Data Collection Support Webinar

2. Data Collection Support Webinar MetaStar, Inc. June 18, 2008 Pam Clemens Candi Davis

3. Announcements • ICD Population and Sampling Counts • Counts for 1Q08 due by August 1st • Best estimate of the patient caseload as of abstraction date • Slight fluctuations of a few cases due to ICD-9 coding corrections are expected • Glaring differences will be monitored

4. Announcements • Inactive QualityNet Accounts • Sign in at least monthly to maintain an “active” status and minimize delays in accessing My QualityNet for data submission or report retrieval • Your account is “locked” following 120 days of inactivity

5. Announcements • Revised QualityNet Security Administrator Forms and Instructions • QualityNet Security Administrators can manage outpatient measures in addition to inpatient measures • Those registering for both the inpatient and outpatient setting are required to mail their completed forms to their QIO • Contact the QualityNet Help Desk to obtain the registration forms and instructions to register an administrator for the outpatient measures only

6. Updates • 3Q07 Validation Final Results • Week 12 • 4 PPS hospitals failed • 7 CAH hospitals failed • 4Q07 Validation Cases have been selected • Due on June 30th

7. Updates • Validation Mismatches: • Invalid record sent (hospice admission) • Incorrect dates of service (wrong admission) • Laparoscopic • Comfort measures only • Antibiotic dose

8. Updates • Antibiotic Dose Abstraction Reminders • The chart must be taken at face value • An external abstractor can only abstract what is documented • Per Spec Manual, you must abstract all doses administered within 36 hours of hospital arrival • As you are unable to determine whether or not undated doses were administered within the 36 hours, the undated doses must be abstracted

9. Updates • Antibiotic Dose Reminders • If a MAR is undated, the physician order cannot be used to determine if the doses were within 36 hours after arrival or not • All doses that are undated must be abstracted • Any doses that are untimed and could be within 36 hours based on the date must be abstracted • This includes narrative documentation in operative reports • Improve the completeness of medication documentation! • Reference: Quest # 121830, 146634, and #142588

10. Questions and Answers • Q: Can you explain the data element “laparoscope”? • A: “…if any additional incision is made, a port is used, or the small incisions that have to be made to insert the laparoscopic instruments are extended, you must answer ‘no’ to the data element.”

11. Questions and Answers • A: “…for many operations the answer to ‘laparoscopic’ will be no because to remove organs (such as a segment of colon), you often have to extend incisions or create new ones. We are clarifying this in an upcoming version of the hospital manual.” • Information provided by Dr. Dale Bratzler on the SCIP Listserve

12. Questions and Answers • Q: What is the SCIP Listserve and how do I sign up? • A: Sign up at www.medqic.org • Under “Hospital” tab, click on SCIP • Click on “Other Resources” • Scroll down to “SCIP Listserve Joining Instructions” • The SCIP Listserve is a community forum for open discussion and sharing. Currently the list has over 2,200 subscribers nationwide

13. Questions and Answers • Q: Do we have to abstract antibiotic doses documented in narrative reports? • A: “In narrative documentation, documentation that reflects the actual administration of the antibiotic can be abstracted. Use ‘UTD’ for any missing information.” • Reference Quest # 143234 & #131326

14. Questions and Answers • A: “If the entries on the records are all identical in content (date, time, route, name) only one has to be abstracted. If there is a difference in the entries, they should all be abstracted. If any of the data is missing, abstract as UTD.”

15. Questions and Answers • Q: Can you confirm that documentation of patient refusal (VTE Prophylaxis) by nurses and others is acceptable in spite of the language in the allowable values? • A: “April 01, 2008 Discharges Forward: Patient refusal does not have to be documented by a physician/APN/PA, but it must be documented in the timeframe of 24 hours prior to surgery to 24 hours after surgery end time.” • (Reference Quest # 157827).

16. Questions and Answers • Q: What is the impact on pneumonia measures when answering “UTD” for the question diagnosis of pneumonia on admission? • A: “Cases are subject to abstraction ONLY if a final diagnosis of pneumonia is on the patient’s bill. So, we assume that all patients for whom chart reviews is undertaken are ultimately diagnosed with pneumonia at some point during the hospital stay. A case is only eligible for the admission performance measures (timely antibiotics, oxygenation, blood cultures) if the ED diagnosis/admit diagnosis for the case includes pneumonia.”

17. Questions and Answers • A: “One way to avoid having cases eligible for the pneumonia measures in the past was simply to leave the ED diagnosis lines on the chart blank. So, for now, if the ED diagnosis is not completed and the case is in the pneumonia measure denominator population, the case will fail the admission measures. The ED physicians need to document their final diagnosis.” • Reference Quest # 166479 & #82291)

18. Questions and Answers • Q: What are the hot topics for 2 Quarter 2008 abstraction?

19. New Contact Information • Kim Horton • 608.441.8253 • Pat Schachtner • 608.441.8213

20. Questions/Feedback

21. Contact Information: MetaStar, Inc. 2909 Landmark Place Madison, WI 53713 (608) 274-1940 or (800) 362-2320 www.metastar.com This material was prepared by MetaStar under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 8SOW-WI-INP-08-37.