Taking Charge of Our Future

1. Taking Charge of Our Future Key Hospital Initiatives 2009-2010 Shirley Schlessinger, MD Associate Dean for Graduate Medical Education

2. Be Aware! • Recent Joint Commission Survey • DRG Assurance Program is on-going (are we documenting all our patient’s problems?) • “Present on Admission” documentation means saving the hospital money • National Patient Safety Goals have been updated • Hospitalcompare.gov / CMS reporting—We can do better! • UHC Benchmarking- ditto • Organ Donation / Conversion Rates can be better!

3. TJC: The “Joint” • TJC accreditation of our hospitals is critical for training program accreditation • Site survey in February 2009 with Continued Accreditation, but Opportunities identified • We have done poorly in a number of areas because of PHYSICIAN behaviors!

4. Key Problem Areas: • Must DATE and TIME all orders • Do NOT use “unacceptable abbreviations” • Avoid DOSE-RANGE orders • No verbal orders except in emergencies; telephone orders to be co-signed within 24 hours • Orders, Notes, and SIGNATURES must be legible!!!!! • H&P or update must be completed within 24 hours of admission • Medication Reconciliation FORMS must be completed with status changes • TIME-OUT & Hand-washing still problems!

5. The DRG Assurance Program: A performance improvement program utilizing a concurrent review process to promote accurate DRG classification according to the regulatory compliance standards set forth by CMS

8. Documentation • Reflects the care you provided • If it’s not documented, “it” never happened • Reflects severity of illness through selection of: • Principal Diagnosis • Secondary Diagnoses • Procedures Performed

9. General Rules Regarding Secondary Diagnoses • Secondary diagnoses require at least one of the following: • Clinical evaluation • Therapeutic treatment • Diagnostic procedures • Extends length of hospital stay • Increased nursing care and/or monitoring

10. Probable, Possible, Suspected, and Unable to Rule Out In the inpatient setting you may use the Probably, Possible, Suspected and unable to Rule Out. If the condition is Ruled Out then state such and it will not be coded.

11. Our Goal Accuracy Accurate documentation appropriately reflects the severity of illness of our patients and the most accurate risk of mortality.

12. Medicare Changes- “POA” • Present on Admission = POA • To better measure hospital performance (good and bad) • To increase validity of hospital report cards related to quality • Distinguish between pre-existing conditions and hospital acquired conditions ($$)

13. Identified Conditions • Decubitus Ulcers • Catheter Associated UTIs • Vascular Catheter Associated Infections • Falls, Burns – Trauma while inpatient • Mediastinitis that Follows Heart Surgery • Object Left in Surgery • Air Embolism • Blood Incompatibility

14. Potential Implications to UMHC • Our public image • Financial

15. Patient: Granny Smith

16. Granny Smith

17. What does this mean? • Last year if the patient developed a UTI post catheter placement we were paid $9463.34 • NOW, we are not reimbursed the additional $1,270.69

18. Granny has surgery Medicare DRG 470 Major Joint Replacement w/o MCC CMS Wt: 1.9871 ALOS 4.0 GLOS 3.7 Principal DX 996.43 Prosthetic joint implant failure Secondary DX 599 Urinary tract infection 780.97 Altered mental status 401.9 HTN 244.9 Hypothyroidism Principal Procedure 81.52 Partial hip replacement Estimated Payment: $15,800.85

19. Granny has surgery Medicare DRG 469 Major Joint Replacement w MCC CMS Wt: 2.6664 ALOS 8.4 GLOS 7.1 Principal DX 996.43 Prosthetic joint implant failure Secondary DX 707.03 Decubitus ulcer, lower back 599.0 Urinary tract infection 780.97 Altered mental status 401.9 HTN 244.9 Hypothyroidism Principal Procedure 81.52 Partial hip replacement Estimated Payment: $21,202.45

20. What does this mean? • Last year if the patient developed a decubitus while hospitalized we were paid $21,202.45 • Now, we are not reimbursed the additional $5,401.60

21. What can you do? • Complete initial admission assessments to include visual inspection of the skin • Document all findings in the medical record • Remember possible, probable and suspected are ok to use in the inpatient setting • Wash your hands • Follow all protocols for dressing changes, IV line insertions and care, foley cath insertions and care

22. National Patient Safety Goals • Identify patients correctly • Improve staff communication • Use medications safely • Prevent infection • Accurately reconcile medications across the continuum of care • Prevent patients from falling • Help patients to be involved in their care • Identify patient safety risks • Improve recognition and response to changes in patient’s condition • Prevent errors in surgery

23. Hospital Compare - A quality tool for adults, including people with Medicare Find and Compare Hospitals Welcome to Hospital Compare. This tool provides you with information on how well the hospitals care for all their adult patients with certain conditions or procedures. This information will help you compare the quality of care hospitals provide. Talk to your doctor about this information to help you, your family and your friends make your best hospital care decisions. Hospital Compare was created through the efforts of the Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services, and other members of the Hospital Quality Alliance: Improving Care Through Information (HQA). The information on this website has been provided primarily by hospitals that have agreed to submit quality information for Hospital Compare to make public.

25. University Hospital Consortium (UHC) Benchmarking: • Similar to CMS reporting, but a broader range of measures • Compares us to other Academic Medical Centers • We are making progress, but many opportunities for performance improvement

31. JCAHO REQUIREMENTS • Federally identified OPO • Procedures in place for notifying OPO in • a “timely manner” of deaths and/or impending deaths • Procedures in place for notifying family of donation option by trained requestor • Written documentation of consent or decline • Hospital works with OPO to educate staff on donation issues • 2005 “Conversion Rates” Focus----75%!!!

32. Organ Donation at UMHC • 2006 conversion 34% • 2007 conversion 63% • 2008 conversion 72% • To date 2009 conversion rate 53% • Active “Donation after Cardiac Death” protocols • Brain Death declaration check sheets available • Potential Donor management protocols available

33. The Potential Organ Donor • Absolute Exclusions • Active UNTREATABLE infection • CURRENT malignancy • (Specific ORGAN failure may rule out organ but NOT donor!)

34. Consent for Organ Donation • Federal regulations mandate ONLY “trained requestors” approach families for donation consent • Minimal acceptable “training” 8 hours • Numerous variables are felt to impact families likelihood to donate • Consent is a PROCESS not a QUESTION!

35. What YOU Can Do… • Learn the FACTS about organ donation • Decide your personal donor status • Tell your family and friends about your donation wishes • Look for opportunities to help others learn about donation • Talk to your patients about donation in advanced directive discussions • ALWAYS follow hospital and federal regulations regarding offering families donation option