Medicare Beneficiary Quality Improvement Project (MBQIP) Overview. January 3 rd 2017 Presented By: Shanelle Van Dyke

Transcription

1 Medicare Beneficiary Quality Improvement Project (MBQIP) Overview January 3 rd 2017 Presented By: Shanelle Van Dyke

2 Flex Grant Program Focuses on four core areas: 1. Support for Quality Improvement in CAHs 2. Support for Operational and Financial Improvement in CAHs 3. Support for Health System Development and Community Engagement Including integrating EMS in regional and local systems of care 4. Designation of CAHs in the State

3 Flex Medicare Beneficiary Quality Improvement Project (MBQIP) Purpose & Benefits A quality improvement activity under the Medicare Rural Hospital Flexibility (Flex) grant program of the Health Resources and Services Administration s Federal Office of Rural Health Policy (FORHP). The purpose is to improve the quality of care provided in critical access hospitals (CAHs), by increasing quality data reporting by CAHs and then driving quality improvement activities based on the data. This project provides an opportunity for individual hospitals to look at their own data, measure their outcomes against other CAHs and partner with other hospitals in the state around quality improvement initiatives to improve outcomes and provide the highest quality care to each and every one of their patients.

4 Flex Medicare Beneficiary Quality Improvement Project (MBQIP) Purpose & Benefits Continued This project puts patients first by focusing on Critical Access Hospital (CAH) improvements to health care services, processes and administration. This goal will be achieved by asking you, the CAHs, to report a specific set of CAH-relevant measures and engage in quality improvement projects to benefit patient care. Data will be aggregated into a national outcome for CAHs and shared with your State Flex Coordinator. This initiative takes a proactive approach to ensure CAHs are well- prepared to meet future quality requirements. The primary objective of this project is for critical access hospitals (CAHs) to implement QI initiatives to improve their patient care and operations. MBQIP uses Flex funding to support CAHs with technical assistance and national benchmarks to improve health care outcomes.

5 Goals of MBQIP CAHs report common set of rural-relevant measures Measure and demonstrate improvement Help CAHs prepare for value-based reimbursement

6 MBQIP Core Measures

7 Quality Reporting Channels - How it s connected CMS

8 Quality Reporting Channels - How it s connected CMS

9 MBQIP Data Submission Deadlines EDTC Data January 31 st 2017 Q (Oct.-Dec.) Inpatient (IQR) Data February 15 th 2017 Q (July-Sept.) Outpatient (OQR) Data February 1 st 2017 Q (July-Sept.) Population & Sampling (Reporting Zero) February 1 st 2017 Q (July-Sept.)

10 Reporting Zero - Population & Sampling via QualityNet Population and sampling refers to the recording of the number of cases the hospital is submitting to the QualityNet warehouse, this is done directly thru the QualityNet Secure Portal. The Population and Sampling application enables a provider or their contracted vendor to enter inpatient and outpatient population data of Medicare and non-medicare patients that meet the inclusion criteria for each of the measure sets. This allows a CAH to enter zero s for each measure, each month, for every quarter that you do not have cases that qualify for submission. By doing this it shows that you are actively participating vs. not reporting

11 MBQIP Additional Measures

12 MBQIP Additional Measures Continued

13 MBQIP and Hospital Compare MBQIP Nationwide effort Critical Access Hospitals Improve quality Public reporting Unique benchmarking Rural Appropriate Measures & Processes Sample size is a non issue Hospital Compare Nationwide effort All Hospitals Improve quality Public reporting Overall benchmarking Minimal case volume required for public reporting

14 Hospital Compare Notice of Participation (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.

15 Advantages of Participating Engage in QI initiatives Improves patient care across a broad population Improves hospital services, administration and operations Allows for clear benchmarking and the identification of best practice CAHs Receive technical assistance regarding cutting edge QI tools and models Prepare CAHs for the future where CAHs will likely have to report measures Fulfills the QI portion of the Flex grant Allows CAHs to remain eligible to receive grant funds under the Small Rural Hospital Improvement Program (SHIP)

16 How We Can Help! You ll receive: Focused technical assistance and the use of data submission software and other programs to submit quality data Training on the Special Innovation Project (SIP): Emergency Department (ED) Transfer Communication quality reporting program Data, data, data and more data that will help to address areas for QI activities Tools and other resources

17 Helpful Resources Outpatient & Inpatient Hospital Quality Reporting Notice of Participation Hospital Quality Reporting (HQR) Population and Sampling Outpatient Quality Reporting (OQR) Web-Based Measures CART Basics CART Patient Set-up/Abstraction and Import/Export Outpatient Specifications Manual Inpatient Specifications Manual EDTC EDTC Data Collection Tool training video EDTC Data Specifications Overview

18 Helpful Resources Continued HCAHPS Submitting Patient Satisfaction (HCAHPS) Data and Submission Reports NHSN

19 THANK YOU! Questions??? Shanelle Van Dyke m

20 This initiative is important to Alaska CAHs because: It will provide CAHs the opportunity to collect, analyze, and benchmark the triage and transfer care and communication they provide in their emergency departments. The measure to be used was developed specifically for CAHs, has been widely tested in rural hospitals, is NQF endorsed, and CAH participation will meet the Phase III MBQIP data collection requirement for the ED Transfer Communication Measure. ASHNHA Flex and Quality Reporting Services, will provide data collection training and technical assistance as well as support for interpretation of data reports and development of an action plan to address opportunities for improvement identified by review of CAH results on the measure.

21 Recruitment Message Critical Access Hospitals are increasingly in the spotlight of federal policy makers. It is more important now than ever to participate in efforts that help demonstrate the quality and value that CAHs provide to rural residents. Improved transitions of care is a key component of increasing the quality, effectiveness, and efficiency of health care services. Effective transfer of patient information from the Emergency Department to the next site of care can to foster continuity of patient care and help to reduce errors, improve outcomes, and increase patient and family satisfaction. Stabilization and transfer of patients in emergency situations is a fundamental role of Critical Access Hospitals in the health care safety net for rural communities. This project allows CAHs to evaluate and improve the effectiveness of that important role.

22 CMS Abstraction & Reporting Tool (CART) For Inpatient & Outpatient Data Collection

23 QualityNet secure portal (a.k.a QNet) For Inpatient & Outpatient Data Submission

24 ED Transfer Communication (EDTC) Excel Database For EDTC Data Collection & Submission to Alaska state Flex Coordinator

25 National Healthcare Safety Network (NHSN) For OP-27 (Outpatient HAI Measure) Collection & Submission