ED Accreditation Update

Joint Commission adds outpatient measures, 5 will have a direct impact on ED managers

The Joint Commission has added an initial set of seven hospital outpatient measures to its current complement of core measure sets that may be used to satisfy ORYX performance measurement requirements. ORYX is the Joint Commission initiative that integrates outcomes and other performance measurement data into the accreditation process.

The hospital outpatient measures are in the calendar year 2008 final rule for the outpatient prospective payment system (OPPS) from the Centers for Medicare & Medicaid Services (CMS). The OPPS rule requires that data collection for these measures begin in April 2008.

"We initially developed a set of 10 measures, seven of which CMS decided were 'ready for prime time,'" explains Jerod M. Loeb, PhD, executive vice president for quality measurement and research at The Joint Commission. Of the seven measures, he says, these five will directly affect the ED:

  • median time to fibrinolysis;
  • fibrinolytic therapy received within 30 minutes of hospital arrival;
  • median time to transfer to another facility for acute coronary intervention;
  • aspirin on arrival;
  • median time to EKG.

"These measures really focus in on systems and processes [that must be] in place to rapidly triage and treat patients with chest pain," Loeb continues. "The ED manager has to have evidence-based practices in place that ensure with a fair degree of accuracy that the diagnosis will be made in timely manner and that appropriate processes are in place to provide therapy quickly."

Millie Perich, Joint Commission associate project director over OPPS measures, AMI, and heart failure, says, "The goal is to get that patient seen immediately, have a process in place that ensures they get the EKG and aspirin quickly, and if they require acute coronary intervention like a bypass and you can't provide that care, that the patient is carried out in a timely manner, because 'minutes are muscle.'"

All of these require careful preplanning, adds Loeb. "It can also involve interplay between the ED and the EMTs, because they may do the EKG en route," he says. "The system, processes, and staffing must be in place."

These measures are really intended to help organizations measure current performance so they can identify opportunities for improvement, notes Linda Hanold, The Joint Commission's director of the Department of Quality Measurement. "If you track your rates over time, you can look for those opportunities," Hanold says.

Money is the new element

The current move by The Joint Commission is "not revolutionary," notes Dennis Beck, MD, FACEP, CEO of Denver-based Beacon Medical Services, an emergency medicine practice management company, and chair of the American College of Emergency Physicians' (ACEP) quality and performance committee.

"The fact is that actually the aspirin and empiric antibiotic were there before [as core measures] and other programs measured time to fibrinolysis and time to EKG, so the fact that CMS has now implemented this does not come as a big surprise," he says. "But now, there's a financial stake tied to it through the pay for performance movement."

He explains that CMS will be requiring hospitals to report on performance levels for these measures, or face a 2% 'market basket' reduction in reimbursement. "Margins are slim enough that they obviously have to participate and report," he adds.

ED physicians should be well prepared for this change, he says. Some of the measures, such as aspirin on arrival, already were part of the Physician Quality Reporting Initiative (PQRI), a voluntary program instituted by CMS in July 2007, he says. "Antibiotic selection is also tied into PQRI, so those two are already being reported on," he says. "There are now 199 different PQRI measures, of which a limited number are appropriate for ED physicians, but ED docs are eligible for a 1.5% bonus based on all their Medicare allowables."

In addition, notes Beck, "ACEP has challenged us to educate the members as to what the measures are and how to document them."

'System' measures

Some of the newer measures, such as median time to EKG and transfer for acute coronary intervention, as well as the two that apply to fibrinolysis, are system measures, Beck says.

"Some others can be attributed directly to doctors, but these are dependent upon the interaction of the ED doc, ED staffing as well as hospital staffing, and protocols and processes you put in place to meet these benchmarks," he says.

While nurse managers will be expected to be accountable for reporting on these measures and department performance, they, like the physicians, will not be operating in a vacuum. "This will require cooperation between nurses and doctors, and in some cases collaboration with the rest of the hospital — or even other hospitals," notes Beck. "For example, with the time to transfer, you would typically have transfer agreements already in place." This might involve having a single number to call or a single facility for whom you are part of their referral system, he says.

ED managers should actively monitor their own data, Beck says. "For example, with aspirin on admission, which is typically done by protocol, review the data abstraction and reporting, and if it's not what it should be, you've got to identify where the 'lesion' is," he advises. "For example, protocols may be in place but they are not getting implemented, or perhaps you do not have the proper protocols in place."

Much of your success will be dictated by whether you have a standardized approach, says Beck. "For example, when a patient comes in with chest pain, everyone should know that an EKG ought to get done within 10 minutes," he observes. "Or if it is a STEMI [ST-segment elevation myocardial infarction] MI, and your facility does fibrinolysis, it should be started within 30 minutes."

Create leverage

Oftentimes, says Loeb, Joint Commission and CMS requirements such as those can create valuable leverage, enabling the ED manager to get the additional resources the department needs.

"We are looking at reimbursement, accreditation, and ultimately public reporting of these data," he notes. "So, for example, you could justify the need for another EKG in the ED because one machine for seven rooms is not enough to ensure the timeliness required by The Joint Commission."

Or, he adds, you might obtain approval for additional discussions with tertiary facilities in your catchment area because you don't have a catheterization lab and there are not a sufficient number of transfer facilities lined up in advance. "These requirements provide the ED manager with leverage — and its leverage to do the right thing," Loeb says.

These seven measures are just the initial set, Loeb says. More will be added in the years ahead. "It was the expectation of Congress that the original measures would be increased in 2009, so CMS needs to figure out how they wish to do that," he explains. "There are more coming, but we don't yet know how many more, which measures, and which clinical areas will be involved."


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