DATA COLLECTION GUIDE Summary Data Submission

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DATA COLLECTION GUIDE

Summary Data Submission

Ambulatory Surgical Center (ASC) Measures 2013

(07/01/2012 to 06/30/2013 Dates of Service)

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Measure Specifications ... 3

Prophylactic IV Antibiotic Timing ... 4

Hospital Transfer/Admission ... 7

Appropriate Surgical Site Hair Removal ... 8

Data Elements & Field Specifications ... 9

Prophylactic IV Antibiotic Timing ... 10

Hospital Transfer/Admission ... 13

Appropriate Surgical Site Hair Removal ... 16

Data Submission Instructions ... 17

About Data Submission ... 18

Participation Requirements and Confidentiality ... 18

Overview of Process and Timeline ... 19

Ambulatory Surgical Center Definition ... 20

Step 1: Registration and Preparations ... 21

Step 2: Identifying the Patient Population (Denominator) ... 22

Total Population Submission and Sample Submission

... 24

Random Sample Selection Methods ...

24 Step 3: Data Collection ... 26

Step 4: Pre-Submission Data Quality Checks ... 28

Step 5: Summary Data Submission ... 29

Calculate Summary Data Counts ...

29 Enter the Summary Counts into the MNCM Data Portal

... 37

Step 6: Required Documentation for Data Validation ... 40

Appendices: Frequently Asked Questions ... 41

Appendix A: Prophylactic IV Antibiotic Timing Frequently Asked Questions………...42

Appendix B: Hospital Admission/Transfer Frequently Asked Questions………....43

Appendix C: General Frequently Asked Questions………..44

Much of the information in this guide is replicated from the ASC Quality Collaboration document, ASC Quality Measures: Implementation Guide Version 1.3. To learn more about the ASC Quality Collaboration visit

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Ambulatory Surgical Center Measures 2013

(07/01/2012 to 06/30/2013 Dates of Service)

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Measure Prophylactic IV Antibiotic Timing

Description Measure used to capture the number of Ambulatory Surgery Center (ASC) admissions (patients) with an order for a prophylactic IV antibiotic for prevention of surgical site infection, who receive the prophylactic antibiotic on time.

Methodology Population identification is accomplished via a query of a practice management system or Electronic Medical Record (EMR) to identify the population of eligible patients (denominator). Data elements are extracted from ASC operational data including medical records, medication administration records, nursing notes, IV flow sheets, clinical logs, incidence/occurrence reports and quality improvement reports. ASCs that had an EMR in place by 07/01/2011 are required to submit data on their full population.

Rationale Surgical site infections are costly for patients. Kirkland et al. found that SSI resulted in a 225% increase in total direct costs per patient after laparotomy and a 77% increase after colon surgery.i The Centers for Disease Control and Prevention reported that patients who develop surgical site infections are 60% more likely to spend time in an ICU, and five times more likely to be readmitted to the hospital, and have twice the incidence of mortality.iiThese statistics relate to hospitals only because there is very little evidence available to determine the impact of surgical site infections within ambulatory surgery centers (ASC). However, in 2009, the ASC Quality Collaboration released data pertaining to IV antibiotic timing measure for a sample of volunteer ASCs across the country. The data reported the fourth quarter of 2008 and the first three quarters of 2009. Overall, the percentage of patients who received IV antibiotics was above 90%.iii

Measurement Period

Measurement period will be a fixed twelve month period: 07/01/2012 to 06/30/2013.

Denominator All ASC admissions with a preoperative order for a prophylactic IV antibiotic for prevention of surgical site infection.

Allowable Exclusions

• ASC admissions with a preoperative order for a prophylactic IV antibiotic for prevention of infections other than surgical site infections (e.g. bacterial endocarditis).

• ASC admission with a preoperative order for a prophylactic antibiotic not administered by the intravenous route.

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Numerator Number of ASC admissions with an order for a prophylactic IV antibiotic for prevention of surgical site infection, who received the prophylactic antibiotic on time.

Definitions:

• Admission – completion of registration upon entry into the facility

• Antibiotic administered on time – antibiotic infusion is initiated within one hour prior to the time of the initial surgical incision or the beginning of the procedure (e.g. introduction of the endoscope, insertion of needle, inflation of the tourniquet) or two hours prior if vancomycin or fluroquinolones are administered. Timing starts at the time antibiotic infusion is initiated.

• Intravenous – administration of a drug within a vein, including bolus, infusion or IV piggyback

• Order – a written order, verbal order, standing order or standing protocol

• Prophylactic antibiotic – an antibiotic prescribed with the intent of reducing the probability of an infection related to an invasive procedure. See complete list on the next page of antibiotics that are considered prophylaxis for surgical site infections.

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List of Prophylactic Antibiotics Considered Prophylaxis for Surgical Site Infection

Aztreonam Cefazolin Cefmetazole Cefotetan Cefoxitin Cefuroxime Ciprofloxacin Clindamycin Ertapenem Erythromycin Gatifloxacin Gentamicin Levofloxacin Metronidazole Moxifloxacin Neomycin Vancomycin

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Measure Hospital Transfer/Admission

Description Measure used to capture the number of ASC admissions (patients) who are transferred or admitted to a hospital upon discharge from the ASC.

Methodology Population identification is accomplished via a query of a practice management system or Electronic Medical Record (EMR) to identify the population of eligible patients (denominator). Data elements are extracted from ASC operational data including administrative records, medical records, incidence/occurrence reports and quality improvement reports. ASCs that had an EMR in place by 07/01/2011 are required to submit data on their full population.

Rationale The National Center for Health Statistics reported a 300% increase in the rate of ambulatory surgery center (ASC) visits for freestanding surgery centers in the United States from 1996 to 2006.ivThis drastic increase resulted in 14.9 million surgeries in freestanding surgery centers across the U.S in 2006. A surgery patient typically experiences a safe discharge, however, the NCHS reported that 0.8% of ASC patients were transferred or admitted to a hospital as a result of a surgery. In a smaller but more recent study conducted by the ASC QC the hospital transfer/admission rates for ambulatory surgery centers was 1.27 per 1000 ASC admissions.

Denominator All ASC admissions.

No allowable exclusions.

Numerator Number of ASC admissions for patients who require a hospital transfer or hospital admission upon discharge from the ASC.

Definitions:

• Hospital transfer/admission – any transfer/admission from an ASC directly to an acute care hospital including hospital emergency room

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Measure Appropriate Surgical Site Hair Removal

Description Measure used to capture the number of admissions (patients) who have appropriate surgical site hair removal.

Methodology Population identification is accomplished via a query of a practice management system or Electronic Medical Record (EMR) to identify the population of eligible patients (denominator). Data elements are extracted from ASC operational data including administrative records, medical records, incidence/occurrence reports and quality improvement reports. ASCs that had an EMR in place by 07/01/2011 are required to submit data on their full population.

Rationale Appropriate surgical site hair removal is recommended in the Centers for Disease Control and Prevention (CDC) guidelines for the prevention of surgical site infections. One of the primary reasons for creating guidelines related to appropriate hair removal is because if hair is not removed properly before a surgery, a razor may cause tiny cuts on a patient that could lead to infection.v Ambulatory surgery centers, patients, and payers benefit when providers follow the guidelines for appropriate surgical site hair removal because minimizing the number of surgical site infections improves patient care, reduces costs, and saves time and resources.

Denominator All ASC admissions with surgical site hair removal.

ASC admissions who perform their own hair removal.

Numerator Number of ASC admissions with surgical site hair removal with clippers or depilatory cream.

Definitions:

i

Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol

1999; 20: 725-730.

ii

Graves EJ, Gillum BS. Detailed diagnoses and procedures, National Hospital Discharge Survey, 1994. National Center for Health Statistics. Vital Health Stat 13(127). 1997.

iii _{Ambulatory Surgery Center Quality Collaboration. ASC Quality Collaboration Quality Report 3rd Quarter}

2009. Retrieved from http://www.ascquality.org/qualityreport.html#Transfer on April 12, 2010.

iv _{Cullen KA, Hall MJ, Golosinskiy A. Ambulatory Surgery in the United States, 2006. National health statistics}

reports; no 11. Revised. Hyattsville, MD: National Center for Health Statistics. 2009.

v

Ambulatory Surgery Center Quality Collaboration. ASC Quality Measures Implementation Guide Version 1.7. Retrieved from http://www.ascquality.org/qualitymeasures.cfm on August 1, 2012.

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Ambulatory Surgical Center Measures 2013

(07/01/2012 to 06/30/2013 Dates of Service)

Data Elements and Field Specifications

Please note that the data elements and field specifications listed in this section are included to assist in your ASC’s data collection and are not required to be included in your ASC’s Summary Data Submission for the Minnesota Statewide Quality Reporting and Measurement System. These Data Elements and Field Specifications correspond to the Data Submission Template.

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Prophylactic Antibiotic IV Timing

Use the tab titled “Data Collection_IV Timing” in the Excel Data Collection Spreadsheet ASC to collect the following data elements for this measure.

Column Field Name Notes Excel Format Example

A ASC ID Enter the ASC ID for every patient/row submitted. MNCM assigns the ASC ID at the time of registration. Use the MNCM ID listed in the portal.

Quality Check: Verify each cell has data and that all ASC IDs match the “MNCM ID” listed in the portal.

Text 9999

B Patient ID Enter a unique patient ID that will identify each patient procedure. This ID is defined by the ASC.

Quality Check: Verify each cell has data. Use Excel’s Pivot Table to verify that IDs were not duplicated. If a duplicate is found, determine which ASC the ID is attributed to and delete the other record or assign a new ID if it is for a different procedure. Keep in mind that if you are submitting a sample, you will need to replace the deleted record with the next sampled patient.

Text 20

C Patient’s Date of Birth Enter the patient’s date of birth.

Quality Check: Verify each cell has data.

Date

(mm/dd/yyyy)

05/08/1985

D Patient’s Date of Admission

Enter the date the patient was admitted to the ASC. In order to be included in the measure, the date of visit must be between 07/01/2012 to 06/30/2013.

Quality Check: Verify each cell has data and all dates are between 07/01/2012 to 06/30/2013.

Date

(mm/dd/yyyy)

04/21/2013

E Provider NPI Enter the NPI number of the surgeon who performed the procedure.

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Column Field Name Notes Excel Format Example F Type of Antibiotic

Ordered

Enter the code for the antibiotic ordered: 1 = Ampicillin/sulbactam 2 = Aztreonam 3 = Cefazolin 4 = Cefmetazole 5 = Cefotetan 6 = Cefoxitin 7 = Cefuroxime 8 = Ciproflaxcin 9 = Clindamycin

10 = Ertapenem 11 = Erythromycin 12 = Gatifloxacin 13 = Gentamicin 14 = Levofloxacin 15 = Metronidazole 16 = Moxifloxacin 17 = Neomycin 18 = Vancomycin Text 7 G Vancomycin or Fluroqiunolones?

Enter a “Yes” if code 8, 12, 14, 16, 18 was entered in the previous cell. Enter a “No” if another code was entered.

Quality Check: Verify “Yes” is entered only if codes 8, 12, 14, 16 or 18 were entered in Column F.

Text Yes

H Date Antibiotic Administered

Enter the date the antibiotic was administered to the patient.

Date

(mm/dd/yyyy)

04/21/2013

I Time Antibiotic Administered

Enter the time the prophylactic IV antibiotic was administered to the patient.

Time (hh:mm) (Military format)

21:10

J Date of Incision Enter the date the incision was made.

Date

(mm/dd/yyyy)

04/21/2013

K Time of Incision Enter the time the incision was made.

Time (hh:mm) (Military format)

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Column Field Name Notes Excel Format Example L Time Difference

between

Administration and Incision

This field is automatically calculated based on a formula Time: (hh:mm) (Military format)

0:50

M Time Difference within 60 minutes?

If the time difference in the previous column (Column L) is less than 1:00 enter “Yes.” If not, enter “No.”

Yes = Time difference in Column L is less than or equal to 1:00 No = Time difference in Column L is 1:00 or greater

Quality Check: Verify “Yes” is entered only if Column L is less than or equal to 1:00.

Text Yes

N Time Difference within 120 minutes?

Only use this field if the patient received Vancomycin or Fluroquinolones.

If the time difference in column K is less than 2:00 enter “Yes.” If not, enter “No.”

Yes = Time difference in Column K is less than or equal to 2:00 No = Time difference in Column K is 2:00 or greater

Quality Check: Verify “Yes” is entered only if Column G has “Yes” entered into it AND Column L is less than or equal to 2:00.

Text Yes

O Exclusion Code Enter the applicable code for the following allowable exclusions:

1 = Patient had a preoperative order for a prophylactic IV antibiotic for the prevention of infections other than surgical site infections (e.g. bacterial endocarditis)

2 = Patient had a preoperative order for a prophylactic antibiotic not administered by the intravenous route

Leave BLANK if patient did NOT meet an allowable exclusion.

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Hospital Transfer/Admission

Use the tab titled “Data Collection Hosp Transfer” in the Excel Data Collection Spreadsheet ASC to collect the following data elements for this measure.

A ASC ID Enter the ASC ID for every patient/row submitted. MNCM assigns the ASC ID at the time of registration. Use the MNCM ID listed in the portal.

Quality Check: Verify that each cell has data and that all ASC IDs match the “MNCM ID” listed in the portal.

Text 9999

Quality Check: Verify that each cell has data. Use Excel’s Pivot Table to verify that IDs were not duplicated. If a duplicate is found, determine which ASC the ID is attributed to and delete the other record or assign a new ID if it is for a different procedure. Keep in mind that if you are submitting a sample, you will need to replace the deleted record with the next sampled patient.

Text 10

Quality Check: Verify that each cell has data.

Date

(mm/dd/yyyy)

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Column Field Name Notes Excel Format Example D ASA Physical Status

Classification

Enter the patient’s ASA Physical Status classification number. Definitions are listed below:

1 = ASA Physical Status 1 – A normal healthy patient

2 = ASA Physical Status 2 – A patient with mild systemic disease 3 = ASA Physical Status 3 – A patient with severe systemic disease

97 = All Other ASA Physical Status Classifications (4, 5 or 6) – A patient was classified as either an:

ASA Physical Status 4 – A patient with severe systemic disease that is a constant threat to life

ASA Physical Status 5 – A moribund patient who is not expected to survive without the operation

ASA Physical Status 6 – A moribund patient who is not expected to survive without the operation

98 = Anesthesiologist/ CRNA (level of sedation) required for this procedure, but No ASA Physical Status Classification Assigned – A patient had a procedure that required an anesthesiologist/ CRNA but did not have an ASA Physical Status assigned prior to the procedure. 99 = Anesthesiologist/ CRNA (level of sedation) is not required for this

procedure– A patient had a procedure that did not require an anesthesiologist/ CRNA and therefore did not have an ASA Physical Status Classification assigned

Quality Check: Verify each cell has an accepted code.

Text 1

E Patient’s Date of Admission

Quality Check: Verify that each cell has data and all dates are between 07/01/2012 to 06/30/2013.

Date

(mm/dd/yyyy)

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Column Field Name Notes Excel Format Example F Provider NPI Enter the NPI number of the surgeon who performed the procedure.

Text 1123456789

G Hospital Transfer Enter “Yes” or “No” for whether the patient was transferred to a hospital upon discharge from your facility.

Yes = Transferred/Admitted to hospital upon discharge from facility No = Not transferred/admitted to hospital upon discharge from facility

Text Yes

H Documentation

Location

If “Yes” to Hospital Transfer (Column G), enter the location of the proper documentation

Quality Check: Verify text is entered only if “Yes” was entered in Column G.

Text Incident

Report

I Reason If “Yes” to Hospital Transfer (Column G), enter the reason for the transfer Quality Check: Verify text is entered only if “Yes” was entered in Column G and Column H.

Text Pain and

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Appropriate Surgical Site Hair Removal

A ASC ID Enter the ASC ID for every patient/row submitted. MNCM assigns the ASC ID at the time of registration. Use the MNCM ID listed in the portal.

Quality Check: Verify that each cell has data and that all ASC IDs match the “MNCM ID” listed in the portal.

Text 9999

Quality Check: Verify that each cell has data. Use Excel’s Pivot Table to verify that IDs were not duplicated. If a duplicate is found, determine which ASC the ID is attributed to and delete the other record or assign a new ID if it is for a different procedure. Keep in mind that if you are submitting a sample, you will need to replace the deleted record with the next sampled patient.

Text 30

Quality Check: Verify that each cell has data.

Date

(mm/dd/yyyy)

05/08/1985

D Patient’s Date of Admission

Quality Check: Verify that each cell has data and all dates are between 07/01/2012 to 06/30/2013.

Date

(mm/dd/yyyy)

04/21/2013

E Provider NPI Enter the NPI number of the surgeon who performed the procedure. Text 1123456789

F Hair Removal Method Enter the method of hair removal used: 1 = Clippers

2 = Depilatory cream 3 = Razor (or other method)

Quality Check: Verify each cell of the accepted codes.

Text 2

G Exclusion Code Enter a 1 in this field if the patient removed own hair. Leave BLANK if patient did NOT meet an allowable exclusion.

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Ambulatory Surgical Center Measures 2013

(07/01/2012 to 06/30/2013 Dates of Service)

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About Data Submission

The goal of data submission is to collect aggregate or summary data from Ambulatory Surgical Centers (ASCs) on specific health care conditions and publicly report comparable rates of health care quality at the ASC site level. All ASCs follow the same instructions for population identification and data collection. MNCM certifies

methodologies prior to data collection. Then, each ASC submits data to the Minnesota Department of Health (MDH) for the Minnesota Statewide Quality Reporting and Measurement System via MNCM’s secure, online data portal. As an independent auditor, MNCM may validate the data for accuracy. The data will be publicly reported.

Purpose and Function of this Guide

This guide is intended to be a comprehensive instruction for the Summary Data Submission (SDS) process. Please contact MNCM with any questions or feedback. Our e-mail address is support@mncm.org.

Important Information for 2013 Reporting

Reporting requirements for the Minnesota Statewide Quality Reporting and Measurement System: By completing the registration process in the MNCM Data Portal and by completing the Summary Data Submission (SDS) process outlined in this guide, an ASC will fulfill the state requirements for reporting on these measures.

Total population submission for ASCs using an electronic medical record: Beginning in 2013, ASCs with electronic medical records (EMR) in place for the prior full measurement period (i.e., 07/01/2011 to

06/30/2012) will be expected to submit data on their full patient population for each measure. ASCs that do not meet this criterion may decide to submit total population or use a random sampling methodology (please see pages 24-25 for more information).

Confidentiality and Patient Personal Health Information (PHI)

Because ASCs will maintain the detailed patient information and will only submit summary data counts for the clinical quality measures, no personal health information (PHI) is transferred during the summary data

submission (SDS) process.

Participation Requirements

ASCs are required to participate in the clinical quality data submission process and to do the following:

 Follow the timeline outlined in this guide

 Agree to MNCM’s Site Terms of Use Agreement (sign electronically on the MNCM Data Portal)

 Submit site level data for all applicable ASCs

 Submit data in required format (summary data counts)

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Overview of the Process and Timeline

Process Step Helpful Dates to Remember

Registration

ASC registers sites and clinical staff on the MNCM Data Portal and electronically signs the Site Terms of Use Agreement.

 NOTE: If you have already registered for 2013, you do not need to register again. If you have not registered, you must do so before you can submit data. If you registered in 2012, you are required to register annually and will need to register for 2013 before you can submit data.

Resource: Download registration Instructions from the MNCM Data Portal https://data.mncm.org/login or www.mncm.org

Registration occurs annually during the spring

Communication is sent to all ASC portal data contacts when portal is open for registration

Contact MNCM at

support@mncm.org if your ASC did

not register

Population Identification (Denominator)

ASCs submit a document outlining the method for identifying the patient population (denominator) to the MNCM Data Portal. MNCM reviews and approves the denominator.

IMPORTANT: It is highly recommended that the denominator method is submitted to MNCM prior to May 31, 2013. MNCM must certify the denominator prior to sampling and data collection to ensure that the correct patient population is being pulled.

Resources: Download from MNCM Data Portal

https://data.mncm.org/login under the Resources tab:

 SDS Data Collection Guide

 Denominator Template

Denominator submission begins after registration

Recommended deadline: June 30, 2013

MNCM responds within 2-3 business days

Data Collection and Submission

ASC collects clinical data and calculates summary counts that are entered in the MNCM Data Portal.

Resources: Download from MNCM Data Portal

https://data.mncm.org/login under the Resources tab:

 SDS Data Collection Guide

 Data Collection Form

 Data Collection Spreadsheet Template

MNCM Data Portal opens: July 1, 2013

MNCM Data Portal closes: August 15, 2013

Respond to Data Validation Requests

After the summary data is successfully entered in the MNCM Data Portal, MNCM may contact the ASC with a data validation request

After August 15, 2013

Data Results

After the successful submission of the clinical data, the results will be

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Ambulatory Surgical Center Definition

To meet the requirements of the Minnesota Statewide Quality Reporting and Measurement System and MN Community Measurement, please refer to the following information that defines ambulatory surgical centers. An ambulatory surgical center (ASC) is a free standing facility organized for the specific purpose of providing elective outpatient surgery for preexamined, prediagnosed, low-risk patients. Services provided at an ASC are limited to surgical procedures which utilize local or general anesthesia and which do not require overnight inpatient care. ASC does not mean emergency medical services, or physician or dentist offices.

Note: The intent of this definition is to include all surgical procedures that utilize any type of sedation including anxiolysis, conscious sedation, analgesia or general anesthesia.

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Step 1: Registration on the MNCM Data Portal and Preparations

Registration must be completed once annually. Please refer to separate registration instructions for this process. A downloadable instructional guide will be available on the MNCM Data Portal.

Other data submission preparations:

 Save these MNCM Web sites in your “Favorites” internet folder for future reference:

o MNCM Data Portal: https://data.mncm.org/login o MNCM Web Site: www.mncm.org

o MN HealthScores: www.mnhealthscores.org

 Create a folder in your network drive dedicated to all data submission documents.

o Save all spreadsheets, forms and data submission materials in the dedicated folder.

 Name versions of documents clearly so you are using the most recent files.

 Log in to the MNCM Data Portal at https://data.mncm.org/login. In the Resources tab of the data portal, you are able to access the following items:

o From the Ambulatory Surgical Center drop down menu download the following:

 Ambulatory Surgical Center Measures Data Collection Guide

 Denominator Certification Form

 Data Collection Form

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Step 2: Identifying the Patient Population (Denominator)

Denominator definition: The denominator is the bottom number in a fraction. In epidemiology, the denominator represents a population group at risk of a specific disease.

In this step, the total number of patients who are eligible for each measure are identified using a standard set of criteria. Please review the “Denominator” section noted in the Measure Specifications in this guide for the detailed criteria used to identify eligible patients for the denominator.

The denominator criteria vary for each measure so the method used for each measure will vary.

Certification of the Patient Population (Denominator Certification)

To help ASCs avoid inadvertently pulling the wrong patient population, MNCM will complete an upfront review of each ASC’s source code or methodology that is used to produce the patient population (denominator). MNCM must certify the method before ASCs begin collecting data for submission. Please contact support@mncm.org with any specific questions.

PLEASE NOTE: Denominator certification may also include a comprehensive review by MNCM of the process steps used to identify the denominator, including the final list of patients. Please save all original queries, documents, spreadsheets, patient lists and process steps that are used to identify the patient population. MNCM may ask to review this information.

Denominator Template Form

This template is provided to ensure all ASCs are using the same set of criteria to identify patients for the denominator. ASCs are asked to complete this form and submit it to the MNCM Data Portal. Source code or “screen shots” are also helpful in MNCM’s review of the denominator.

1. Login to the MNCM Data Portal (https://data.mncm.org)

2. Go to the Resources tab and select Ambulatory Surgical Centers from the drop-down menu. Download the ASC Denominator Template form.

3. Complete the form and save the form on your network directory.

4. Login to the MNCM Data Portal and click on Denominator Certification on the home page. Follow the instructions to upload the form to the data portal.

5. MNCM will review the method and respond within 2-3 business days. MNCM will either (1) contact the ASC if more clarification is needed, in which case the ASC will need to make the necessary revisions and re-upload the form, or (2) certify the method in the MNCM Data Portal; an automatic e-mail will notify the ASC that the method is certified.

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Details for the Denominator Methodology

The following elements are included on the denominator template form; MNCM should be able to identify:

 Date of service range

 Data sources and location

 Whether exclusions will be taken and how exclusions will be handled

o EMR groups can list which accepted exclusions will be filtered through the query process

o ASCs can describe that any exclusions will be identified and documented during record review

 Whether total population or a sample of the patient population will be submitted; if a sample, the process for generating a sample

System Query: Helpful data elements that can be included in the system query

 ASC Site: This information must be substituted with the ASC ID in the data file that is submitted to MNCM as noted in the MNCM Data Portal.

 Patient name and ID number

 Patient date of birth (DOB)

 Admission date

 Provider performing the procedure

For ASCs that implemented a new practice management system or EMR in the last two years: Please consider how to generate the patient population using both systems. Two queries or patient lists may be necessary. The lists should then be combined and a common identifier(s) selected to de-duplicate the list. Please contact

support@mncm.org with any questions.

Allowable Exclusions

Allowable exclusions are kept to a minimum and are supported by evidence. The evidence must show frequency of occurrence in which the results would be distorted without the exclusion or is clinically appropriate. Please see the “Allowable Exclusions” noted in the Measure Specifications in this guide for a complete list of allowable exclusions for each measure.

If a patient meets the established patient criteria for the population and none of the allowable exclusions apply, the patient must be included.

Tracking excluded patients found during data collection:

 If a patient meets the inclusion criteria, you will collect data for that patient on the data collection spreadsheet for the applicable measure. If that patient also meets the exclusion criteria for a measure, there is a column on the data collection spreadsheet for you to enter the applicable exclusion code.

 If a sample will be submitted, you should choose a patient from your oversample to ensure that a total sample of 60 patients is submitted.

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Total Population Submission

ASCs are encouraged to submit total population instead of samples if possible. Beginning in 2013, ASCs with an electronic medical record (EMR) in place for the prior full measurement period will be expected to submit data on a full population basis. Thus, ASCs that have an EMR in place for the full measurement period of 07/01/2011 to 06/30/2012 would be required to submit data on their total population. By submitting total population, the confidence interval around the rate narrows, indicating a higher likelihood that the rate accurately reflects the ASC’s performance.

Sample Submission

Submitting a sample is also an option (e.g., for ASCs that use paper records or for ASCs that do not have a fully implemented EMR). ASCs without an electronic medical record in place for the prior full measurement period of 07/01/2011 through 06/30/2012 may submit data on a random sample of relevant patients in 2013 or they may choose to submit total population. The requirements for submitting a sample are as follows:

 If submitting a sample, each ASC site must submit a sample.

 If an ASC has less than 60 patients in the population for a given measure, submit ALL patients (e.g., if a total of 59 patients are in the population for the measure, submit all 59 patients).

 If an ASC has 60 or more patients, first consider submitting all patients, otherwise you may submit a sample. The minimum required sample is 60 patients per site (e.g., if there are 79 eligible patients in the population, first consider submitting all 79 patients, otherwise submit a sample of at least 60).

Random Sample Selection Methods

Method 1: Excel Random Number Generator Sample Selection:

Enter all the patient data into the ASC 2013 Data Spreadsheet Template on the appropriate measure tabs and complete the following steps using the data entered on the appropriate tab. For patient lists generated in Excel, use the “RAND” function to assign a random number to each record (please also see Microsoft Excel Help, topic RAND for more information):

Please verify that you are pulling a sample using the correct patient population. For example, please verify that if you are pulling a sample for the Appropriate

Surgical Site Hair Removal measure, that you are ONLY using data from that patient population. 1. Insert a blank column on the leftmost side of the spreadsheet

2. Label new column “RAND”

3. Place cursor in the first blank cell (A2) and type =RAND()

4. Press enter (a number like 0.793958 will appear)

5. Place the cursor back into this cell; resting over the corner to have the pointer change to a black cross, double click or drag the formula down to the last row/patient

6. Highlight the whole column and click Edit, Copy, Paste Special = Values to freeze the random number (otherwise it will change with every click on the spreadsheet)

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8. Work down the list row by row, starting with row 1 until the number of records in the sample is met for submission (at least 60 patients per ASC, per measure)

9. If a patient meets one of the accepted exclusions, note this on the exclusions spreadsheet and keep working down the list. Use oversample records following the last record/row of the original sample. For example, if 60 records will be submitted and exclusions were found in the first 60 records/rows, use patients from rows 61, 62, and so forth to replace the excluded records.

Method 2: Paper List Sample Selection:

For paper-generated lists, complete the following steps:

1. Start with a list that has patients sorted by some unique patient related variable.

a. Identifying number like a medical record number [MRN] or chart number is ideal.

b. Sorting alphabetically is the least desirable in terms of randomness; however, this may be used when there is no other alternative.

2. Select every Nth patient for the number of patients that will be reported.

a. N should equal the ASC’s total population divided by the number of patients that will be submitted (if needed, round down to the nearest whole number). Highlight or mark every Nth patient on the list. This is the sample.

b. Example: If an ASC has 600 patients who meet criteria for a measure and 60 patients will be submitted, divide 600/60 = 10. Select every 10th patient on the list.

3. If a patient meets one of the accepted exclusions, note this on the data collection form and exclusions spreadsheet and select the next patient on the list (just below the excluded patient).

Missing records when using Method 1 or Method 2: If a record in the sample is not available or “missing,” do NOT exclude this record. Either locate the record and complete the data collection, or include the record and leave the data fields blank if the record cannot be located.

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Step 3: Data Collection

ASCs can collect clinical data from ASC operational data, including administrative records, medical records, incidence/occurrence reports and quality improvement. Data collection occurs after:

1. The ASC’s billing and medical record updates are complete for the measurement period, 2. The denominator method is certified by MNCM, and

3. The patient population is pulled, and if applicable, a sample is selected according to the measure specifications and sampling instructions.

Tools for Data Collection and Data Entry

Data Collection Form

A data collection form for each measure was created for ASCs that manually collect data from an EMR or paper record. The necessary data elements are on the form. These forms can also be used to note where certain data elements were found in the ASC operational data. Data collected on these forms must also be entered into the Excel file mentioned below. Please download these forms from the MNCM Data Portal under the Resources tab, select Ambulatory Surgical Center Measures from the drop-down menu.

Excel Submission Template

The Excel Submission Template was created to ensure all necessary data elements are collected. This file contains all of the necessary fields as well as the correct column formatting according to the measure specifications. There are separate tabs for the detailed patient clinical data for each measure and the final summary counts. Please download the Excel template from the MNCM Data Portal under the Resources tab, select Ambulatory Surgical Center Measures from the drop-down menu.

Using Multiple Data Collectors and Inter-Rater Reliability (IRR)

Ideally, one data collector or data collection process is preferred because it ensures that the data is collected in one consistent way. If, however, more than one person will collect data, we recommend improving IRR by conducting an internal training and discussing the process with all persons who will collect data. This ensures that the measurement specifications are interpreted consistently and that the data is collected in a uniform way. Internal training could include a review of the guide and data collection form, and instructions for locating information in the clinic’s medical record. Also, refer to data collection errors made in previous submissions, make plans to improve the data collection process, and perform quality checks on the data.

Field Formatting in the Excel File:

Prior to entering data in the Excel file it is important that the field formats follow the measure specifications in this guide. Pay special attention to field formatting (e.g., dates look like dates, etc.).

Do NOT use “General” formatting in Excel. The Excel template provided on the MNCM Data Portal will provide the correct formatting.

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Locating Data Elements in the Patient Record

Each ASC may choose the source of patient level data for each measure. Possible data sources for each measure are listed below:

Prophylactic IV Antibiotic Timing:

ASC operational data, including medical records, medication administration records, nursing notes, IV flow sheets, clinical logs, incident/occurrence reports and quality improvement reports.

Hospital Transfer/Admission:

ASC operational data, including administrative records, medical records, incident/occurrence reports and quality improvement reports.

Appropriate Surgical Site Hair Removal:

ASC operational data, including administrative records, medical records, incident/occurrence reports and quality improvement reports.

Tracking Where Data is Located in the Patient Record

It is important to keep track of where data is located in the patient record. Please document the source on the data collection form or Excel spreadsheet.

If you are collecting data directly in the Excel spreadsheet, create a “NOTES” column and enter the data source details in this column.

Data Collection

Tips:

When manually

collecting data using an EMR, highlight the row, column or cell that contains the data needed. This reduces the chance of looking at the wrong row, column or cell.

Watch for TYPOS when entering data (number transpositions, etc.).

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Step 4: Pre-Submission Data Quality Checks

MNCM recommends completing several internal quality checks of the data before submitting the data. Performing quality checks ensures that the data is accurate and able to be validated by a MNCM auditor. If corrections are needed, make these in the Excel file.

Excel’s AutoFilter

Use the Filter function in Excel to look for incorrect or missing data:

 Click inside any data cell and activate the AutoFilter by doing the following:

o In Excel 2003, click the Data menu, point to Filter, and then click AutoFilter.

o In Excel 2007 and 2010, click the Data tab and in the Sort & Filter area click Filter.

 The AutoFilter arrows now appear to the right of each column heading.

 Click on the drop-down boxes of any column and scan for key entry errors, “out-of-range” or missing data and determine if the data needs to be corrected (e.g., If a date for a LDL is entered as free text, “About three months ago,” the field would not be accepted.)

 To display all data again, click on the same drop-down box and select (All).  Remove the Filter option by doing the following:

o In Excel 2003, click Data, Filter, and AutoFilter again

o In Excel 2007 and 2010, click the Filter option again in the Sort & Filter area

Important Pre-Submission Quality Checks (Excel File): Please review the “Quality Checks” listed for each data element in the Data Elements and Field Specifications section of the guide on pages 10-16.

It is important to complete the quality checks of the file before submitting data counts to MNCM. Completing these checks can help avoid delays in the file submission and ensure that you have the most accurate data. Do these checks on each tab of the data submission template. Make any changes/additions in the Excel file before submitting data to MNCM.

Internal Audit of Clinical Data: Before submitting the data file, you may wish to review a random sample of records (8-10) to see if the data matches what was collected from the patient record. If errors are found, make the corrections in the Excel file, however also consider if the errors were isolated cases or indicative of a larger data collection problem. Example of a larger data collection problem: You have no patients who meet the inclusion criteria for a measure and you are sure the ASC should have some patients who meet the inclusion criteria.

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Step 5: Summary Data Submission (SDS)

Calculate Summary Data Counts

The next step is to calculate summary counts for each ASC. These counts will be submitted to MNCM. The Excel data submission template that was used to enter detailed patient clinical data will be used to calculate the summary counts. A tab/worksheet within the Excel data submission template is included for entering the final summary counts by ASC.

Before you start, it is important to finalize data collection, data entry and quality checks. Once this is complete, you may begin calculating the summary data counts. Excel’s Pivot Tables and Filters functions are used to complete the calculations (see more information about these functions in Excel’s Help).

Enter your ASC IDs into Column A on the Summary tab. Calculate the following summary counts and enter these counts in the Summary tab in the Excel data submission template (see separate instructions for each measure):

Prophylactic IV Antibiotic Timing

Use the Data Collection IV Timing tab in the Excel Data Collection Spreadsheet 2013 containing detailed patient

clinical data as the data source for the following calculations:

Data Element Suggested Calculation Method

Number of Patients That Meet Inclusion Criteria (Less Exclusions)

Use your original spreadsheet or list of patients meeting the established patient criteria, generated from a practice management system, billing system or EMR.

If you are using your original spreadsheet , you may use the following instructions to calculate this count:

Turn the filter ON on the Data Collection IV Timing tab and complete each step in order. 1. From the filter drop down menu for the Exclusion Code column (Column O), click

on the “Select All” box to deselect all option and then select the “(Blank)” box 2. If you have more than one ASC site, click on the “Select All” box to deselect all

options in the ASC ID column (Column A) then select the first ASC ID 3. Count the number of rows (exclude the header row)

4. Enter this number in Column B on the Summary tab of the data collection spreadsheet in the corresponding row for the ASC ID site that you selected in Step 1

5. Repeat steps 2-4 for each additional ASC ID (begin with selecting the next ASC ID)

After all ASC counts are complete, turn the filter OFF on the Data Collection IV Timing Tab.

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Number of Patients Submitting

Enter the number of patients on the data collection spreadsheet minus the number of patients excluded. If you submitted total population this will be the same as the number of patients that meet inclusion criteria (less exclusions). If you submitted a sample, this will be the number of patients randomly selected (must be at least 60).

You may use the following instructions to calculate this count:

on the “Select All” box to deselect all option and then select the “(Blank)” box 2. If you have more than one ASC site, click on the “Select All” box to deselect all

4. Enter this number in Column D on the Summary tab of the data collection spreadsheet in the corresponding row for the ASC ID site that you selected in Step 2

Number of Patients Excluded

on the “Select All” box to deselect all option and then select the “1” and “2” boxes

2. If you have more than one ASC site, click on the “Select All” box to deselect all options in the ASC ID column (Column A) then select the first ASC ID

3. Count the number of rows (exclude the header row)

4. Enter this number in Column C on the Summary tab of the data collection spreadsheet in the corresponding row for the ASC ID site that you selected in Step 2

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Number of Patients with an order for a prophylactic IV antibiotic, who received the prophylactic antibiotic on time

Turn the Filter ON on the Data Collection IV Timing tab and complete each step in order: 1. From the filter drop down menu for the Exclusion column (Column O) click on

the “Select All” box to deselect all options and then select the “(Blanks)” box 2. If you have more than one ASC site, click on the “Select All” box to deselect all

options and then select the first ASC ID in the ASC ID column (Column A) 3. From the filter drop down menu for the Vancomycin/Fluroquinolones column

(Column G) click on the “Select All” box to deselect all options and then select the “No” box

4. From the filter drop down menu for the Time Difference within 60 minutes? column (Column M), click on the “Select All” box to deselect all options and then select the “Yes” box

6. From the filter drop down menu for the Vancomycin/Fluroquinolones column (Column G) click on the “Select All” box to deselect all options and then select the “Yes” box

7. From the filter drop down menu for the Time Difference within 120 minutes? column (Column N), click on the “Select All” box to deselect all options and then select the “Yes” box.

9. Add the two totals from steps 5 and 9. This will be the number you enter in the

Summary tab of the data collection spreadsheet. Enter the sum of steps 5 and 9 in Column E of the Summary tab of data collection spreadsheet in the

corresponding row for the ASC ID site you selected in Step 2

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Hospital Transfer/Admission

Use the Data Collection Hospital Transfer tab in the Excel Data Collection Spreadsheet 2013 containing detailed

patient clinical data as the data source for the following calculations:

Number of Patients That Meet Inclusion Criteria

Turn the filter ON on the Data Collection Hospital Transfer tab and complete each step in order.

3. Enter this number in Column F on the Summary tab of the data collection spreadsheet in the corresponding row for the ASC ID site that you selected in Step 1

After all ASC counts are complete, turn the filter OFF on the Data Collection Hospital Transfer tab.

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Enter the number of patients on the data collection spreadsheet minus the number of patients excluded for each category listed below in Step 5.

Turn the filter ON on the Data Collection Hospital Transfer tab and complete each step in order.

2. From the drop down filter menu for “Physical Status Classification” column (Column D), click on the “Select All” box to deselect all options. Then click on the “1” box to select “ASA Physical Status 1” patients

4. Enter this number in Column G on the Summary tab of the data collection spreadsheet in the corresponding row for the ASC ID site that you selected in Step 1

5. Repeat Steps 2-4 for each Physical Status Classification categories. Below lists each category and the corresponding column on the Summary Tab in which to enter the number of patients that submitting:

 Number of Patients that Meet Inclusion Criteria for ASA Physical Status Classification 2 = Click “2” and enter count into Column I

 Number of Patients that Meet Inclusion Criteria for ASA Physical Status Classification 3 = Click “3” and enter count into Column K

 Number of Patients that Meet Inclusion Criteria for All Other ASA Physical Status Classifications (4, 5 or 6) = Click “97” and enter count into Column M

 Number of Patients that Meet Inclusion Criteria for Anesthesia Required, No ASA Physical Status Classification Assigned = Click “98” and enter count into Column O

 Number of Patients that Meet Inclusion Criteria for Anesthesia Not Required = Click “99” and enter count into Column Q

After all ASC counts are complete, turn the filter OFF on the Data Collection Hospital Transfer tab.

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Number of admissions

requiring a hospital transfer or hospital admission upon discharge from the ASC

Turn the Filter ON on the Data Collection Hospital Transfer tab and complete each step in order:

1. Select the Hospital/Transfer column (Column G) on the Data Collection Hospital Transfer tab and from the drop down menu, click on the “Select All” box to deselect all options and then select the “Yes” box

2. If you have more than one ASC site, click on the “Select All” box to deselect all options and then select the first ASC ID in the ASC ID Column (Column A) 3. Select the Physical Status Classification column (Column D) on the Data

Collection Hospital Transfer tab and from the drop down menu click on the “Select All” box to deselect all options and then select the “1” box

4. Count the number of rows that remain (exclude the header row)

5. Enter this number in Column H on the Summary tab of the data collection spreadsheet in the corresponding row for the ASC ID site that you selected in Step 2

6. Repeat Steps 3-5 for each Physical Status Classification categories. Below lists each category and the corresponding column on the Summary tab in which to enter the number of patients that submitting:

 Number of Patients that Meet Inclusion Criteria for ASA Physical Status Classification 2 = Click “2” and enter count into Column J

 Number of Patients that Meet Inclusion Criteria for ASA Physical Status Classification 3 = Click “3” and enter count into Column L

 Number of Patients that Meet Inclusion Criteria for All Other ASA Physical Status Classifications (4, 5 or 6) = Click “97” and enter count into Column N

 Number of Patients that Meet Inclusion Criteria for Anesthesia Required, No ASA Physical Status Classification Assigned = Click “98” and enter count into Column P

 Number of Patients that Meet Inclusion Criteria for Anesthesia Not Required = Click “99” and enter count into Column R

7. Repeat the steps 2-6 for other ASC sites (begin with selecting the next ASC ID) After all ASC counts are complete, turn the filter OFF on the Data Collection Hospital Transfer tab.

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Appropriate Surgical Site Hair Removal

Use the Data Collection Hair Removal tab in the Excel Data Collection Spreadsheet 2013 containing detailed

Number of Patients That Meet Inclusion Criteria

Turn the filter ON on the Data Collection Hair Removal tab and complete each step in order.

1. From the filter drop down menu for the Exclusion Code column (Column G), click on the “Select All” box to deselect all option and then select the “(Blank)” box 2. If you have more than one ASC site, click on the “Select All” box to deselect all

4. Enter this number in Column S on the Summary tab of the data collection spreadsheet in the corresponding row for the ASC ID site that you selected in Step 1

After all ASC counts are complete, turn the filter OFF on the Data Collection Hair Removal tab.

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Enter the number of patients on the data collection spreadsheet minus the number of patients excluded. If you submitted total population this will be the same as the number of patients that meet inclusion criteria (less exclusions). If you submitted a sample, this will be the number of patients randomly selected (must be at least 60).

Turn the filter ON on the Data Collection Hair Removal tab and complete each step in order.

1. From the filter drop down menu for the Exclusion Code column (Column G), click on the “Select All” box to deselect all option and then select the “(Blank)” box 2. If you have more than one ASC site, click on the “Select All” box to deselect all

4. Enter this number in Column T on the Summary tab of the data collection spreadsheet in the corresponding row for the ASC ID site that you selected in Step 2

Number of Patients Excluded

Turn the filter ON on the Data Collection IV Timing tab and complete each step in order. 1. From the filter drop down menu for the Exclusion Code column (Column G), click

on the “Select All” box to deselect all option and then select the “1” and “2” boxes

4. Enter this number in Column U on the Summary tab of the data collection spreadsheet in the corresponding row for the ASC ID site that you selected in Step 2

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Number of ASC admissions with surgical site hair removal with clippers or depilatory cream

Turn the Filter ON on the Data Collection Hair Removal tab and complete each step in order:

1. From the filter drop down menu for the Exclusion column (Column G) click on the “Select All” box to deselect all options and then select the “(Blanks)” box 2. If you have more than one ASC site, click on the “Select All” box to deselect all

options and then select the first ASC ID in the ASC ID Column (Column A) 3. From the filter drop down menu for the Hair Removal Method column (Column

F) click on the “Select All” box to deselect all options and then select the “1” and “2” box

4. Count the number of rows that remain (exclude the header row)

5. Enter this number in Column V on the Summary tab of the data collection spreadsheet in the corresponding row for the ASC ID site that you selected in Step 2

Enter the Summary Counts into the MNCM Data Portal

The final step in the SDS process is to enter the summary counts into the MNCM Data Portal. Use the summary counts that were entered in the Summary tab in the Excel data submission template. Also complete the following:

Step 1: Prophylactic IV Antibiotic Timing:

Enter the following counts for each ASC:

1. Number of Patients That Meet Inclusion Criteria (Less Exclusions) - Column B on Summary Tab:

Enter the number of patients who are eligible or met the inclusion criteria for the measure. Do NOT include patients who met an accepted exclusion. Including excluded patients in this count will decrease the final rate, so remember to subtract these patients from the total population.

2. Total Patients Excluded – Column C on Summary Tab: Enter a count for each exclusion type for each ASC.

3.Number of Patients Submitting – Column D on Summary Tab: Enter the number of patients in the ASC that are being submitted. For total population submission, enter the same number as what

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4.Number of Patients Meeting Measure Criteria – Column E onSummary Tab: Enter the number of patients with an order for a prophylactic IV antibiotic, who received the prophylactic antibiotic on time.

Click Save and Continue.

Step 2: Hospital Transfer/Admission:

Enter the following counts for each ASC:

1. Number of Patients That Meet Inclusion Criteria (Less Exclusions) – Column Fon Summary Tab:

Enter the number of patients who are eligible or met the inclusion criteria for the measure. Do NOT include patients who met an accepted exclusion. Including excluded patients in this count will decrease the final rate, so remember to subtract these patients from the total population.

2. Number of Patients Submitting: For total population submission, enter the same number as what was entered in the Number of Patients That Meet Inclusion Criteria category. For a sample submission, enter the number of patients being submitted for the sample.

 Enter the number of patients classified under “ASA Physical Status Classification 1” (Column Gon Summary Tab)

 Enter the number of patients classified under “ASA Physical Status Classification 2” (Column I on Summary Tab)

 Enter the number of patients classified under “ASA Physical Status Classification 3” (Column K on Summary Tab)

 Enter the number of patients classified under “ALL Other ASA Physical Status Classifications (4, 5 and 6)” (Column M on Summary Tab)

 Enter the number of patients classified under “Anesthesia Required, No ASA Physical Status Classification Assigned” (Column O on Summary Tab)

 Enter the number of patients classified under “Anesthesia Not Required”

(Column Q on Summary Tab)

3. Number of Patients Meeting Measure Criteria: Enter the number of admissions requiring a hospital transfer or hospital admission upon discharge from the ASC:

 Enter the number of patients classified under “ASA Physical Status Classification 1” admissions requiring a hospital transfer or hospital admission upon discharge from the ASC. (Column H on Summary Tab)

 Enter the number of patients classified under “ASA Physical Status Classification 2” admissions requiring a hospital transfer or hospital admission upon discharge from the ASC. (Column J on Summary Tab)

 Enter the number of patients classified under “ASA Physical Status Classification 3” admissions requiring a hospital transfer or hospital admission upon discharge from the ASC. (Column L on Summary Tab)

 Enter the number of patients classified under “All Other ASA Physical Status Classifications (4, 5 or 6)” admissions requiring a hospital transfer or hospital admission upon discharge from the ASC. (Column N on Summary Tab)