8/6/2018. Quality Improvement Basics for Ambulatory Clinics Part Two. Goals. What is ecqi?

Transcription

1 Quality Improvement Basics for Ambulatory Clinics Part Two ecqi: A Comprehensive Approach to MIPS Sharon Phelps, RN, BSN, CPHIMS, CHTS-CP Mountain-Pacific Quality Health August 8, 2018 Goals 1) Review and understand key concepts of Electronic Clinical Quality Improvement (ecqi) 2) Review and understand the ecqi process 3) Identify alignment opportunities across MIPS categories and quality programs for identified areas of need 4) Discuss using patient experience data within a Quality Improvement Program. 2 What is ecqi? Optimizing health information technology (HIT) and standardized electronic data to achieve measurable improvement in quality of care Streamlining quality reporting and improving accuracy of electronic health record (EHR) data through improvement of data entry process and user workflows within EHR Incorporating data and functionality of EHR into quality improvement projects as part of daily work 3 1

2 ecqi: A Combination of 1 EHR functionality Computer Provider Order Entry (CPOE) Clinical Decision Support (CDS) Patient portal/engagement Patient panels/tracking/risk stratification Health Information Exchange (HIE) Interfaces and registries Report utilities/population analytics Evidence-based clinical best practices Data tracking and analytics Proven quality improvement methodologies 4 ecqi The bottom line It is simply a name for a consistent methodology and approach for providers and hospitals to utilize EHR data and technology to improve care delivery. EHRs are now mainstream. This methodology literally applies to EVERY PROJECT IN HEALTH CARE TODAY! EHRs are used to enter patient data. EHRs are used to mine patient data. EHRs are used to guide and decide the course of patient care. EHRs are used to share patient information. EHRs should be used to improve care! 5 As said by Dr. Allen Gee: We need to learn to use our EHRs as tools to provide better care and make improvements to the delivery of care. It is not intended to simply be a record of what we did today. Dr. Allen Gee Neurologist 6 2

3 Certified Electronic Health Record Technology (CEHRT) 7 STANDARDS used in CEHRT Use of standardized language for certain functions: LOINC ICD 10 SNOMED CT NCPDP Script Standards Logical observation identifiers names and codes International statistical classification of diseases and related health problems Systematized nomenclature of medicine clinical terms HL7 Health language 7 National Council for Prescription Drug Programs Standard language sets the stage for standardized and efficient national quality reporting. 8 What CEHRT standards do NOT mean: Certification means EHR workflows are standardized or accessibility is universal. It simply indicates software has met basic functional criteria to support Meaningful Use (MU). The outcome = software differs greatly in workflow between companies and even between installations. EHR software vendors apply their functionality and interpret rules (MU, Physician Quality Reporting System [PQRS], MIPS, etc.) in different ways. 9 3

4 All roads lead to structured data If it is not documented in a discrete field, the system does not know it happened and cannot trigger the next event. CDS rules and other functionality will not work Reports will be inaccurate Billing may not be accurate either Pertinent patient information does not get where it needs to be 10 How to do ecqi! 11 ecqi Process Cycle 12 4

5 ecqi Project Process 1. Identify project and develop a project team 2. Determine project scope 3. Determine metrics (align with quality measures) 4. Identify changes and create change backlog (list of possible changes/process measures to help improve outcome measure) 5. Prioritize change backlog based on value of each change 6. Create sprint/pdsa cycle 7. Plan sprint/pdsa cycle 8. Complete PDSA cycle 9. Perform a review 10. Update and reprioritize change backlog 11. Begin new sprint 13 ecqi Process Steps 1-3: Identify and develop a project team Determine project scope Determine metrics 14 ecqi Process Step 4: Identify EHR change points If there is no struggle, there is no progress. - Frederick Douglass 15 5

6 What is a change point? Specific points or steps within the process that could be changed to improve data output and/or the clinical outcome. 16 Change Identification Method 1: Data Validation Process 17 What do we mean by data validation? Using a process to ensure data pulled from the EHR reflects the care being delivered and documented. (Don t laugh, it can happen!) 18 6

7 A data validation process will: Help clearly identify problem areas in EHR on which to focus Improve data entry, because it is now being monitored and used for improvement Build reliability and confidence in data output for reporting to external entities 19 Report s generated... Now what? Validate your report data by: Working backwards from the report to ensure data being collected is data you want for your metric Getting patient level data and find the field that is supposed to be populated that feeds the report Once you find the right fields, ensuring this is where providers and staff are actually trained to document Ensuring there are not other areas where the same item can be/is being documented 20 An example of a data validation process: 6. Does the report reflect what you found? 1. Run report. 2. Run patient list. Who met the denominator? Who met the numerator? 5. Talk to staff. Do they usually document there? 3. Review patient content. 4. Find data field. 21 7

8 The data validation change point is key: Once the opportunity for improvement has been identified through report validation, use the rest of the ecqi process to improve the accuracy of information being entered and reported out. This is a very important first change step! It results in valid reports so your future changes are backed by solid data. 22 Change Identification Method 2: Workflow Reviews 23 Purpose of workflow analysis Creating a visual map of workflows can increase key stakeholder understanding of the process, allowing further quality improvement to occur by acting as: Information display Visual/thought stimulation Data collection tool Change management tool Discovery method for RCA 24 8

9 When to use a workflow exercise: Bad data ( garbage in, garbage out ) Process is wasteful Root cause analysis/problem/error prone area New device/product/supply is added to current process Patient/staff dissatisfied with current process Examples: Data collection and reporting for MIPS is burdensome, no one believes the data Patient scheduling takes too long Increase in med errors with bedside barcode scanning 25 Layers of Workflows in ecqi Physical Electronic Data Includes environmental layout of patient room, equipment, devices and supplies How is the work documented? What screens and fields are used? Where does the documented information go? Why does it go there (triggers or reports)? How does it get there (interfaces, uploads, etc.)? 26 Analyzing Workflows 27 9

10 General Rules of Thumb Clearly define and understand the scope of the process you are planning to map. Keep it small you have three layers now! Map the REALITY not the DREAM what is actually occurring on a daily basis. Don t solve the problem before you map it out. You may solve the wrong problem and never solve the real one. 28 Staff Participation Short term pains = long term gains Cover a few hours work = accurate flow mapping Go to them! Get out of the conference room! Simply watch them work and document it Display the mapping for staff in break room. Have them write feedback on sticky notes and put the notes on the map Incentives work, too 29 Physical Workflows Environmental layout of patient room, equipment, devices, supplies, etc. Use floor plans if available or just sketch it out Count physical steps between significant places: Number of steps from patient room to med room, supply room and documentation stations/computers Steps from computer to printer 30 10

11 Physical change point analysis: How many steps is it to a documentation area? How many steps to a printer? How often do they have to go to the printer? Are staff using the portable equipment/laptops, etc.? Why not? Work through barriers. Take users concerns about technology seriously and help them to adapt with training, role playing and testing equipment until they are comfortable. Set expectations of using equipment and monitor performance. If everything else is at the bedside, how far away are supplies and medications? What needs to change to support EHR use as a tool? 31 EHR Workflow Mapping Does the software company already have it done? DON T BE AFRAID TO ASK! Compare your workflow to the software company what is different? Take screenshots at each point of data entry Get multiple steps on a screenshot; just keep track of them with a numbering system One step is defined as one point of data entry Where is each component entered? Who is entering it? Does it trigger a key next step to the process? Where does that data go? Does it go anywhere? To stay focused, keep in mind your purpose for workflow analysis 32 EHR workflow example (cont.) 36 11

12 EHR Change Point Analysis Questions How many steps are staff really going through, what is reasonable for the task? Be sure to multiply the steps by how many times a day staff would be doing the task to understand the realistic data entry effect. Example: Patient has 12 medications to be given per shift x 20 steps to enter each medication in the chart = 240 steps for medication entry for that patient per shift. Is that reasonable? Do the right staff have the right user access to enter the right information? What needs to change to improve EHR use as a tool? 34 Information/Data Flow Mapping Data/information flow mapping: Define data type Text, string, date, value, formula, etc. Determine where each data point travels and what function/process happens as a result of data getting there Example: Does it trigger a Clinical Decision Support (CDS) rule, or need to go to an interface? How many different people, modules, applications or forms are capturing the same data? Does duplicate information flow or does it have to be entered by multiple different people? Determine if it is reportable data 35 Data Flow Analysis Questions? Are the key data points that should flow ACTUALLY flowing where they are needed? Why not? What needs to change to support EHR use as a tool? 36 12

13 In Summary All of the tools we reviewed can be used to identify specific steps in a process, either EHR or physical, that need to be changed to improve data collection and outcomes. 1. Data Validation 2. Physical workflow analysis 3. Electronic workflow analysis 4. Information flow analysis 37 Change points have been identified, now what? Let s go back to the ecqi process. 38 ecqi Project Process 1. Identify project and develop a project team 2. Determine project scope 3. Determine metrics (align with quality measures) 4. Identify changes and create change backlog (a list of possible changes/process measures that will help improve the outcome measure) 5. Prioritize change backlog based on value of each change 6. Create spring/pdsa cycle 7. Plan sprint/pdsa cycle 8. Complete PDSA cycle 9. Perform a review 10. Update and reprioritize change backlog 11. Begin new sprint 39 13

14 Change Backlog: Identify and Prioritize Changes As changes are identified, create change backlog (list of possible changes/process measures to help improve outcome measure) Prioritize change backlog based on value of each change 40 Create PDSA Sprint Cycles 41 ecqi Project Process 1. Identify project and develop a project team 2. Determine project scope 3. Determine metrics (align with quality measures) 4. Identify changes and create change backlog (a list of possible changes/process measures that will help improve the outcome measure) 5. Prioritize change backlog based on value of each change 6. Create sprint/pdsa cycle 7. Plan sprint/pdsa cycle 8. Complete PDSA cycle 9. Perform a review 10. Update and reprioritize change backlog 11. Begin new sprint 42 14

15 PDSA Cycle Template: Create sprint/pdsa cycle Plan sprint/pdsa cycle Complete PDSA cycle Perform a review Update and reprioritize change backlog Begin new sprint 43 MIPS: Getting Started with ecqi Let s apply ecqi to MIPS 44 ecqi Keep in Mind When choosing ecqi projects: Focus on return on investment opportunities as well (financial, efficiency gains, resource utilization, etc.) Review current quality program requirements, align project for biggest return on investment or alignment across programs For MIPS: If possible, choose an ecqi project outcome or activity that benefits more than one MIPS category 45 15

16 MIPS ecqi Process 1. Run the required Quality Measures and Advancing Care Information (ACI) reports. 2. Choose Quality Measures that align with other program requirements (CPC+, PCMH). 3. Compare current performance to goals. 4. Complete a data validation process and review required workflows. 5. Correct workflow entry should start to improve your performance on measures then utilize more accurate data to support more quality improvement. 46 MIPS - Example 1 CQM - Diabetes Foot Exam CMS 123/MIPS Confirm correct data entry in EHR for CQM. 2. Set up a clinical decision support (CDS) rule to enhance your workflow (alert for DM patients being seen who are due for a foot exam). 3. Use ecqi process to monitor progress and continued improvement. Benefits: MIPS: Improve score for Quality, PI and IA for primary care and specialists MIPS: Receive 10% bonus for use of EHR in IA Improve patient satisfaction (CAHPS) Improve data and advance use of EHR to improve patient safety and quality reporting accuracy 47 MIPS - Example 2 Align with existing community diabetes classes 1. Utilize EHR data to identify high-risk DM patient panel. 2. Utilize EHR functionality to provide patient education and establish care plans/set goals. 3. Coordinate with existing resources to provide DM education (DEEP or other) to patients. 4. Utilize ecqi process to monitor progress and continued improvement. Benefits: MIPS: Improve score for Quality, PI, IA and Cost MIPS: Receive 10 percent bonus for use of EHR in IA Reduce burden and cost for clinic (classes available via QIO or other community resources) 48 16

17 ecqi Proven Results Improved consistency on workflows and use of EHR Trained staff on repeatable QI process for ongoing use Improved clinical outcomes for patients Rapid improvement gains on PDSA goals (PDSA cycles or sprints average time = 30 days) Improved alignment of QI projects and resources Automated data tracking for ecqi projects and consistent/validated data Efficient approach; reduces time and resource use 49 MIPS ecqi Resources Mountain-Pacific ecqi resources and templates CMS MIPS Quality Measures CMS MIPS Advancing Care Information Measures CMS MIPS Improvement Activities Lists CMS information on Medicare Transition of Care Management Code CMS Antimicrobial Stewardship/MIPS crosswalk 50 Resource Links Health IT/electronic enabled Clinical QI (healthit.gov) Mountain-Pacific ecqi resources Certified Health IT Product List (healthit.gov)

18 Questions or Comments? Developed by Mountain-Pacific Quality Health, the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Montana, Wyoming, Alaska, Hawaii and the U.S. Pacific Territories of Guam and American Samoa and the Commonwealth of the Northern Mariana Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Contents presented do not necessarily reflect CMS policy. 11SOW-MPQHF-WY-D Acronyms AMI Acute Myocardial Infarction (heart attack) CAH critical access hospital CART CMS Abstraction and Reporting Tool CEHRT Certified Electronic Health Record Technology CMS Centers for Medicare and Medicaid Services ecqi electronic Clinical Quality Improvement ecqm Electronic Clinical Quality Measure ED Emergency Department EDTC Emergency Department Transfer Communication EHR Electronic Health Record 53 Acronyms (cont.) HIT Health Information Technology HCAHPS - hospital consumer assessment of healthcare providers & systems HRSA Health Resources and Services Administration IQR Inpatient Quality Reporting IMM Immunizations IQR inpatient quality reporting OP Outpatient PDSA Plan, Do, Study, Act QCDR Qualified Clinical Data Registry QI Quality improvement VBP Value Based Payment 54 18