Transcript PowerPoint - Missouri Hospital Association

FLEX-MBQIP Regional Meeting
October, 2016
Welcome and Introductions
Stephen Njenga, MPH, MHA, CPHQ, CPPS
Director of Performance Measurement Compliance
Missouri Hospital Association
[email protected]
573/893-3700, ext. 1325
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Housekeeping
 Mileage reimbursement
This only applies to you if you travelled over
50 miles one way.
 Expense sheet in your handouts
 The timeframe to submit them for
reimbursement
 Handouts

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FLEX Grant Activities
Quality
Financial and
Operational
Population
Health
• Patient safety, patient engagement,
care transitions, outpatient care
• Financial and operational assessments
and actions, revenue cycle
management, operational improvement
• Identify specific health needs of CAH
communities and implement activities
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Medicare Rural Hospital
Flexibility Grant
Create or
sustain
improvement in
quality, patient
safety, financial
and operational
outcomes, and
population
health
management
National
program with
resources and
benchmarking
Critical Access
Hospitals only!
32 out of 36
Missouri
hospitals
participating
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Goals of MBQIP
 CAHs report common set of rural-relevant
measures
 Measure and demonstrate improvement
 Help CAHs prepare for value-based
reimbursement
MBQIP and Hospital Compare
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MBQIP
Nationwide effort
Critical Access Hospitals
Improve quality
Public reporting
Unique benchmarking
Rural Appropriate
Measures & Processes
Sample size is a non
issue
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Hospital Compare
Nationwide effort
All Hospitals
Improve quality
Public reporting
Overall benchmarking
Minimal case volume
required for public
reporting
Finance and Operations
Current Activities and Projects
 Strategic planning and data analysis led to:
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Generalized support to all FLEX participants
Individualized support extended to six
financially stressed hospitals
– In-depth financial analysis with scope of work
identified
– Support from BKD CPAs and advisors
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Future Activities and Projects
 Continue generalized and individualized support
 Create a financial dashboard
 In-person CAH financial/operational education
session focused on revenue cycle management,
coding, service line analysis and chargemaster
review
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Population Health
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Current Activities and Projects
 Distribution of MHA’s Community Health Needs
Assessment guidance document
 Reimbursement for data collection and analysis
related to the assessment
 Access to national population health portal and
resources
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Future Activities and Projects
 Statewide CAH CHNA analysis with focused
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support
Update Community Health Needs Assessment
guidance document
Creation of Community Health Needs
Assessment Strategy Implementation Guide
Creation of Community Health Needs
Assessment Legal Guide
Webinar — How to Identify and Implement
Strategies using Community Health Needs
Assessment
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MBQIP Requirements
Data Submission Deadlines
Emergency Department
Transfer Communication
EDTC
Emergency Department Transfer
Communication
 EDTC reporting has increased from five
hospitals reporting to 26, which equates to
a 400 percent increase.
 The number of individual records reviewed
and reported has increased from 225, to
1033 per the Q12016 data report, which is
a 360 percent increase.
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CY2015 EDTC PERFORMANCE COMPARED TO Q 1&2 2016
EDTC 1
EDTC 2
EDTC 3
EDTC 4
EDTC 5
EDTC 6
EDTC 7
77%
73%
72%
98%
98%
95%
91%
87%
84%
97%
91%
Q22016
91%
Q12016
92%
91%
91%
97%
97%
94%
97%
98%
93%
94%
94%
93%
CY2015
ALL EDTC
Performance Trending
CY2015 EDTC PERFORMANCE COMPARED TO CY 2016 YTD
EDTC 1
EDTC 2
EDTC 3
EDTC 4
EDTC 5
EDTC 6
EDTC 7
75%
72%
98%
95%
89%
84%
94%
91%
CY2016 YTD
92%
91%
97%
94%
97%
93%
94%
93%
CY2015
ALL EDTC
Statewide EDTC Measures Snapshot
Baseline CY15
2Q16
Percent
Change
EDTC - 1
93%
94%
1.1%
EDTC - 2
93%
97%
4.3%
EDTC - 3
94%
97%
3.2%
EDTC - 4
91%
92%
1.1%
EDTC - 5
91%
97%
6.5%
EDTC - 6
84%
91%
8.3%
EDTC - 7
94%
98%
4.3%
ALL EDTC
71%
77%
8.4%
Overall improvement (EDTC 1-7, ALL EDTC)
37.2%
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Performance Improvement Strategy
EDTC-4: Medication Information
Medications administered
in ED
Allergies/Reactions
Home Medications
Performance Improvement Strategy
Nursing Notes
Sensory Status
EDTC-6 Nurse
Generated Information
Catheters/IV
Immobilizations
Respiratory
Support
Oral Restrictions
EDTC Statistical Methodology
 CMS uses the “All or Nothing” approach for
EDTC calculation
 Cases abstracted MUST meet all the 27 different
data elements to get credit
 This methodology does not use the “average”
concept
Outpatient Reporting
Participation, Performance and Reporting process
Outpatient Measures
 OP-1: Median Time to Fibrinolysis
 OP-2: Fibrinolytic Therapy Received Within 30
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Minutes
OP-3: Median Time to Transfer to Another
Facility for Acute Coronary Intervention
OP-4: Aspirin at Arrival
OP-5: Median Time to ECG (electrocardiogram)
OP-18: Median Time from ED Arrival to ED
Departure for Discharged ED Patients
Continued…
 OP-20: Door to Diagnostic Evaluation by a
Qualified Medical Professional
 OP-21: Median Time to Pain Management for
Long Bone Fracture
 OP-22: Left Without Being Seen (Emergency
Department
Patient Safety Measures:
 OP-27 Influenza Vaccination Coverage among
Healthcare Personnel
 IMM-2 Influenza Immunization (Only IP
Measure)
Missouri Aggregate OP/Patient
Safety Report
Outpatient Reporting Gap
OP Measures Reporting in Missouri
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6
4
NON MBQIP CAHS
NOT ON HOSPITAL
COMPARE
ON HOSPITAL COMPARE
REPORTING OP
MEASURES
Outpatient Reporting Nationwide
OP Reporting and Performance
OP Reporting and Performance
Reminder: IMM-2 Measure
 Abstraction and reporting required throughout
the year
 Data reported from April to September is
excluded because it is not during the flu season.
 Hospitals are to answer questions on patients
meeting IP guidelines
 Only required for October-March
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Hospital Consumer
Assessment of Healthcare
Providers and Systems
(HCAHPS)
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Completed Surveys and Response
Rates for CAHs Q2 2014 – Q1 2015
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CAH’s Reporting HCAHPS
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Response rates and your HCAHPS
vendor
 Your HCAHPS survey vendor can have a big
influence on your HCAHPS response rates. When
choosing a vendor, ask them:
 What are your typical response rates? Is the
response rate around the national average of
29 percent?1 If it’s lower or higher, why might
that be?
 How long do you wait to administer the
surveys after you’ve received the list of
patients from us?
Response rates and your HCAHPS
vendor
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How often, and how many times, do you try
to reach patients to get their completed
response? Consider how it fit your
expectations.
What mode do you use to administer the
survey? Phone, paper, or mixed mode (i.e.
both)? One CMS study found that mixed mode
may produce the best response rates,
followed by mail, but consider what might be
best given your patient population.
Important Information
 You may also consider connecting with your
vendor regularly. For example, having quarterly
calls to talk about HCAHPS and any suggestions
they may have for you.
Response rates and your hospital
 The vendor isn’t all that matters. Here are some
ways that might increase response rates that
your hospital can control:
 Administer surveys quickly after patient
discharge. Send your list of eligible patients to
the survey vendor on a weekly basis, not
monthly.
 Confirm with your patients before they leave
the hospital that you have their correct phone
numbers and/or mailing addresses.
Response rates and your hospital
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Let your patients know the survey will be
coming. Even though you can’t try to influence
their responses, give some advance notice
that they may be contacted. Make sure they
know if this contact will be by mail or by
phone, as well.
Tell patients why their input matters. One
hospital gives patients a “calling card”
notifying them that they may receive two
calls: “One so that we can check on you, and
one so that you can help us improve.”
Remember
 Hospitals with higher HCAHPS scores also tend
to have better response rates. Perhaps the key
to higher response rates, as well as better
scores, is providing a positive overall patient
experience.
SHIP Grant
Small Rural Hospital Improvement
Grant Program (SHIP)
Department of Health and Senior Services
Office of Primary Care and Rural Health
State Office of Rural Health
SHIP Hospital Eligibility
 Forty-nine (49) staffed beds or less as reported
on the hospital’s most recently filed Medicare
Cost Report, line 14.
 Hospital must be located in a rural area outside
a Metropolitan Statistical Area (urban area).
Check the Rural Health Information Hub ‘s “Am I
Rural”? website
http://www.ruralhealthinfo.org/am-i-rural/tool)
to find out if you are Rural.
 Critical Access Hospitals (CAHs) are all eligible.
Funding Availability
 Fiscal Year (FY) 2015 Grant Period:
September 1, 2015 – May 31, 2016 $9,596.00
 FY 2016 Grant Period :
 June 1, 2016 - May 31, 2017 - (not awarded
yet)
 Approximate amount for each hospital:
 $9,000.00
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SHIP Program - Use of Funds
 The SHIP funds should be prioritized by Critical
Access Hospitals (CAHs) in the following
manner:
 Priority 1: HCAHPS or ICD-10 Activities
 Both of these must be fully implemented and
HCAHPS must be publicly reported to Hospital
Compare, before your hospital can select any
other investment options. Priority is not given
to one over the other so your hospital may
choose both.
SHIP Program - Use of Funds
 Priority 2:
If your hospital is already participating fully in
HCAHPS and ICD-10, you may select a
different investment listed on the SHIP
purchasing menu
 Priority 3:
 If your hospital has already completed ALL
investments your hospital may identify an
alternative piece of equipment and/or service
ONLY IF: See next page

SHIP Program - Use of Funds
 The purchase will optimally affect your hospital's
transformation into an accountable care
organization, increase value-based purchasing
objectives and/or aid in the adoption of ICD-10;
 Your hospital receives pre-approval from both
your state SHIP Director - Lisa Branson and the
appropriate FORHP Project Coordinator.
 Click here to watch the SHIP Webinar Link
Contact Information
Lisa Branson
SHIP Director
State Office of Rural Health
(573) 526-2825
[email protected]
Overall Star Rating
CAHS
What it Encompasses
 The Overall Hospital Quality Star Rating
combines 64 measures that are already public
on Hospital Compare into one star rating. The
measures fall into seven groups:
 Mortality,
 Safety of care,
 Readmission,
 Patient experience,
 Effectiveness of care,
 Timeliness of care
 Efficient use of medical imaging.
Measure Groups & Percent Weight
To meet the minimum threshold to have a star
rating calculated hospitals must have at least three
measures, in at least three groups, with at least
one outcome group.
Overall Star Rating
 Because the quality measures used for the
overall rating reflect routine care and hospitalacquired infections, specialized care provided by
certain hospitals is not reflected in the ratings
 A hospital's rating is only calculated using as
many measures for which data is available. That
means hospitals' star ratings could be based on
as few as nine measures or as many as 64; the
average is roughly 40.
Analysis Methodology
 If a hospital doesn't have data for three
measures within at least three of the seven
measure groups, including one outcome group
(meaning mortality, safety or readmission), the
hospital doesn't get a score. Currently, 937
hospitals do not have an overall star rating.
 Star ratings will be updated each quarter.
Concerns on CMS Methodology
 CMS delayed launching the program for three
months because of pushback it received from
stakeholders and members of congress.
 They argued that because the methodology is
not risk-adjusted and doesn't account for
socioeconomic factors, it puts certain hospitals,
like academic medical centers and safety-net
hospitals, at a disadvantage.
Star Rating Release – July 2016
Overall Star Rating Designation
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Spotlight Hospital
OP Reporting Process
CART Tool
Quality Reporting Channels
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Quality Reporting Channels
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Quality Reporting Process
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Reporting using CART tool?
 Access using the QualityNet
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Specifications Manuals
CART (Centers for Medicare and Medicaid
Services Abstraction and Reporting Tool)/data
collection tool
Secure Log-in
Enter Cases and Submit
 Enter cases into the CART tool and submit by
the designated deadline per the CMS guidelines.
 Make sure to do the necessary checks to make
sure your submission is successiful
 If you get errors on the detailed report, resolve
them per instructions and resubmit per the
guidelines.
 If you are using a vender, they should be able to
guide you through this process to resolve any
errors.
Watch: Cart Tool 101 Video
 MBQIP Webinar: Cart Tool 101 - PowerPoint
Recording
Notice of Participation
Pledging Process
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Notice of Participation
 Although it is not necessary for Critical Access
Hospitals (CAHs) to complete the inpatient or
outpatient notice of participation (NOP) in order
to participate in the Medicare Beneficiary Quality
Improvement Project (MBQIP), the NOPs must
be completed in order for data submitted to
QualityNet to appear on Hospital Compare.
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Notice of Participation Process
 Complete the registration process to gain access
to the QualityNet secure web portal
 Designated security administrator is the only
individual who may complete the “Notice of
Participation” so that hospital-specific data may
appear on the Hospital Compare website
 NOP MUST be completed for Inpatients and
Outpatients. NOTE: Same process should be
completed for HCAHPS reporting.
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Steps to Complete the NOP
 Log into the QualityNet secure portal.
 Under “Quality Programs,” select “Hospital
Quality Reporting.” You now will see the “My
Tasks” page.
 In the box titled “Manage Notice of
Participation,” click “View/Edit Notice of
Participation, Contacts and Campuses.”
 Follow the instructions to see your hospital’s
status. Once your hospital’s NOP is accepted, it
remains active unless your hospital changes its
pledge status.
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MBQIP Dashboard Reports
HIDI Analytic Advantage® Sample Reports
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EDTC Dashboard Report
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EDTC Dashboard Report
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FLEX Webpage & Resources
MBQIP
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References
 MHA http://web.mhanet.com/mbqip.aspx
 QualityNet https://www.qualitynet.org
 Hospital Compare
https://www.medicare.gov/hospitalcompare/sear
ch.html
 National Rural Health Resource Center
https://www.ruralcenter.org/tasc/mbqip
 Quality Improvement Implementation
Guide and Toolkit for Critical Access
Hospitals.
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Guide and toolkit for CAHS
This guide and toolkit offers strategies and resources to help critical
access hospital (CAH) staff organize and support efforts to implement
best practices for quality improvement.
 Quality Improvement Implementation Guide and Toolkit for Critical
Access Hospitals [PDF 1 MB]
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Brainstorming Tool [Word 33KB]
Internal Quality Monitoring Tool [Excel 558 KB]
Internal Quality Montiroing Tool video tutorial [WMF 23min ]
Project Action Plan Template [Word 23 KB]
Quality and Patient Safety Meeting Agenda/Minute Template [Word 35 KB]
Rapid Tests of Change Tool [Word 25 KB]
Rapid Tests of Change Tool - Example [PDF 168 KB]
Ten Step Quality Improvement Project Documentation Template [Word 30 KB]
CAH Quality Prioritization Tool [Excel 296 KB]
Video Links
 QualityNet Secure Portal: New User Enrollment
Training
 Hospital Quality Reporting Notice of Participation
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Resources
 Measures of Variation
Quality Resource Brief
 Using Data to Drive Improvement
 Quality Resource Brief

Upcoming Events
 Fall Regional Meetings
October 6 — Carrollton
 October 11 — Springfield
 October 25 — Festus
 Remainder of 2016 MCE events
 Please refer to memo dated August 3.
 Register using the FLEX payment option.
 Registrations are released approximately
eight to 12 weeks out, depending on speaker.

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Questions
Primary Contact
Stephen Njenga, MPH, MHA, CPHQ, CPPS
Director of Performance Measurement Compliance
Missouri Hospital Association
[email protected]
573/893-3700, ext. 1325
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