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Implications of CMS’s Present on Admission Provisions in the ICU: Making Dollars and Sense Todd M. Grivetti, MSN, RN, CCRN, CNML Clinical Nurse Manager Regional Neurosciences Center Poudre Valley Hospital Ft. Collins, CO 2008 Award Recipient
Disclosure Statement ,[object Object],[object Object],[object Object],[object Object]
House Keeping tips ,[object Object],[object Object],[object Object],[object Object]
Learning Objectives ,[object Object],[object Object],[object Object],[object Object]
Definitions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Evolution to Quality Based Payment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Evolution to Quality Based Payment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Evolution to Quality Based Payments ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Deficit Reduction Act - 2005 ,[object Object],[object Object]
Hospital Acquired Conditions selected for Present on Admission Provisions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Hospital Acquired Conditions selected for Present on Admission Provisions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Hospital Acquired Conditions selected for Present on Admission Provisions ,[object Object],[object Object],[object Object],[object Object]
Phased Implementation of POA ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Phased Implementation of POA ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Practical Implications of POA Financial Clarifying Implications Limitations
Practical Implications of POA Indicators ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Source: CMS - HAC/POA
POA Indicator Details* *Every diagnosis code required to have one of five POA indicator codes Exempt from POA reporting Unreported/ Not Used 1 (One) Provider unable to clinically determine whether the condition was present on admission or not Clinically Undetermined W Documentation insufficient to determine if the condition was present on admission Unknown U Not present at the time of admission No N Present at the time of admission Yes Y Reason for Code Definition POA Indicator
CMS Broadening the List: Private Payers Likely to Follow “ It’s not a matter of not paying for them. It’s about getting them not to happen in the first place.” Thomas Granatir Director of Policy & Research Humana, Inc.   “ Having a financial incentive will increase hospitals’ awareness of the need to make the systematic changes necessary to avoid these errors… We are considering making non-payments for never events a standard part of our contract.” Charles Cutler, MD Chief Medical Director, Aetna
Practical Implications of POA Indicators ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Financial Burden – POA/NI ,[object Object],[object Object],[object Object],[object Object],[object Object]
Financial burden ,[object Object],[object Object],[object Object],[object Object],[object Object]
Payment Implications: Present/Absent Decubitus Ulcers on Admission Source: Advisory Board; CMS Analysis Worst Case Scenario -9.5% -$283,432,250 $2,688,620,270 $2,972,052,520 259,356 259,356 TOTALS Cost, exclude ulcer codes Cost, as is # Discharges, exclude ulcer Codes #  Discharges, as is
Clarifying the Mechanics of No Pay Events Patient 1 Patient 2 Patient 3 Source: Advisory Board – Nurse Executive Center $27,831 $20,208 $27,831 Basic Payment Coronary bypass w/o Cardiac Cath w/ MCC Coronary bypass w/o Cardiac Cath w/o MCC Coronary bypass w/o Cardiac Cath w/ MCC DRG Assignment (Aorto)coronary Bypass of two coronary arteries (Aorto)coronary Bypass or two coronary arteries (Aorto)coronary Bypass of two coronary arteries Primary Px Y Cardiogenic Shock Secondary Dx N Decubitus Ulcer Stage III N Decubitus Ulcer Stage III Y Decubitus Ulcer Stage III Secondary Dx Y Coronary Atherosclerosis (41401) Y Coronary Atherosclerosis (41401) Y Coronary Atherosclerosis (41401) Primary Dx POA? MS-DRG POA? MS-DRG POA? MS-DRG
CMS No-Pay policy targets – High-volume, costly adverse events  $50,455 $71,636 $63,631 $299,237 $103,027 $44,043 $33,894 $43,180 $$ Per Hospitalization* $1.2 Million 24 Blood incompatibility $4.0 Million 57 Air emboli $47.7 Million 750 Objects left inside $20.0 Million 69 Surgical Site Infections $3.0 Billion 29,536 Vascular catheter  Associated Infections $536.7 Million 12,185 Catheter Associated UTI’s $6.6 Billion 193,566 Preventable injuries – Fractures, burns, and dislocations $11.1 Billion 257,142 Pressure Ulcers Stages III, IV Total Medicare Cost* Cases * Effective Oct. 1, 2008
CMS No-Pay policy – High-volume, costly adverse events * At all US hospitals in fiscal year 2007 Source: CMS: O’Reily, AMNews, 7/14/08 $34.0 Million $37.5 Million $63,135 $180,142 539 208 Surgical site infections acquired in a hospital following:  - Orthopedic procedures, e.g., total knee - Bariatric surgery $492.9 Million $52.0 Million $42,974 $45,989 11,469 1,131 Manifestations of poor blood glucose control: - diabetic ketoacidosis - hypoglycemic coma $7.1 Billion $50,937 140,010 Deep Vein Thrombosis or pulmonary embolism following certain orthopedic surgeries Total Medicare cost * Avg. charge per hospital stay* Cases * Effective Oct. 1 2009
Cost Avoidance Additional cost compared to Worst Case Scenario Additional Cost per Infection MSI – Mediastinitis
Aggregate Costs and Revenue at Risk of Mediastinitis (MSI) 111 Discharges with Mediastinitis in FY06 Additional Cost of Care 8x Worst case Revenue at risk .
Limitations – Analytical Challenges ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Case Scenario ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Changes Related to Inpatient Nursing Care Quality - ICU Impact Outcomes of Outlier Patients (90 th  Percentile of costs) 41.% Nursing care hours % 32.4% Deaths % 44.9% 50.0% Total costs % 37.8% Total days % 48.7% ICU days % 58,473 10,606 Patients =  (N) Medical University of South Carolina Data University of North Carolina Study - ICU
Aligning Payment  Health Care Quality & Safety Nurses & Physicians
Patient Safety Organizations ,[object Object],[object Object],[object Object],[object Object]
 
 
Patient Safety Organizations ,[object Object],[object Object],[object Object],[object Object],[object Object]
 
 
Patient Safety Organizations ,[object Object],[object Object]
 
Patient Safety Organizations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Patient Safety Organizations ,[object Object],[object Object],[object Object]
 
 
Nursing ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Physicians ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Evidence Based Research on Implications of POA Implementing Changes based on best practices
Data collection tools - Processes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Source: Institute for Healthcare Improvement –  http://www.ihi.org/topics/criticalcare
Measurement for Learning & Process Improvement vs. Research “ Small tests of significant changes” accelerates the rate of improvement.  Can take long periods of time to obtain results Duration Gather “just enough” data to learn and complete another cycle Gather as much data as possible, “just in case” Data Stabilize the biases from test to test  Control for as many biases as possible Bias Many sequential, observable tests One Large “Blind” Test Test To bring new knowledge into daily practice To discover new knowledge Purpose Measurement for Learning and Process Improvement Measurement for Research
Utilization of PDCA in ICU’s… AND Beyond ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Source: Institute for Healthcare Improvement
Sample Measures - ICU ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Best Practice for preventing falls ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Best Practice for Preventing Pressure Ulcers ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Nursing directives on measuring cost, quality, and intensity of nursing care  ,[object Object],[object Object]
Nursing directives on measuring cost, quality, and intensity of nursing care ,[object Object],[object Object],Welton, 2008: JONA Vol. 38, No. 7/8.
Established Protocols for Prevention ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Established Protocols for Prevention ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Established Communication Tools ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Transforming Care at the Bedside (TCAB) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
POA Identification Methodology and Hospital Acquired Complication reduction Risk Assessment
Pre-Determined comprehensive analysis programs ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
PDCA or PDSA – Process Flow
POA Surveillance - Goals
POA - Surveillance
POA Surveillance
POA Surveillance
Project Initiative Tool: Average Variable Cost per day 5 Avg. Length of stay (ALOS) - days $1400 Total Avg. Cost/day for target population*  $685 Total (Avg. variable cost/day) 50 All other 75 Supplies 300 Nursing 60 Pharmacy 125 Radiology $75 Laboratory Example Your Unit Patient Subgroups
Run Charts Source: Institute for Healthcare Improvement
Flow Charts Source: Institute for Healthcare Improvement
Flow Charts Source: Institute for Healthcare Improvement
Cause & Effect Charts - Fishbone
Cause & Effect - Process Source: Institute for Healthcare Improvement
Summary ,[object Object],[object Object]
Thank You Contact Information Todd M. Grivetti, MSN, RN, CCRN, CNML [email_address] [email_address]
References ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
References ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

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Implications Of Cm Ss Present On Admission (Poa) Provisions Making Dollars And Sense

  • 1. Implications of CMS’s Present on Admission Provisions in the ICU: Making Dollars and Sense Todd M. Grivetti, MSN, RN, CCRN, CNML Clinical Nurse Manager Regional Neurosciences Center Poudre Valley Hospital Ft. Collins, CO 2008 Award Recipient
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  • 15. Practical Implications of POA Financial Clarifying Implications Limitations
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  • 17. POA Indicator Details* *Every diagnosis code required to have one of five POA indicator codes Exempt from POA reporting Unreported/ Not Used 1 (One) Provider unable to clinically determine whether the condition was present on admission or not Clinically Undetermined W Documentation insufficient to determine if the condition was present on admission Unknown U Not present at the time of admission No N Present at the time of admission Yes Y Reason for Code Definition POA Indicator
  • 18. CMS Broadening the List: Private Payers Likely to Follow “ It’s not a matter of not paying for them. It’s about getting them not to happen in the first place.” Thomas Granatir Director of Policy & Research Humana, Inc. “ Having a financial incentive will increase hospitals’ awareness of the need to make the systematic changes necessary to avoid these errors… We are considering making non-payments for never events a standard part of our contract.” Charles Cutler, MD Chief Medical Director, Aetna
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  • 22. Payment Implications: Present/Absent Decubitus Ulcers on Admission Source: Advisory Board; CMS Analysis Worst Case Scenario -9.5% -$283,432,250 $2,688,620,270 $2,972,052,520 259,356 259,356 TOTALS Cost, exclude ulcer codes Cost, as is # Discharges, exclude ulcer Codes # Discharges, as is
  • 23. Clarifying the Mechanics of No Pay Events Patient 1 Patient 2 Patient 3 Source: Advisory Board – Nurse Executive Center $27,831 $20,208 $27,831 Basic Payment Coronary bypass w/o Cardiac Cath w/ MCC Coronary bypass w/o Cardiac Cath w/o MCC Coronary bypass w/o Cardiac Cath w/ MCC DRG Assignment (Aorto)coronary Bypass of two coronary arteries (Aorto)coronary Bypass or two coronary arteries (Aorto)coronary Bypass of two coronary arteries Primary Px Y Cardiogenic Shock Secondary Dx N Decubitus Ulcer Stage III N Decubitus Ulcer Stage III Y Decubitus Ulcer Stage III Secondary Dx Y Coronary Atherosclerosis (41401) Y Coronary Atherosclerosis (41401) Y Coronary Atherosclerosis (41401) Primary Dx POA? MS-DRG POA? MS-DRG POA? MS-DRG
  • 24. CMS No-Pay policy targets – High-volume, costly adverse events $50,455 $71,636 $63,631 $299,237 $103,027 $44,043 $33,894 $43,180 $$ Per Hospitalization* $1.2 Million 24 Blood incompatibility $4.0 Million 57 Air emboli $47.7 Million 750 Objects left inside $20.0 Million 69 Surgical Site Infections $3.0 Billion 29,536 Vascular catheter Associated Infections $536.7 Million 12,185 Catheter Associated UTI’s $6.6 Billion 193,566 Preventable injuries – Fractures, burns, and dislocations $11.1 Billion 257,142 Pressure Ulcers Stages III, IV Total Medicare Cost* Cases * Effective Oct. 1, 2008
  • 25. CMS No-Pay policy – High-volume, costly adverse events * At all US hospitals in fiscal year 2007 Source: CMS: O’Reily, AMNews, 7/14/08 $34.0 Million $37.5 Million $63,135 $180,142 539 208 Surgical site infections acquired in a hospital following: - Orthopedic procedures, e.g., total knee - Bariatric surgery $492.9 Million $52.0 Million $42,974 $45,989 11,469 1,131 Manifestations of poor blood glucose control: - diabetic ketoacidosis - hypoglycemic coma $7.1 Billion $50,937 140,010 Deep Vein Thrombosis or pulmonary embolism following certain orthopedic surgeries Total Medicare cost * Avg. charge per hospital stay* Cases * Effective Oct. 1 2009
  • 26. Cost Avoidance Additional cost compared to Worst Case Scenario Additional Cost per Infection MSI – Mediastinitis
  • 27. Aggregate Costs and Revenue at Risk of Mediastinitis (MSI) 111 Discharges with Mediastinitis in FY06 Additional Cost of Care 8x Worst case Revenue at risk .
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  • 30. Changes Related to Inpatient Nursing Care Quality - ICU Impact Outcomes of Outlier Patients (90 th Percentile of costs) 41.% Nursing care hours % 32.4% Deaths % 44.9% 50.0% Total costs % 37.8% Total days % 48.7% ICU days % 58,473 10,606 Patients = (N) Medical University of South Carolina Data University of North Carolina Study - ICU
  • 31. Aligning Payment Health Care Quality & Safety Nurses & Physicians
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  • 46. Evidence Based Research on Implications of POA Implementing Changes based on best practices
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  • 48. Measurement for Learning & Process Improvement vs. Research “ Small tests of significant changes” accelerates the rate of improvement. Can take long periods of time to obtain results Duration Gather “just enough” data to learn and complete another cycle Gather as much data as possible, “just in case” Data Stabilize the biases from test to test Control for as many biases as possible Bias Many sequential, observable tests One Large “Blind” Test Test To bring new knowledge into daily practice To discover new knowledge Purpose Measurement for Learning and Process Improvement Measurement for Research
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  • 59. POA Identification Methodology and Hospital Acquired Complication reduction Risk Assessment
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  • 61. PDCA or PDSA – Process Flow
  • 66. Project Initiative Tool: Average Variable Cost per day 5 Avg. Length of stay (ALOS) - days $1400 Total Avg. Cost/day for target population* $685 Total (Avg. variable cost/day) 50 All other 75 Supplies 300 Nursing 60 Pharmacy 125 Radiology $75 Laboratory Example Your Unit Patient Subgroups
  • 67. Run Charts Source: Institute for Healthcare Improvement
  • 68. Flow Charts Source: Institute for Healthcare Improvement
  • 69. Flow Charts Source: Institute for Healthcare Improvement
  • 70. Cause & Effect Charts - Fishbone
  • 71. Cause & Effect - Process Source: Institute for Healthcare Improvement
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  • 73. Thank You Contact Information Todd M. Grivetti, MSN, RN, CCRN, CNML [email_address] [email_address]
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