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Quality & Patient Safety Committee 2015-16 Annual Report

Chair: Stephen V. Cantrill, MD, FACEP
Vice-Chair: Michael P. Phelan, MD, FACEP
Board Liaison: Vidor E. Friedman, MD, FACEP
Staff Liaison: Stacie Jones, MPH

1. Monitor quality initiatives and comment on behalf of ACEP to external organizations to ensure appropriateness of quality measures that impact the practice of emergency medicine, the emergency department, and the reimbursement of emergency physicians.

The QPSC submitted comments on quality measures that impact the emergency department including:

  • CMS: Safe Use of Opioids—Concurrent Prescribing measure.
  • CMS: Measures under Consideration 2015-2016
  • OP-21- Median Time to Pain Management for Long Bone Fracture
  • The Joint Commission: Acute Stroke Measures
  • New Endorsement and Ratification Process for comment
  • NCQA: HEDIS 2017

2. Develop and submit recommended measures and measure concepts to the Board of Directors through the multi-stakeholder Quality Measures Technical Expert Panel that protect and enhance emergency medicine.
a. Follow through on the development, specification, and testing of the ACEP Board approved or adopted measure concepts through NQF endorsement (optional) and CMS and MOC Part IV implementation.
b. Initiate the next phase of quality measures development by:

  • Continue to explore methods to reduce measurement burden by aligning with hospital efforts for quality measurement.
  • Align measure development work with the Clinical Data Registry Committee (Subcommittee #2) to ensure valid and reliable measures are developed for CEDR.
  • Work with the Clinical Policies Committee as needed to identify new performance measures in new and revised clinical policies. (Clinical Policies is the lead committee).

c. Develop a transition plan to fully migrate measure development to the Clinical Data Registry Committee for 2016-2017.

 Action Item memo was approved by the Board of Directors regarding proposed Quality Measurement Concepts for CEDR:

• Pediatrics
1. Percentage of pediatric patients<18 years old, weighed in kilograms in the emergency department
2. Initiation of systemic corticosteroids prior to or within one hour of emergency department arrival for patients 2-18 years old with acute asthma exacerbation, who receive a second dose of a bronchodilator.
• Ultrasound
3. FAST exam for hemodynamically unstable blunt trauma patients (systolic blood pressure < 90 mmHg or heart rate > 130) in the emergency department
• Affordability
4. Use of generic prescriptions among patients in the emergency department
• Geriatrics
5. Falls risk assessment (Patient Safety)
• Population health and equity
6. Interpreter health service measure

The WG will continue their work with subject matter experts for each concept moving forward.

Transition plan for QPSC and CEDR Committee measure development is as follows:

  • QPSC subcommittee for QMs will continue the measure solicitation and measure concept
  • Prioritization and measure concept development process.
  • CEDR subcommittee for QMs will continue the measure specification and data element definition process.
  • Both subcommittees will continue to meet jointly with PCPI consultants to ensure that the measure specifications and data elements are consistent with the original clinical intention of the measures.

3. Nominate emergency physicians to represent ACEP to internal and external bodies developing quality measures that have relevance to the practice of emergency care.

ACEP’s QSPC Nominations WG3 made recommendations to the ACEP Board to ensure emergency physician representation to several national quality initiatives:

  • Donald Yearly’s nomination was accepted by NQF and now serves on the Pulmonary and Critical Care Steering Committee
  • Stephen Huff’s nomination was accepted by NQF and now serves on the Neurology Standing Committee
  • Keith Kocher’s nomination was accepted by NQF’s Attribution: Principles and Approaches 2015-2016 Committee
  • Dr. Mike Phelan’s nomination was accepted to CMS’s Technical Expert Panel End-Stage Renal Disease Emergency Department Visits
  • Dr. Mitesh Rao's application was submitted to NQF: Person- and Family-Centered Care
  • Dr. Schuur's name was submitted to the 2016-2017 roster for NQF's Measure Applications Partnership (MAP)
  • Dr. Arjun Venkatesh is currently serving on NQF’s Health and Well-Being Phase 3
  • Drs. Wes Fields and Jeremiah Schuur are currently serving on NQF’s All- Cause Admissions/Readmission

4. Comment on the quality provisions of the Inpatient Prospective Payment System (IPPS), Outpatient Prospective Payment System (OPPS), the Physician Fee Schedule (PFS), Medicare Access and CHIP Reauthorization Act (MACRA) and Affordable Care Act (ACA) related regulations and educate members regarding implementation and best practices for quality measures and federal quality measurement programs. Develop educational resources and tools to assist members with navigating the Physician Quality Reporting System (PQRS), Measure Applicability Validation (MAV) Process, Value-Based Modifier (VBM) and future Merit-Based Incentive Payment System (MIPS).

The WG contributed and submitted comments on the quality provisions of many federal proposed rules and RFI that impact the emergency department including:

  • CMS: Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
  • Cross-cutting and CMS final rule comments and information paper
  • Centers for Medicaid and Medicare Quality Measure Development Plan (MDP)
  • Proposed Medicare Physician Fee Schedule (MPFS) and Outpatient Prospective Payment System (OPPS) rules
  • Inpatient prospective payment system (IPPS)

5. Monitor and respond to requests from the Choosing Wisely initiative. Obtain input from the Emergency Medicine Practice Committee and the Medical-Legal Committee.
a. Provide periodic evidence-based literature review and updates to existing Choosing Wisely recommendations. (Obtain input from the Emergency Medicine Practice Committee and Medical-Legal Committee, Quality and Patient Safety Committee is the lead committee).
b. Provide periodic evidence-based reviews and consensus activities to support new areas for ACEP Choosing Wisely recommendations.
c. Monitor recommendations of other Choosing Wisely partners for their potential impact on emergency care. Identify opportunities for collaboration on future efforts.
d. Make recommendations for responding to other requests from the Choosing Wisely initiative.

WG 5 identified 49 Choosing Wisely recommendations highly relevant to emergency care, and narrowed them down to 38 recommendations after removing those that were redundant. The workgroup is currently reviewing this smaller set of recommendations to identify those with the greatest potential impact on emergency medicine and will develop a summary of these findings for review by the QPSC and the Board, after which we may consider publicizing the results through ACEP Now and a publication in the Annals of EM. A literature search of the currently published ACEP Choosing Wisely recommendations was conducted and reviewed by the subcommittee. In addition, the Medical-Legal committee also independently reviewed the recommendations. Both found evidence that antibiotics could improve cure rates in a small but statistically significant proportion of patients (ACEP CW Recommendation #4). After further consultation with the Medical Legal Committee as well as the Emergency Medicine Practice Committee, the QPSC intends to conduct a more focused and specific literature review on a separate topic, and recommend a replacement recommendation to the ACEP Board during the 2016-2017 committee year.

6. Work with the Emergency Medicine Informatics Section as needed to monitor implementation of measures using EHRs and other electronic systems. (EM Informatics Section is the lead on this objective.)

The QPSC continues to work with the Physician Consortium for Performance Improvement (PCPI) consultants to develop quality measures using electronic data.

7. Complete development of an information paper on readmissions vs. observation as an “outcome” of quality measures. Work with the Observation Section, Federal Government Affairs Committee, and Reimbursement Committee as needed. (Quality & Patient Safety is the lead committee.)

In light of the recent changes to federal regulations, it was felt by many that the "readmission vs
observation" issue will be assuming a role of diminished importance in the future. Given this and the volume of ongoing efforts by the QPSC, it was decided to put this objective in abeyance.

8. Work with the Emergency Medicine Practice Committee and the Geriatric Emergency Medicine Section as needed to explore the development of a policy statement in support of quality improvement initiatives for the care of geriatric patients in the ED and ensure its consistency with the Geriatric ED Guidelines. (EM Practice is the lead committee.)

The Board of Directors approved the policy, “Quality Improvement Initiatives for the Care of Geriatric Patients in the Emergency Department” in April 2016.

9. Develop a definition of “admit time.” Work with the Emergency Medicine Practice Committee as needed. (Quality & Patient Safety is the lead committee.)

Action Item memo approved by Board of Directors regarding the approval of the definition of “Admit Time”:

“The time when ‘Order to Admit’ is placed by the ED Provider or the time when the inpatient bed request is placed, whichever is earliest.
This definition may be difficult to operationalize in some environments. In those cases, we propose alternate possible definitions that could be used (EDBA-2014):
First documented date and time of the disposition to admit the patient from the ED. As admission processes vary at different hospitals, this can use the first documented time of any of the following: 1) admission order (this may be an operational order rather than the hospital admission to inpatient status order), 2) disposition order (must explicitly state to admit), 3) documented bed request, or 4) documented acceptance from admitting physician. This is not the ‘bed assignment time’ or ‘report called time’.”

10. Review the IOM report on diagnostic errors and provide recommendations for next steps. Solicit input from the Public Health & Injury Prevention Committee (Quality & Patient Safety is the lead committee.)

The WG has reviewed the IOM report and had no objections to their findings.

11. Work with the Emergency Medicine Practice Committee as needed to explore the development of an information paper on the clinical pharmacist as part of the emergency medicine team. (EM Practice is the lead committee.)

Representatives from the American Society of Hospital Pharmacists worked with content experts and committee members on the development of the information paper. The plan is to complete the paper and submit for Board review in October. After 30 day Board review the paper will be embar

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