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Emergency Medicine News:
Quality Matter

A New Model for Physician Group Structure

Welch, Shari J. MD

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Dr. Welch is the quality improvement director in the emergency department at LDS Hospital in Salt Lake City, a clinical faculty member at the University of Utah School of Medicine, a quality improvement consultant to Utah Emergency Physicians, and a member of the Emergency Department Benchmarking Alliance.

You've hidden the coffee pot, covered the supply carts, and checked the thermometers in the refrigerators. You have copies of your restraints policy, and your conscious sedation forms are on hand. The Joint Commission on Accreditation of Healthcare Organizations is coming, and you are ready for inspection. Or are you?

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Since 1986, the Joint Commission has been engaged in a process to develop, test, and implement sets of standardized performance measures. These measures, with an eye toward improving safety and quality in health care, have begun to be incorporated into the accreditation process. A number of organizations have collaborated with the Joint Commission to bring this about, including the National Quality Forum, Quality Improvement Organizations, and the Institute of Medicine. Since 2004, hospitals have been required to select three core measure sets to meet accreditation requirements.

The Joint Commission's progress to date has included infrastructure building, standardization of metrics, and expansion of these measurements and their use. First, the Joint Commission embarked on developing performance measures with the inception of the “Agenda for Change.” This became known as the ORYX initiative. Since 1999, the JCAHO has solicited input from professionals, hospitals, consumers, hospital associations, and medical societies. In fact, even after advisory panels developed focus areas and core measures, the Joint Commission called for feedback on its web site, receiving more than 1600 comments. These core measures were piloted at 83 hospitals. More details can be found about these pilot studies on the JCAHO web site (www.jcaho.org/pms).

Ultimately, a number of standardized metrics (core measures) were identified for implementation at the hospital level. Five core performance measurement sets have been established so far: myocardial infarction, congestive heart failure, pneumonia, pregnancy, and surgical infection prevention. Of these measures, the first three have particular relevance to the emergency department. Their selection ought not to raise objections. In fact, a panel of Canadian emergency physicians (Acad Emerg Med 2002;9[11]:1131) as well as a panel of respected American counterparts (Acad Emerg Med 2002;9[11]:1091) arrived at remarkably similar lists of metrics. The Centers for Medicare and Medicaid Services (CMS) also decided in September 2004 to have its quality documentation requirements dovetail with those of the Joint Commission. This collaboration will help control the administrative burdens placed on health care institutions. (JCAHO, “CMS to Make Common Performance Measures Identical.” Sept. 16, 2004.) CMS will be moving toward a “pay-for-performance” model of reimbursement in the coming years. Areas of future core measure implementation include pediatric asthma, pain management, ICU care, and inpatient psychiatric services measures.

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AMI Core Measure Set

The nine-measure acute myocardial infarction dataset was implemented in 2002, and is well established in most hospitals. AMI was identified by the Joint Commission as a priority based on disease prevalence (900,000 cases in the U.S. each year and 225,000 cases of death). (“Overview of the Acute Myocardial Infarction (AMI) Core Measure Set,” www.jcaho.org/pms, March 2005.) This was predictably an easier dataset to implement because most AMI cases are admitted to a coronary care unit with cardiologists as attending physicians or consultants. The core measure logistics for AMI are easier than other core measure datasets which involve less uniform care management patterns. The nine AMI core measures are:

▪ AMI-1: Aspirin at arrival.

▪ AMI-2: Aspirin prescribed at discharge.

▪ AMI-3: ACE inhibitors for left ventricular systolic dysfunction.

▪ AMI-4: Adult smoking cessation advice/counseling.

▪ AMI-5: Beta blocker prescribed at discharge.

▪ AMI-6: Beta blocker at arrival.

▪ AMI-7: Time to thrombolysis.

▪ AMI-8: Time to percutaneous transluminal coronary angioplasty.

▪ AMI-9: Inpatient mortality.

AMI 1, 3, 6, 7, and 8 are most influenced by ED performance. Though counseling patients about smoking is not likely to be considered an ED responsibility, one could imagine asking at triage about smoking habits and distributing an educational pamphlet to meet this goal. There is another measure relevant to ED care planned for future implementation: obtaining a lipid profile within 24 hours of arrival. The ED practitioner could easily add a lab order for lipids in AMI. Based on pilot studies, the numbers to beat in these core measures are as follows.

▪ Aspirin at arrival: 94%

▪ ACE inhibitors for left ventricular systolic dysfunction: 83%

▪ Adult smoking cessation counseling: 65%

▪ Beta blocker at arrival: 85%

▪ Time to thrombolytics: 30 minutes

▪ Time to PTCA: 90 minutes

▪ Mortality rate: 0.09%

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Heart Failure Core Measure Set

Because nearly five million people in the U.S. have heart failure and more Medicaid dollars are spent on heart failure diagnostic-related groups than any other category, the Joint Commission has developed four measures in this performance data set. (Overview of Heart Failure [HF] Core Measure Set, www.jcaho.org/pms, March 2005.)

Because education of patients with heart failure and their families is deemed critical to successful health management, two of these measures involve educational initiatives. Both the measurement of left ventricular function and the administration of ACE inhibitors are considered critical. Because heart failure is treated by cardiology specialists as well as internists and family physicians and is cared for in different hospital units (even within the same institution), standardizing care has been less successful than with acute myocardial infarction. The HF core measures are:

To keep JCAHO accreditation and be reimbursed by Medicare and Medicaid, the gauntlet has been thrown down

▪ HF-1: Discharge instructions (with six specific instruction areas recommended).

▪ HF-2: Left ventricular function assessment.

▪ HF-3: ACE inhibitors for left ventricular systolic dysfunction.

▪ HF-4: Adult smoking cessation advice/counseling.

Once again the numbers to beat are:

▪ Discharge instructions: 28%

▪ LVF assessment: 79%

▪ ACE inhibitors: 86%

▪ Smoking cessation counseling: 39%

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CAP Core Measure Set

Community-acquired pneumonia (CAP) was the third priority focus by the Joint Commission. There are between two million and three million cases of CAP a year in the U.S. and deaths due to CAP and influenza are on the rise. There are 500,000 hospitalizations a year for pneumonia, and it takes a particular toll on patients 65 and older. Seven core measures were implemented in this category in 2002, and a number of future core measures are on the horizon. (Overview of Community-Acquired Pneumonia [CAP] Core Measure Set, www.jcaho.org/pms, March 2005.)

These include the appropriate timing of the switch from IV to PO antibiotics (certainly relevant to outpatient pneumonia cases whose care may be started in the ED), excessive antibiotic use, discharge within 24 hours of switch to PO, mortality rate, influenza/pneumococcal vaccine screening in the over 65 population (also possibly an ED measure), and the screening of high-risk younger patients for vaccines. Once again, CAP may be cared for by physicians of many specialties, inpatient or outpatient, and on many different wards in the same hospital, producing significant variability in management. The CAP core measures are:

▪ CAP-1: Oxygenation assessment.

▪ CAP-2: Pneumococcal screening and/or vaccination.

▪ CAP-3: Blood cultures.

▪ CAP-4a: Adult smoking cessation advice/counseling.

▪ CAP-4b: Pediatric smoking cessation advice/counseling.

▪ CAP-5: Antibiotic timing.

▪ CAP-6: Initial antibiotic selection consistent with current recommendation-ICU patients.

▪ CAP-7: Initial antibiotic selection consistent with current recommendations-non-ICU patients.

Documenting pulse oximetry, obtaining blood cultures, and administering antibiotics early (with a mechanism for selecting the appropriate antibiotic) ought to be on everyone's clinical goals list in the ED. Though counseling for smoker's and screening for vaccines have not been identified as ED requirements, again it could be argued that these measures would be relatively easy to institute in the ED. Once again, the numbers to beat:

▪ Oxygen assessment: 95%

▪ Pneumococcal vaccine screening: 29%

▪ Blood cultures prior to antibiotics: 79%

▪ Smoking cessation counseling for adults: 35%; for children: 18%.

▪ Time to antibiotics: 3.2 hours (194 minutes)

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Pediatric Asthma Core Measures

There are currently candidate core measure datasets being studied for future implementation which will include sepsis, ICU core measures, and pediatric asthma. Emergency departments with significant pediatric populations may want to take an anticipatory approach to these measures, and begin plans for the appropriate data captures to meet the Joint Commission's requirements. The six pediatric asthma care measures are listed below. (Overview of Pediatric Asthma Care Core Measure Set, www.jcaho.org/pms, March 2005.) The use of inhalers, steroids, home care arrangements, and the tracking of ED return visits would all be part of ED practice and data mining efforts.

▪ CAC-1: Return to the hospital with same asthma diagnosis within 7 days following inpatient discharge.

▪ CAC-1a: Return to hospital with same asthma diagnosis within 30 days following inpatient discharge.

▪ CAC-2: Return to hospital with same asthma diagnosis within 7 days following ED visit or observation stay.

▪ CAC-2a: Return to hospital with same asthma diagnosis within 30 days following ED visit or observation stay.

▪ CAC-3: Use of relievers for inpatient asthma.

▪ CAC-4: Use of systemic corticosteroids for inpatient asthma.

▪ CAC-5: Risk adjusted length of stay for asthma patients.

▪ CAC-6: Home management plan of care discussed with patient/family.

As yet, there are no established numbers to beat available. These are the performance measures set by the Joint Commission and stakeholders, with buy-in by CMS. The long and short of it is that if you want to keep your accreditation and be reimbursed by Medicare and Medicaid, the gauntlet has been thrown down. Are you ready? Maybe it is time to get the coffee pot back out, and start planning how your department is going to beat the numbers.

© 2005 Lippincott Williams & Wilkins, Inc.

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