Inpatient Quality Reporting (IQR) Program Support Contractor SEP-1 - PDF document

Inpatient Quality Reporting (IQR) Program Support Contractor SEP-1 Early Management Bundle, Severe Sepsis/ Septic Shock: v5.1 Measure Updates Presentation Transcript Moderator: Candace Jackson, RN Project Lead, Hospital Inpatient Quality Reporting Program (IQR) Hospital Inpatient Value, Incentives, and Quality Reporting (VIQR) Outreach and Education Support Contractor (SC) Speaker: Bob Dickerson, MSHSA, RRT Lead Health Informatics Solution Coordinator Hospital Inpatient and Outpatient Process and Structural Measure Development and Maintenance Contractor June 29, 2016 2 p.m. ET Candace Jackson: Hello, everyone, and welcome to our SEP-1 Early Management Bundle, Severe Sepsis/Septic Shock: v5.1 Measure Updates webinar. My name is Candace Jackson, and I will be your host for today’s event. Before we begin, I’d like to make a few announcements. This program is being recorded. A transcript of the presentation, along with the Q&As, will be posted to our Inpatient website at www.qualityreportingcenter.com within 10 business days, and will be posted to QualityNet at a later date. If you registered for this event, a reminder email, as well as a link to the slides, were made available to you about two hours ago. If you did not receive the email, you can download the slides again at our Inpatient website at www.qualityreportingcenter.com . And now, I’d like to introduce our guest speaker for today. Bob Dickerson is the lead health informatics solution coordinator for the measures development and maintenance team at Telligen. He is a registered Respiratory Therapist with a master’s of Page 1 of 29

Inpatient Quality Reporting (IQR) Program Support Contractor science degree in Health Services Administration from the University of St. Francis in Joliet, Illinois. Most recently, Bob has been supporting the Centers for Medicare & Medicaid Services with development and maintenance of hospital clinical quality measures. Bob has extensive healthcare process and quality improvement experience, including development and implementation with intervention, processes, and systems in the hospital setting to support national quality measures. His experience includes facilitation and intervention, implementation, data collection, and process improvements related to severe sepsis and septic shock in the hospital setting for the surviving sepsis campaign. I would now like to turn the floor over to Bob. Bob, the floor is yours. Bob Dickerson: Thank you, Candace, and hello, everyone. Welcome to the SEP-1 Early Management Bundle, Severe Sepsis/Septic Shock: v5.1 Measure Updates . CMS, the measure steward and the measure writers have been listening to feedback related to SEP-1 from the structures, facilities, organizations, and professional groups. Recommendations and comments have been carefully considered and evaluated in relation to published evidence where applicable. The revisions to the measure illustrate the outcome of this review. Note, there are many factors involved in this process that may have limited the ability to implement every change considered appropriate and feasible. As such, CMS, the measure steward, and the measure writers continue to evaluate feedback and recommendations and ways to improve upon the measure. The fundamental purpose of the SEP-1 measure, as is with all CMS measures, is to identify opportunities for improvement in patient care that are consistent with published evidence and best practices. This fundamental principle is the basis for consideration of all revisions to the measure while endeavoring to maintain balance with the effort involved in abstracting information from medical records. During this call, we’ll discuss revisions to the SEP -1 Measure in version 5.1 of the specifications manual, and focus on how these changes impact abstraction. Page 2 of 29

Inpatient Quality Reporting (IQR) Program Support Contractor The objectives for this presentation are listed on this slide, and focus on identifying and understanding updates to SEP-1 data elements and algorithm flow in version 5.1 of the specifications manual. Please note, this review will focus on algorithm changes and key data element changes in version 5.1 that primarily impact abstraction. We will not be discussing every edit. In particular, we will not cover changes that do not impact abstraction or they’re limited to suggested data resources, inclusion guidelines for abstraction, or exclusion guidelines for abstraction. For a complete listing of changes to the measure, please refer to the Release Notes, version 5.1 that are posted on QualityNet . This slide includes a link to that location. Also available via this link are the SEP-1 additional notes for abstraction for version 5.1 of the specs manual. While there are points in this presentation I may reference these additions for abstraction, we will not be discussing the guidance contained in them. This document being posted this week should be used in conjunction with version 5.1 of the specifications manual for abstraction of SEP-1 cases. It contains additional abstraction guidance that address the situations revealed in your questions and comments that needed clarification but unfortunately were received after the timeline for being published in version 5.1 of the specs manual. The administrative contraindication to care, which was the first data element in the algorithm, and effective from reliable through discharge has been removed and replaced with two similar, but more specific data elements. Those are the administrative contraindication of care, severe sepsis, and administrative contraindication to care, septic shock. We’ll discuss the specifics of these data elements and where they reside in the algorithm as we continue. Now, this change results in transfer from the other hospital or ASC now being the first data element in the algorithm. For version 5.1, no changes were made to this data element. The algorithm continues to the severe sepsis present family of data elements. There are no algorithm changes for these data elements, but there are a couple of edits to the severe sepsis present data elements. Page 3 of 29

Inpatient Quality Reporting (IQR) Program Support Contractor In the Severe Sepsis Present, Notes for Abstraction, under Criteria C, Organ Dysfunction section of the first bullet point, edits were made to better clarify determining whether a decrease of more than 40 millimeters of mercury occurred in the systolic blood pressure. The clarification requires Physician/APN/ PA documentation be in the medical record indicating the decrease in systolic blood pressure occurred and that it is related to infections, severe sepsis or septic shock and not other causes. Now, a decrease in systolic blood pressure of more than 40 is a blood pressure criteria within other data elements such as septic shock present, septic shock presentation date and time and persistent hypertension. The same change in determining the presence of a decrease of more than 40 has been applied to these other data elements as well. At the end of the Organ Dysfunction, Criteria C, is a statement reflecting to not use evidence of organ dysfunction that is considered due to a chronic condition or medication. An example is added related to decreases in systolic blood pressure associated with administration of blood pressure medication. It’s important to note for Organ Dysfunction, determining if an abnormal allowable value or blood pressure is due to a chronic condition or medication. There must be some documentation that reflects or supports the abnormal allowable value of blood pressure, if considered to be due to a chronic condition or medication. Assumptions should not be made. Next in the algorithm, a new data element that I’ve mentioned previously is added to the specific for Administrative Contraindication to Care, Severe Sepsis. Now, if allowable values one or two indicating yes are selected, the case is excluded from the measure. If allowable value three, indicating No is selected, the case will continue to the next data element. The next data element is Directive for Comfort Care or Palliative Care, Severe Sepsis. This is not a new data element, however, some changes have been made to it. Next, we’re going to talk just a little bit more about Administrative Contraindication of Care, Severe Sepsis. Page 4 of 29