SPOTLIGHT

ON

SPRING 2009 | VOL. 7 NO. 2 | WWW.OHIOKEPRO.COM

Quality
A n e w s l e t t e r a b o u t O h i o s h e a lt h c a r e q u a l i t y i m p r ov e m e n t

SAFE JOURNEY

TOOLS OF THE TRADE: PROCESS MAPPING

HELP FOR PROVIDERS AND BENEFICIARIES

PROMOTING PREVENTIVE CARE

MRSA SURVEILLANCE SYSTEMS: THEN & NOW

NURSING HOME DISPARITIES PROJECT

11

CALENDAR/REMINDERS

13

REGULATORY UPDATE

14

PREVENTION EHR INITIATIVE

15

Safe Journey

levator Trim - Set for takeoffMixture - RichThrottle

- 1700 rpmMagnetos - CheckEngine Instruments GreenComm/Nav/Radios/Avionics - SetFlaps - Set
for TakeoffRomeo Sierra 192448 ready for takeoff.
The before takeoff run-up check - it was automatic. I
learned it the first day I stepped into the cockpit of the
Cessna. It was not optional. My life depended on it.
When we step into the operating room, we embark upon
a mission far more complex than flying a single engine
aircraft. The surgical team is a multifaceted crew of
medical talent and disparate resources that must operate
in a highly integrated manner. The success of the
procedure requires it. The patients life depends on it. Yet,

all too often, the before takeoff run-up check

consists simply of Scalpel!

Fortunately, there is growing support and

demand for the use of checklists in medicine,
including but not limited to such settings
as the ICU and the operating room. The
World Health Organization has proposed
a surgical safety checklist,1 and a recent
study of over 3,700 patients at eight sites
worldwide documented a reduction in mortality
from 1.5 percent at baseline to 0.8 percent
(p=0.003) after introduction of the checklist,
and a corresponding reduction in inpatient
complications from 11.0 percent to 7.0 percent
(p<0.001).2 Although the study did not correlate
specific items on the checklist with specific
complications, one item, confirming that
antibiotic prophylaxis was given in the last 60
minutes, almost certainly accounted for the
reduction in surgical site infections. It is difficult
to understand how other items on the list such
as team members introducing themselves by
name, and correctly labeling the specimen could
possibly reduce morbidity and mortality. Perhaps
most interesting were the results at one site,
where adherence to all six safety indicators was
94.1 percent at baseline and 94.2 percent (N.S.)
after institution of the checklist, but nonetheless,
mortality decreased from 1.0 percent to 0.0
percent (p<0.05) and complications from 11.6
percent to 7.0 percent (p<0.05).3

2 SPOTLIGHT ON QUALITY SPRING 2009

What accounts for this significant improvement?

Perhaps more important than the individual
items on the checklist is the culture change that
accompanies the use of the checklist and the
development and support of a team approach to
the operative procedure. The acceptance of the
team concept fosters a crew resource management
attitude. A time out encourages all members
of the team to stop, think and raise any issues or
concerns they may have. As a vascular surgeon
performing a technically challenging bypass on
a critically ill patient, I fully understand that the
success of the procedure depends on every member
of the team functioning at the highest level. I not
only welcome their input, I demand it just as
they should demand mine.

What is actually on the checklist may not be nearly

as important as the fact that it exists and, more
importantly, is used routinely. Developing and
executing a surgical checklist transforms individual,
well trained professionals into a high performance
surgical team. Inclusion of a time out affords each
member an opportunity to stop, think and speak
out, without fear of interrupting the procedure or
distracting others. The surgical checklist part of
every operative flight plan.
Romeo Sierra 192448 on final approach, Over.

- Ronald A. Savrin, MD, MBA, FACS

Medical Director
rsavrin@ohqio.sdps.org

1 World Health Organization. Surgical Safety Checklist, 1st Ed.

Available at http://www.who.int/patientsafety/safesurgery/tools_
resources/SSSL_Checklist_finalJun08.pdf. Accessed February 6, 2009.
2 Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist
to reduce morbidity and mortality in a global population. N Engl J
Med. 2009; 360(5): 491-499.
3 Ibid.

Tools of the Trade:

Process Mapping

Is your organization getting less-than-optimal results on particular clinical measures,

despite having thorough and well-written policies, procedures and protocols for staff
to follow? For example, your organization may have a well-thought-out approach to
preventive skin care, but still be struggling with the incidence of nosocomial pressure
ulcers.
Poor outcomes are often associated with poorly designed processes, but the
underlying problem may be in the way staff members implement the process,
rather than in the process itself. Because these implementation issues are often far
from obvious, process mapping can be extremely valuable in facilitating quality
improvement efforts. Process mapping can help your organization objectively define
how a process is carried out while identifying specific parts of an established process
that contribute to poor outcomes.
Benefits

Process mapping is a quality improvement tool

endorsed by such industry leaders as the United
Kingdoms National Health Service (NHS)
Modernisation Agency, which describes it as
a key starting point for quality improvement
efforts, and the Agency for Healthcare Research
and Quality (AHRQ), which notes that
process mapping can help mistake-proof an
organizations processes.

Used properly, this tool enables each team

member to freely discuss their actual steps in
day-to-day processes (even if they dont quite
adhere to official policies and procedures),
allowing for the identification of previously
unknown or unresolved issues. It fosters a culture
of ownership, responsibility and accountability,
and offers such benefits as:

understanding of how individual steps of the

process are actually performed in day-to-day
patient care.

The task can be rather complex, but building a

good process map involves three basic steps:
Defining the current process.
Write out each step as everyone agrees it is
carried out.

Analyzing the current process.

Decide how often each step is carried out
the right way, by the right person, at the right
time.

A clearly defined overview of a specific process

An effective aid in planning and testing
quality improvements, and

A highly visual, easy-to-understand end

product.

Getting Started

The best way to begin process mapping is by

assembling a multidisciplinary team including
staff members who contribute to, or who are
impacted by, the process. It is crucial to involve
direct care staff, as they have the most intimate

CONTINUED ON NEXT PAGE

A NEWSLETTER ABOUT HEALTHCARE QUALITY IMPROVEMENT 3

FROM PAGE 3

Making improvements.
Determine what changes need to be made
to improve performance at each step.
An abbreviated example of a process map is
illustrated in Figure 1.
Fig. 1: Sample Process Map

Resident is
admitted

Charge nurse
completes Braden
Scale on day of
admission
90%

Resident is
discharged

Continue stepby-step process

breakdown and
evaluation
100%

Charge nurse
completes visual
skin inspection
within two hours
of admission
50%

Charge nurse writes

standing orders for
pressure ulcer
prevention, per
facility protocol
(turning schedule,
moisture barrier, etc.)
by end of shift
75%

Note: This is an abbreviated example of process mapping. The percentages listed in the diagram reflect
how often each step is carried out completely and accurately.

Tips for Success

In addition to an environment of complete honesty,

team engagement and participation are essential to
the success of process mapping. Group leaders can
help foster positive team dynamics and productive
discussion by:

Staying focused.
Other important issues are often uncovered
through process mapping, but these should be set
aside for discussion in separate meetings.

Being the groups conscience.

Reinforce and encourage honesty among all
participants by asking questions such as Are we
sure thats what really happens? and How often
does that step happen completely and accurately?
Allowing time.
Allow sufficient time for all team members to
discuss the steps in a process.
Establishing a safe environment.
Complete honesty can only be possible in a
blame-free environment that is free of
accusation and retribution.

More Process Mapping

This article describes a very simple approach to

process mapping for healthcare organizations;
the concepts behind this tool originated in the
manufacturing industry in the Ford and Toyota
4 SPOTLIGHT ON QUALITY SPRING 2009

Motor Corporations. From these concepts

came two process mapping models now
commonly used in quality improvement
efforts in healthcare and other industries:
Value Stream Mapping (Lean Enterprise
Institute) and Material and Information Flow
Mapping (Toyota Production System). More
information on these models is available at
the Lean Enterprise Institute (http://www.
lean.org) and Toyota (http://www.toyota.
co.jp/en/vision/production_system/index.
html) Web sites.
Other valuable resources:
The NHS Modernisation Agency.
Process Mapping, Analysis and Redesign
Improvement Leaders Guide 1.2.
Available at www.institute.nhs.uk/index.
php?option=com_content&task=view&id
=134&Itemid=351.
Agency for Healthcare Research and
Quality (AHRQ). Mistake-Proofing
the Design of Health Care Processes
Available at www.ahrq.gov/qual/
mistakeproof.

Process mapping can help

your organization define how
a process is carried out while
identifying specific parts of
an established process that
contribute to poor outcomes.
Regardless of which approach you take,
troubleshooting processes can facilitate
quality improvement efforts at your
organization. Commit to improved care for
your patients and staff by using a process
map as your next quality improvement
intervention!
- Leasa Novak, LPN, BA
Quality Improvement Project Coordinator
lnovak@ohqio.sdps.org
- Ann Fitzsimons, RN, MBA
Quality Improvement Specialist
afitzsimons@ohqio.sdps.org

Help for Providers and Beneficiaries

As Ohios Medicare Quality

Improvement Organization, Ohio
KePRO works with healthcare
providers to improve patient
outcomes and reduce medical errors
throughout the healthcare system. As
part of our contract with the Centers
for Medicare & Medicaid Services
(CMS), we provide Helpline services
to Medicare beneficiaries, and process
beneficiary discharge appeals cases
initiated by healthcare facilities
throughout the state.

The Helpline is accessible seven days a week

during working hours (8 a.m. to 4:30 p.m.) at
800-589-7337. Staffed by administrative
personnel, it serves as a triage of sorts, from which
calls are forwarded to the appropriate personnel
or agency. Over the past ten years, weve processed
and acted upon nearly 30,000 Medicare medical
review cases initiated through the Helpline. These
cases include those related to discharge appeals,
Diagnosis Related Group (DRG) review, and
beneficiary complaints. Misdirected calls (such as
those regarding billing issues or plans other than
Medicare) are referred to the appropriate agencies.

Discharge Appeals

We perform patient-initiated appeals for all

Medicare beneficiaries, including those enrolled
in a Medicare Advantage plan. We also perform
appeals for patients in hospitals, skilled nursing
facilities, home health agencies, comprehensive
outpatient rehabilitation facilities, and long-term
acute care hospitals. For each appeal, our staff
requests medical records from the provider(s)
involved and sends the records to a Boardcertified physician for review. If the notice is
upheld, beneficiaries or their representatives have
the opportunity for reconsideration.

DRG Reviews

DRG reviews are performed on all medical

records for which the hospital has billed at a
higher DRG. Ohio KePRO requests the medical

records from the provider and performs an

initial screening of the chart. If the stay meets
InterQual criteria and the higher DRG is
justified, the case is approved. If the stay fails
InterQual criteria and/or the medical record lacks
the documentation to support the higher DRG,
the medical record is sent to an independent,
Board-certified physician reviewer. Based on the
determination made by the reviewer, the provider

Ohio KePRO performs patientinitiated appeals for all Medicare

beneficiaries.
and practitioner may be given an opportunity
for discussion. The provider and/or practitioner
then submit the billing rationale in writing, and
this response is sent back to the same physician
reviewer for consideration. If the reviewer still
feels that the stay did not meet medical criteria,
or disagrees with the higher DRG, the stay
is denied. The provider and practitioner are
then given an opportunity for reconsideration.
When this occurs, the medical record is sent to
a second, independent physician reviewer. If the
second physician reviewer upholds the decision
made by the initial reviewer, there is no further
opportunity for discussion. Alternatively, if the
second physician overturns the original decision,
the hospital is reimbursed for the stay.

CONTINUED ON NEXT PAGE

A NEWSLETTER ABOUT HEALTHCARE QUALITY IMPROVEMENT 5

FROM PAGE 5
Fig. 2: Ohio KePRO Quality of Care Reviews, 2008

Quality of Care Review Case Volume

Cases resolved at nurse
level of review (1C)
Cases resolved at
physician reviewer first
review (1P)

73.78%

Cases resolved at
physician reviewer second
review (2P)

17.98%

Cases confirmed at
physician reviewer second
review (2P)

5.98% 2.25%
Source: Case Review Information Systems (CRIS) data, 2008

Quality of Care Reviews

Quality of care reviews are performed on all cases submitted to Ohio KePRO, regardless of the
review type (appeals, DRG reviews, or utilization reviews). All beneficiary complaints undergo a
quality of care review. These calls are directed by the Helpline operator to a nurse reviewer, who
then requests the medical records and sends the chart to a physician reviewer. For such cases, we
are careful to perform a specialty and like practice match, meaning that we always ensure that the
physician reviewer has the same area of specialization as the physician under review, and we attempt
to select a reviewer who also practices in a like setting. In order to facilitate the most accurate
review possible, we try to avoid, for example, sending a chart from a tertiary medical center to a
small town practice, and vice versa. As with other reviews, the provider and practitioner are given an
opportunity for discussion, and an opportunity for reconsideration when appropriate.
When a quality of care concern is identified, Ohio KePRO initiates action with the provider or
practitioner, which can range from a simple letter with suggestions for future care to a complete
quality improvement plan (QIP). In cases calling for QIPs, we work with the provider or
practitioner to formulate a corrective action plan, and monitor the implementation through selfreporting mechanisms.

Last year, Ohio KePRO conducted 2,441 quality of care reviews. Details are provided in Figure 2.
- Jennifer Bitterman, RHIA, MBA
Review Director
jbitterman@ohqio.sdps.org

6 SPOTLIGHT ON QUALITY SPRING 2009

PROMOTING
PREVENTIVE CARE

Ohio has been struggling economically for the past decade, but has been
particularly hard-hit by the recent economic downturn. Our state ranks 7th
in foreclosures, and as of December 2008, Ohio saw an increase of 9 percent
in Food Stamp program recipients and an increase of 2 percent in the
unemployment rate over the previous year.1 With these grim statistics, it may
come as no surprise that fewer Ohioans are making non-emergent care such as
preventive services a priority.

Seniors are no exception. Of Ohios 1.8 million

Medicare beneficiaries, more than a third are low
income (at or below 200% of the federal poverty
level).2 Because some preventive services such
as breast cancer screening and certain colorectal
cancer screenings require a payment from the
beneficiary, many forgo these services.3,4 Influenza
and pneumococcal immunizations are fully
covered by Medicare, but because these services
are sometimes administered during office visits
for which beneficiaries are required to make
a financial contribution, many have failed to
obtain recommended immunizations as well.
Nearly 12 percent of Ohios Medicare population
are minorities identified by CMS as being
underserved in the healthcare system, including
African Americans, Hispanics/Latinos, Asians/
Pacific Islanders, and American Indians/Alaska
Natives.5

African Americans, who comprise 85 percent of

Ohios underserved population,6 are at higher risk
for colorectal cancer,7 the fourth most common
cancer among men and women in the state.8 More

than 6,000 Ohioans are affected by colorectal

cancer, and nearly 2,500 die each year,9 but despite
concerted efforts by the Ohio Department of
Health (ODH) and federal agencies such as
CMS and the Centers for Disease Control and
Prevention (CDC), colorectal cancer screenings
are declining. The senior population is at the
highest risk, but the majority of Ohios Medicare
beneficiaries fail to get regular screeningsand
unfortunately, this rate has continued to decline.

It is incumbent upon all healthcare

providers to help increase awareness of
the need for preventive services.
From an already low rate of 49.1 percent in
December 2007, statewide screening rates dropped
to just 48.5 percent as of June 2008. Rates have
dropped in every region in the state (See Figure 3,
next page).
Many Medicare beneficiaries may not be aware
of their risk factors, so it is incumbent upon all
healthcare providers to help increase awareness.
Ohio KePROs efforts have focused on increasing
preventive services as one of the best means of
safeguarding the health of Ohioans. We continue
to work on educating physician practices on how
to most effectively incorporate recommendations,
patient education, resource identification, and
follow-up in the daily workflow to improve
screening rates. Providers and their healthcare

CONTINUED ON NEXT PAGE

A NEWSLETTER ABOUT HEALTHCARE QUALITY IMPROVEMENT 7

FROM PAGE 7

teams can aid in these efforts by talking with

Medicare beneficiaries about:
Individual risk factors.
These include racial/ethnic background,
and personal and family history.

Medicare-covered services.
Breast cancer screenings and colorectal cancer
screenings are covered by Medicare.
Ohios economic climate will be a challenge
for all of us as we strive to meet our goals in
improving patient care, but we encourage you
to remind your patients of the importance of
preventive services. Visit our Web site
(www.ohiokepro.com) to access no-cost
tools and interventions, or look for resources
from community-based services such as
Susan G. Komen for the Cure, regional
organizations, and county health departments.

Fig. 3: CRC Screening Rates by Ohio Region

Source: CMS claims data for Medicare fee-for-service beneficiaries aged 50-80

8 SPOTLIGHT ON QUALITY SPRING 2009

If you have a particular area of interest and

would like help in identifying communitybased services in your region, contact Erica
Stanton, quality improvement specialist, at
estanton@ohqio.sdps.org or 440-321-2929.
1 Kaiser Family Foundation. State Health Facts.org. Available at www.
statehealthfacts.kff.org. Accessed January 31, 2009.
2 Ibid.
3 Trivedi AN, Rakowski W, Ayanian JZ. Effect of cost sharing on
screening mammography in Medicare health plans. N Engl J Med. 2008;
358:375.
4 The American Cancer Society. How to Increase Colorectal Cancer Screening
Rates in Practice: A Primary Care Clinicians Evidence-Based Toolbox and
Guide. Atlanta, GA: The American Cancer Society, 2006.
5 Kaiser Family Foundation. State Health Facts.org. Available at www.
statehealthfacts.kff.org. Accessed January 31, 2009.
6 Ibid.
7 The American Cancer Society. The American Cancer Society Web site.
Available at www.cancer.org. Accessed February 20, 2009.
8 U.S. Cancer Statistics Working Group. United States Cancer Statistics:
19992005 Incidence and Mortality Web-based Report. Atlanta: U.S.
Department of Health and Human Services, Centers for Disease Control
and Prevention and National Cancer Institute; 2009. Available at: www.
cdc.gov/uscs.
9 Ibid.

MRSA SURVEILLANCE
SYSTEMS: THEN & NOW
ethicillin-resistant Staphylococcus
aureus (MRSA) hasnt exactly been
a household name, but MRSA
infections have been in the U.S. for
the past four decades.1 And, with
recent coverage in local and national
news publications such as The New
York Times2 and The Washington
Post3 identifying the infection as a
staph superbug, its clear that the
publics interest is increasing.

In contrast, epidemiology surveillance of

MRSA has been going on for many years. In
1974, MRSA infections accounted for just 2
percent of the total number of healthcareassociated staphylococcus infections in U.S.
Intensive Care Units (ICUs), but this rate
increased to 22 percent in 1995 and 63 percent
in 2004.4 In this time, MRSA has been
monitored by the Centers for Disease Control
and Prevention (CDC) as part of the agencys
surveillance of drug-resistant organisms. The
CDC has established several monitoring
systems for this purpose, in an effort to obtain
the information needed to prevent the incidence
and transmission of such infections.

One of the early systems created for this

purpose was the National Nosocomial Infection
Surveillance (NNIS) system, which monitored
the incidence of healthcare-associated infections
and the risk factors and pathogens associated
with those infections.5 Developed in the early
1970s, NNIS was the only national system for
tracking healthcare-associated infections at that
time. Its objectives were to detect and monitor
adverse events, assess risk and protective factors,
evaluate preventive interventions, and provide
information and partner to implement effective
prevention strategies. The NNIS database was
used to study the epidemiology, associated
antimicrobial resistance, and aggregate rates to
be used for interhospital comparisons. Because
the use of this voluntary participation system

was limited to hospitals meeting the infection

control staff and bed size requirements, the
number of reporting facilities was never very
large, reaching approximately 300 at its peak.6

In 1995, the Active Bacterial Core surveillance

(ABCs) system was established as a
collaboration between the CDC, state health
departments, and universities.7 Initially
established in just four states, participation has
increased to 10 state sites. This active
surveillance system monitors six pathogens
including MRSA, and uses case reports sent to
the CDC and reference laboratories to collect
demographic information and bacterial isolates.
These samples and data are used for research in
studying disease trends, identifying risk factors,
evaluating vaccine effectiveness, and
monitoring the effectiveness of prevention
policies. Lessons learned from research
stemming from ABCs served as the impetus

Monitoring systems and technological

advancements make it possible for us to more
effectively study MRSA and other infections,
and work to prevent them.

for the development of a program to assist state

and local health departments with surveillance
for MRSA and drug-resistant Streptococcus
pneumoniae.8

CONTINUED ON NEXT PAGE

A NEWSLETTER ABOUT HEALTHCARE QUALITY IMPROVEMENT 9

FROM PAGE 9

In addition to this collaborative system, the

CDC took advantage of innovations made
possible in this digital age to establish the
National Healthcare Safety Network (NHSN)
as the Internet-based successor to NNIS.
Participation was restricted when the system
was originally established in 2005, but by 2007,
enrollment was open to any hospital or
outpatient dialysis center in the U.S.9 Using
information technology for secure data
collection and for selective data sharing when
appropriate, NHSN monitors adverse events,
adherence to prevention practices, trends,
interfacility comparisons and quality
improvement, patient or personnel safety
problems, prompt interventions, and
collaborative research. The system allows for
timely data sharing between a facility and
public health agencies, with other facilities, or
for research or quality improvement activities.10

NHSNs latest addition is the Multi-Drug

Resistant Organism (MDRO) module,
which will be used for surveillance of the many
drug-resistant organisms we deal with today,
including MRSA. Not surprisingly, the NHSN
system and the new MDRO module are being
utilized in the current Quality Improvement
Organization (QIO) project related to
tracking MRSA cases in hospitals in each
state. The facilities participating in this project
in Ohio will be contributing to the national
surveillance database of MRSA cases and
allow for a sample of Ohio data to be compiled.

10 SPOTLIGHT ON QUALITY SPRING 2009

The aggregation of this data will be compiled

on a monthly basis and will be available to be
shared with the participating facilities.

The prevalence of MRSA may be on the rise,

but tools such as these make it possible for us
to more effectively study this and other
infections, and work to prevent their spread.
Our ability to collect data and share it for
analytic purposes on a nearly real-time basis is
a significant epidemiological advancement,
giving us better, more current information to
fight MRSA and other superbugs.
- Linda Stokes, MSPH, ABD
Senior Scientist
lstokes@ohqio.sdps.org

1 Centers for Disease Control and Prevention. Management of

Multidrug-Resistant Organisms in Healthcare Settings, 2006.
Available at www.cdc.gov/ncidod/dhqp/pdf/armdroGuideline2006.
pdf. Accessed October 20, 2008.
2 Robin RC. Childrens staph infections increasingly resistant to
drugs. The New York Times. 21 January 2009. Available at
www.nytimes.com/2009/01/21/health/research/21staph
html?scp=5&sq=staph&st=cse. Accessed February 23, 2009.
3 Tanner L. ICUs see a big drop in dangerous staph superbugs.
The Washington Post. 17 February 2009. Available at www.
washingtonpost.com/wp-dyn/content/article/2009/02/17/
AR2009021702299.html. Accessed February 23, 2009.
4 Centers for Disease Control and Prevention. S. aureus and
MRSA Surveillance Summary 2007. Available at
www.cdc.gov/ncidod/dhqp/ar_mrsa_surveillanceFS.html.
Accessed February 24, 2009.
5 Centers for Disease Control and Prevention. National
Nosocomial Infections Surveillance System (NNIS). Available at
www.cdc.gov/ncidod/dhqp/nnis.html. Accessed February 22, 2009.
6 Ibid.
7 Centers for Disease Control and Prevention. Active Bacterial Core
Surveillance. Available at www.cdc.gov/ncidod/dbmd/abcs/team-
start.htm#background. Accessed February 22, 2009.
8 Ibid.
9 Centers for Disease Control and Prevention. National Healthcare
Safety Network (NHSN). Available at http://www.cdc.gov/ncidod/
dhqp/nhsn.html. Accessed February 22, 2009.
10 Ibid.

Nursing Home
Disparities Project

In the current Quality Improvement Organization (QIO) contract cycle, the

Centers for Medicare & Medicaid (CMS) has directed QIOs to examine
issues and factors that are pertinent to the states population and that may
have an influence on healthcare disparities in the nursing home population.
QIOs will submit reports to CMS every six months throughout the duration
of the 9th Statement of Work (SOW). Ohio KePRO plans to focus on a
rural areas in Ohio, it seemed appropriate to
determine what quality disparities, if any, could
be identified between the states rural and urban
nursing facilities in the state.6

different factor or aspect of care that may

identify a disparity in each of the reports.
The following is a summary of the analysis
conducted by Ohio KePRO in the first
reporting period.

Background

Methodology

This initial report is focused on determining

if there is any disparity seen in the quality
of care in nursing homes, as represented
by Quality Indicator/Quality Measures
(QI/QM) between urban and rural facility
locations in Ohio. Previous research has
examined a number of possible factors as
potential indicators of disparity of care in
rural versus urban settings. An issue paper
published by the National Rural Health
Association (2001)1 voiced concerns about
the quality of care found in nursing homes in
rural areas, and studies conducted by Coburn
et al (1994)2 and Phillips et al (2000, 2001,
2004)3,4,5 found no significant difference in
the quality of care between urban and rural
nursing homes for the indicators examined.
With 12 percent of the population, 17 percent
of nursing homes, and 14 percent of total
nursing home certified beds being located in

Ohio KePRO extracted 3rd Quarter 2008 QI/

QM data from CASPER for all Ohio nursing
homes in ten selected measures (See Table
1). These measures were selected due to their
similarity to those referenced in the studies
by Coburn et al and Phillips et al. In order to
incorporate OSCAR survey results, Nursing
Home Compare Five-Star ratings for Ohio
nursing homes were extracted (on January 22,
2009) to include ratings through September
2008. Nursing homes were classified as rural
or urban, based on the county location and
Core Based Statistical Area (CBSA).7 The
study examined a total of 924 nursing homes;
155 were classified as rural and 769 were
classified as urban. Facilities with missing data
in multiple measures were excluded from this
study.
The analysis included conducting a t-test
comparing each of the QI/QM measures for
the urban and rural groups to determine if a

Table 1: QI/QM Measure Averages

QI/QM Measure
1.2 Falls
2.1 Depression
4.1 Cognitive Impairment
5.3 Incontinent w/o Toileting Plan
7.1 Weight Loss
8.1 Pain
9.1 ADL Decline
10.1 Antipsychotic Use
11.1 Restraints
12.1 Pressure Ulcers

State
Average
Score

Rural
Facilities
Average
Score

Urban
Facilities
Average
Score

Rural
Variation
from State
Average

14.4%
19.3%
11.7%
51.4%
9.4%
7.9%
13.9%
19.2%
4.8%
12.7%

19.1%
29.6%
21.1%
76.5%
12.8%
13.8%
21.7%
31.3%
9.1%
17.7%

19.2%
28.1%
24.4%
80.2%
13.5%
14.1%
21.2%
29.0%
10.4%
18.5%

4.7%
10.3%
9.4%
25.1%
3.4%
5.9%
7.8%
12.1%
4.3%
5.0%

Urban
Variation
from State
Average
4.8%
8.8%
12.7%
28.8%
4.1%
6.2%
7.3%
9.8%
5.6%
5.8%

CONTINUED ON NEXT PAGE

A NEWSLETTER ABOUT HEALTHCARE QUALITY IMPROVEMENT 11

FROM PAGE 11
FROM PAGE 11

significant difference existed. QI/QM scores were also

significant
scores
also
compared difference
to the stateexisted.
averageQI/QM
score for
eachwere
measure.
compared
to the with
state aaverage
score
forgreater
each measure.
Nursing homes
QI/QM
score
than the
Nursing
homes
withconsidered
a QI/QMto
score
greater than
state average
were
be exceeding
thethe
state
state
average
were
considered
to
be
exceeding
the
state
average in that measure. The average for each of the QI/
average
in that measure.
The average
for each
QI/
QM measures
was calculated
and then
used of
to the
determine
QM
measures
was
calculated
and
then
used
to
determine
the difference of the measure average score and the state
the
difference
the determined
measure average
and the state
average
score.of
Also
were score
the maximum
and
average
score.
Also
determined
were
the
maximum
and
minimum scores, the percentage of facilities that were
minimum
theaverage
percentage
of facilities
exceeding scores,
the state
in each
measure,that
thewere
number
exceeding
the
state
average
in
each
measure,
the
number
of measures (0-10) exceeding the state average per
of
measures
(0-10)
the state
average homes
per
nursing
home,
andexceeding
the percentage
of nursing
per
nursing
home,
and
the
percentage
of
nursing
homes
per
number of measures exceeding the state average.
number of measures exceeding the state average.
Five-Star ratings (1-5 stars) were shown as a percentage
Five-Star
ratings
(1-5per
stars)
wereThese
shown
as a percentage
of the total
facilities
rating.
ratings
were also
of
the
total
facilities
per
rating.
These
ratings
were also
aggregated to above average (4-5 stars), average
(3
aggregated
to above
average
(4-5
stars),
average
stars), and below
average
(1-2
stars),
and
shown (3
as a
stars),
and below
(1-2 stars), and shown as a
percentage
of totalaverage
facilities.
percentage of total facilities.

Results
Results

Therewerenosignificantdifferences found in theQI/QM

There were no significant differences found in the QI/QM
measures examined between urban and rural nursing
measures examined between urban and rural nursing
home facilities in Ohio in this time frame. No significant
home facilities in Ohio in this time frame. No significant
difference between urban and rural facilities was found in
difference between urban and rural facilities was found in
facilityaverage
averagescores
scoresfor
forthe
theselected
selectedmeasures.
measures.InIna areview
review
facility
of
the
minimum
and
maximum
scores
for
each
measure
of the minimum and maximum scores for each measure forfor
eachfacility
facility(except
(exceptfor
forthree
threeoutlier
outlierurban
urbanfacilities
facilitieswith
with
each
highmaximum
maximumscores),
scores),high
highand
andlow
lowscores
scoresfor
forboth
bothurban
urban
high
and
rural
nursing
homes
were
found
to
be
comparable
and rural nursing homes were found to be comparable
(SeeTable
Table1,1,previous
previouspage).
page).InInthe
thet-test
t-testcomparing
comparingQI/
QI/
(See
QM
measures,
none
of
the
measures
showed
a
significant
QM measures, none of the measures showed a significant
Fig.4:
4:Rural/Urban
Rural/UrbanNursing
NursingHomes
HomesExceeding
ExceedingState
State
Average
Fig.
Average

Source:
Source:CMS
CMSCASPER
CASPERdata,
data,3Q08
3Q08

12
12 SPOTLIGHT
SPOTLIGHTON
ONQUALITY
QUALITY SPRING
SPRING2009
2009

difference (p<0.001) between the urban and rural groups.

difference (p<0.001) between the urban and rural groups.
As shown in Figure 4, of the urban facilities, 77.2 percent
Asexceeded
shown inthe
Figure
of the in
urban
percent
state 4,
average
five facilities,
or fewer 77.2
QI/QM
exceeded
the
state
average
in
five
or
fewer
QI/QM
measures, compared to 73.5 percent of rural facilities.
measures,
compared
to 73.5
percent
rural facilities.
Rural nursing
homes
(2.6%)
had aofgreater
percentage
Rural
nursing
homes
(2.6%)
had
a
greater
percentage
with no measures exceeding state average
than urban
with
no measures
exceeding state average than urban
nursing
homes (0.5%).
nursing homes (0.5%).
There was no significant difference (p=0.1706) seen
There
was no
(p=0.1706)
seen
between
thesignificant
urban anddifference
rural groups
in the Five-Star
between
urban and
rural groups
in the Five-Star
ratings.the
Although
Five-Star
comparisons
showed rural
ratings.
Although
Five-Star
comparisons
showed
rural3 or
facilities to have 56 percent of the facilities scoring
facilities
to
have
56
percent
of
the
facilities
scoring
3 or
more stars (average and above average), urban facilities
more
stars
(average
and
above
average),
urban
facilities
had 48 percent scoring 3 or more stars.
had 48 percent scoring 3 or more stars.

Conclusion
Conclusion
This study revealed no disparity between urban and rural

This
studyhomes
revealed
between
rural
nursing
in no
thedisparity
state of Ohio
forurban
theth 4thand
Quarter
nursing
homes
in
the
state
of
Ohio
for
the
4
Quarter
2008 QI/QM measures selected. Despite these
2008 QI/QM measures selected. Despite these
findings, there is reason to consider further subdivision
findings, there is reason to consider further subdivision
of the urban facilities (i.e., suburban and true urban)
of the urban facilities (i.e., suburban and true urban)
to determine if disparities are seen between the more
to determine if disparities are seen between the more
finely grouped locations. A possible differentiation in
finely grouped locations. A possible differentiation in
the suburban areas is expected because factors that were
the suburban areas is expected because factors that were
previously considered to be rural issuessuch as higher
previously considered to be rural issuessuch as higher
unemployment,
lower
literacy
and
lack
medical
unemployment,
lower
literacy
and
lack
of of
medical
treatmentare
now
prevalent
in
urban
areas
as well.
treatmentare now prevalent in urban areas as well.
Thiswill
will
examined
next
reporting
period.
This
bebe
examined
in in
thethe
next
reporting
period.
Other
factors
will
examined
subsequent
reports
Other
factors
will
bebe
examined
in in
subsequent
reports
in in
this
series,
including
ethnicity/race,
facility
characteristics,
this series, including ethnicity/race, facility characteristics,
environmental
factors,
and
socioeconomic
factors.
environmental
factors,
and
socioeconomic
factors.

- Rikki
Gruden,
- Rikki
Gruden,
BABA
Health
Data
Analyst
Health
Data
Analyst
rgruden@ohqio.sdps.org
rgruden@ohqio.sdps.org
Linda
Stokes,
MSPH,
ABD
- Linda
Stokes,
MSPH,
ABD
Senior
Scientist
Senior Scientist
lstokes@ohqio.sdps.org
lstokes@ohqio.sdps.org
1 National
Rural
Health
Association.
Long-term
in rural
1 National
Rural
Health
Association.
Long-term
care care
in rural
America.
2001.
Available
at www.ruralhealthweb.org/
America.
MayMay
2001.
Available
at www.ruralhealthweb.org/
download.cfm?downloadfile=406F7351-1185-6B66-8848CE2
download.cfm?downloadfile=406F7351-1185-6B66-8848CE2
D9A21B8E8&typename=dmFile&fieldname=filename.
D9A21B8E8&typename=dmFile&fieldname=filename.
Accessed
January
19, 2009.
Accessed
January
19, 2009.
2 Coburn,
Fralich
JT, McGuire
C, Fortinsky
Variations
2 Coburn,
AF,AF,
Fralich
JT, McGuire
C, Fortinsky
RH.RH.
Variations
in outcomes
of care
in urban
nursing
facilities
in outcomes
of care
in urban
and and
ruralrural
nursing
facilities
in in
Maine.
Journal
of Applied
Gerontology.
1996;
15(2):
202-223.
Maine.
Journal
of Applied
Gerontology.
1996;
15(2):
202-223.
3 Phillips,
CD,CD,
Hawes
C, Williams
ML.ML.
Nursing
Homes
in Rural
3 Phillips,
Hawes
C, Williams
Nursing
Homes
in Rural
and
Urban
Areas,
2000.
College
Station,
TX:TX:
Texas
A&M
and
Urban
Areas,
2000.
College
Station,
Texas
A&M
University
System
Health
Science
Center,
School
of Rural
University
System
Health
Science
Center,
School
of Rural
Public
Health,
Southwest
Rural
Health
Research
Center;
2003.2003.
Public
Health,
Southwest
Rural
Health
Research
Center;
4 Phillips
CD,CD,
Hawes
C, Williams
ML.ML.
Nursing
Homes
in Rural
4 Phillips
Hawes
C, Williams
Nursing
Homes
in Rural
and
Urban
Areas,
2001.
College
Station,
TX:TX:
Texas
A&M
and
Urban
Areas,
2001.
College
Station,
Texas
A&M
University
System
Health
Science
Center,
School
of
Rural
University System Health Science Center, School of Rural
Public
Health,
Southwest
Rural
Health
Research
Center;
2004.2004.
Public
Health,
Southwest
Rural
Health
Research
Center;
5 Phillips
CD,CD,
Holan
S, Sherman
M, Williams
ML,ML,
Hawes
C. C.
5 Phillips
Holan
S, Sherman
M, Williams
Hawes
Rurality
andand
nursing
home
quality:
Results
fromfrom
a national
Rurality
nursing
home
quality:
Results
a national
sample
of
nursing
home
admissions.
American
Journal
of
sample of nursing home admissions. American Journal of
Public
Health.
2004;
94(10):
1717-1722.
Public
Health.
2004;
94(10):
1717-1722.
6 U.6 S.
Bureau.
United
States
Census
2000.
U.Census
S. Census
Bureau.
United
States
Census
2000.
Available
at www.census.gov/main/www/cen2000.html.
Available
at www.census.gov/main/www/cen2000.html.
Accessed
January
19,
2009.
Accessed January 19, 2009.
7 U.7 S.
of Commerce.
U.S.U.S.
Department
of of
U.Department
S. Department
of Commerce.
Department
Commerce
WebWeb
site.site.
Available
at www.commerce.gov/.
Commerce
Available
at www.commerce.gov/.
Accessed
January
19, 2009.
Accessed
January
19, 2009.

19

26

28

21

14

29

22

30

23

16
25

18

11

24
31

17

10

25

18

11

26

19

12

27

20

13

28

21

14

29

22

15

30

23

16

28

21

14

29

22

15

Tear out this calendar and post it as a reminder of upcoming deadlines and events.

24

17

10

May

30

23

16

24

17

10

June

25

18

11

26

19

12

Online resources. Weve added new online resources for healthcare providers to our
Web site, including those related to CMS, HCAHPS, ICD-10, and legislation. Just click on
the link from our home page, or go directly to the Healthcare Providers section at www.
ohiokepro.com/providers.asp.

Industry news and updates. Be sure to check our Web site (www.ohiokepro.com) for the
latest developments in healthcare.

Patient Safety Events

Reporting Hospital Quality Data for Annual Payment Update

(RHQDAPU)

July 8, 2009
Deadline for submission of 1Q09 HCAHPS
survey data.

July 1, 2009
Medical records due to the CDAC.

July

LOOKING AHEAD:

June 30, 2009

Submit 4Q08 validation charts to the CDAC.

June 15-21, 2009

National Mens Health Week

June 1, 2009
CDAC to send out 4Q08 validation chart
requests.

June

27

20

13

Has your hospital experienced a change in one of the following personnel:

CEO, QI contact, medical records contact, or QNet security administrator?
If so, please contact Fran Hober at fhober@ohqio.sdps.org or 216-447-9607,
ext. 2115. Fran is your contact for important CMS public reporting program
changes and deadlines.

Hospitals

Reminders

May 15, 2009

Submit 4Q08 inpatient and outpatient quality
measures data to the CDW.

May 11, 2009

National Womens Checkup Day

May 10-16, 2009

National Womens Health Week

May 1, 2009
Submit 4Q09 inpatient and outpatient ICD-9
population and sampling counts to the CDW.

Older Americans Month

American Stroke Month
National Arthritis Awareness Month
National Cancer Research Month
National High Blood Pressure Education Month
National Osteoporosis Awareness & Prevention Month

For all Ohio Healthcare Providers

April 8, 2009
Submit 4Q08 survey data to the Clinical Data
Warehouse (CDW).

April 7, 2009
World Health Day

May

Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) Program Calendar - 2Q09 reporting deadlines:

27

20

13

National Cancer Control Month

National Minority Health Awareness Month

April

12

15

April

REGULATORY

UPDATE

QualityNet

Retired Quality Measures

(Effective with 1Q09 Discharges)
PN-1 Pneumonia Patient with Oxygenation Assessment
This measure was found to be consistently at 100%
compliance.
PN-5b Pneumonia Patients who Receive Their Initial
Antibiotics Within 4 Hours of Hospital Arrival
The National Quality Forum (NQF) has withdrawn its
endorsement of this measure.

AMI-6 Acute Myocardial Infarction Patients Without

Beta-Blocker Contraindications who Received a Beta-
Blocker Within 24 Hours of Hospital Arrival
The American College of Cardiology (ACC) and the
American Heart Association (AHA) withdrew their
endorsement of this measure in November 2008, and CMS
has removed AMI-6 from Hospital Compare as of
January 15, 2009. However, data abstractors are required
to continue to submit data on AMI-6 through the end of the
1Q09 discharges. For background on the retirement of
AMI-6 and details about data collection and submission
requirements, please refer to the AMI-6 fact sheet,
available in the Downloads section of the Hospital Quality
Initiatives page of the CMS Web site (www.cms.hhs.gov/
HospitalQualityInits/).

Quest
The QualityNet Quest online question and answer
system is now available, with recent upgrades to
enhance performance and stability. Users may now
access Quest to submit questions regarding SDPS
applications, quality measures, communications
partnerships, and other Theme-specific issues, as well
as to perform searches of past Q&As based on
keyword or topic.

APU Dashboard
This new monitoring tool will help assess your
organizations status in terms of meeting RHQDAPU
program requirements. The dashboard provides a real-
time status report with links to specific QNet reports
providing greater detail. Contact your internal QNet
SA if you cannot currently access this dashboard report,
and would like to be able to do so.

QNet SAs
Each facility should have more than one designated
QualityNet Security Administrator (QNet SA).
Having a backup QNet SA allows work related to
CMS public reporting initiative to continue
uninterrupted if the primary contact is not available.

Contact Fran Hober at fhober@ohqio.sdps.org or 216-447-9607, ext. 2115 with any questions about CMS public
reporting program changes and deadlines.

Other Updates

Hospital Compare
Data on Medicares Hospital Compare site
(www.medicare.gov/hospital) were updated in March.
The Mortality Measures data were not updated, as this
information is updated annually; the next update of these
measures is scheduled for June 2009.

PEPPER
Review activity and reports Support for the Program for
Evaluation of Payment Patterns Electronic Report
(PEPPER) activity is no longer a component of the QIO
Program in the 9th Statement of Work. However, providers
may access valuable information on this topic at the
Hospital Payment Monitoring Program Web site
(www.hpmpresources.org), including:

14 SPOTLIGHT ON QUALITY SPRING 2009

Hospital Payment Monitoring Program Compliance

Workbook (updated March 2008)
National payment error data (updated January 2009),
and
Information on PEPPER summary statistics of
administrative claims data for CMS target areas
(areas likely to have payment errors due to billing,
DRG/coding, and/or admission necessity issues).

RAC Program
CMS announced on February 2 that the parties
involved in protesting the award of contracts in the
Recovery Audit Contractor (RAC) Program settled
their protests. The stop work order has been lifted, and
CMS will now continue its implementation of the RAC
Program. Information on the program is available on
the CMS Web site at www.cms.hhs.gov/RAC/.

Prevention EHR Initiative

Primary care practices throughout the
state have joined with Ohio KePRO
on an important health project:
the Medicare-funded Prevention
Electronic Health Record (EHR)
Initiative. Over the next two years,
our quality improvement specialists
will work with targeted practices
to maximize the capabilities of
their EHR systems in delivering
patient care by increasing efficiency,
engaging patients in self-care, and
proactively evaluating practice
performance in four preventive care
measures: mammography, colorectal
cancer screening, and influenza and

pneumococcal immunizations. By taking advantage of the

capabilities of their EHR systems, participants will also be
able to prepare for upcoming pay-for-performance initiatives,
as well as those focusing on increasing transparency and
accountability.

Ohio KePRO quality improvement

specialists will work with targeted
practices to maximize the capabilities
of their EHR systems.
Of the nearly 100 practices involved, 62 are active
participants, and 35 have agreed to act as a reference group
to set the benchmarks for their performance in this project.
As part of the Prevention EHR Initiative, our quality
improvement specialists will visit with participants, and use
internal and external resources to provide:

A comprehensive assessment of office workflow and EHR

reporting capabilities
Care management education and training

Review of quality data reports for accuracy

Assistance in identifying focus areas for improvement

Appropriate clinical topic interventions

Implementation of follow-up protocols, and

Identification of community-based services for

patients to receive free or low-cost screenings
and/or immunizations.

With recruitment finalized in January, we are still

in the early stages of this project, and participating
practices are working through the unique challenges
of optimizing an EHR system. One challenge faced by
many participants is in proper data entry; because data
has not been entered into the appropriate field in the
EHR, the information is not captured in the resulting
population reports. For example, some practices have
scanned test results indicating that a service has been
performed, but because this documentation is not
captured in a reportable field, the data does not show
up in the reports. As many practices have found,
missing information or lack of documentation in the
EHR may demonstrate less-than-desirable results.

As we move forward with the Prevention EHR

Initiative, it is our goal to assist participating practices
in improving these processes in the daily workflow of
the practice so that they can accurately capture data
for reporting, and help improve patient care and health
outcomes.
- Bonnie Hollopeter, LPN, CPHQ, CPEHR, CPHIT
Project Manager
bhollopeter@ohqio.sdps.org

A NEWSLETTER ABOUT HEALTHCARE QUALITY IMPROVEMENT 15

Presorted Standard
U.S. Postage
PAID
Cleveland, OH
Permit No. 882

Rock Run Center, Suite 100

5700 Lombardo Center Drive
Seven Hills, OH 44131
All material presented or referenced herein is intended
for general informational purposes and is not intended
to provide or replace the independent judgment of a
qualified healthcare provider treating a particular patient.
Ohio KePRO disclaims any representation or warranty with
respect to any treatments or course of treatment based
upon information provided.
Publication No. 900100-OH-135-3/2009. This material
was prepared by Ohio KePRO, the Medicare Quality
Improvement Organization for Ohio, under contract with
the Centers for Medicare & Medicaid Services (CMS),
an agency of the U.S. Department of Health and Human
Services. The contents presented do not necessarily
reflect CMS policy.

PUTTING YOU IN THE SPOTLIGHT

This quarterly newsletter was designed with your interests and needs in mind,
and we welcome your feedback to make it better. What kind of information
would you like to see in future issues of Spotlight on Quality? What other
changes would make it more useful to you? E-mail your comments to
webmaster@ohiokepro.com.

SPOTLIGHT
ON

SPRING 2009 | VOL. 7 NO. 2 | WWW.OHIOKEPRO.COM

Quality
A n e w s l e t t e r a b o u t O h i o s h e a lt h c a r e q u a l i t y i m p r ov e m e n t

SUBSCRIBE TO OUR E-NEWSLETTERS

Spotlight on Quality - Quarterly newsletter providing news, events
and best practices in Ohio healthcare

Information Updates - Receive timely notifications on available
Ohio KePRO educational and training opportunities, industry
regulatory updates and other important news
To subscribe, go to www.ohiokepro.com/subscribe.
To be removed from our printed newsletter mailing list, please send an e-mail to webmaster@
ohiokepro.com with Remove from Mailing List in the subject line. Please include your name,
address, and place of employment (if applicable). You may also fax your request to
(216) 447-7925 Attn: Stefanie Day.

SAFE JOURNEY

TOOLS OF THE TRADE: PROCESS MAPPING

HELP FOR PROVIDERS AND BENEFICIARIES

PROMOTING PREVENTIVE CARE

MRSA SURVEILLANCE SYSTEMS: THEN & NOW

NURSING HOME DISPARITIES PROJECT

9
11

CALENDAR/REMINDERS

13

REGULATORY UPDATE

14

PREVENTION EHR INITIATIVE

15