D.59 NMVAHCS current performance measures 8.5.20.pdf

Version: 4.20.01

PRELIMINARY REPORT

This report will provide the outcome of abstraction for Clinical Guideline and Prevention Indicators (CGPI) of care provided to veterans in VHA outpatient clinics. Cases were selected from a specific time period designated as the ''study interval.'' To qualify an outpatient record for abstraction, the patient must have been seen by an MD, DO, APN, PA, or Psychologist in one of the Nexus clinics within twelve months from the first day of the study interval. All cases selected for review must also have had another visit anywhere in VHA within the past two years. The ''Nexus clinics'' include primary care and specialty clinics as well as selected mental health clinics. Although all applicable data is collected, mental health patients whose primary care is received in a non-VHA setting are excluded from VHA designated indicators.

7/30/2020Exit Report Date:

CLINICAL GUIDELINE AND PREVENTION INDICATORS EXIT REPORT

VHA EXTERNAL PEER REVIEW PROGRAM

VAMC #

07/06/2020

Total CGPI records in sample :

Data Collection for Pull List Dated:

Indicator Description Cases (True Num)

Cases (True Den)

Score (as %)

QTD 3Q20

CANCER SCREENING

p32h *Breast Screen age 50 - 74 (includes 3D mammogram) 10 14 65.0 65.0 85.70 p33 *Breast Screen age 45 - 74 timely per ACS guidelines 13 19 60.9 60.9 61.90 p41h *Cervical Screen age 21 - 64 15 18 90.2 90.2 92.40 p42 *Cervical Screen age 21 - 29 1 2 94.1 94.1 100 p43h *Cervical Screen age 30 - 64 14 16 89.6 89.6 92.20 p61h *Colorectal Screen age 51 - 75 46 54 86.7 86.7 77.80

Female

Fourth Quarter FY2020

''These documents or records, or information contained herein, which resulted from a medical record review conducted as per the External Peer Review Program, are confidential and privileged under the provisions of 38 U.S.C. 5705, and its implementing regulations. This material can not be disclosed to anyone without authorization as provided for by that law or its regulations. NOTE:

The statute provides for fines up to $20,000 for unauthorized disclosures.''

VHA DIRECTIVE - Quality Management and Patient Safety Activities That Can Generate Confidential Documents, 2008-077 November 07, 2008

Outpatient Study Interval: 06/01/2020 - 06/30/2020

OUTPATIENT CLINICS

- An asterisk (*) before a measure indicates the number/score may be influenced by exclusion from the

) indicates lower is better for that measure. - A down arrow (

CGPI

Measures eligible for reconsideration are in bold print. NOTE: These data are preliminary and are intended only as a reflection, rather than an absolute measure, of facility performance for clinical guideline and prevention indicators.

VAMC scores should not be calculated /reported without correctly accounting for patient weights. The accurate weighted scores are included in this report. Verification of below scores is possibleby selecting “Monthly Aggregate” from the Report Format slicer on the Combined Measure Master (CMM).

Note to VHA Staff: Questions regarding weighting ONLY may be submitted by email to the RAPID Helpdesk ( http s://vaww.car.rtp.med.va.gov/hd/helpTicket.aspx?requestID=0&l1Type=2)

Please see the Combined Measure Master (CMM, http://vaww.rs.rtp.med.va.gov/Reports/Pages/Report.aspx?ItemPath=%2fE

BB+Reports%2fEPRPAggregate)for YTD scores.

Prevention and Mental Health Indicators due to terminal illness.

http://vaww.rs.rtp.med.va.gov/Reports/Pages/Report.aspx?ItemPath=%2fEBB+Reports%2fEPRPAggregate http://vaww.rs.rtp.med.va.gov/Reports/Pages/Report.aspx?ItemPath=%2fEBB+Reports%2fEPRPAggregate

VHA EXTERNAL PEER REVIEW PROGRAM Version: 4.20.01 CGPI Exit Report

PRELIMINARY REPORT

Indicator Description Cases (True Num)

Cases (True Den)

Score (as %)

QTD 3Q20

chl1 *Chlamydia screen age 16 - 24 0 0

CARDIOVASCULAR

Heart Failure Diagnosis

Number of Cases Reviewed 12 chf14 LVSF < 40 on ACEI or ARB 5 6 97.9 97.9 100

Hypertension Diagnosis

Number of Cases Reviewed 60 ihd53h HTN: BP < 140/90 age 18 - 85 39 47 84.0 84.0 79.40

Hyperlipidemia p10 Hyperlipidemia Screening - Overall 97 99 96.4 96.4 96.10

Chronic Vascular Disease cvrm2 Statin therapy for patients with cardiovascular disease 5 5 100.0 100.0 95.40

Diagnosis of Old MI (AMI > 8 weeks)

Number of Cases Reviewed 7 ihd20h Received persistent beta blocker treatment for 6 months post AMI DC

1 1 100.0 100.0 100 c12 ASA at most recent visit 6 6 100.0 100.0 93.70 ihd6 LVSF < 40 on ACEI or ARB at most recent visit 2 3 66.6 66.6 100

ENDOCRINE

Diabetes Mellitus Diagnosis

Number of Cases Reviewed 22 c9h HgbA1c Annual 17 17 100.0 100.0 100 dmg23h HbA1c > 9 or not done in past year 2 17 17.4 17.4 20.20 dmg27h BP < 140/90 14 17 80.8 80.8 77.30 dmg31h Retinal exam, timely by disease 14 17 89.2 89.2 72.60 dmg34h Renal Testing 17 17 100.0 100.0 94.70 cvrm1 Statin therapy for patients with diabetes 11 12 89.5 89.5 91.60 c5 Foot inspection 20 22 87.6 87.6 85.50 c6 Pedal pulses checked 17 22 79.8 79.8 83.50 c7n Foot sensory exam using monofilament 16 22 79.6 79.6 80.50

Mental Health sa7 *Screened for alcohol use with AUDIT-C 105 111 96.7 96.7 94.10

PRELIMINARY REPORT

Indicator Description Cases (True Num)

Cases (True Den)

Score (as %)

QTD 3Q20

sa17 *AUDIT-C score 5 or greater and brief alcohol counseling documented

9 10 80.8 80.8 100 mdd40 *Screened annually for depression 47 53 92.3 92.3 95.30 ptsd51 *PTSD screening 63 64 98.3 98.3 97.10 sui40 Primary suicide risk screening while screening for depression

47 53 92.3 92.3 95.30 sui51 Primary suicide risk screening while screening for PTSD 31 32 97.0 97.0 90.80 sui2 Timely secondary suicide risk screening 2 3 99.2 99.2 100

Immunizations pvc12 *Pneumococcal Immunization age 66 and greater 35 42 92.3 92.3 84 p24 Pneumococcal immunization refused 4 42 3.8 3.8 5.80 p25h *Influenza Immunization age 65 and greater 36 47 83.8 83.8 81 p26h *Influenza Immunization age 18 - 64 41 65 63.6 63.6 66.80 p27 Influenza immunization refused 27 112 23.5 23.5 20.60

Osteoporosis ostp10 *Female > 64 had bone density test after age 60 4 7 72.2 72.2 94.40

Tobacco smg8 * Tobacco Use Cessation - Advised to Quit (outpt) 25 25 100.0 100.0 100 smg10 * Tobacco Use Cessation - Discussed Cessation Medications (outpt)

25 25 100.0 100.0 100 smg9 * Tobacco Use Cessation - Discussed Cessation Strategies (outpt)

25 25 100.0 100.0 100 smg19mn *Current tobacco use every day or some days (Nexus Clinics MH)

13 35 37.9 37.9 35.40 smg19n *Current tobacco use every day or some days (Nexus Clinics non-MH)

3 11 21.4 21.4 3.80 p7 *Screened for tobacco use Nexus Clinics 97 112 88.5 88.5 86.90

MOVE!

mov6 Participation in MOVE!/Weight Management Treatment 3 55 8.9 8.9 5.40

Medication Reconciliation mrec43 Reconciled medication list provided to patient 5 70 7.1 7.1 36 mrec54 Essential medication list for review with all components in note

20 70 28.5 28.5 36.80 mrec55 Essential medication list for review includes active VA prescriptions

39 70 55.7 55.7 80 mrec56 Essential medication list for review includes remote active VA prescriptions

35 70 50.0 50.0 69.60

PRELIMINARY REPORT

Indicator Description Cases (True Num)

Cases (True Den)

Score (as %)

QTD 3Q20

mrec57 Essential medication list for review includes non-VA medications

38 70 54.2 54.2 72.80 mrec58 Essential medication list for review includes expired VA prescriptions

20 70 28.5 28.5 36.80 mrec59 Essential medication list for review includes discontinued VA prescriptions

20 70 28.5 28.5 36.80 mrec60 Essential medication list for review includes pending medication orders

31 70 44.2 44.2 59.20 mrec61 Essential medication list reviewed with patient/caregiver 37 39 94.8 94.8 93 mrec62 Essential medication list for review includes patient allergies 20 70 28.5 28.5 36.80

CGPI Pilot Indicators csra1 Timely VA comprehensive suicide risk evaluation (CSRE) 0 0 csra2 Evidence of clinical impression of acute risk on CSRE 0 0 csra3 Evidence of clinical impression of chronic risk on CSRE 0 0 csra4 Evidence of risk mitigation on CSRE 0 0

ACOVE (age 75 years or older) fe1 Assessed for urinary incontinence in past 12 months 15 16 98.6 98.6 94.80 fe3 Fall history documented in the past 12 months 12 18 58.1 58.1 64.20 fe9 Assessed functional status (ADL and IADL) in past 12 months

14 18 72.3 72.3 88.80

SCI & D INDICATORS

Number of Cases Reviewed 8

Diabetes scid3 HbA1c > 9 or not done in past year 0 1 0.0 0.0 0 scid5 Retinal exam, timely by disease 0 1 0.0 0.0 75 scid4 BP < 140/90 0 1 0.0 0.0 100

Immunizations pvc12s *Pneumococcal Immunization 4 4 100.0 100.0 100 p19s *Influenza Immunization 5 8 62.5 62.5 80

Tobacco smg8s * Tobacco Use Cessation - Advised to Quit 1 1 100.0 100.0 100 smg10s * Tobacco Use Cessation - Discussed Cessation Medications

1 1 100.0 100.0 100 smg9s * Tobacco Use Cessation - Discussed Cessation Strategies 1 1 100.0 100.0 100 smg19sn *Current tobacco use every day or some days 1 4 25.0 25.0 14.20

PRELIMINARY REPORT

Indicator Description Cases (True Num)

Cases (True Den)

Score (as %)

QTD 3Q20

p7s *Screened for tobacco use 4 7 57.1 57.1 48.20