ED Accreditation Update

Quality Check measures added by Joint Commission

As of January 2010, The Joint Commission has incorporated into its Quality Check web site (www.qualitycheck.org/consumer/searchQCR.aspx) the Centers for Medicare & Medicaid Services' (CMS') 30-day readmission rates for heart attack, heart failure, and pneumonia Medicare patients.

Quality Check displays data on National Quality Improvement Goals for hospitals on selected performance measures in six treatment areas: children's asthma care, heart attack, heart failure, pneumonia, pregnancy, surgical care, and pregnancy. The ED's performance in all of these areas becomes part of the hospital's data submission to Quality Check. That information then can be accessed by consumers as part of their search for hospital care.

Bruce S. Auerbach, MD, FACEP, vice president and chief, emergency and ambulatory services at Sturdy Memorial Hospital in Attleboro, MA, says, "Once a person has been admitted to the hospital, the ED really has no further involvement in what goes on while in they're in the hospital or upon discharge." However, he notes, "Some EDs have instituted programs that process or provide more care in the ED or through which patients are overseen in adjacent areas — like observation or clinical decision units — as a means to manage those individuals they think they can take care of within a 24-hour-period and not admit them." These patients, he continues, will be discharged from the ED or the other units, in which case the ED staff that oversee that unit will provide discharge instructions, he says.

In addition, he notes, some institutions will put case managers in the ED. "Because they have so much to do with discharge planning, they will use them in the ED even for patients who are being admitted since they can start work early on discharge planning so that when they're discharged there are no obstacles in the way of going home," Auerbach explains. (For more information, see the story below.)

Margaret VanAmringe, vice president of public policy and government relations in the Washington, DC, office of The Joint Commission, says that in addition to accreditation status and performance data, the Quality Check site also indicates "merit badges" for organizations that meet certain criteria for recognition, such as the Malcolm Baldrige National Quality Award. That annual award recognizes U.S. organizations in the health care, business, education, and nonprofit sectors for performance excellence.

Why were these particular measures added? "We're trying to follow what is going on at the Hospital Compare web site [www.hospitalcompare.hhs.gov] so that people who got to ours do not have to go to another site just to get a couple of measures that are part our core measures set," VanAmringe explains. "We really had to be careful about these three because they are only for Medicare patients, while all the others are for all adult patients." That presents the need to identify for consumers that the cohort is narrower, and that by and large it only represents the elderly, she says.

The need to show "good" numbers in these areas has taken on increased importance with the emphasis placed by national organizations on limiting preventable readmissions. The need for positive numbers might increase soon, warns VanAmringe. "Everybody right now, from a public policy and quality and safety standpoint, is looking at preventable readmissions, and if Congress passes a health care reform bill and it has a penalty for high readmission rates, then it becomes a monetary incentive as a quality and safety issue," she notes.

Data hold the key to low readmit rates

With The Joint Commission incorporating the Centers for Medicare & Medicaid Services' (CMS) 30-day readmission rates for heart attack, heart failure, and pneumonia Medicare patients into its Quality Check web site (www.qualitycheck.org/consumer/searchQCR.aspx), the performance of individual facilities will come under greater scrutiny. Additionally, health care reform legislation might include penalties for poor performance.

As a first step toward decreasing readmission rates, examine your data, says Margaret VanAmringe, MPH, vice president of public policy and government relations in the Washington, DC, office of The Joint Commission. "Look at readmissions and discern whether there are opportunities to reduce the number," she advises. "That will, of course, depend on disease category, population, age, and many different factors."

It will behoove you "to really analyze readmissions, assess these data, use a random sample of charts, and look to see if there is a certain group of patients in these three areas where you feel there could be the potential to prevent readmissions," VanAmringe says.

Michael C. Choo, MD, MBA, FACEP, FAAEM, ACHE, president and CEO of Clinton Memorial Hospital in Wilmington, OH, says, "It's always been very important to evaluate the data on a monthly basis and find solutions." Choo, who served for 10 years as the ED medical director at Dayton Heart Hospital, is bringing what he learned there to his new position. "Congestive heart failure is the most difficult of the three because it's especially problematic in [the Medicare] population," he says. "Initiatives we've used include trying to identify at the time of discharge those patients who need extra support at home or additional education." For those patients who are identified as high-risk, arrangements are made for intense home health care followed by outpatient therapy sessions, he says. His current health system has Congestive Heart Failure clinics, where patients' status is monitored to make sure they stay stable and don't return to the ED or the hospital, he says.

Myocardial infarctions and pneumonia are much easier, he says. "At the time of discharge, we make sure to assess the risk for return, such as home situation compliance probabilities, and communicate those risks with the primary care physician," Choo says. If the patient qualifies, he adds, home health care is recommended.

In the end, says Choo, "it comes down to how well you work with case managers. They identify the risks and coordinate discharge planning, education, and follow-up so the condition does not exacerbate." He has become "much more aggressively proactive in managing these issues," and, in fact, has begun placing case managers within the ED.

With sites such as Quality Check and hospitalcompare, VanAmringe adds, there also is a definite opportunity for benchmarking and for contacting facilities that are performing well and comparing notes. "Health care providers are very interested in comparing how they're doing, and what percentile they're in, compared either with similar facilities or those, say, in the same state," she says. "Being able to benchmark and compare is a very important aspect of quality improvement."