Transcript IQI SFY2016
IQI SFY2016 Specifications Manual Updates – 3Q2015 Discharges Revised 06/24/2015 Removal of SUB-3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge Table of Contents New Data Elements: Alcohol Use Status Brief Intervention Removed Data Elements Table of Contents Arrival Date Arrival Time Cognitive Impairment Data element was removed and has been integrated into the Tobacco Use Status and Alcohol Use Status data elements Delivery Date Delivery Time Performance Measures Criteria OBS 4: Early Elective Delivery OBS 5: Exclusive Breast Milk Feeding OBS 6: Cesarean Section: Nulliparous Women TOB 1: Tobacco Use Screening TOB 2: Tobacco Use Treatment Provided or Offered TOB 3: Tobacco Use Treatment Provided or Offered at Discharge NBS 1: Timely Collection of Newborn Screening Specimen NBS 2: Timely Submission of Newborn Screening Specimen to the AR Department of Health Public Health Laboratory Submission Measures SUB 1: Alcohol Use Screening SUB 2: Alcohol Use Brief Intervention Provided or Offered Outcome Measures OP 10: Abdomen CT – Use of Contrast Material OBS 4: Elective Delivery Numerator Statement Included Populations Measure Information Form Cesarean section as defined in Appendix A, Table 11.06 and all of the following: not in Labor, no history of a Prior Uterine Surgery Denominator Statement Excluded Populations Gestation Age <37 Weeks or UTD Data Elements Prior Uterine Surgery Updated Algorithm OBS 5: Exclusive Breast Milk Feeding No Changes OBS 6: Cesarean Section: Nulliparous Women Measure Information Form Denominator Statement Excluded Populations Gestation age <37 Weeks or UTD Updated Algorithm NBS 1: Timely Collection of Newborn Screening Specimen No Changes NBS 2: Timely Submission of Newborn Screening Specimen to the AR Department of Health Public Health Laboratory No Changes TOB 1: Tobacco Use Screening Denominator Statement Excluded Populations Patients less than 18 years of age Measure Information Form Data Elements Tobacco Use Status Updated Algorithm TOB 2: Tobacco Use Treatment Provided or Offered Data Elements Comfort Measures Only Updated Algorithm TOB 3: Tobacco Use Treatment Provided or Offered at Discharge No Changes Measure Information Form SUB 1: Alcohol Use Screening SUB 2: Alcohol Use Brief Intervention Provided or Offered Please read measure information and email me with any questions. Measure Information Form OP 10: Abdomen CT: Use of Contrast Material Claims Based Thresholds for SFY2016 are based on Hospital Compare data Will use 3rd and 4th Qtrs 2015 Medicaid Claims for the SFY2016 program. Data Elements with No Changes Alphabetical Data Dictionary Admission Date Birth Date Birth Time Clinical Trial Discharge Date Discharge Disposition First Name ICD-9-CM Other Diagnosis Codes ICD-9-CM Other Procedure Codes ICD-9-CM Other Procedure Dates ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure Code ICD-9-CM Principal Procedure Date Last Name Patient Identifier Prescription for Tobacco Cessation Medication Reason for No Tobacco Cessation Medication at Discharge Referral for Outpatient Tobacco Cessation Counseling Sex Tobacco Use Treatment FDA-Approved Cessation Medication Admission to NICU Alphabetical Data Dictionary Removed, “…to receive critical care services…” from the Suggested Data Collection Question Notes for Abstraction: If the newborn is admitted to the NICU for observation or transitional care, select allowable value “no.” Transitional care is defined as a stay of 4 hours or less in the NICU If an order to admit to the NICU is not found in the medical record, there must be supporting documentation present in the medical record indicating that the newborn received critical care services in the NICU in order to answer “yes.” Examples of supporting documentation include, but are not limited to the NICU admission assessment and NICU flow sheet. Alcohol Use Status Alphabetical Data Dictionary The patient must be screened for alcohol use within the first three days of admission The CAGE tool is not an acceptable screening tool for this measure set An example of an Audit-C form is attached New Data Element – Please email me with any questions Brief Intervention Alphabetical Data Dictionary Definition: A brief intervention focuses on increasing the patient’s understanding of the impact of substance use on his or her health and motivating the patient to change risky behaviors. The components of the intervention include feedback concerning the quantity and frequency of alcohol consumed by the patient in comparison with national norms; a discussion of negative physical, emotional, and occupational consequences; and a discussion of the overall severity of the problem. The qualified health care professional engages the patient in a joint decision-making process regarding alcohol use and plans for followup care are discussed and agreed to. New Data Element – Please email me with any questions Comfort Measures Only Notes for Abstraction Alphabetical Data Dictionary New – Discussion of comfort measures State-authorized portable orders (SAPOs) Documentation of an inclusion term in the following situations should be disregarded. Continue to review the remaining physician/APN/PA documentation for acceptable inclusion terms. If the ONLY documentation found is an inclusion term in the following situation, select value “4.” See list of these inclusion terms on page 100 If there is physician/APN/PA documentation of an inclusion term in one source that indicates the patient is Comfort Measures Only, AND there is physician/APN/PA documentation of an inclusion term in another source that indicates the patient is NOT CMO, the source that indicates the patient is CMO would be used to select value “1,” “2,” or “3” for this data element. See examples on page 101 Alphabetical Data Dictionary Comfort Measures Only – continued Suggested Data Sources – New Consultation notes History and physical Inclusion Guidelines for Abstraction - New Terminal extubation Alphabetical Data Dictionary Exclusive Breast Milk Feeding Notes for Abstraction If the newborn received drops of water or formula dribbled onto the mother’s breast to stimulate latching and not an actual feeding, select “Yes.” Gestational Age Alphabetical Data Dictionary Notes for Abstraction If the patient has not received prenatal care, select allowable value “UTD.” If the gestational age entered by the clinician in the first document listed above is obviously incorrect (in error) but it is a valid number, or two different numbers are listed in the first document, and the correct number can be supported with other documentation in the other acceptable data sources in the medical record, the correct number may be entered. Alphabetical Data Dictionary Hospital Stay > 24 Hours This is the actual time the baby leaves the hospital Suggested Data Sources – New Nurses’ discharge documentation Alphabetical Data Dictionary Labor Notes for Abstraction Documentation of labor by the clinician should be abstracted at face value. There is no requirement for acceptable descriptors to be present in order to answer “yes” to labor. Documentation of regular contractions or cervical change without mention of labor cannot be used to answer “yes” to labor. Alphabetical Data Dictionary Parity Notes for abstraction (page 123) If the number for parity documented in the EHR includes the delivery for the current hospitalization, parity should be answered as one number less than the number documented. If primigravida is documented select zero for parity. Alphabetical Data Dictionary Prior Uterine Surgery Inclusion Guidelines for Abstraction – New History of cornual ectopic pregnancy Alphabetical Data Dictionary Reason for No Tobacco Cessation Medication During the Hospital Stay Notes for Abstraction The timeframe for documenting a reason for not administering FDAapproved tobacco cessation medications must have occurred within the first three days of admission. The day after admission is defined as the first day. Reason for Not Exclusively Feeding Breast Milk Allowable Values Alphabetical Data Dictionary 1. There is documentation by physician/advanced practice nurse (APN)/physician assistant (PA)/certified nurse midwife (CNM)/international board certified lactation consultant (IBCLC)/certified lactation counselor (CLC) of a reason for not exclusively feeding breast milk during the entire hospitalization due to a maternal medical condition with which breast milk feeding should be avoided. 2. There is documentation by physician/APN/PA/CNM/IBCLC/CLC/RN that the newborn’s mother’s initial feeding plan for the hospitalization included formula upon admission of the newborn. Reason for Not Exclusively Feeding Breast Milk – Continued Notes for Abstraction Alphabetical Data Dictionary Last Bullet, page 137 – Bottle is a method of feeding and is not the same as formula. Bottle cannot be used interchangeably for formula, since breast milk can also be fed via a bottle. – I am still seeing a lot of “bottle” documentation instead of “formula.” The notes for abstraction have changed. Please read all and email me if you have any questions. Suggested Data Sources – New Nursing Assessment Inclusion Guidelines for Abstraction 2nd bullet, page 138 – Newborn and mother will be separated after discharge from the hospital, and the mother will not be providing care for the newborn after the hospitalization. Some examples include, but are not limited to: adoption, foster home placement, surrogate delivery, incarceration of the mother. Specimen Collection Must be done prior to discharge Alphabetical Data Dictionary Specimen Collection Date, Specimen Collection Time, Specimen Submission, Specimen Submission Date, Specimen Submission Time Suggested Data Sources for all NBS Data Elements Hospital’s laboratory report: As long as there is a copy of the NBS tool in the medical record Arkansas Department of Health Newborn Screening Results Report Note: This can only be used to document the date and time the specimen was collected and that it was submitted. Do not use the “Received” date or time when abstracting the date and time of submission. Tobacco Use Status Alphabetical Data Dictionary Documentation of the adult patient’s tobacco use status within the past 30 days prior to the day of hospital admission. Allowable Values – New 6. The patient was not screened for tobacco use during the first three days of admission because of cognitive impairment Notes for Abstraction Last bullet, page 153 – If there is documentation that the patient has temporary cognitive impairment due to acute substance use (e.g., overdose or acute intoxication) value “6” cannot be selected. See examples on page 153 Tobacco Use Treatment Practical Counseling Alphabetical Data Dictionary Definition: The components of practical counseling require interaction with the patient to address the following: recognizing danger situations, developing coping skills, and providing basic information about quitting. There must be documentation in the medical record that the patient received all components of practical counseling in a face to face setting. Appendix A Appendices Table 11.01 Complication Mainly Related to Pregnancy Table 11.02 Normal Delivery and Other Indications for Care Table 11.03 Complication Mainly in the Course of Labor and Delivery Table 11.04 Complication of the Peurperium Table 11.05 Medical Induction of Labor Table 11.06 Cesarean Section Table 11.06.1 Planned Cesarean Section in Labor Table 11.07 Conditions Possibly Justifying Elective Delivery Prior to 39 Weeks Gestation Table 11.08 Outcome of Delivery Table 11.09 Multiple Gestations and Other Presentations Appendix A – Continued Appendices Table 11.10.3 Liveborn Newborn Table 11.20.1 Single Liveborn Newborn Table 11.21 Galactosemia Table 11.22 Parenteral Infusion Table 11.23 Premature Newborns Table 12.3 Pregnancy Appendix B Hospitals with a Qualifying Level III NICU Appendices Appendix C Table 9.1 FDA-Approved Tobacco Cessation Medications Appendix H Table 2.6 Table 2.6 Qualifiers and Modifiers Table Qualifiers Modifiers • Qualifiers are words used as adjectives to indicate some uncertainty about whether or not a condition really exists. • The following qualifiers should be abstracted as negative findings, unless otherwise specified in a data element’s guidelines – Consider this list allinclusive: ο And/or (+/-; e.g., “ST abnormalities consistent with ischemia and/or injury”), except when comparing only Inclusions (e.g., “ST segment elevation and/or STEMI”) ο Cannot exclude ο Cannot rule out ο Could/may/might be ο Could/may/might have ο Could/may/might have been ο Could/may/might have had ο Could/may/might indicate ο Or, except when comparing only Inclusions ο Possible ο Questionable (?) ο Risk of ο Ruled out (r’d/o, r/o’d) ο Suggestive of ο Suspect ο Suspicious ο Vs., except when comparing only Inclusions • Quantitative modifiers are adjectives that quantitatively describe a condition. • The following quantitative modifiers should be abstracted as negative findings, unless otherwise specified in a data element’s guidelines- Consider this list all-inclusive: ο Borderline ο Insignificant/not significant/no significant ο Minor ο Scant ο Slight ο Sub-clinical ο Subtle ο Trace ο Trivial Example: If the in-hospital echocardiogram report documents “questionable LVSD,” this should be abstracted as a negative finding. Note: These guidelines apply only to those data elements that refer to them in their Guidelines for Abstraction Exclusion list(s). AUDIT-C e-form Example Questions and Answers ~~~~~~~~~~~~~~~~~~~~~~~~QUESTION DETAILS~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ QUESTION: What defines a patient as needing a Brief intervention? Could you clearly define what a Brief Intervention is? Is it simply informing the patient of the consequences of use or must it include a outline of steps that must be done in order to mark "YES"? ANSWER: No, the brief intervention must be performed by personnel specially trained. Information on training, technical assistance, and a variety of services in the area of Screening, Brief Intervention & Referral to Treatment (SBIRT) is available at: http://www.hospitalsbirt.webs.com/ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Q&A ~~~~~~~~~~~~~~~~~~~~~~~~QUESTION DETAILS~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ QUESTION: SUB 3 This measure addresses BOTH alcohol and drug use disorder diagnosed patients. SUB 1 & 2 focus specifically on ETOH abuse. Does this mean that any patient that has an alcohol or drug use disorder dx have to have a med received or refused at discharge OR referral received or refused, to meet this measure? ANSWER: Yes, that is correct. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~QUESTION DETAILS~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ QUESTION: Alcohol Use Status In the body of this data element it stipulates "the first three questions of the AUDIT, The AUDIT-c, ask about alcohol consumption and can be used reliably and validly to identify unhealthy alcohol use." My question is the AUDIT-C stipulates that if the patient scores a certain number, then the remainder of the test needs to be taken. Will JUST the three questions of the AUDIT-C be sufficient To meet the measure, or will the entire assessment test results need to be shown to meet the measure? ANSWER: You need to complete the entire screen if directed to do so in order to determine if the patient has unhealthy alcohol use. Answer no screen was done if this is not followed. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~QUESTION DETAILS~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ QUESTION: Brief intervention Can the terms "brief intervention" please be defined? Is it simply making the patient aware of substance Abuse options and or intervention with FDA approved drugs during the inpatient stay? What documentation is required for the Discharge Planning aspect ? Can an RN or other certified personnel Document this? If a social worker or case manager is not certified (either as an RN or social worker or Case Manager Does another party who is, document this? Thank you) ANSWER: Anyone who is specially trained can perform the brief intervention. Information on training, technical assistance, and a variety of services in the area of Screening, Brief Intervention & Referral to Treatment (SBIRT) is available at: http://www.hospitalsbirt.webs.com/ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Q&A ~~~~~~~~~~~~~~~~~~~~~~~~QUESTION DETAILS~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ QUESTION: Data Element Name: Alcohol Use Status: Is there a specific numeric level that defines "acute Intoxication" Does each hospital determine that level Or is the state legal level the determining factor? Thank you ANSWER: Until 10/1/15 discharges there must be documentation by the clinician that the patient was acutely intoxicated based on lab report. Beginning with 10/1/15 a blood alcohol concentration of .08 or more alone can be used to answer "yes" for acute intoxication. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~QUESTION DETAILS~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ QUESTION: Patients on VENT The terminology used in the Data Elements do not appear to address patients who are on vent support, specifically in the case of patients that may be documented as "acute intoxication." They are documented as acute on admission, sometimes they remain on the vent and never resolve. How do we answer this for this scenario? ANSWER: If the patient is on a ventilator for the entire first 3 days after admission, they are receiving sedation which makes them cognitively impaired and thus excluded from SUB-1 which is required before you know whether a brief intervention is needed. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~