the right drug
at the right time-is effective in preventing infections after surgery.
Opportunity Statement
Confidential: For Quality Improvement Purposes Only
Hospital Outpatient Quality Data Reporting Program
National Program• Progression of CMS Value-based purchasing plan.
• Program is modeled on the current quality data reporting system for inpatient services (Core Measures: Heart Failure, Pneumonia, SCIP & AMI)
• To meet requirements and receive full reimbursement for CY 2008 services, hospital must submit data for seven quality measures, if applicable.
• Failure to report data will incur a reduction in their annual payment update factor by 2%.
HOP QDRP
Confidential: For Quality Improvement Purposes Only
• Force 7: Quality Improvement• Force 11: Nurses as Teachers• Force 13: Interdisciplinary
Relationships
Forces of Magnetism
Confidential: For Quality Improvement Purposes Only
• Administer antibiotics within one hour before surgical incision
• Administer appropriate antibiotic identified for select procedures
AIM STATEMENT
Confidential: For Quality Improvement Purposes Only
•Met with specific out-patient surgical areas to introduce project and identify improvement opportunities– Lack of consistent documentation of procedure
start times– Lack of consistent documentation of antibiotic
administration– Lack of consistent documentation for use of
Vancomycin– Use of appropriate antibiotic
Department Specific Initiatives
Confidential: For Quality Improvement Purposes Only
Outpatient Surgical Care• Perioperative Care: Timing of Antibiotic Prophylaxis• Perioperative Care: Selection of Prophylactic Antibiotic
– Departments Involved: Ambulatory Surgery Center, Main OR, EP Lab, Labor/Delivery, & Urology
– Over 200 Procedure Codes– Types of Surgeries:
• Cardiac: Pacemaker revisions, battery change-outs• Vascular: grafts• Genitourinary: Transrectal prostate biopsy• Gastric biliary: peg placements, laparoscopic
appendectomy • Gynecology: Vaginal hysterectomy, synthetic
pubovaginal sling• Head and Neck: Treatment of jaw fractures
Quality Measures
Confidential: For Quality Improvement Purposes Only
Analysis: Patients received the proper prophylactic antibiotics within one hour of surgery start time 87% of the time. Knowledge deficits of project requirements and lack of proper documentation of required
elements are identified as opportunities for improvement in this new imitative. Last month’s data demonstrate improvement towards
stretch goal of 95%.
Perc
ent
National Hospital Quality MeasuresHospital Outpatient Department Quality Measures
Q2-3 2008 Antibiotic Selection
For Quality Improvement Purposes Only
70
75
80
85
90
95
100
105
Mean
UCL
Mean
LCL
Stretch goal 95%
Project begins 4/1/4008
Correct Antibiotic Selection
Confidential: For Quality Improvement Purposes Only
Perc
ent
National Hospital Quality MeasuresHospital Outpatient Department Quality Measures
Quarter 2-3 2008Antibiotics within One Hour of Surgey/Procedure
For Quality Improvement Purposes Only
50
60
70
80
90
100
110
Mean
UCL
Mean
LCL
Analysis: Patients received prophylactic antibiotics within one hour of surgery start time 79% of the time. Knowledge deficits of project
requirements and lack of proper documentation of required elements are identified as opportunities for improvement in this new imitative. Last two
months demonstrate improvement towards stretch goal of 95%.
Project begins 4/1/2008
Stretch goal: 95%
Antibiotics Within One Hour of Surgery/Procedure Start Time
Confidential: For Quality Improvement Purposes Only
• Develop physician specific reports for results
• Educate departments on initiative and opportunities for improvement
• Report to key stakeholders• Re-education of data abstractors to
changing specifications
Next Steps