6 Steps to Meet CMS' Stroke Quality Reporting Requirements
Beginning Jan. 1, 2013, hospitals and health systems will be required to report data on 76 measures for CMS' Hospital Inpatient Quality Reporting Program to receive full Medicare reimbursement in 2015. The 76 measures feature several new measures from previous years, including eight for stroke care: venous thromboembolism prophylaxis, antithrombotic therapy for ischemic stroke, anticoagulation therapy for A-fib/A-flutter, thrombolytic therapy for acute ischemic stroke, antithrombotic therapy by the end of hospital day two, discharged on statin, stroke education and assessment for rehab.
If healthcare facilities fail to report these measures, they risk not only receiving reduced reimbursement beginning in 2015, but also losing an opportunity to improve quality, increase volume and compete effectively with other stroke providers. In addition, while the Hospital IQR Program bases reimbursement only on the action of reporting the data, the Value-Based Purchasing Program will penalize hospitals for not meeting performance standards for certain IQR measures. The eight stroke measures are not currently included in the VBP Program, but they could be in the future, meaning hospitals should work to both report and improve outcomes in those areas. Timothy Shephard, PhD, vice president of Bon Secours Neuroscience Institute in Virginia, shares six steps to correctly report each measure and use the reporting to improve the organization's overall clinical and financial strength.
1. Recognize the value of reporting quality data. The goal of the quality reporting program is to ensure hospitals are implementing evidence-based standards of care. However, the program can have more far-reaching effects than the quality of one service line. Improving quality in even one area can play a role in reducing readmissions, which can help hospitals avoid financial penalties for an excessive amount of preventable readmissions. Standardizing clinical processes can also improve throughput and decrease length of stay and complication rates — other sources of cost for hospitals. "I encourage [hospitals] to be intentional about using data to improve their stroke care," Dr. Shephard says. "If they have to capture and submit data, they should maximize the value of the process as it will make a clinical and fiscal difference."
In addition to clinical and financial implications, reporting quality data and using the data to improve performance could have legal implications for a hospital, Dr. Shephard says, especially because patients will have access to hospitals' performance data. "As things become more transparent, if [hospitals] market a service and can't deliver, their liability will increase."
2. Assess the relevance of stroke measures to the organization. While the reporting requirements apply to all hospitals receiving Medicare reimbursement, the impact of the requirements can vary depending on the role of stroke care in an individual hospital. Dr. Shephard suggests hospitals assess the importance of the service to the hospital's overall strategic plan to determine the amount of resources dedicated to collecting, analyzing and acting on the data. "The hospital must understand the relevance of the program based on the general strategy for the hospital, he says." For example, he says a children's hospital or boutique orthopedic hospital may not want to expend resources on a population they don't primarily target. A hospital with a neuroscience center, however, should focus on meeting or exceeding the requirements to remain competitive in the market for stroke care.
"If hospitals are intentional about their efforts — if they discern how [the reporting program] fits into their strategy relative to the primary focus of their hospital and define gaps in the community services — it can be a very beneficial process. If they look at it as just another process pushed by CMS, they will have more difficulty and realize very little benefit from the process," he says.
3. Consider the viability of establishing a certified stroke or neuroscience center. The quality reporting requirements present an opportunity for hospitals to revamp their entire neuroscience service line. Hospitals should study the local market to identify any gaps in care that the hospital could fill by expanding their neuroscience services. Stroke patients can have a "significant impact" on a hospital's performance because they often raise the bar for a comprehensive range of services, such as emergency medical services collaboration, ED processes, imaging techniques and rehabilitation care, to address their needs, Dr. Shephard says.
If a hospital decides to pursue the Primary Stroke Center designation by The Joint Commission, it should integrate the quality reporting program into efforts to meet certification guidelines. While Stroke Center certification will require hospitals to report on additional measures, the CMS program can help hospitals become acclimated to the process of collecting and analyzing data for this patient population. "It's a beneficial process regardless if your facility desires to become a stroke or neuroscience center, but it's an essential process if you want to grow into a stroke or neuroscience center," he says.
Hospitals that already have a certified stroke or neuroscience center are accustomed to reporting these quality metrics. However, they should compare The Joint Commission's requirements to those of CMS to ensure they do not need to record additional measures, Dr. Shephard suggests.
4. Recruit strong leaders. Strong neuroscience leadership is essential for nearly every major initiative. Regulations that deal with specific clinical information and that could affect reimbursement may demand greater diligence in finding appropriate leaders, however. "If you don't have skilled leadership clinically and administratively, the CMS measures will be a quagmire," Dr. Shephard says. Collecting and analyzing neuroscience and stroke data appropriately requires neuroscience-specific knowledge. "For hospitals that lack neuroscience expertise and administrators, it will be more challenging."
5. Execute performance-improvement methods. The performance-improvement process requires several steps: capture and validate data, analyze the data, determine how the data impacts the program, develop improvement strategies based on the data analysis, implement improvement strategies; study the results; and continue changing strategies until goals are met. Most importantly is to quantify the fiscal impact of the performance improvement process to clearly demonstrate the costs and benefits of the time and resources expended while improving care and outcomes, Dr. Shephard says. This process, whether organized in a Lean, Six Sigma or Plan-Do-Study-Act approach, will reveal either a flaw in the process of care delivery or in the documentation of care delivery, according to Dr. Shephard.
6. Improve documentation. Documentation problems are the culprit of performance deficiencies as often as actual care deficits, Dr. Shephard says. The key to efficient documentation is to standardize who is responsible for different kinds of documentation and where documentation will be placed in the medical record. For example, documentation on whether a patient was educated on his or her stroke medication may be recorded by the nurse and filed only in nurses' notes. Currently, many hospitals duplicate documents and have to search for documentation in different places to find the measure needed. Standardizing who is responsible for each piece of documentation and where the data is placed will allow hospitals to record accurate data more quickly and will ease their data abstraction processes. "Again, it is the very deliberate act to dissect these mundane processes of healthcare delivery that will yield notable benefits in cost savings and improved clinical care," Dr. Shephard says.
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