Hospital Outpatient Quality Reporting Back to the Basics: Critical Access Hospitals

Transcription

1 Hospital Outpatient Quality Reporting Back to the Basics: Critical Access Hospitals Sophia Cherry, RPh, MPH Quality Improvement Specialist Health Services Advisory Group (HSAG) November 9, 2017

2 HSAG and the State Flex Programs Hospital Outpatient Quality Reporting Program-Medicare (HOQR) Medicare Beneficiary Quality Improvement Project-Flex Program (MBQIP) 2

3 Objectives Understand the importance of quality measures in healthcare Understand the goals of the Hospital Outpatient Quality Reporting Program Identify resources available for outpatient quality reporting and improvement 3

4 HSAG: QIN-QIO U.S. Virgin Islands HSAG is the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands. 4

5 Back to the Basics

6 What Is a Measure? Meas ure n. A standard: a basis for comparison; a reference point against which other things can be evaluated; they set the measure for all subsequent work. v. To bring into comparison against a standard. Source: National Quality Forum. ABCs of Measurement. Available at 6

7 Quality of Healthcare: Why Measure? A measure tells you how your hospital is performing and leads to improved patient care. 7

8 How Are Healthcare Quality Measures Used? Quality improvement Public reporting Provider incentive programs Accreditation and certification 8

9 Hospital Outpatient Quality Reporting (HOQR)

10 HOQR Program Pay for Quality Data Reporting Program Implemented by the Centers for Medicare & Medicaid Services (CMS) Measure data on the quality of care provided by hospitals in outpatient settings Voluntary for critical access hospitals (CAHs) Required for MBQIP 10

11 Benefits of Working With HSAG Quality improvement on individual quality measures is offered through: Technical assistance Education Tools and resources Support 11

12 Reporting Tips

13 Tip #1: Security Administrator Recommendations: More than one QualityNet Security Administrator per hospital Security Administrator should log into account monthly to maintain an active account 13

14 Tip #2: Run Reports Case status summary report Submission summary report Provider participation report QualityNet My Reports Run reports 14

15 Tip #3: Five or Fewer Cases Rule How Small is Too Small and The Power of One MBQIP: Report all cases per measure set, even if fewer than 5. CMS: Not required to report 5 or fewer cases per measure set. Common Measures: Acute myocardial infarction (AMI), chest pain, and stroke. AMI and chest pain case measures are a combined measure set. 15

16 Tip #4: Join the ListServ The Quality Net ListServ provides timely information related to: Quality initiatives Educational webinars Enhancements and new releases Timeline or process/policy modifications 16

17 Tip #5: Know The Resources: Demonstration HSAG (QIN-QIO) Quality Reporting Center QualityNet National Rural Health Resource Center 17

18 Hospital OQR Program Changes: CMS Final Rule Removal of six measures from the HOQR Program for the 2020 payment determination and subsequent years Measure Description OP-1 OP-4 OP-20 OP-21 OP-25 OP-26 Median time to fibrinolysis Aspirin at arrival Door to diagnostic evaluation by a qualified medical professional Median time to pain management for long bone fracture Safe surgery checklist use Hospital outpatient volume data on selected outpatient surgical procedures Source: 18

19 Thank You! For more information, contact: Sophia Cherry, RPh, MPH Quality Improvement Specialist

20 This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. QN-11SOW-D