CMS Inpatient Measures (Domain: Patient Safety) Measure Importance Improvement Reported On Available On Best Practices/Resources IMM-2: Immunization for Influenza (Inpatient) 1 in 5 people in the U.S. get influenza each season. Combined in pneumonia, influenza is the 8th leading cause of death, two-thirds of those attributable to patients hospitalized during the flu season. Hospitalization is an underutilized opportunity to vaccinate. Increase in the rate (%) QualityNet via Inpatient CART/Vendor Hospital Compare MBQIP Data and FMT Reports Offer influenza vaccination by October, if possible. Vaccination should continue to be offered as long as influenza viruses are circulating (generally October – March) Incorporate influenza vaccination status into initial patient assessment and identify a process for when needed Review influenza vaccination status in the discharge process with administration of vaccine if indicated on initial assessment and not already given during hospitalization Emergency Department Transfer Communication/EDTC (Domain: Care Transitions) Measure Importance Improvement Reported To Available On Best Practices/Resources All/None Composite Calculation (all 27 data elements in EDTC sub-measures 1-7 can be used as an overall evaluation of performance on this measure set.) Timely, accurate, & direct communication facilitates the handoff to the receiving facility, provides continuity of care, & avoids medical errors & redundant tests. Increase in the rate (%) State Flex Office, then to FORHP MBQIP Data Reports EDTC SUB 1: Administrative Communication EDTC SUB 2: Patient Information EDTC SUB 3: Vital Signs EDTC SUB 4: Medication Info. EDTC SUB 5: Physician & Practitioner Generated Info. EDTC SUB 6: Nurse Generated Info. EDTC SUB 7: Procedures & Tests up
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Domain: Patient Engagement Improvement: Increase in percent (%) always Reported To: QualityNet via HCAHPS vendor or self-administered if in compliance with program requirements. Available On: Hospital Compare, MBQIP Data Reports, Flex Monitoring Team Reports Measure Importance Data Elements (Questions) Best Practices/Resources HCAHPS General Consider exercises where staff and providers complete the HCAHPS survey based on their experience and/or knowledge of the hospital, and discuss strategies to improve patient perception on care HCAHPS response rates are positively correlated with high HCAHPS performance. Work closely with HCAHPS vendors to monitor and improve HCAHPS response rates. Composite 1: Communication with Nurses Growing research shows positive associations between patient experience & health outcomes, adherence to recommended medication & treatments, preventive care, health care During this hospital stay, how often did nurses treat you with courtesy and respect? During this hospital stay, how often did nurses listen carefully to you? During this hospital stay, how often did nurses explain things in a way you could understand? Provide staff training and promote awareness relating to empathy and effective communication Use teach-back, limit jargon and employ other health literacy principles () Standardize shift change processes and/or bedside report and use as an opportunity to engage the patient and family in care Implement intentional hourly rounding Use scripting for key messages and/or employ a communication frameworks such as AIDET () ( A Focus On Nurse Communication ()
resource use & quality & safety of care. Composite 2: Communication with Doctors During this hospital stay, how often did doctors treat you with courtesy and respect? During this hospital stay, how often did doctors listen carefully to you? During this hospital stay, how often did doctors explain things in a way you could understand? Physician and Nurse Teamwork () Enhancing Communication Skills for Physicians () Composite 3: Responsiveness of Hospital Staff During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted? Establish protocols and identify accountability for responding to inpatient calls Track the type and timing of inpatient call requests to target support and response processes Implement intentional hourly rounding Establish processes and expectations regarding communication for nurses when stepping away from the floor or when assistance is needed Types of Rounding () Rounding Checklist: () () Best Practice Protocols Clinical Procedures Safety () Composite 4: Pain Management During this hospital stay, how often was your pain well controlled? During this hospital stay, how often did the hospital staff do everything they could to help you with your pain? Chronic Pain Guidelines () () Pain Management and Opioids Guidelines ()