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Implications Of Cm Ss Present On Admission (Poa) Provisions Making Dollars And Sense

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Implications Of Cm Ss Present On Admission (Poa) Provisions Making Dollars And Sense

  1. 1. Implications of CMS’s Present on Admission Provisions in the ICU: Making Dollars and Sense Todd M. Grivetti, MSN, RN, CCRN, CNML Clinical Nurse Manager Regional Neurosciences Center Poudre Valley Hospital Ft. Collins, CO 2008 Award Recipient
  2. 2. Disclosure Statement <ul><li>Todd M. Grivetti, MSN, RN, CCRN, CNML </li></ul><ul><li>Disclosure </li></ul><ul><ul><li>Speaker’s Bureau – AACN </li></ul></ul><ul><ul><li>Financial Interest - None </li></ul></ul>
  3. 3. House Keeping tips <ul><li>Class Code – 169 </li></ul><ul><li>Session Times – 2:15 – 3:30 pm </li></ul><ul><li>Please turn cell phones and pagers off or to Vibrate. </li></ul><ul><li>Please utilize the microphones in the room for questions. </li></ul>
  4. 4. Learning Objectives <ul><li>Review, Discuss, and Understand the Present on Admission Provisions </li></ul><ul><li>Discuss practical implications of hospital acquired conditions </li></ul><ul><li>Incorporate evidence-based research with confidence to establish unit specific guidelines to eliminate hospital-acquired conditions </li></ul><ul><li>Develop and implement a customized POA risk assessment. </li></ul>
  5. 5. Definitions <ul><li>CMS – Centers for Medicare and Medicaid Services </li></ul><ul><li>IPPS – Inpatient Prospective Payment System </li></ul><ul><li>DRG – Diagnosis Related Group </li></ul><ul><li>HAC – Hospital Acquired Conditions </li></ul><ul><li>NI – Nosocomial Infection </li></ul><ul><li>POA – Present on Admission </li></ul>
  6. 6. Evolution to Quality Based Payment <ul><li>Public Awareness </li></ul><ul><ul><li>1999 – IOM’s To Err is Human is published. </li></ul></ul><ul><ul><li>2001 – IOM’s Crossing the Quality Chiasm. </li></ul></ul><ul><li>Quality Reporting </li></ul><ul><ul><li>2003 – CMS Begins quality reporting in-patient initiatives. </li></ul></ul><ul><ul><ul><li>Ten Metrics </li></ul></ul></ul><ul><ul><li>2008 – CMS Begins Quality reporting out-patient initiatives. </li></ul></ul><ul><ul><ul><li>Seven Metrics </li></ul></ul></ul>
  7. 7. Evolution to Quality Based Payment <ul><ul><li>2007 – Physician Quality reporting </li></ul></ul><ul><ul><li>2008 – Outcome measures introduced </li></ul></ul><ul><li>Other entities monitoring hospital quality and safety initiatives: </li></ul><ul><ul><li>Joint Commission </li></ul></ul><ul><ul><li>Association of Healthcare Research & Quality (AHRQ) </li></ul></ul><ul><ul><li>Leap Frog </li></ul></ul><ul><ul><li>Health Grades </li></ul></ul><ul><ul><li>State Governments </li></ul></ul><ul><ul><li>Private Insurance companies </li></ul></ul><ul><ul><li>Patient Safety Organizations </li></ul></ul>
  8. 8. Evolution to Quality Based Payments <ul><li>Individual contracts between hospitals and insurers </li></ul><ul><li>2004 - CMS/Premier begins demonstration project. </li></ul><ul><ul><li>Pay for Performance </li></ul></ul><ul><ul><li>Hospital Quality Indicator Demonstration (HQID) </li></ul></ul><ul><ul><ul><li>Uses national measures to test payment methods. </li></ul></ul></ul><ul><li>Deficit Reduction Act (2005) </li></ul><ul><ul><li>IPPS – 2008 </li></ul></ul><ul><ul><ul><li>Severity adjusted payments </li></ul></ul></ul><ul><ul><ul><li>POA Provisions </li></ul></ul></ul>
  9. 9. Deficit Reduction Act - 2005 <ul><li>CMS selected a variety of hospital-acquired conditions deemed to be reasonably preventable that will receive lower payment if not coded at present on admission. </li></ul><ul><li>If a claim includes one of the conditions falling under this policy as a secondary diagnosis without a present on admission indicator, it will be reimbursed as if the secondary diagnosis was not present, leading to reduced payment. </li></ul>
  10. 10. Hospital Acquired Conditions selected for Present on Admission Provisions <ul><li>FY – 2008 </li></ul><ul><ul><li>Pressure Ulcers (decubitus ulcers) </li></ul></ul><ul><ul><li>Catheter-associated urinary tract infections </li></ul></ul><ul><ul><li>Object left in surgery </li></ul></ul><ul><ul><li>Mediastinitis after CABG surgery </li></ul></ul><ul><ul><li>Air embolism </li></ul></ul><ul><ul><li>Blood incompatibility </li></ul></ul><ul><ul><li>Vascular catheter associated infections </li></ul></ul><ul><ul><li>Falls </li></ul></ul>
  11. 11. Hospital Acquired Conditions selected for Present on Admission Provisions <ul><li>FY-2009 – Conditions not selected but being considered. </li></ul><ul><ul><li>Clostridium difficile – associated disease </li></ul></ul><ul><ul><li>Deep vein thrombosis (DVT) </li></ul></ul><ul><ul><li>Pulmonary embolism </li></ul></ul><ul><ul><li>Staphylococcus aureus septicemia </li></ul></ul><ul><ul><li>Ventilator associated pneumonia (VAP) </li></ul></ul><ul><ul><li>Methicillin Resistant Staphylococcus aureus (MRSA) </li></ul></ul><ul><ul><li>Delerium </li></ul></ul>
  12. 12. Hospital Acquired Conditions selected for Present on Admission Provisions <ul><li>Conditions NOT SELECTED for FY-2009 and will not be subjected to provisions </li></ul><ul><ul><li>Legionnaires disease – Not typically a HAC </li></ul></ul><ul><ul><li>Wrong site or Wrong surgery </li></ul></ul><ul><ul><ul><li>Medicare WILL NOT pay at all </li></ul></ul></ul>
  13. 13. Phased Implementation of POA <ul><li>August 2007 – </li></ul><ul><ul><li>FY 08 IPPS Final rule announced: POA provision finalized </li></ul></ul><ul><li>October 2007 – </li></ul><ul><ul><li>Short term, acute care hospitals required to begin reporting POA codes, information not used in claims. </li></ul></ul><ul><li>January 2008 – </li></ul><ul><ul><li>CMS begins processing POA data and provide feedback on POA reporting errors </li></ul></ul><ul><ul><li>Hospitals submitting invalid POA code receive remark code on remittance advice; claims with errors still processed. </li></ul></ul>
  14. 14. Phased Implementation of POA <ul><li>April 1, 2008: </li></ul><ul><ul><li>Claims that are submitted for payment that do not contain proper POA data will be returned to the provider for correct submission of POA information. </li></ul></ul><ul><li>April 15 2008: </li></ul><ul><ul><li>FY09 IPPS Proposed Rule announced; CMS outlines plan to expand POA provision to additional conditions </li></ul></ul><ul><li>August 2008: </li></ul><ul><ul><li>FY09 IPPS Final Rule expected; expansion of condition list in POA provision likely. </li></ul></ul><ul><li>October 2008: </li></ul><ul><ul><li>POA provision set to officially launch; reimbursement at stake. </li></ul></ul>
  15. 15. Practical Implications of POA Financial Clarifying Implications Limitations
  16. 16. Practical Implications of POA Indicators <ul><li>General Reporting Requirements: </li></ul><ul><ul><li>POA indicators required for all claims involving Medicare inpatient admissions to acute care hospitals. </li></ul></ul><ul><ul><li>POA is defined as present at the time the order for inpatient admission occurs – conditions that occur during an outpatient encounter, including emergency department, observation, or outpatient surgery are considered POA. </li></ul></ul><ul><ul><li>POA indicators is assigned to both primary and secondary diagnoses. </li></ul></ul><ul><ul><li>Issues related to inconsistent, missing, conflicting or unclear documentation must be resolved by the provider. </li></ul></ul><ul><ul><li>If a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current official coding guidelines, then POA indicator would not be reported. </li></ul></ul><ul><ul><li>CMS does not require POA indicators for external cause of injury code unless it is being reported as an “other diagnosis.” </li></ul></ul>Source: CMS - HAC/POA
  17. 17. POA Indicator Details* *Every diagnosis code required to have one of five POA indicator codes Exempt from POA reporting Unreported/ Not Used 1 (One) Provider unable to clinically determine whether the condition was present on admission or not Clinically Undetermined W Documentation insufficient to determine if the condition was present on admission Unknown U Not present at the time of admission No N Present at the time of admission Yes Y Reason for Code Definition POA Indicator
  18. 18. CMS Broadening the List: Private Payers Likely to Follow “ It’s not a matter of not paying for them. It’s about getting them not to happen in the first place.” Thomas Granatir Director of Policy & Research Humana, Inc. “ Having a financial incentive will increase hospitals’ awareness of the need to make the systematic changes necessary to avoid these errors… We are considering making non-payments for never events a standard part of our contract.” Charles Cutler, MD Chief Medical Director, Aetna
  19. 19. Practical Implications of POA Indicators <ul><li>Financial </li></ul><ul><ul><li>Revenue </li></ul></ul><ul><ul><ul><li>Increased cost of nosocomial injuries or infections </li></ul></ul></ul><ul><ul><ul><li>Increased Length of Stay (LOS) </li></ul></ul></ul><ul><ul><ul><li>Impact on revenue cycle </li></ul></ul></ul><ul><ul><ul><li>Number of conditions and revenue risk with 2009 IPPS rulings increasing. </li></ul></ul></ul><ul><ul><li>Accurate documentation is important </li></ul></ul><ul><ul><li>Nursing care accounts for 30% of total hospital operating budget and 44% of direct care costs. </li></ul></ul><ul><ul><ul><li>Payment systems do not account for the variable time nurses spend with different patients or for their efforts in providing care to different types of patients. </li></ul></ul></ul>
  20. 20. Financial Burden – POA/NI <ul><li>Kilgore (2008) – </li></ul><ul><ul><li>NI’s are associated with $12,197 in incremental cost. </li></ul></ul><ul><li>Advisory Board (2008) </li></ul><ul><ul><li>Based on projections outlined in the FY08 IPPS Final Rule CMS estimates the overall impact would be relatively modest – Expected aggregate payments to all hospitals of $20M/yr. </li></ul></ul><ul><ul><ul><li>Advisory Board – calculates for decubitus ulcers alone, worse case scenario of $283M/year </li></ul></ul></ul>
  21. 21. Financial burden <ul><li>Zahn & Miller (2003) </li></ul><ul><ul><li>Account for 18 types of medical errors could account for 2.4 million extra hospital days or $9.3B in extra charges/annually </li></ul></ul><ul><li>Kurtzman & Buerhaus (2008) </li></ul><ul><ul><li>CMS estimates in 2007 – </li></ul></ul><ul><ul><ul><li>Prevalence of certain HAC’s, up to 490,000 claims could be paid at lower rate under CMS-1533-FC – Once again, identifying a $20M savings in Medicare direct payments </li></ul></ul></ul>
  22. 22. Payment Implications: Present/Absent Decubitus Ulcers on Admission Source: Advisory Board; CMS Analysis Worst Case Scenario -9.5% -$283,432,250 $2,688,620,270 $2,972,052,520 259,356 259,356 TOTALS Cost, exclude ulcer codes Cost, as is # Discharges, exclude ulcer Codes # Discharges, as is
  23. 23. Clarifying the Mechanics of No Pay Events Patient 1 Patient 2 Patient 3 Source: Advisory Board – Nurse Executive Center $27,831 $20,208 $27,831 Basic Payment Coronary bypass w/o Cardiac Cath w/ MCC Coronary bypass w/o Cardiac Cath w/o MCC Coronary bypass w/o Cardiac Cath w/ MCC DRG Assignment (Aorto)coronary Bypass of two coronary arteries (Aorto)coronary Bypass or two coronary arteries (Aorto)coronary Bypass of two coronary arteries Primary Px Y Cardiogenic Shock Secondary Dx N Decubitus Ulcer Stage III N Decubitus Ulcer Stage III Y Decubitus Ulcer Stage III Secondary Dx Y Coronary Atherosclerosis (41401) Y Coronary Atherosclerosis (41401) Y Coronary Atherosclerosis (41401) Primary Dx POA? MS-DRG POA? MS-DRG POA? MS-DRG
  24. 24. CMS No-Pay policy targets – High-volume, costly adverse events $50,455 $71,636 $63,631 $299,237 $103,027 $44,043 $33,894 $43,180 $$ Per Hospitalization* $1.2 Million 24 Blood incompatibility $4.0 Million 57 Air emboli $47.7 Million 750 Objects left inside $20.0 Million 69 Surgical Site Infections $3.0 Billion 29,536 Vascular catheter Associated Infections $536.7 Million 12,185 Catheter Associated UTI’s $6.6 Billion 193,566 Preventable injuries – Fractures, burns, and dislocations $11.1 Billion 257,142 Pressure Ulcers Stages III, IV Total Medicare Cost* Cases * Effective Oct. 1, 2008
  25. 25. CMS No-Pay policy – High-volume, costly adverse events * At all US hospitals in fiscal year 2007 Source: CMS: O’Reily, AMNews, 7/14/08 $34.0 Million $37.5 Million $63,135 $180,142 539 208 Surgical site infections acquired in a hospital following: - Orthopedic procedures, e.g., total knee - Bariatric surgery $492.9 Million $52.0 Million $42,974 $45,989 11,469 1,131 Manifestations of poor blood glucose control: - diabetic ketoacidosis - hypoglycemic coma $7.1 Billion $50,937 140,010 Deep Vein Thrombosis or pulmonary embolism following certain orthopedic surgeries Total Medicare cost * Avg. charge per hospital stay* Cases * Effective Oct. 1 2009
  26. 26. Cost Avoidance Additional cost compared to Worst Case Scenario Additional Cost per Infection MSI – Mediastinitis
  27. 27. Aggregate Costs and Revenue at Risk of Mediastinitis (MSI) 111 Discharges with Mediastinitis in FY06 Additional Cost of Care 8x Worst case Revenue at risk .
  28. 28. Limitations – Analytical Challenges <ul><li>Lack of Information </li></ul><ul><ul><li>Lack of specific codes </li></ul></ul><ul><ul><ul><li>Only 6:8 of approved conditions have specific diagnosis codes in FY06 </li></ul></ul></ul><ul><ul><ul><li>4:6 of the tentative conditions have specific diagnosis codes in FY06 </li></ul></ul></ul><ul><ul><li>Lack of POA indicators </li></ul></ul><ul><ul><ul><li>Datasets with POA indicators not available until 2009 </li></ul></ul></ul><ul><ul><ul><li>100% coverage (entire year and hospitals) 2010 </li></ul></ul></ul>
  29. 29. Case Scenario <ul><li>Ms. Lewis, an 82 year old Medicare beneficiary is hospitalized with a diagnosis of intracerebral hemorrhage. Admitted to the ICU with neurological impairment. </li></ul><ul><ul><li>Requires: </li></ul></ul><ul><ul><ul><li>Urinary catheter for acute urinary retention. </li></ul></ul></ul><ul><ul><li>Discharged from hospital after recovery. </li></ul></ul><ul><ul><li>Hospital bills Medicare coding the UTI as “ICD-9-CM-996.64 signifying it was a complication of care </li></ul></ul><ul><ul><ul><li>Hospital is paid $8,117.05 including $1,089.91 (13%) extra for cost incurred in treating Ms. Lewis. </li></ul></ul></ul>
  30. 30. Changes Related to Inpatient Nursing Care Quality - ICU Impact Outcomes of Outlier Patients (90 th Percentile of costs) 41.% Nursing care hours % 32.4% Deaths % 44.9% 50.0% Total costs % 37.8% Total days % 48.7% ICU days % 58,473 10,606 Patients = (N) Medical University of South Carolina Data University of North Carolina Study - ICU
  31. 31. Aligning Payment Health Care Quality & Safety Nurses & Physicians
  32. 32. Patient Safety Organizations <ul><li>Joint Commission – </li></ul><ul><ul><li>National Patient Safety Goals </li></ul></ul><ul><ul><li>Mission </li></ul></ul><ul><ul><li>The mission of The Joint Commission is to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. </li></ul></ul>
  33. 35. Patient Safety Organizations <ul><li>LeapFrog Group – </li></ul><ul><ul><li>Aims to reduce medical mistakes and improve the quality and affordability of healthcare. </li></ul></ul><ul><ul><li>Encourage health care providers to publicly report their quality and outcomes so that consumers and purchasing companies can make informed health care decisions. </li></ul></ul><ul><ul><li>Reward doctors and hospitals for improving their quality, safety and affordability of health care. </li></ul></ul><ul><ul><li>Help consumers reap the benefits of making smart health care decisions. </li></ul></ul>
  34. 38. Patient Safety Organizations <ul><li>Agency for Healthcare Research and Quality (AHRQ) </li></ul><ul><ul><li>AHRQ Mission The Agency for Healthcare Research and Quality's (AHRQ) mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. Information from AHRQ's research helps people make more informed decisions and improve the quality of health care services. AHRQ was formerly known as the Agency for Health Care Policy and Research. </li></ul></ul>
  35. 40. Patient Safety Organizations <ul><li>HealthGrades </li></ul><ul><ul><li>Leading independent healthcare ratings organization. </li></ul></ul><ul><ul><li>Provides Ratings and profiles of: </li></ul></ul><ul><ul><ul><li>Hospitals </li></ul></ul></ul><ul><ul><ul><li>Nursing homes </li></ul></ul></ul><ul><ul><ul><li>Physicians </li></ul></ul></ul><ul><ul><li>Available to: </li></ul></ul><ul><ul><ul><li>Consumers </li></ul></ul></ul><ul><ul><ul><li>Corporations </li></ul></ul></ul><ul><ul><ul><li>Health plans and hospitals </li></ul></ul></ul>
  36. 41. Patient Safety Organizations <ul><li>HealthGrades </li></ul><ul><ul><li>Hospitals </li></ul></ul><ul><ul><ul><li>HealthGrades helps hospitals understand, improve and communicate the quality of care they deliver through a suite of products and physician-led clinical-advisory services. HealthGrades currently works with more than 400 hospitals nationwide and produces well-respected public studies of hospital quality in areas that include clinical excellence, patient safety and women's health. </li></ul></ul></ul>
  37. 44. Nursing <ul><li>Optimize Nursing Documentation Time </li></ul><ul><ul><li>Appropriately leverage staff nurse time for detailed admission assessment </li></ul></ul><ul><ul><li>Must be more comprehensive </li></ul></ul><ul><ul><li>Eliminate redundancies and streamline assessment forms </li></ul></ul><ul><li>Provide Data for Reporting </li></ul><ul><ul><li>Capture discrete data needed for reporting key quality indicators </li></ul></ul><ul><ul><ul><li>UTI’s </li></ul></ul></ul><ul><ul><ul><li>MRSA </li></ul></ul></ul><ul><ul><li>Facilitate automated data collection </li></ul></ul><ul><li>Inform Prevention strategies </li></ul><ul><ul><li>Reveal key important opportunities </li></ul></ul><ul><ul><li>Select and implement appropriate interventions. </li></ul></ul>
  38. 45. Physicians <ul><li>Must document NOT stage </li></ul><ul><ul><li>Detailed H&P </li></ul></ul><ul><ul><li>Identify Primary and Secondary diagnoses </li></ul></ul><ul><li>Dual penalties for: </li></ul><ul><ul><li>Over-utilized diagnostics </li></ul></ul><ul><ul><li>Longer times to treatment </li></ul></ul><ul><ul><li>Increased costs </li></ul></ul><ul><li>Increased knowledge of new coding indicator options and definitions. </li></ul><ul><ul><li>UB-04 Data Specifications manual </li></ul></ul><ul><ul><li>ICD-9-CM Official Guidelines for Coding and Reporting </li></ul></ul>
  39. 46. Evidence Based Research on Implications of POA Implementing Changes based on best practices
  40. 47. Data collection tools - Processes <ul><li>Available at </li></ul><ul><ul><li>Measurement tools </li></ul></ul><ul><ul><ul><li>Critical part of measuring and implementing changes </li></ul></ul></ul><ul><ul><ul><li>Measurement for change should not be confused with measurement for research. </li></ul></ul></ul><ul><ul><li>IHI reports: </li></ul></ul><ul><ul><ul><li>Despite numerous local improvements in various elements of ICU care, many promising improvements remain unused, fragmented, isolated and dispersed </li></ul></ul></ul><ul><ul><ul><li>Implementing system wide model of care and developing skilled, coordinated, and collaborative care teams, organizations can establish new systems of ICU care that will produce better clinical outcomes, lower costs, improved satisfaction, better coordination of care and enhanced communication with all hospital areas and departments. </li></ul></ul></ul>Source: Institute for Healthcare Improvement –
  41. 48. Measurement for Learning & Process Improvement vs. Research “ Small tests of significant changes” accelerates the rate of improvement. Can take long periods of time to obtain results Duration Gather “just enough” data to learn and complete another cycle Gather as much data as possible, “just in case” Data Stabilize the biases from test to test Control for as many biases as possible Bias Many sequential, observable tests One Large “Blind” Test Test To bring new knowledge into daily practice To discover new knowledge Purpose Measurement for Learning and Process Improvement Measurement for Research
  42. 49. Utilization of PDCA in ICU’s… AND Beyond <ul><li>Aim: (overall goal you wish to achieve) </li></ul><ul><ul><li>Every goal will require multiple smaller tests of change </li></ul></ul><ul><ul><li>Describe your first (or next) test of change: </li></ul></ul><ul><ul><li>Person responsible </li></ul></ul><ul><ul><li>When to be done </li></ul></ul><ul><ul><li>Where to be done </li></ul></ul><ul><li>Plan </li></ul><ul><ul><li>List the tasks needed to set up this test of change </li></ul></ul><ul><ul><li>Person responsible </li></ul></ul><ul><ul><li>When to be done </li></ul></ul><ul><ul><li>Where to be done . </li></ul></ul><ul><ul><li>Predict what will happen when the test is carried out </li></ul></ul><ul><ul><ul><li>Measures to determine if prediction succeeds </li></ul></ul></ul><ul><li>Do </li></ul><ul><ul><li>Describe what actually happened when you ran the test </li></ul></ul><ul><li>Check OR Study </li></ul><ul><ul><li>Describe the measured results and how they compared to the predictions </li></ul></ul><ul><li>Act </li></ul><ul><ul><li>Describe what modifications to the plan will be made for the next cycle from what you learned </li></ul></ul>Source: Institute for Healthcare Improvement
  43. 50. Sample Measures - ICU <ul><li>Critical Care – </li></ul><ul><ul><li>Average ICU Length of stay </li></ul></ul><ul><ul><li>ICU mortality rate </li></ul></ul><ul><ul><li>Percent of patients/families satisfied with care </li></ul></ul><ul><ul><li>Average days on mechanical ventilation </li></ul></ul><ul><ul><li>Percent of patients with VAP </li></ul></ul><ul><ul><li>Percent of patients with CLBSI </li></ul></ul><ul><ul><li>Percent of patients admitted with Pressure ulcers </li></ul></ul><ul><ul><li>Percent of patients admitted with UTI’s </li></ul></ul><ul><ul><li>Percent of patient falls </li></ul></ul>
  44. 51. Best Practice for preventing falls <ul><li>Optimal Assessment </li></ul><ul><ul><li>Prompt Critical Thinking </li></ul></ul><ul><ul><ul><li>Assessment driven prompts </li></ul></ul></ul><ul><ul><ul><li>Serious injury risk screening </li></ul></ul></ul><ul><ul><ul><li>Immediate post-fall diagnostics </li></ul></ul></ul><ul><li>Targeted Care Mandates </li></ul><ul><ul><li>Bolster Patient Toileting protocols </li></ul></ul><ul><ul><ul><li>Safe toileting schedule </li></ul></ul></ul><ul><ul><ul><li>Mandatory assisted toileting </li></ul></ul></ul><ul><li>360-Degree Support </li></ul><ul><ul><li>Enfranchise Patients and families </li></ul></ul><ul><ul><ul><li>Teach-back Protocol </li></ul></ul></ul><ul><ul><ul><li>Patient-Centered technologies </li></ul></ul></ul><ul><ul><ul><li>Family education tools </li></ul></ul></ul><ul><li>Innovations for Complex Patients </li></ul><ul><ul><li>Deploy Cost-Effective Alternatives for Observation </li></ul></ul><ul><ul><ul><li>Multiple room monitors </li></ul></ul></ul><ul><ul><ul><li>High-Risk Video Surveillance </li></ul></ul></ul>
  45. 52. Best Practice for Preventing Pressure Ulcers <ul><li>Complete Head-to-toe assessment </li></ul><ul><li>Assess for risk using the Braden scale and reassess during status changes </li></ul><ul><li>Order nutrition consult </li></ul><ul><li>Turn and position patient every two hours </li></ul><ul><li>Use moisturizers on dry skin </li></ul><ul><li>Don’t massage bony prominences </li></ul><ul><li>Protect skin of incontinent patients from moisture </li></ul>
  46. 53. Nursing directives on measuring cost, quality, and intensity of nursing care <ul><li>Develop ways to predict which patients are at risk of developing HAC on admission to the hospital and provide interventions to decrease adverse events before they occur </li></ul><ul><li>Identify relationships between nurses and patients to better understand the effects of nursing intensity, direct nursing costs, expertise, academic preparation, skill mix, and other nurse-specific characteristics on outcomes of care. </li></ul>
  47. 54. Nursing directives on measuring cost, quality, and intensity of nursing care <ul><li>Create methods to compare inpatient nursing performance across hospitals to identify inequities between nursing intensity, performance, and reimbursement rates </li></ul><ul><li>Place renewed focus and attention on patients with high cost, high resource use, and extended length of stay, who expend a disproportionate amount of days, dollars, and deaths at US hospitals. </li></ul>Welton, 2008: JONA Vol. 38, No. 7/8.
  48. 55. Established Protocols for Prevention <ul><li>Pressure Ulcer Prevention Guidelines </li></ul><ul><ul><li>New Jersey Hospital Association </li></ul></ul><ul><ul><ul><li>NO ULCERS </li></ul></ul></ul><ul><ul><ul><li>N – Nutrition and fluid status </li></ul></ul></ul><ul><ul><ul><li>O – Observation of skin </li></ul></ul></ul><ul><ul><ul><li>U – Up and walking or turn/position </li></ul></ul></ul><ul><ul><ul><li>L – Lift, don’t drag skin </li></ul></ul></ul><ul><ul><ul><li>C – Clean skin and continence care </li></ul></ul></ul><ul><ul><ul><li>E – Elevate heals </li></ul></ul></ul><ul><ul><ul><li>R – Risk Assessment </li></ul></ul></ul><ul><ul><ul><li>S – Support surfaces </li></ul></ul></ul>
  49. 56. Established Protocols for Prevention <ul><li>VHA – Volunteer Hospital Association </li></ul><ul><ul><li>Fall Prevention Toolkit </li></ul></ul><ul><ul><ul><li>High Risk room set up </li></ul></ul></ul><ul><ul><ul><li>Medication Review </li></ul></ul></ul><ul><ul><ul><li>Toileting schedules </li></ul></ul></ul><ul><ul><ul><li>Increased Observation (Rounding, video monitoring) </li></ul></ul></ul><ul><ul><ul><li>Visual identification </li></ul></ul></ul><ul><ul><ul><li>Protective devices </li></ul></ul></ul><ul><ul><ul><li>Bed/chair alarms </li></ul></ul></ul><ul><ul><ul><li>Mobility aids </li></ul></ul></ul>
  50. 57. Established Communication Tools <ul><li>SBAR </li></ul><ul><ul><li>S – Situation </li></ul></ul><ul><ul><li>B – Background </li></ul></ul><ul><ul><li>A – Assessment </li></ul></ul><ul><ul><li>R – Recommendations </li></ul></ul><ul><li>Purpose – Provides framework for communicating between members of the health care team about a patient’s condition. </li></ul><ul><ul><li>Easy to remember. </li></ul></ul><ul><ul><li>Concrete mechanism useful for framing any communication, especially critical ones. </li></ul></ul><ul><ul><li>Allows for easy and focused way to set expectations for what will be communicated and how between members of the team. </li></ul></ul>
  51. 58. Transforming Care at the Bedside (TCAB) <ul><li>Through IHI and the Robert Wood Johnson foundation </li></ul><ul><ul><li>Framework for change </li></ul></ul><ul><ul><li>Improved communications </li></ul></ul><ul><ul><li>Improved and redesigned work areas </li></ul></ul><ul><ul><li>Improved care practices to identify & prevent: </li></ul></ul><ul><ul><ul><li>Pressure ulcers </li></ul></ul></ul><ul><ul><ul><li>UTI’s </li></ul></ul></ul><ul><ul><ul><li>DVT’s </li></ul></ul></ul><ul><ul><ul><li>Falls </li></ul></ul></ul>
  52. 59. POA Identification Methodology and Hospital Acquired Complication reduction Risk Assessment
  53. 60. Pre-Determined comprehensive analysis programs <ul><li>PDCA’s </li></ul><ul><li>Simplified database analysis </li></ul><ul><li>Utilization of Infectious Disease department to assist with </li></ul><ul><ul><li>Reporting methods </li></ul></ul><ul><ul><ul><li>UTI’s </li></ul></ul></ul><ul><ul><ul><li>CLBSI </li></ul></ul></ul><ul><ul><ul><li>VAP </li></ul></ul></ul><ul><ul><li>Dissemination of data to staff </li></ul></ul><ul><ul><ul><li>Graphs (monthly, quarterly, annually) </li></ul></ul></ul><ul><ul><li>Creating action plans to correct issues. </li></ul></ul>
  54. 61. PDCA or PDSA – Process Flow
  55. 62. POA Surveillance - Goals
  56. 63. POA - Surveillance
  57. 64. POA Surveillance
  58. 65. POA Surveillance
  59. 66. Project Initiative Tool: Average Variable Cost per day 5 Avg. Length of stay (ALOS) - days $1400 Total Avg. Cost/day for target population* $685 Total (Avg. variable cost/day) 50 All other 75 Supplies 300 Nursing 60 Pharmacy 125 Radiology $75 Laboratory Example Your Unit Patient Subgroups
  60. 67. Run Charts Source: Institute for Healthcare Improvement
  61. 68. Flow Charts Source: Institute for Healthcare Improvement
  62. 69. Flow Charts Source: Institute for Healthcare Improvement
  63. 70. Cause & Effect Charts - Fishbone
  64. 71. Cause & Effect - Process Source: Institute for Healthcare Improvement
  65. 72. Summary <ul><li>The Centers for Medicare and Medicaid Services will no longer pay for additional costs of care related to Hospital Acquired Conditions such as pressure ulcers and nosocomial infections, falls, pneumonia, objects left in after surgery, transfusion reactions, and air embolisms. </li></ul><ul><li>Hospitals must strongly implement methods to identify best practices, utilize evidence base research, and educate clinical staff on the importance of nursing care as it pertains to improved clinical quality, improved outcomes, and improved reimbursement rates. </li></ul>
  66. 73. Thank You Contact Information Todd M. Grivetti, MSN, RN, CCRN, CNML [email_address] [email_address]
  67. 74. References <ul><li>Advisory Board Company. 2008. Hospital Acquired Conditions: Implications of CMS’s Present on Admission Provisions. </li></ul><ul><li>Advisory Board Company. 2008. Safeguarding Against Nursing Never Events. Washington, D.C. </li></ul><ul><li>Aiken, L. 2008. Economics in Nursing. Policy, Politics, & Nursing Practice. 9 (2) 73-79. </li></ul><ul><li>Ash, A. 2008. Measuring Quality. Medical Care. 46:2 – 105-108. </li></ul><ul><li>Catalano, K. 2008. Preventable Hospital Acquired Conditions: The Whys and Wherefores. Plastic Surgical Nursing . 28:3 – 158-161. </li></ul><ul><li>Finkler, S. 2008. Measuring and Accounting for the Intensity of Nursing Care. Is it Worthwhile? Policy, Politics & Nursing Practice. 9 (2). 112-117. </li></ul><ul><li>Ginsburg, P. 2008. Paying Hospitals on the Basis of Nursing Intensity: Policy and Political Considerations. Policy, Politics & Nursing Care. 9 (2) 118 – 120. </li></ul><ul><li>Glance, L., Osler, T., Mukamel, D., Dick, A. 2008. Impact of the Present on Admission Indicator on Hospital Quality Measurement: Experience with the Agency for Healthcare Research and Quality (AHRQ) Inpatient Quality Indicators. Medical Care. 46 (2) 112-119. </li></ul><ul><li>Iezzoni, L. 2007. Finally Present on Admission but Needs Attention. Editorial. Medical Care . 45 (4). 280-282. </li></ul>
  68. 75. References <ul><li>Kilgore, M., Ghosh, K., Beavers, M., Wong, D., Hymel, P., Brossette, S. 2008. The cost of Nosocomial Infections. Medical Care. 46 (1) 101-104. </li></ul><ul><li>Kohn, L., Corrigan, J., Donaldson, M. 2000. To Err is Human: Building a Safer Health System. Institute of Medicine Executive Summary. </li></ul><ul><li>Kurtzman, E., Buerhaus, P. 2008. New Medicare Payment Rules: Danger or opportunity for nursing? AJN 108 (6) 30-35. </li></ul><ul><li>Needleman, J. 2008. Is What’s Good for the patient Good for the Hospital: Aligning Incentives and the Business care for nursing. Policy, Politics & Nursing Practice. 9 (2) 80-87. </li></ul><ul><li>Unruh, L., Hassmiller, S., Reinhard, S. 2008. The Importance and Challenge of Paying for Quality Nursing Care. Policy, Politics & Nursing Practice. 9 (2) 68-72. </li></ul><ul><li>Welton, J. 2008. Implications of Medicare Reimbursement Changes Related to Inpatient Nursing Care Quality. JONA 38 (7/8) 325-330. </li></ul>

Notas del editor