Hospital Outpatient Quality Reporting Program

1. Hospital Outpatient Quality Reporting Program Kayur V. Patel, MD, MRO,FACP, FACPE Physician Consultant Health Care Excel, Inc.

2. Objectives • Describe the outpatient measures as the measures relate to rural and Critical Assess Hospitals • Demonstrate the importance of hospitals publically reporting outpatient measures and share best practices

3. Hospital Outpatient Quality Reporting (OQR) Program • Background: • Centers for Medicare & Medicaid Services (CMS) implemented quality measure reporting programs for multiple settings of care. • These programs promote higher quality, more efficient health care for Medicare beneficiaries. • Hospital OQR Program focused on measures that have high impact and support CMS priorities for improved quality and efficiency of care for Medicare beneficiaries.

4. Chart Abstracted Measures • OP-1: Median Time to Fibrinolysis • OP-2: Fibrinolytic Therapy Received Within 30 Minutes • OP-3: Median Time to Transfer to Another Facility for Acute Coronary Intervention • OP-4: Aspirin at Arrival • OP-5: Median Time to ECG • OP-6: Timing of Antibiotic Prophylaxis • OP-7: Prophylactic Antibiotic Selection for Surgical Patients

5. Claims-Based Measures • OP-8: MRI Lumbar Spine for Low Back Pain • OP-9: Mammography Follow-up Rates • OP-10: Abdomen CT: Use of Contrast Material • OP-11: Thorax CT: Use of Contrast Material • OP-13: Cardiac Imaging for Preoperative Risk Assessment for Non Cardiac Low Risk Surgery

6. Claims-Based Measures cont. • OP-14: Simultaneous Use of Brain Computed Tomography (CT) and Sinus Computed Tomography • OP-15: Use of Brain Computed Tomography in the Emergency Department for Atraumatic Headache

7. Why Important! Reasons why these measures are important!

8. Successes • Educate staff • Include measures as part of the annual staff performance evaluation • Transparency • Accountability for outliers • Celebrating and rewarding successes

9. Lessons Learned • Develop physician orientation to review measures • Continue to work with departments to ensure compliance on the measures • Need to have a physician champion • Create a culture where staff are accountable for their performance

14. Need to fill additional campuses’ if there are any.

15. Need to fill in contacts

17. For PPS Hospitals No Choice to publish results or not

18. For CAH with choice to Publicly Report or not. Save

19. Results of the Abstracted Measures Q32011

20. Benefits of Participating • Assistance for improving data collection and reporting of quality measures • Reports available to help hospitals identify opportunities to improve clinical quality • By publicly reporting data, a hospital demonstrates commitment to making meaningful information about performance available to the public and can encourage patients to make informed decisions about where to access health care services

21. Questions? Kayur V. Patel, MD, MRO, FACP, FACPE Physician Consultant KPatel@hce.org Cathie Pritchard, Quality Data Reporting Technologist 812-234-1499, extension 229 cpritchard@inqio.sdps.org This material was prepared by Health Care Excel, the Medicare Quality Improvement Organization for Indiana , under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-IN-INDPAT-11-007 09/06/2011