Transcript Joint Commission Blood Management Performance Measures

Joint Commission Blood
Management Performance
Measures
Mark T. Lucas, MPS, CCP
Joint Commission Technical Advisory Panel
Blood Management Performance Measures
Project
The Joint Commission
• "To continuously improve health care for the public, in
collaboration with other stakeholders, by evaluating
health care organizations and inspiring them to excel in
providing safe and effective care of the highest quality
and value“
• The Joint Commission accredits over 19,000 health care
organizations and programs in the United States.
• 400+ programs internationally.
• Centers for Medicare Services recognize Joint
Commission accreditation as a condition of licensure
and the receipt of Medicaid and Medicare
reimbursement.
History of The Joint Commission
• 1951 – ACP, AHA, AMA, CMA join with ACS to create the Joint
Commission, an independent, not-for-profit organization
whose primary purpose is to provide voluntary accreditation of
hospitals on minimum standards for patient safety and
efficacy of treatment.
• 1953 - JC published Standards for Hospital Accreditation
• 1965 – Congress passes the Social Security Amendments,
stating that hospitals who meet JC standards can participate
in Medicare and Medicaid programs.
History of The Joint Commission
• 1995 – Federal Government recognizes Joint
Commission laboratory accreditation services as
meeting CLIA 1988 requirements.
• 1997 – JC introduces ORYX to integrate outcomes
and performance measures into accreditation.
• 2003 National Patient Safety Goals are instituted.
• 2005 – JC goes global. WHO recognition.
History of The Joint Commission
• 2007 – JC launches VAD Certification Program for
destination therapy
• 2007 JC says “Hospitals go smoke free”
• 2007 Blood Management becomes important as a
means of reducing unnecessary transfusions and
costs
JC is coming!!!!!
The Joint Commission
Standardized performance measures
NQF endorsed
Inpatient hospital care
 Required for accreditation since 2002
Shared with Centers for Medicare & Medicaid
Services (mostly)
Currently 10 sets
More in development
Performance Measures
Indicators, statistics, or metrics that are used to gauge the
performance of an activity, process, or operating entity.
Performance measures are also the reference markers
used to measure whether a goal is being achieved
• Patient decision-making based on data and scientific
evidence.
• The results demonstrate improvements in health care
quality and patient safety.
Joint Commission Standards
• Standards address the organization’s level of
performance in key functional areas
• Standards set forth performance expectations
for activities that affect the safety and quality
of patient care
• The Joint Commission develops its standards
in consultation with health care experts,
providers, measurement experts, purchasers,
and consumers
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Transfusions in the United States
1.
80,000 transfusion decisions occur each day
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U.S. txfs 44% more blood than Europe and Canada
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Variability in txfsn practice, inadequate training in txfsn
medicine, no standards for tx.
4.
Rising costs of healthcare, blood products
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New evidence for safety of blood txfsn
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Importance and utility of blood management to reduce
cost and promote effective use of resources
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Joint Commission
All the variability in transfusion practices
shows "there is both excessive and
inappropriate use of blood transfusions in
the U.S.," advisers to Health and Human
Services Secretary Kathleen Sebelius
concluded earlier this month.
"Improvements in rational use of blood
have lagged."
Stakeholder Panel Meeting - February 5, 2007
• Stakeholders Meeting at Joint Commission in Chicago
• Feasibility and utility of developing a set of blood management
performance measures
• Unrestricted educational grant from Bayer Healthcare
Pharmaceuticals
Objectives:
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Investigate the current state of blood management practices
Review evidence-based studies, clinical guidelines and performance
measures for use in improving blood management practices
Establish the need and desire for standardized performance measures
focused on blood management
Stakeholder Organizations
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National Partnership for Women and Families
Society of Thoracic Surgeons
Cleveland Clinic
Department of Health and Human Services
American Academy of Orthopaedic Surgeons
American Association of Blood Banks
Food and Drug Administration
American College of Surgeons
American Society of Hematology
American Society of Anesthesiology
National Heart, Lung and Blood Institute
American Nurses Association
Society for Critical Care Medicine
American Red Cross
Society for the Advancement of Blood Management
Office of Blood Research and Review
Technical Advisory Panel
•David J. Ballard, MD, MSPH, PhD,
FACP, Co-chair
•Neil Bangs, MS, MT (ASCP) SBB
•Richard J. Benjamin, MD, PhD,
FRCPath, MS
•Laurence Bilfield, MD
•Victor A. Ferraris, MD, PhD
•John Freedman, MD, FPCPC
•Jonathan C. Goldsmith, MD
•Lawrence Tim Goodnough, MD
•Penny S. Gozia, MD, MBA
•Jerry Holmberg, PhD, MT (ASCP),
SBB
•Jonathan H. Waters, MD, Co-chair
•Harvey Klein, MD
•Mark T. Lucas, MPS, RCS, CCP
•Vijay K. Maker, MD, FACCS
•John (Jeffrey) McCullough, MD
•Aryeh Shander, MD, FCCM, FCCP
•Bruce D. Spiess, MD, FAHA
•Lynne, Uhl, MD
•Jeffrey Wagner, BSN, RN
•Rosalyn Yomatovian, MD
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The Gathering
Panel Discussion
PBM Development
Over 68 candidate measures considered
by technical advisory panel (TAP)
19 measures selected for public comment
10 measures underwent alpha testing
7 measures selected for pilot testing
Draft Measures for Alpha Testa
Transfusion indication
Transfusion consent
Blood administration documentation
Evaluation between multiple red blood cell transfusions
Timely emergency transfusions
Red blood cell administration
Prophylactic platelet administration
Plasma administration
Preoperative testing
Pretransfusion specimen rejections
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8 of the measure populations would be determined based on medical record
documentation of transfusion ICD-9-CM procedure codes (eg, 99.02, 99.04, etc).
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Final 7 Measures
•BM-1 Informed Consent
•BM-2 RBC Transfusion Indication
•BM-3 Plasma Transfusion indication
•BM-4a Platelet Transfusion Indication
•BM-4b Prophylactic Platelet Transfusion Indication
•BM-5 Blood administration documentation
•BM-6 Preoperative Anemia Screening
•BM-7 Preoperative Blood Type Testing and Antibody Screening
Transfusion Consent
• Numerator: Patients with a signed consent who
received information about the risks, benefits and
alternatives prior to the initial blood transfusion or
the initial transfusion was deemed a medical
emergency
• Denominator: Patients of all ages who received red
blood cell, plasma or platelet transfusions
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Transfusion Consent
Rationale
• The rate of transfusion consent in the US is unknown
• Studies in other countries showed there is poor
documentation and room for improvement
• Involving patients in healthcare decisions is a
national priority
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Transfusion Consent Data
Elements
• Transfusion Consent
• Information Addressed Risks, Benefits and
Alternatives to transfusion
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Transfusion Alternatives
• Preoperative Period
o Erythropoietin
o Androgens
o Iron, folate, B12 supplements
• Avoidance of anticoagulant
drugs
o NSAIDS
o Herbal supplements
o Antiplatelet drugs
o Heparin/warfarin
• Intraoperative Period
o Normovolemic hemodilution
o Cell salvage
• Adjuncts
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o Point of care testing
o Microsampling
Drug therapy
o desmopressin
o ε-aminocaproic acid
o recombinant factor VIIa
Deliberate hypotension
Maintenance of normothermia
Avoidance of normal saline
Appropriate positioning
• Postoperative Period
o Washed or unwashed cell
salvage
o Erythropoietin/Iron
o Hyperbaric oxygen therapy
o Minimize phlebotomy
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RBC Transfusion
Indication
N:Number of RBC transfusion units with pretransfusion hemoglobin or hematocrit and
clinical indication documented
D:Number of red blood cell transfusion units
evaluated
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RBC Indication Rationale
• The rate of RBC transfusions in US hospitals is
unknown
• Promotes a standardized process of:
o checking a lab result prior to each transfusion
o documentation of a reason why blood was
transfused
• Information about total blood use could be used
to determine benchmarks by diagnoses or
procedure
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RBC Data Elements
• Clinical Indication for RBCs
• Pre-transfusion Hemoglobin/hematocrit Result
• RBC ID
• Trauma patients excluded
• RBC unit exclusions
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Plasma Transfusion
Indication
N:Number of plasma transfusion units with pretransfusion laboratory value AND clinical indication
documented
D:Number of plasma units evaluated
Trauma patients excluded
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Plasma Rationale
• The rate of plasma transfused in the US hospitals is
unknown
• Promotes a standardized process of:
o checking a lab result prior to transfusion
o documentation of a reason why blood was
transfused
• STS recommends transfusion based on bleeding
and preferably guided by POC tests (Grade C,
Class IIa)
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Plasma Data Elements
• Clinical Indication for Plasma
• Pre-transfusion Laboratory Testing
• Plasma ID
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Platelet Transfusion
Indication
N:Number of platelet transfusion units with pretransfusion platelet testing AND clinical
indication documented
D:Number of platelet units evaluated
Trauma patients excluded
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Platelet Rationale
• The rate of platelets transfused in the US
hospitals is unknown
• Transfusion of platelets associated with
adverse events
• Promotes a standardized process of:
o checking a lab result prior to transfusion
o documentation of a reason why platelets
were transfused
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Platelet Data Elements
• Platelet Clinical Indication
• Pre-transfusion Platelet Testing
• Platelet ID
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Blood Administration
Documentation
N:Number of transfusion units (bags) or doses
with documentation for all of the following:
o patient identification and transfusion order
(or Blood ID) confirmed prior to the
initiation of transfusion
o date and time of transfusion
o blood pressure, (pulse) and temperature
recorded pre, during and post transfusion
D:Number of red blood cells, plasma and
platelet units or doses evaluated
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Blood Administration
Rationale
• Majority of blood is transfused in hospitals
• Numerous errors are associated with
incorrect Patient ID
• The transfusion process is very complex and
has been identified as a high-risk area for
error
• Standardizing the process will enable reliable
tracking of potential adverse events nationally
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Administration Data
Elements
• Patient ID Verification
• Transfusion Order
• Transfusion Start Date
• Transfusion Start Time
• Vital Sign Monitoring
• Blood ID Number
Note: Patients with trauma codes or RBC
unit exclusions are not in this measure
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Preoperative Anemia
Screening
N:Patients with preoperative anemia screening
14 - 45 days before Anesthesia Start Date
D:Selected elective surgical patients
Cardiac patients removed
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Anemia Screening
Rationale
• Preoperative anemia is associated with increased
morbidity and mortality
• A national audit found that 35% of patients
scheduled for joint replacement therapy had a hgb
<13 at preadmission testing
• Formal protocols for early detection, evaluation
and management of high-blood loss surgeries has
been identified as an unmet need
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Anemia Screening Data
Elements
• Preoperative Anemia Screening Result Date
• Reasons for No Preoperative Anemia
Screening
• Point of Origin for Admission or Visit
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Preoperative Blood Type
Screening
N:Patients with preoperative type and screen
or type and crossmatch completed prior to
Surgery Start Time Anesthesia Start Time
D:Selected elective surgical patients
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Blood Type Testing
Rationale
• This measure is supported by the Joint
Commission National Patient Safety Goal
• Patient safety is a national priority
• This issue affects the majority of hospitals
and other high-blood use procedures
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Blood Type Testing Data
Elements
• Preoperative Blood Type Testing
• Blood Type Testing Ordered
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Lessons learned…
• Measuring blood transfusions and associated
processes would enable hospitals to identify
areas for improvement
• Optimizing a patient’s hemoglobin level before
surgery may result in less blood use during and
after surgery
• Checking to make sure blood is available
before surgery (if ordered) is in the patient’s and
hospital’s best interest
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Lessons learned…
• These are general measures that collect data on
all patients that can be further analyzed by
diagnoses and/or procedure code, age group or
appropriateness as studies become available
• There is a lack of literature regarding “gaps in
care” that these measures address
• The lack of national guidelines for blood – impacts
the ability to standardize clinical indications
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Lessons learned…
• The abstraction burden for these measures using
paper-based records is
• Complete data on all transfusions could be
collected by eMeasures with minimal effort and
provide comprehensive data on product usage and
benchmarking
• Some of the measures are similar to the measures
collected in Australia
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Final Lessons Learned…
• Use of these measures could be used in
conjunction with the hemovigilance measures
on transfusion related events
• If the rate of blood transfusions in hospitals is
unknown, how will outcomes be monitored?
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Next Steps
• Measures have been placed in The Joint
Commission’s Library of Other Measures for
use by anyone interested
• Encourage use of the PBM measures at the
local level
• Funding pending for retooling the
specifications for retrieval from the
electronic medical record
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PBM Data Collection
PBM Data Collection
National Quality Foundation
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NQF established a set of national voluntary consensus standards for
measuring the quality of hospital care. These measures will permit consumers,
providers, purchasers, and quality improvement professionals to evaluate and
compare the quality of care in general acute care hospitals across the nation
using a standard set of measures. The majority of the Joint Commission’s
measures are endorsed by NQF and are denoted on the measure information
forms.
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Final 7 measures were recommended by the TAP in November 2010 and
submitted to the National Quality Forum (NQF) for consideration of
endorsement in December 2010
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Not endorsed for use at the national level.
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Final measure specifications were posted in the Joint Commission Library of
Other Measures in 2011. Measures that reside in the library are not collected,
but are fully specified and available at the local level.
Implementation Guide for The Joint
Commission Patient Blood
Management
Performance Measures
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180 page document
How to use and implement the measures
Measure interpretation, rationale, responsible parties
ICD-9 relationship to measures
Data collection, documentation
Patient base
Algorithms for implementation
References, definitions, ICD-9 codes
What Does This All Mean for Perfusion
• Participating Hospitals will collect data on
transfusion for appropriateness and cost
effectiveness to compare with national standards
• New informed consent will mandate the explanation
of transfusion alternatives, bringing about physician
and patient knowledge and awareness of blood
management
• Documentation and lab testing will be required, may
increase costs
• Adoption of blood management will decrease costs
and preserve resources
• Other agencies, CMS (?), may get on board
Duh!!!
Blood Management