Performance Measures for Advanced Certification in THKR Webinar
September 28, 2017
Q&A
Transcription
QUESTION: Can we print off the handouts?
Answer: Yes, the slide presentation is availablehere.
QUESTION: When do you expect the requirement to submit via eCQMs?
Answer: We do not anticipate eCQM submission to become a requirement in the near future. We hope to present eCQM submission as an option, so that sites will have the ability to choose to submit either chart based measures or eCQMs.
QUESTION: Is it required to submit data for both inpatient and outpatientsurgeries to achieve certification?
Answer: This depends on the structure of your program. We can certify a program that is inpatient only, outpatient only, or a mixture of the two. You submit data on the program that you have defined. If you have questions, please contact your Account Executive.
QUESTION: We are having our initial TJC survey for the advanced program in late November. Can we switch to these new measures now to be a part of our initial submission, rather than switching to them from our previously selected measures?
Answer: If you have already applied, you should have the measures that your site specified in your application available for the review, but you will need to begin collecting the new measures as of January 1, 2018.
QUESTION: If our ready date for application is January 2018, can we switch to these measures now if our application measures are currently different?
Answer: Sites must begin to collect the new measures as of January 1, 2018, however, you should also continue to collect the measures submitted with your application, as we will want to review this data during the onsite review. After the on-site review, your self-selected measures can be retired (at least from Joint Commission reporting requirements) and only the standardized measures would be required.
QUESTION: We are going for the advanced certification in the spring. If we do not obtain the advanced certification and are able to maintain our core certification, will the standardized measures meet the criteria for our core program to replace the non-standardized measures, as the core program has to include two measures that are clinical?
Answer: Yes, by collecting the standardized measures you will meet the requirement for the core program measures as well.
QUESTION: Could there be a shared electronic tool that assists abstractors with data collection?
Answer: Currently, there is not an electronic tool available.
QUESTION: Do you have to wait until January, 2018 to collect the data?
Answer: You may begin collecting data on these measures now. Advanced certified programs are required to begin data collection with discharges as of January 1, 2018.
QUESTION: Please explain the difference between the core program and the advanced. Is the core program our standard accreditation with The Joint Commission?
Answer: The certification program is not accreditation. Sites must apply for certification as a separate option, specifically to highlight your hip and knee programs. We recommend core certification as a first step to familiarize yourself with the program, but sites may decide, after reviewing the requirement, to apply for the advanced certification over core certification initially. See the Key differences between the Core Hip/Knee option for more details.
QUESTION: Are there stated goals for each measure?
Answer: The Joint Commission does not establish specific goals/targets for standardized measures. We are looking for continuous improvement, with the goal being performance on these measures will approach 100%.The program is looking for continued process improvement.
QUESTION: Are these measures up for validation?
Answer: There is not a validation component to this measure set.
QUESTION: Will there be an opportunity to attend an orthopedic conference on the west coast soon?
Answer: This year’s orthopedic certification program is being held in the Chicago area on October 20. Next year’s schedule may be open for alternatives. Please contact The Joint Commission Resources to request that a conference be available on the west coast.
QUESTION: For the current 2017 advanced certification survey, should the data include only total knee and total hip patients?
Answer: Yes that is correct.
QUESTION: Are revisions and unilateral knees included?
Answer: No, these procedures are not included in the advanced certification program.
QUESTION: Are bilateral procedures included?
Answer: Yes, they are included for allmeasures except discharge to home (THKR-3).
QUESTION: If a patient had a hip ORIF that failed and went on to have a total hip replacement, would they be included?
Answer: From the measure perspective, hip fractures are excluded from allmeasures with the exception of THKR-1.
QUESTION: The Certification Conference that is coming up on October 20th is for facility certification correct, not nursing for example?
Answer: Correct, the conference will address certification for joint replacementprogram, not for individual nurses.
QUESTION: Who is responsible for collecting the functional and health status assessment?
Answer: There are many different models for collecting the functional and health status assessments. For example, some organizations have the assessment completed during a preoperative visit in the surgeon’s office. Other organizations have the assessment completed while the patient is attending the preoperative education class. There is not a required process for who is to collect the data. The program only requires that the assessmentsare completed and documentation reflected in the medical record.
QUESTION: Are sites required to score the functional and health status assessments and do something further with the information gathered?
Answer: Currently this is a process measure that measures if the assessments were completed. Organizationsare required to report the number of cases where the preoperative functional and health status assessments were completed in the 90-day period prior to surgery. Organizations are not required to include assessment scores at this time.
QUESTION: Will Joint Commission have HOOS/KOOS and VR12 tools available?
Answer: You will find links to these tools in the Implementation Guide, under the Measure Information Form (MIF) reference section. They are also listed below for your convenience:
- HOOS
- HOOS Jr.
- KOOS
- KOOS Jr.
- VR-12
- PROMIS-Global
QUESTION: For THKR-4, do all surgeons need to utilize the same tools or can they choose (e.g. VR-12 over PROMIS)?
Answer: Your site may choose to use either the VR-12 or PROMIS-Global for the general health assessment and the HOOS Jr/KOOS Jr. or subscales as listed in the table below. Ideally, all providers within your organization would utilize the same tool for consistency and possible benchmarking opportunities.
QUESTION: For the functional assessment, if we are using an external tool that is not linked to the EHR, will this be acceptable?
Answer: This is acceptable, providing documentation exists in the EHR stating which assessment was completed and the date the assessment was completed (e.g. HOOS JR form completed on 1/1/2018). A copy of the tool can also be uploaded to the patient’s electronic record, if you are able to do so.
QUESTION: Who typically conducts preoperative home visits to determine if the patient’s home environment is safe and is this covered by patient’s insurance?
Answer: During the program’s pilot testing, we did observe that some organizations are performing preoperative visits to assess the home environment. These visits are typically conducted by a social worker or physical therapist. Please note, this is not a requirement of the advanced certification program. We cannot speak to insurance coverage matters.
QUESTION: Is a depot injection into the incision considered a peripheral nerve block (e.g. liposomal bupivicaine or Exparel)?
Answer: No. Local infiltration of liposomal bupivicaine is not a peripheral nerve block and would not be considered regional anesthesia.Please note, that this response is different from the one given during the live webinar.
QUESTION: What if the surgery is ordered as a general anesthesia by the physician, is the surgery excluded?
Answer: No, this is not considered an exclusion. A reason for not using regional anesthesia must be documented by the physician/APN/PA.
QUESTION: What is the rationale behind accepting BOTH general and regional anesthesia, when the goal seems to be decreasing the number of patients who receive general anesthesia?
Answer: The goal is to encourage regional anesthetic techniques due to improvement in patient outcomes, such as decrease in intraoperative blood loss, length of stay and patient mortality.
QUESTION: A regional anesthesia extremity block counts if it is the main form of anesthesia, not if using general and an adductor block for a knee.
Answer: If an adductor block is used in the absence of general anesthesia, the measure is met. If an adductor block is used with general anesthesia, the measure is met.
QUESTION: In all instances of regional blocks, spinal etc., there is sedation that is added by IV, such as propofol for sedation, which is acceptable?
Answer: Yes, sedation is acceptable and will meet the measure when used with regional techniques.
QUESTION: Could you give an example of a social reason for not discharging to home that would be acceptable?
Answer: An acceptable reason would be documentation that the patient is a hoarder and the home environment is not safe for discharge.
QUESTION: If physical therapy deems a patient unsafe for discharge to home and recommends a SNF, is that an acceptable exclusion?
Answer: Yes, providing there is documentation in the medical record by the appropriate discipline stating SNF is recommended as it would be unsafe for patient to rehab at home.
QUESTION: For discharge to home, is it acceptable as a social reason if it is stated "patient lives alone" or does there need to be further information documented?
Answer: Documentation that the patient lives alone, in and of itself, is not an acceptable social reason to not be discharged to home. There must be documentation as to why it is not safe for the patient to go home, such as “patient lives alone on the 3rd floor of an apartment building without an elevator. Per physical therapy the patient is unable to walk up stairs without assistance, will dc to rehab”.
QUESTION: If a patient comes from an assisted living or a retirement home etc. and returns to the same setting, that counts as “D/C to home”, they are returning to the previous setting (i.e. home). Is that correct?
Answer: Correct. Assisted living, retirement home (not SNF) are equal to value 1 (see Discharge Disposition data element, page 39 of Inpatient Implementation Guide). According to the algorithm, discharge disposition = 1 goes to category E (in numerator population, i.e. passes the measure).
QUESTION: If the patient refused to ambulate, is this acceptable as long as there is a stated reason, such as c/o nausea?
Answer: Documentation that the patient refuses to ambulate is not an acceptable exclusion. If there is documentation in the record stating the patient is nauseated and because of the nausea is unable to ambulate, this is acceptable.
QUESTION: Is ambulating the patient in the middle of the night the safest thing we can do for the patient if they get to the inpatient unit very late?
Answer: We do not want to have a double standard of care for late cases. All patients should have the benefit of early ambulation.
QUESTION: If the patient has to walk across the room to the bathroom, does that count as ambulation?
Answer: Yes, this would count as ambulation. See the notes for abstraction for the data element “Ambulation” in the Implementation Guide (page 32). There is no minimum distance requirement.
QUESTION: For the ambulation measure, you stated that using the commode was not acceptable, but if the patient ambulates to the commode, then that’s acceptable.
Answer: If the commode is located at the patient’s bedside and the patient only pivots to commode, this is not considered ambulation. The patient must take steps to constitute ambulation.
QUESTION: We are currently certified in the core program. One of our measures is to ambulate the patient within 4 hours. Would it be possible to change the advanced certification measure, because we do not want to do less than what we are doing currently?
Answer: We would recommend that you have 2 measures. One aligned with the measure presented today and one that aligns with the measure your site is using to collect data.
QUESTION: Is there a requirement on the timing of the documentation that patient ambulated? For example, are late entries such as the nurse charts on POD 1 that the patient ambulated on the date of surgery acceptable?
Answer: Real time documentation is preferable. Ambulation should be documented on the day it occurs.