Joint Commission Publishes new Monograph about CLABSIs

On May 16th, the Joint Commission released a new Monograph reviewing the most recent evidence and thoughts surrounding Central Line-Associated Bloodstream Infections.

The free monograph can be downloaded here: http://www.jointcommission.org/assets/1/18/CLABSI_Monograph.pdf

Below is an excerpt from the press release announcing the free monograph (emphasis added in red):


New Monograph Aims to Decrease Central Line-Associated Bloodstream Infections (CLABSIs)

The Joint Commission, in collaboration with Joint Commission Resources (JCR) and Joint Commission International (JCI), developed a new monograph containing the most current information, evidence-based guidance and resources to help health care organizations reduce the current risks and resulting harm associated with CLABSI. JCR and JCI are not-for-profit affiliates of The Joint Commission. The monograph was produced in partnership with infection prevention leaders from the Society for Hospital Epidemiology of America (SHEA), the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC), the National Institutes of Health (NIH), the Infectious Diseases Society of America (IDSA), the Association for Vascular Access (AVA), and the International Nosocomial Infection Control Consortium (INICC). In addition, several other domestic and international infection prevention leaders from countries such as Argentina, Australia, Egypt, Switzerland, Thailand and Saudi Arabia have lent their expertise to the monograph.

“Recent patient safety initiatives have demonstrated how preventable CLABSIs can be when evidence-based guidelines are consistently put into practice at the bedside,” says Jerod M. Loeb, Ph.D., executive vice president, Division of Healthcare Quality Evaluation, The Joint Commission. “Our hope is that these resources will empower health care providers to implement practices that have been shown to not only improve patient safety, but also reduce costs.”

The project is supported by a research grant from Baxter Healthcare Corporation and focuses on the identification and broad dissemination of preferred practices and technological solutions to prevent CLABSI. 

Schneck Medical Center (Seymour, IN) Named 2011 Baldrige Award Recipient

Schneck Medical Center of Seymour, Indiana, was named a 2011 Baldrige Award Recipient in the Healthcare Category. Schneck is the first organization from Indiana to receive the Baldrige Award.

Until recently, Indiana did not have a State level Baldrige-based award program. Schneck thus partnered with the Ohio Partnership for Excellence. The Ohio program has since expanded its scope and now covers the State of Indiana (as well as West Virginia). The program has now been renamed The Partnership for Excellence.

The press release announcing the other Baldrige Award winners can be found here.

The profile of Schneck Medical Center released with the announcement can be found here.

Below are excerpts from the profile of Schneck Medical Center outlining its quality performance that may be interesting to the healthcare quality professional. Note that the 50 page Baldrige application from Schneck will become public domain in a few months and thus awailable for public examination and learning. Schneck (as required by all Baldrige award winners) will also be participating in national and regional conferences where they will be sharing thier Baldrige journey.

• SMC consistently demonstrates high levels of performance in relation to patient-focused health care measures. Specifically, on 17 of 22 core measures reported for the Centers for Medicare and Medicaid Services (CMS), SMC scored 100 percent in the second quarter of 2011.
• SMC ranked second among 94 hospitals in its geographic region and outperformed all local competitors when measured for its value-based purchasing (VBP). VBP is a method that holds health care providers accountable for the quality and cost of their services through a system of rewards and consequences. Incentives discourage inappropriate, unnecessary, and costly care.
• Patient satisfaction surveys reflect SMC’s year-to-year favorable performance, meeting or exceeding top 10 percent or top 25 percent levels on nine of 10 Press Ganey (a national consulting firm focused on improving health care performance) measures, including inpatient quality of care, inpatient family support, inpatient coordination of care, and inpatient customer service. On measures of ambulatory care, including timeliness, customer service, and ambulatory education, SMC’s performance exceeds the top 25 percent level.
• SMC’s commitment to a “Patient First” culture has led to many innovative health care options. For example, to address its limited treatment options for myocardial infarctions, SMC and its largest competitor, located 25 miles away, created a collaborative initiative for coordinated handoffs of patients needing emergency cardiac catheterizations. Through this effort, “door-to-balloon” times (the critical period for assessing and diagnosing a heart attack and delivering the needed intervention) have been reduced from 120 to as low as 60 minutes, ensuring patients get the best and quickest treatment.
• SMC has achieved high performance levels in all areas measured by the Hospital Consumer Assessment of Healthcare Providers and Systems, with SMC outperforming its Indiana peers from 2008 to 2011 (year-to-date) in the areas related to the ability of nurses and physicians to listen, understand, and provide clear discharge instructions.
• SMC demonstrates role-model performance through its low overall rates of hospital-acquired infections, which have been maintained at or below 1 percent since 2008. There have been no occurrences of postoperative infections from bariatric surgeries, one of SMC’s focus areas. No patient has acquired ventilator-associated pneumonia since 2009, while central line-associated bloodstream infections have remained at low numbers since 2008, with zero cases in 2011 (year-to-date).
• SMC demonstrates excellence in measures of its operating margin, cash flow, and cash position, with its reported results comparing favorably to the Standard & Poor’s (S&P) “A-” and “AA” rated median levels. From 2008 to 2010, SMC’s gross revenue results showed growth in the organization’s strategic focus areas—women’s health, joint replacement, noninvasive cardiac care, cancer care, and bariatric surgery.

CMS Announces final details of Value Based Purchasing for Inpatient Acute Care

On April 29th, CMS announced the final rules of its upcoming Value Based Purchasing program for Inpatient Acute Care. This long anticipated program transitions the inpatient care provided to Medicare beneficaries from "pay for reporting" to "pay for performance".

The HHS press release itself is of little value to the healthcare quality professional. You can view it here: http://www.hhs.gov/news/press/2011pres/04/20110429a.html. However, it links to a CMS press release that contained more details. You can view it here: http://www.cms.gov/apps/media/press/factsheet.asp?Counter=3947.

Although these rules become effective with fiscal year 2013, CMS also released the list of measures for 2014 as well.

The following are excerpts from the CMS press release:


PERFORMANCE SCORING:

Performance Period: CMS has established a performance period that runs from July 1, 2011 through March 31, 2012, for the FY 2013 Hospital VBP payment determination. CMS anticipates that in future program years, if it becomes feasible, it may propose to use a full year as the performance period.

Scoring Methods: CMS will score each hospital based on achievement and improvement ranges for each applicable measure. A hospital’s score on each measure will be the higher of an achievement score in the performance period or an improvement score, which is determined by comparing the hospital’s score in the performance period with its score during a baseline period.

For scoring on achievement, hospitals will be measured based on how much their current performance differs from all other hospitals’ baseline period performance. Points will then be awarded based on the hospital’s performance compared to the threshold and benchmark scores for all hospitals. Points will only be awarded for achievement if the hospital’s performance during the performance period exceeds a minimum rate called the “threshold,” which is defined by CMS as the 50th percentile of hospital scores during the baseline period.

For scoring on improvement, hospitals will be assessed based on how much their current performance changes from their own baseline period performance. Points will then be awarded based on how much distance they cover between that baseline and the benchmark score. Points will only be awarded for improvement if the hospital’s performance improved from their performance during the baseline period.

Finally, CMS will calculate a Total Performance Score (TPS) for each hospital by combining the greater of its achievement or improvement points on each measure to determine a score for each domain, multiplying each domain score by the proposed domain weight and adding the weighted scores together. In FY 2013, the clinical process of care domain will be weighted at 70 percent and the patient experience of care domain will be weighted at 30 percent.

Incentive Payment Calculations: CMS will utilize a linear exchange function to calculate the percentage of value-based incentive payment earned by each hospital. Those hospitals that receive higher Total Performance Scores will receive higher incentive payments than those that receive lower Total Performance Scores. CMS will notify each hospital of the estimated amount of its value-based incentive payment for FY 2013 through its QualityNet account at least 60 days prior to Oct. 1, 2012. CMS will notify each hospital of the exact amount of its value-based incentive payment on Nov. 1, 2012.

FISCAL YEAR 2013 MEASURES

Clinical Process of Care Measures
AMI-7a - Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
AMI-8a - Primary PCI Received Within 90 Minutes of Hospital Arrival
HF-1 - Discharge Instructions
PN-3b - Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hospital
PN-6 - Initial Antibiotic Selection for CAP in Immunocompetent Patient
SCIP-Inf-1 - Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
SCIP-Inf-2 - Prophylactic Antibiotic Selection for Surgical Patients
SCIP-Inf-3 - Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
SCIP-Inf-4 - Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose
SCIP-Card-2 - Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period
SCIP-VTE-1 - Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered
SCIP-VTE-2 - Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery

Patient Experience of Care Measures (HCAHPS)
· Communication with Nurses
· Communication with Doctors
· Responsiveness of Hospital Staff
· Pain Management
· Communication About Medicines
· Cleanliness and Quietness of Hospital Environment
· Discharge Information
· Overall Rating of Hospital

ADDITIONAL MEASURES FINALIZED FOR FY2014

Mortality Measures:
· Mortality-30-AMI: Acute Myocardial Infarction (AMI) 30-day Mortality Rate
· Mortality-30-HF: Heart Failure (HF) 30-day Mortality Rate
· Mortality-30-PN: Pneumonia (PN) 30-Day Mortality Rate

Hospital Acquired Condition Measures:
· Foreign Object Retained After Surgery
· Air Embolism
· Blood Incompatibility
· Pressure Ulcer Stages III & IV
· Falls and Trauma: (Includes: Fracture, Dislocation, Intracranial Injury, Crushing Injury, Burn, Electric Shock)
· Vascular Catheter-Associated Infections
· Catheter-Associated Urinary Tract Infection (UTI)
· Manifestations of Poor Glycemic Control

AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs), and Composite Measures:
· Complication/patient safety for selected indicators (composite)
· Mortality for selected medical conditions (composite)

Unadjusted "Fall and Trauma" Rates for Hospitals in Indiana

On April 6, 2011, CMS released a spreadsheet linked to its Hospital Compare website showing the frequency of the eight (8) Hospital Acquired Conditions (HAC) in hospitals participating in the Medicare Program. This data set is of Medicare beneficiaries only, is not risk adjusted for the severity of the patients, and is based on administrative data only for patients discharged between Oct 1, 2008 to June 30, 2010.

The data can be downloaded from CMS here.

The table below shows the performance of the listed Indiana hospitals for the "Fall and Trauma" measure sorted from high to low.

Hospital name	Rate (per 1,000 discharges)	Number of eligible discharges (Denominator)	Number of HACs (Numerator)	National HAC rate (per 1,000 discharges)
UNITY MEDICAL AND SURGICAL HOSPITAL	7.634	131	1	0.564
RIVERVIEW HOSPITAL	2.428	3707	9	0.564
THE HEART HOSPITAL AT DEACONESS GATEWAY LLC	1.878	1065	2	0.564
SAINT CATHERINE REGIONAL HOSPITAL	1.641	1219	2	0.564
FAYETTE REGIONAL HEALTH SYSTEM	1.553	1932	3	0.564
REID HOSPITAL & HEALTH CARE SERVICES	1.257	9549	12	0.564
FRANCISCAN PHYSICIANS HOSPITAL LLC	1.233	811	1	0.564
MEMORIAL HOSPITAL OF SOUTH BEND	1.205	9955	12	0.564
ST. CLARE MEDICAL CENTER	1.179	1697	2	0.564
WITHAM HEALTH SERVICES	1.174	1704	2	0.564
KOSCIUSKO COMMUNITY HOSPITAL	1.084	2767	3	0.564
PARKVIEW HUNTINGTON HOSPITAL	1.065	939	1	0.564
INDIANA UNIVERSITY HEALTH ARNETT HOSPITAL	1.02	4904	5	0.564
MARION GENERAL HOSPITAL	0.962	4158	4	0.564
HENRY COUNTY MEMORIAL HOSPITAL	0.957	3134	3	0.564
BLUFFTON REGIONAL MEDICAL CENTER	0.944	2118	2	0.564
CLARK MEMORIAL HOSPITAL	0.932	8581	8	0.564
INDIANA UNIVERSITY HEALTH NORTH HOSPITAL	0.906	3313	3	0.564
COMMUNITY HOSPITAL NORTH	0.9	6664	6	0.564
ST. FRANCIS HOSPITAL - BEECH GROVE	0.853	9377	8	0.564
THE ORTHOPAEDIC HOSPITAL	0.788	1269	1	0.564
ST. VINCENT CARMEL HOSPITAL, INC.	0.767	2609	2	0.564
ST. MARGARET MERCY - DYER	0.725	5515	4	0.564
WESTVIEW HOSPITAL	0.7	1429	1	0.564
INDIANA UNIVERSITY HEALTH WEST HOSPITAL	0.689	4352	3	0.564
ELKHART GENERAL HOSPITAL	0.676	8879	6	0.564
GOOD SAMARITAN HOSPITAL	0.641	6241	4	0.564
DEARBORN COUNTY HOSPITAL	0.617	3239	2	0.564
DUPONT HOSPITAL LLC	0.603	1658	1	0.564
BALL MEMORIAL HOSPITAL INC	0.591	11840	7	0.564
METHODIST HOSPITALS, INC	0.588	13602	8	0.564
ST. CATHERINE HOSPITAL, INC	0.576	5211	3	0.564
INDIANA ORTHOPAEDIC HOSPITAL LLC	0.565	1770	1	0.564
COMMUNITY HOSPITAL	0.557	16165	9	0.564
COMMUNITY HOSPITAL SOUTH, INC.	0.549	5468	3	0.564
SAINT ANTHONY MEDICAL CENTER	0.545	9179	5	0.564
SAINT JOSEPH REGIONAL MEDICAL CENTER - SOUTH BEND	0.541	11100	6	0.564
LUTHERAN HOSPITAL OF INDIANA	0.535	13088	7	0.564
INDIANA HEART HOSPITAL, THE	0.528	3791	2	0.564
ST. MARY'S MEDICAL CENTER OF EVANSVILLE INC	0.514	11672	6	0.564
GOSHEN GENERAL HOSPITAL	0.489	4088	2	0.564
PORTER HOSPITAL, LLC, VALPARAISO HOSP CAMPUS	0.481	10389	5	0.564
PARKVIEW HOSPITAL	0.465	10748	5	0.564
MAJOR HOSPITAL	0.457	2189	1	0.564
BLOOMINGTON HOSPITAL	0.445	8981	4	0.564
ST. FRANCIS HOSPITAL - MOORESVILLE	0.435	2299	1	0.564
DEACONESS HOSPITAL INC	0.422	18959	8	0.564
SCHNECK MEDICAL CENTER	0.421	2378	1	0.564
JOHNSON MEMORIAL HOSPITAL	0.421	2378	1	0.564
TERRE HAUTE REGIONAL HOSPITAL	0.411	4861	2	0.564
MEMORIAL HOSPITAL AND HEALTH CARE CENTER	0.385	5190	2	0.564
UNION HOSPITAL INC	0.383	13057	5	0.564
ST. JOSEPH HOSPITAL	0.381	2626	1	0.564
FLOYD MEMORIAL HOSPITAL AND HEALTH SERVICES	0.375	10678	4	0.564
WILLIAM N WISHARD MEMORIAL HOSPITAL	0.368	5431	2	0.564
ST. VINCENT HOSPITALS AND HEALTH SERVICES	0.358	19569	7	0.564
CLARIAN HEALTH PARTNERS, INCORPORATED	0.321	28027	9	0.564
ST. FRANCIS HOSPITAL - INDIANAPOLIS	0.313	6388	2	0.564
COLUMBUS REGIONAL HOSPITAL	0.296	6766	2	0.564
THE KING'S DAUGHTERS' HOSPITAL AND HEALTH SERVICES	0.28	3574	1	0.564
ST. ELIZABETH EAST	0.244	4090	1	0.564
COMMUNITY HOSPITAL EAST	0.244	8195	2	0.564
LA PORTE HOSPITAL AND HEALTH SERVICES	0.235	4263	1	0.564
ST. MARGARET MERCY HEALTHCARE CENTERS - HAMMOND	0.228	8754	2	0.564
ST. MARY MEDICAL CENTER, INC.	0.224	8912	2	0.564
ST. ELIZABETH CENTRAL	0.219	4558	1	0.564
COMMUNITY HOSPITAL OF ANDERSON AND MADISON COUNTY	0.179	5601	1	0.564
SAINT JOHN'S HEALTH SYSTEM	0.169	5918	1	0.564
SAINT ANTHONY MEMORIAL HEALTH CENTER	0	5335	0	0.564
KENTUCKIANA MEDICAL CENTER LLC	0	619	0	0.564
MEMORIAL HOSPITAL	0	1480	0	0.564
HENDRICKS REGIONAL HEALTH	0	3423	0	0.564
DAVIESS COMMUNITY HOSPITAL	0	1727	0	0.564
HOWARD REGIONAL HEALTH SYSTEM	0	4148	0	0.564
PHYSICIANS' MEDICAL CENTER LLC	0	180	0	0.564
SURGICAL HOSPITAL OF MUNSTER	0	31	0	0.564
ST. JOSEPH HOSPITAL & HEALTH CENTER, INC	0	3856	0	0.564
PINNACLE HOSPITAL	0	542	0	0.564
HANCOCK REGIONAL HOSPITAL	0	2989	0	0.564
MONROE HOSPITAL	0	1335	0	0.564
ST. VINCENT HEART CENTER OF INDIANA, LLC	0	5756	0	0.564
WOMEN'S HOSPITAL, THE	0	114	0	0.564
PARKVIEW WHITLEY HOSPITAL	0	807	0	0.564
STARKE MEMORIAL HOSPITAL	0	785	0	0.564
PARKVIEW NOBLE HOSPITAL	0	1175	0	0.564
SAINT JOSEPH REGIONAL MEDICAL CENTER - PLYMOUTH	0	1773	0	0.564
DEKALB MEMORIAL HOSPITAL INC	0	1100	0	0.564
MORGAN HOSPITAL AND MEDICAL CENTER	0	1472	0	0.564
ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH LLC	0	1039	0	0.564