Medicolegal Issues

Performance and Standards Committee Furthers SHM’s Quality Mission


 

The Performance and Standards Task Force (PSTF) was formed in May 2006 when SHM leadership recognized the need for a coordinated approach to working with other organizations in the quality arena.

A task force normally would have a beginning and an end to its scope of work. However, PSTF’s ongoing mission has matured, becoming more and more engaged in quality activities. In late fall 2007, the time had come for the PSTF to evolve into SHM’s Performance and Standards Committee (PSC).

What We Do

As SHM’s senior adviser for quality standards and compliance, I continue to work with PSC Chair Patrick Torcson, MD, along with senior staff and leadership of the Public Policy Committee (PPC), to monitor the national performance and quality landscape. The PSC, which engages with national organizations and is charged with developing performance measures and building consensus, also works to develop relationships with other professional medical societies and organizations.

Recognizing the need to communicate more frequently on SHM quality/policy issues related to quality improvement and patient safety, the PSC has also forged a stronger tie with the Hospital Quality and Patient Safety Committee (HQPSC) and was represented in the HQPSC-led Quality Summit in October.

Through the PSC, SHM has worked to influence performance measure development, consensus, and the endorsement process by joining the AMA Physician Consortium for Performance Improvement (PCPI) and the National Quality Forum (NQF).

Broader Reach

SHM members have contributed to the process by participating in activities relevant to hospital medicine and building relationships with senior staff and leadership within these national stakeholder groups.

The PCPI is committed to enhancing quality of care and patient safety by taking the lead in the development, testing, and maintaining evidence-based clinical performance measures and performance measurement resources for physicians. The NQF is a nonprofit organization charged by Congress to endorse consensus-based national standards for measurement and public reporting of healthcare performance data. Beginning in 2006, the PCPI and NQF have worked to influence the development of physician-level performance measures as part of the CMS Physician Quality Reporting Initiative (PQRI). Joining the PCPI has given SHM the opportunity to participate with other organizations on expert work groups to develop performance measures. SHM has been involved in performance measure development for topics such as geriatrics, emergency medicine, outpatient parenteral antimicrobial therapy, and anesthesiology issues including perioperative normothermia and critical care.

Many of these measures have been included in the PQRI program. SHM submitted feedback during public comment periods on measures related to perioperative care and chronic kidney disease. Most importantly, PCPI participation has given SHM high visibility among measurement stakeholder groups, including CMS and NQF. This has raised the acceptance of hospital medicine as a specialty, as well as the influence and credibility of SHM as a professional society.

As a collaborative effort on behalf of SHM, the PSC and PPC drafted and submitted a comment letter on the 2008 Centers for Medicare and Medicaid Studies (CMS) Proposed Rule regarding the future of the PQRI. SHM has supported the CMS value-based purchasing initiative and the PQRI in general. The PSC recommended that CMS and national stakeholder groups like the PCPI and NQF re-evaluate the denominators of several measures, existing and proposed, to make them applicable to the inpatient setting for hospitalist reporting.

PSC senior staff attended the PCPI meeting in Chicago last October and met with Susan Nedza, MD, of the CMS Special Program Office, Value-Based Purchasing, to express SHM’s appreciation of increased CMS recognition of hospitalists through its quality initiatives. This also was an opportunity to receive input on additional ways hospitalists can become engaged in the 2008 PQRI and other CMS quality efforts.

PQRI Success

In early November, Dr. Nedza and her staff, Dr. Torcson, and SHM senior staff met via conference call to discuss the preliminary results of the 2007 PQRI and exchange thoughts on the program related to hospitalists. A concern for hospitalists was the intent for the PQRI to include performance measures for each of the 39 medical specialties recognized by CMS; hospitalists were lumped under general internal medicine. By working closely with CMS and the PCPI, SHM succeeded in achieving denominator specification changes for additional relevant measures to become available for hospitalist reporting through the 2007 PQRI.

Soon thereafter, the CMS Final Rule on Physician Payment was released, indicating that 10 of the 11 measures available for hospitalist reporting in the 2007 PQRI also were to be included for 2008. “Beta-blocker on Arrival for Acute Myocardial Infarction” was the one measure no longer part of the 2008 PQRI. One new measure available for hospitalist reporting in 2008 is measure No. 75, “Prevention of Ventilator-Associated Pneumonia—Head Elevation,” for which hospitalists can report using a critical care code.

The 2007 PQRI included the following measures on which hospitalists could report:

  • No. 5: “Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)”;
  • No. 6: “Oral Antiplatelet Therapy Prescribed for Patients with Coronary Artery Disease”;
  • No. 7: “Beta-blocker Therapy for CAD Patients with Prior Myocardial Infarction”;
  • No. 29: “Beta-blocker at Time of Arrival for Acute Myocardial Infarction”;
  • No. 31: “Stroke and Stroke Rehabilitation: Deep Vein Thrombosis Prophylaxis”;
  • No. 32: “Stroke and Stroke Rehabilitation: Discharged on Antiplatelet Therapy”;
  • No. 33: “Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atrial Fibrillation at Discharge”;
  • No. 34: “Stroke and Stroke Rehabilitation: Tissue Plasminogen Activator Considered”;
  • No. 35: “Stroke and Stroke Rehabilitation: Screening for Dysphagia”;
  • No. 36: “Stroke and Stroke Rehabilitation: Consideration of Rehabilitation Services”; and
  • No. 47: “Documentation of an Advanced Care Plan.”

After the final specifications for the 2008 PQRI were released, there was a proposal for denominator specification changes that would preclude inpatient reporting for many of the measures relevant and available to hospitalists in 2007. The PSC again worked closely with the PCPI and relevant professional organizations to preserve the measure specifications for the 2008 PQRI to allow inpatient and thus hospitalist reporting. This experience has further enhanced productive SHM relationships with the PCPI and CMS.

The PSC has an ongoing commitment to recommend SHM members for appointments to PCPI expert measure workgroups, depending on the topic. For example, SHM was recently asked to identify a member to join a newly forming asthma measures workgroup that will be looking to develop inpatient measures. SHM will be notified when a palliative care measures workgroup is being formed.

Senior staff and leadership will meet PCPI senior staff to discuss formation of an expert workgroup on care transitions measures. This work group will be co-chaired by SHM and the American College of Physicians (ACP) and include societies such as the Society of General Internal Medicine (SGIM), the American Geriatrics Society (AGS), and others engaged in the development of the transitions of care consensus document in summer 2007. The work group also will refer to the principles and standards that resulted from the ABIM Foundation’s Stepping Up to the Plate (SUTTP) Alliance as a resource in its development of measures.

Looking ahead to the 2009 PQRI, the PSC has requested measure specification changes to the following PQRI measures:

  • No. 56: “Vital Signs for Community Acquired Pneumonia”;
  • No. 57: “Oxygenation Assessment for Community Acquired Pneumonia”;
  • No. 58: “Assessment of Mental Status for Community Acquired Pneumonia”; and
  • No. 59: “Empiric Antibiotic for Community Acquired Pneumonia.”

These measures harmonize with the Joint Commission’s core measures and are relevant for hospitalist performance reporting.

With the NQF

On Sept. 26-28, PSC member Greg Seymann represented SHM at NQF’s 8th Annual Meeting in Washington, D.C. This meeting featured plenary sessions focusing on issues at the forefront of policy discussions related to quality of care including:  

  • Chronic care episodes across care settings;
  • Medications and quality;
  • Medicare performance monitoring and payment initiatives;
  • Moving performance measures into electronic health record requirements; and
  • Nursing leadership in measurement activities and achieving higher performance.
  • In the first quarter of 2008, the PSC has:
  • Reviewed and commented on NQF’s “National Voluntary Consensus Standards for Hospital Care: Additional Priorities–2007, Part 2”;
  • Sent a representative to the steering committee for the National Voluntary Consensus Clinician-Level Perioperative Care Standards meeting;
  • Submitted nominees for the National Voluntary Consensus Standards for Emergency Care Phase II steering committee and the Prevention and Management of Stroke Across the Continuum steering committee (our nominee was accepted for the latter);
  • Reviewed and commented on the National Voluntary Consensus Standards for Prevent­­ion and
  • Care of Venous Thromboembolism: Performance Measures/Phase II; and;
  • Has sent senior leadership and staff to the NQF Spring Meeting and Implementation Conference on Care Coordination.

In the Works

The PSC and the HQPSC submitted a comment letter on CMS’ selection of hospital-acquired conditions and present on admission indicator reporting for 2009. SHM supported CMS’ efforts to improve the quality of care for hospitalized patients by preventing avoidable hospital-acquired conditions and outlining its concerns regarding unintended consequences as relates to the various conditions.

With its new status as the PSC, this enthusiastic and committed group is preparing to extend its mission and scope of work in 2008.

The PSC plans to restructure and serve as expert liaisons for internal and external activities. This not only will empower committee members to become more engaged in our performance agenda, but also allow them to serve as key contacts for staff when monitoring the ever-growing landscape of performance measurement, quality, and policy. TH

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