Hospital Outpatient Quality Reporting Program

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Hospital Outpatient Quality Reporting Program

• Kayur V. Patel, MD, MRO,FACP, FACPE
• Physician Consultant
• Health Care Excel, Inc.

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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

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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.

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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

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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

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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

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Why Important!

• Reasons why these measures are important!

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Successes

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

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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

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Hospital Outpatient Quality Reporting (OQR) Program Hospital Outpatient Quality Reporting (OQR) Program Hospital Outpatient Quality Reporting (OQR) Program Hospital Outpatient Quality Reporting (OQR) Program
Critical Access Hospitals Reporting Hospital OQR Program Data Critical Access Hospitals Reporting Hospital OQR Program Data Critical Access Hospitals Reporting Hospital OQR Program Data Critical Access Hospitals Reporting Hospital OQR Program Data
Health Care Excel, Indiana Health Care Excel, Indiana Health Care Excel, Indiana Health Care Excel, Indiana
The summary report identifies the total number of Medicare Critical Access Hospitals (CAH) The summary report identifies the total number of Medicare Critical Access Hospitals (CAH) The summary report identifies the total number of Medicare Critical Access Hospitals (CAH) The summary report identifies the total number of Medicare Critical Access Hospitals (CAH)
in the state, and the number and percentage of CAHs reporting Hospital OQR Program Data. in the state, and the number and percentage of CAHs reporting Hospital OQR Program Data. in the state, and the number and percentage of CAHs reporting Hospital OQR Program Data. in the state, and the number and percentage of CAHs reporting Hospital OQR Program Data.
       
  Q111 Q211 Q311
Total CAH 35 35 35
Number Reporting 12 14 13
Percentage Reporting 34.3 40.0 37.1
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For PPS Hospitals No Choice to publish results
or not
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For CAH with choice to Publicly Report or not.
Save
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Results of the Abstracted Measures Q32011
  OP-1 OP-2 OP-3 OP-4 OP-5 OP-6 OP-7
Average 27.75 minutes 100 55 minutes 95.91 5.27 minutes 90.11 91.78
State Performance 27 minutes 64 45 minutes 95 6 minutes 95 96
National Performance 29 minutes 57 60 minutes 96 8 minutes 95 95
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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

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Questions?

• Kayur V. Patel, MD, MRO, FACP, FACPE
• Physician Consultant
• KPatel_at_hce.org
• Cathie Pritchard, Quality Data Reporting
  Technologist
• 812-234-1499, extension 229
• cpritchard_at_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