Outcome-Based Quality Improvement (OBQI)

2202.5 - Outcome-Based Quality Improvement (OBQI) (Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) OBQI is a systematic approach that HHAs can implement and follow in order to continuously improve the quality of care they provide. OBQI manuals are available on the CMS Home Health Quality website. Under OBQI, quality is measured against the ultimate yardstick - patient outcomes. OBQI is fundamentally a two-stage process that requires the collection of OASIS data for all patients in the agency, except those excluded by exemption. The first stage of OBQI is outcome analysis based on the OASIS data. The analysis is based on an agency-level report showing the agency’s present performance regarding patient outcomes relative to a national measure of HHA patients. Outcome reports are generated at the SA and retrieved by the HHA through the same communication process the HHA uses to transmit OASIS data. Subsequent outcome reports contain comparisons of an agency’s present patient outcomes performance relative to the preceding time period for the agency and relative to a national measure of HHA patients. From these reports, HHAs can target areas for improvement as part of their overall quality assurance process. The second stage of OBQI is outcome enhancement, whereby the agency, using the data from its outcome analysis, identifies opportunities to improve care and develops plans. HHAs are provided with reports on a series of outcomes for their patients in the current year that compares its performance to the prior year and to the national reference (i.e., benchmarking) values. 2202.5A - Using Outcome Based Quality Monitoring (OBQM) and Risk Adjusted OBQI Reports in the Survey Process (Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) The OBQM reports consist of the patient-related characteristics and potentially avoidable event outcome reports, which are derived from the OASIS data that HHAs submit to the State. The agency patient-related characteristics and potentially avoidable event reports can be used by HHAs for quality monitoring and improvement purposes. The risk- adjusted OBQI reports provide measures of patient care based on all of the OASIS data items. These reports allow an HHA to proceed to outcome enhancement. It is the outcome enhancement activities that allow an HHA to focus its quality (or performance) improvement activities on select target outcomes, to investigate the care processes that contributed to these outcomes, and to make agency-specific changes in clinical actions that will lead to improved patient outcomes. Using these reports is a first step toward full implementation of the OBQI program. As a part of the pre-survey preparation, surveyors should access and review the OBQM and OBQI reports before surveying an HHA. These reports contain valuable information that may assist surveyors in identifying areas to review during the survey and possibly identify individuals or types of patients to include in the sample selection when on site following guidance provided in the Home Health Survey Protocol Enhancements, effective May 1, 2003 published February 13, 2003 as S&C Memorandum 03-13. The OBQM Manual, (titled “Quality Monitoring Using Case- Mix and Adverse Event Outcome Report” available on the OASIS Web site), provides examples of possible surveyor actions related to adverse event outcomes. The OBQI Manual (titled Outcome-Based Quality Improvement Implementation Manual provides guidance to HHAs for establishing a quality improvement program using the risk-adjusted OBQI reports. This manual is also available on the OASIS Web site. 1. Agency Patient-Related Characteristics Report The agency patient-related characteristics report presents a picture, or snapshot, of an HHA’s patients at the beginning of a care episode for the time period selected for the report. The beginning of a care episode is marked by either a SOC assessment or a ROC assessment. The body of the case-mix report describes the characteristics of an HHA’s Medicare and Medicaid patients receiving skilled services compared to the rest of the Medicare and Medicaid patients receiving skilled home health services across the country during the same time period. Surveyors should review the case-mix outcome report as described in the OBQM Manual and the Appendix titled “Guidelines for Reviewing Agency Patient-Related Characteristics and Potentially Avoidable Event Reports.” Any significant results should be identified after reviewing the report, and highlights noted. This will allow surveyors to begin to identify potential clinical groups of patients that can be included in the case-mix stratified sample for record review and home visits, as part of the onsite survey. 2. Potentially Avoidable Event Reports The Potentially Avoidable Event Report displays incidence rates for untoward events (or outcomes) comparing one HHA’s patients to patients in the CMS OASIS National repository for the same time period. Potentially avoidable events serve as markers for potential problems in care because of their negative nature and relatively low frequency. The Patient Listing can be used to investigate the care processes that contributed to these outcomes and to make agency-specific changes in clinical actions that will lead to improved patient outcomes. As a part of the pre-survey preparation, surveyors should access and review the OBQM and OBQI reports before surveying an HHA. These reports contain valuable information that may assist surveyors in identifying areas to review during the survey. Surveyors do not look at the potentially avoidable event report in a vacuum. They review this report in light of the actual circumstances surrounding the delivery of care to the specific patients. As a part of the CoPs (§484.16, Group of Professional Personnel and §484.52, Evaluation of the Agency’s Program), HHAs are required to conduct an annual evaluation of their total program, including patient services. HHAs are also required to conduct quarterly clinical record reviews to evaluate the care provided under the HHA’s policies. The CoPs require an agency to have policies and procedures to promote patient care that are appropriate, adequate, effective and efficient. HHAs have access to the OBQM reports and the OBQI reports and may incorporate a review and investigation of these reports into their evaluation and patient care review programs and include them as part of their quarterly record review. 3. Risk Adjusted OBQI Reports The risk adjusted OBQI reports are the third and final of the OASIS-based reports. These agency-level reports allow individual HHAs to assess their own performance with respect to patient outcomes and compare their performance to a national reference or benchmark. In addition, HHAs can use the OBQI data to target and develop plans of action to improve or maintain HHA performance and patient outcomes. The risk adjusted OBQI reports became available to all HHAs in February 2002. CMS anticipates that HHAs will choose to use the OBQI reports for quality improvement and for consumer education. In CMS-sponsored demonstrations where the OBQI process has been tested, many HHAs have demonstrated significant improvements in targeted patient outcomes. These data rich reports now represent a decade of benchmarking that is risk adjusted for each HHA. This means that every HHA can be compared to the national reference values, regardless of the types of patients it serves, when compared to another HHA. Therefore, an HHA that strives to provide quality care services to its patients will be able to determine its performance and to identify areas for improvement or reinforcement with the quality reports available to them. Process Measures were added to the OASIS in 2010. For further information, refer to the PBQI Manual which is located at: http://www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment-Instruments/HomeHealthQualityInits/PBQIProcessMeasures.html The OASIS C Process Measure Reports are now available in the CASPER Reporting System. The reports are located in the OASIS C - Quality Improvement report category. Resources are located on the following CMS websites: • PBQI – http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/HomeHealthQualityInits/PBQIProcessMeasures.html • OBQI - http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/HomeHealthQualityInits/HHQIOASISOBQI.html 2202.5A - Using Outcome Based Quality Monitoring (OBQM) and Risk Adjusted OBQI Reports in the Survey Process (Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) The OBQM reports consist of the patient-related characteristics and potentially avoidable event outcome reports, which are derived from the OASIS data that HHAs submit to the State. The agency patient-related characteristics and potentially avoidable event reports can be used by HHAs for quality monitoring and improvement purposes. The risk- adjusted OBQI reports provide measures of patient care based on all of the OASIS data items. These reports allow an HHA to proceed to outcome enhancement. It is the outcome enhancement activities that allow an HHA to focus its quality (or performance) improvement activities on select target outcomes, to investigate the care processes that contributed to these outcomes, and to make agency-specific changes in clinical actions that will lead to improved patient outcomes. Using these reports is a first step toward full implementation of the OBQI program. As a part of the pre-survey preparation, surveyors should access and review the OBQM and OBQI reports before surveying an HHA. These reports contain valuable information that may assist surveyors in identifying areas to review during the survey and possibly identify individuals or types of patients to include in the sample selection when on site following guidance provided in the Home Health Survey Protocol Enhancements, effective May 1, 2003 published February 13, 2003 as S&C Memorandum 03-13. The OBQM Manual, (titled “Quality Monitoring Using Case- Mix and Adverse Event Outcome Report” available on the OASIS Web site), provides examples of possible surveyor actions related to adverse event outcomes. The OBQI Manual (titled Outcome-Based Quality Improvement Implementation Manual provides guidance to HHAs for establishing a quality improvement program using the risk-adjusted OBQI reports. This manual is also available on the OASIS Web site. 1. Agency Patient-Related Characteristics Report The agency patient-related characteristics report presents a picture, or snapshot, of an HHA’s patients at the beginning of a care episode for the time period selected for the report. The beginning of a care episode is marked by either a SOC assessment or a ROC assessment. The body of the case-mix report describes the characteristics of an HHA’s Medicare and Medicaid patients receiving skilled services compared to the rest of the Medicare and Medicaid patients receiving skilled home health services across the country during the same time period. Surveyors should review the case-mix outcome report as described in the OBQM Manual and the Appendix titled “Guidelines for Reviewing Agency Patient-Related Characteristics and Potentially Avoidable Event Reports.” Any significant results should be identified after reviewing the report, and highlights noted. This will allow surveyors to begin to identify potential clinical groups of patients that can be included in the case-mix stratified sample for record review and home visits, as part of the onsite survey. 2. Potentially Avoidable Event Reports The Potentially Avoidable Event Report displays incidence rates for untoward events (or outcomes) comparing one HHA’s patients to patients in the CMS OASIS National repository for the same time period. Potentially avoidable events serve as markers for potential problems in care because of their negative nature and relatively low frequency. The Patient Listing can be used to investigate the care processes that contributed to these outcomes and to make agency- specific changes in clinical actions that will lead to improved patient outcomes. As a part of the pre-survey preparation, surveyors should access and review the OBQM and OBQI reports before surveying an HHA. These reports contain valuable information that may assist surveyors in identifying areas to review during the survey. Surveyors do not look at the potentially avoidable event report in a vacuum. They review this report in light of the actual circumstances surrounding the delivery of care to the specific patients. As a part of the CoPs (§484.16, Group of Professional Personnel and §484.52, Evaluation of the Agency’s Program), HHAs are required to conduct an annual evaluation of their total program, including patient services. HHAs are also required to conduct quarterly clinical record reviews to evaluate the care provided under the HHA’s policies. The CoPs require an agency to have policies and procedures to promote patient care that are appropriate, adequate, effective and efficient. HHAs have access to the OBQM reports and the OBQI reports and may incorporate a review and investigation of these reports into their evaluation and patient care review programs and include them as part of their quarterly record review. 3. Risk Adjusted OBQI Reports The risk adjusted OBQI reports are the third and final of the OASIS-based reports. These agency-level reports allow individual HHAs to assess their own performance with respect to patient outcomes and compare their performance to a national reference or benchmark. In addition, HHAs can use the OBQI data to target and develop plans of action to improve or maintain HHA performance and patient outcomes. The risk adjusted OBQI reports became available to all HHAs in February 2002. CMS anticipates that HHAs will choose to use the OBQI reports for quality improvement and for consumer education. In CMS-sponsored demonstrations where the OBQI process has been tested, many HHAs have demonstrated significant improvements in targeted patient outcomes. These data rich reports now represent a decade of benchmarking that is risk adjusted for each HHA. This means that every HHA can be compared to the national reference values, regardless of the types of patients it serves, when compared to another HHA. Therefore, an HHA that strives to provide quality care services to its patients will be able to determine its performance and to identify areas for improvement or reinforcement with the quality reports available to them. Process Measures were added to the OASIS in 2010. For further information, refer to the PBQI Manual which is located at: http://www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment-Instruments/HomeHealthQualityInits/PBQIProcessMeasures.html The OASIS C Process Measure Reports are now available in the CASPER Reporting System. The reports are located in the OASIS C - Quality Improvement report category. Resources are located on the following CMS websites: • PBQI – http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/HomeHealthQualityInits/PBQIProcessMeasures.html • OBQI - http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/HomeHealthQualityInits/HHQIOASISOBQI.html • OBQM http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/HomeHealthQualityInits/HHQIOASISOBQM.html 2202.5B - Case-Mix Stratified Sample (Rev. 1, 05-21-04) Surveyors will continue to select a case-mix stratified sample for record reviews and home visits since this requirement is explicitly referenced in §1891 of the Act. For example, surveyors will continue to routinely assess the ability of the HHA to provide quality care by conducting the following activities: • Evaluating the current status of the patient as reflected in the comprehensive assessment, plan of care and visit notes; • Verifying that all drugs and treatments are provided according to a physician’s order and that the HHA has reviewed all drugs for potential adverse effects and drug reactions; • Reviewing the plan of care to identify whether the HHA used the comprehensive assessment to make sound care planning decisions appropriate to the patient’s needs; • Reviewing the timeliness of services provided to the patient; • Evaluating the HHA’s ability to coordinate care and services; • Reviewing the patient’s progress toward the achievement of desired outcomes; • Verifying that any changes in the patient’s medical condition were reported to the physician and recorded, including documentation of verbal orders with written confirmation; and • Evaluating the appropriateness of patient’s continuation of services or discharge at the time of record review. However, the scope of patients eligible for the case-mix stratified sample may include both current and discharged patients. Surveyors may also identify clinical areas and select patients for review on site as part of their off-site survey preparation. The outcome reports may point to concerns that surveyors need to address during the survey and surveyors will now be able to include in the sample patients representing the identified concerns. The surveyor should continue to use the HHA’s current visit schedule (or plans for visits) during the week that the surveyor(s) is on site to develop the sample for clinical record review with home visits. The sample for clinical record review without home visits may include records of patients that have been discharged by the HHA. 2202.5C - Privacy Act Requirements (Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 1. SA/RO Use of OASIS Data Each SA or RO user authorized to access and use the OASIS data or reports derived from OASIS data must comply with the provisions governing the privacy and security of this Federal information system. Each user with authorized access to the system, records, and reports must agree to effectively maintain CMS approved administrative, technical, procedural, and physical safeguards to ensure protection of the confidentiality of the patient identifiable data and to prevent unauthorized access to the data. Each user is required to have individual valid user identification and a secure password. Each user is obligated to protect the confidentiality of the OASIS data. As noted in the June 18, 1999, December 27, 2001, and November 13, 2007 “Federal Register” notices of the OASIS system of records: “No user shall disclose, release, reveal, show, sell, rent, lease, loan or otherwise grant access to the data to any person.” The Federal Privacy Act of 1974 provides criminal penalties and fines for certain violations. The November 13, 2007 Notice describes routine uses. 2. HHA Use of OASIS Data The HHAs are required, as a part of the CoPs to maintain the confidentiality of all patient identifiable information contained in the clinical record, including OASIS data and reports, and may not release patient identifiable OASIS information to the public. Therefore, neither the State nor the HHA may release any of the OBQM or OBQI reports or the information contained in them. 2202.5D - Accessing the OBQM, OBQI, and Process Based Quality Improvement (PBQI) Reports (Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) The authorized SA and RO user needing access to these reports must have a valid user identification and a secure password. These are obtained by submitting a request to the CMS Central Office via the State system coordinator through the CMS RO. Approved requests will be assigned the required user identification and password. SAs and ROs will access the OBQI, PQBI and OBQM reports from the Certification and Survey Provider Enhanced Reports (CASPER) link located under the CASPER title on the QIES to Success Web site. The CASPER Home page will display, requiring entry of the login ID and password necessary to access the reporting tool. For most SA and RO users, this login ID and password are the same that are currently used when accessing the OBQM Reports. HHAs access their OBQI and OBQM reports in the same way they access their OASIS validation reports, by connecting to the OASIS State System via the CMSnet and selecting the applicable menu option. The CASPER Reporting User’s Guide is located on the state OASIS Welcome page. 2202.5E - Role of the OASIS Coordinators in OBQI (Rev. 1, 05-21-04) The OASIS coordinators work directly with the HHAs to help them access and review the OBQM, risk-adjusted OBQI, and Data Management System reports. In addition, the OASIS Coordinators support and train State surveyors to access, review, and interpret the reports as needed. States do not advise HHAs on which outcomes to target nor do they provide advice on care practices.