Hospital Quality Improvement Program (QIP) Measurement Specifications for Large Hospitals ( 50 general acute beds)

Transcription

1 Hospital Quality Improvement Program (QIP) Measurement Specifications for Large Hospitals ( 50 general acute beds) Developed by: The Hospital QIP Team Contact: HQIP@partnershiphp.org Published on: May 15, 2017

2 Table of Contents PROGRAM OVERVIEW... 2 Measurement Set Development... 2 Participation Requirements: Contract and Community HIE ADT Interface... 2 Performance Methodology... 3 Payment Methodology... 4 Timeline and Reporting SUMMARY OF MEASURES MEASUREMENT SET SPECIFICATIONS... 9 READMISSIONS DOMAIN ) All-Cause 30-Day Adult Readmission Rate a) Conditional Measure: Follow-up Post Discharge Visits ADVANCE CARE PLANNING DOMAIN ) Advance Directive for Patients 65 Years of Age or Older CLINICAL QUALITY DOMAIN: OB/NEWBORN/PEDIATRICS ) Elective Delivery before 39 Weeks ) Exclusive Breast Milk Feeding Rate ) Vaginal Birth after Cesarean (VBAC) Rate, Uncomplicated ) Participation in California Perinatal Quality Care Collaborative (CPQCC) ) Participation in California Maternal Quality Care Collaborative (CMQCC)..21 PATIENT SAFETY DOMAIN ) VTE Prophylaxis Rates for Stroke, Surgery, ICU, and Non ICU Patients OPERATIONS AND EFFICIENCY ) Inpatient Treatment Authorization Requests- Electronic Submissions (etars) Appendix I: HIE Participation Forms Appendix II: Hospital QIP Measure Submission Forms Works Cited Hospital QIP Page 1

3 Program Overview Partnership HealthPlan of California (PHC) has value-based purchasing programs in the areas of primary care, hospital care, specialty care, long-term care, community pharmacy, and mental health. These value-based programs align with PHC s organizational mission to help our members and the communities we serve be healthy. The Hospital Quality Improvement Program (Hospital QIP), established in 2012, offers substantial financial incentives for hospitals that meet performance targets for quality and operational efficiency. The measurement set was developed in collaboration with hospital representatives and includes measures in the following domains: Readmissions Advance Care Planning Clinical Quality: OB/Newborn/Pediatrics Patient Safety Operations/Efficiency Measurement Set Development The Hospital QIP uses a set of comprehensive and clinically meaningful quality metrics to evaluate hospital performance across selected domains proven to have a strong impact on patient care. The measures and performance targets are developed in collaboration with providers and are aligned with nationally reported measures and data from trusted healthcare quality organizations, such as the National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), Agency for Healthcare Research and Quality (AHRQ), National Quality Forum (NQF), and the Joint Commission. Annual program evaluation and open channels of communication between Hospital QIP and key hospital staff guide the measurement set development. This measurement set is intended to both inform and guide hospitals in their quality improvement efforts. Participation Requirements Hospitals with more than 50 general acute beds are considered large for our purpose and report on the Large Hospital Measurement Set. Other requirements include: 1) Contracted Hospital Hospital must have a PHC contract within the first three months of the measurement year, by October 1, to be eligible. Hospital must remain contracted through June 30, 2017 to be eligible for payment. Participation will require signing a contract amendment by July 1, 2016 to participate in the Hospital QIP. Hospitals that are invited to participate must be in good standing with state and federal regulators as of the month the payment is to be disbursed. Good standing means that the hospital is open, solvent, and not under financial sanctions from the state of California or Centers for Medicare & Medicaid Services. If a hospital appeals a financial sanction and prevails, PHC will entertain a request to change the hospital status to good standing Hospital QIP Page 2

4 2) Community Health Information Exchange (HIE) For hospitals with more than 50 general acute beds, HIE participation is a pre-requisite to joining the Hospital QIP. Hospitals must complete Admission, Discharge, and Transfer (ADT) interface with a community HIE by the end of the measurement year, June 30, This requirement will be satisfied upon completion of a two-part form confirming participation (Available in Appendix I): Part I: Implementation Plan, due October 31, 2016 Part II: Attestation of Completion of ADT Interface, due August 31, 2017 Community HIEs from whom attestation will be accepted: Connect Healthcare, Redwood Mednet, Sac Valley Med Share, North Coast Health Information Network, and Marin County Health Information Exchange. PHC will verify hospitals participation in community HIEs upon receipt of attestations. PHC is currently building infrastructure for interface if a local HIE is not available. Electronic HIE allows doctors, nurses, pharmacists, and other health care providers to appropriately access and securely share a patient s vital medical information electronically. Providing physicians with information regarding their patients significant hospital events via ADT interface allows for more streamlined follow-up care, considering access to this information via claims data can potentially take anywhere from days after an episode of care is delivered. 1 HIE interface has been associated with not only an improvement in hospital admissions and overall quality of care, but also with other improved resource use: studies found statistically significant decreases in imaging and laboratory test ordering in EDs directly accessing HIE data. In one study population, HIE access was associated with an annual cost savings of $1.9 million for a hospital. 2 Performance Methodology Participating hospitals are evaluated based on a point system, with points being awarded when performance meets or exceeds the threshold listed for each measure (outlined in specifications). Select measures present the opportunity for hospitals to earn partial points, with two distinct thresholds for full and partial points. Each hospital has the potential to earn a total of 100 points. Rounding Rules: The target thresholds are rounded to the nearest 10 th decimal place. Please see below for various rounding examples and respective points for Readmissions (measure 1). Table 1. Rounding Examples for Readmissions Target (Full Points: 12.0 % Partial Points: >12.0 % %) Raw Rate Final Rate Rounding Final Points 15.05% 15.1% None 15.04% 15.0% Partial 12.05% 12.1% Partial 12.04% 12.0% Full Hospital QIP Page 3

5 Payment Methodology The Hospital QIP has both capitated and non-capitated hospital participants, with different payment mechanisms for each. Capitated hospital methodology: The incentives provided through the Hospital QIP are separate and distinct from a hospital s usual reimbursement. The entire incentive pool is distributed based on the PHC member volume of the hospital, the score attained, and the performance of other participating hospitals. The entire incentive pool is distributed among participants. PHC does not retain any of the incentive pool. Year-end payments will be mailed by October 31 following the measurement year. Non-capitated hospital methodology: The Board of Directors has approved that each participating hospital can earn up to a 2.25% of its contract per diem rates. The Hospital QIP incentives are separate and distinct from a hospital s usual reimbursement. Each hospital s potential earning pool is structured as a withheld bonus, with 2.25% of the hospital s payments set aside from each claims payment and paid out at the end of the measurement year according to the number of points earned. The withheld funds are specific to each facility and will only be paid out to the extent points are awarded. Unspent funds will be retained by PHC. Year-end payments will be mailed by October 31 following the measurement year Hospital QIP Page 4

6 Timeline and Reporting The Hospital QIP runs on an annual program period, beginning July 1 and ending June 30. While data reporting on most measures follows this timeline, exceptions are made in order to align with national reporting done by participants. For all measures, the deadline for data submission is August 31 following the measurement year. Please see the reporting summary below: Table Hospital QIP Reporting Timeline Measure/ Requirement Data Measurement Period Hospital Submission PHC Reporting/ Outreach to hospitals HIE Participation Hospitals July 1, June 30, 2017 Implementation Plan: Oct 31, 2016 N/A Attestation Form: Aug 31, Readmissions PHC July 1, June 30, 2017 N/A Interim Report : March 14, a. Post Discharge Follow-Up* PHC July 1, June 30, 2017 N/A Final Report: October 31, 2017 (conditional) 2. ACP Hospitals July 1, June 30, 2017 August 31, 2017 N/A 3. Elective Delivery Hospitals Jan 1, Dec 31, 2016 August 31, 2017 N/A 4. Exclusive Breast Milk Feeding Hospitals July 1, June 30, 2017 August 31, 2017 N/A 5. Vaginal Birth after Cesarean (VBAC) 6. CPQCC PHC/ CPQCC 7. CMQCC PHC/ CMQCC Hospitals July 1, June 30, 2017 August 31, 2017 N/A July 1, June 30, 2017 N/A Outreach: March 14, 2017 Report: August 10, 2017 July 1, June 30, 2017 N/A Outreach: March 14, 2017 Report: August 10, VTE Prophylaxis Hospitals Jan 1, Dec 31, 2016 August 31, 2017 N/A 9. etars PHC July 1, June 30, 2017 N/A Monthly reports *Conditional Measure, only applies if Measure 1 not met Hospital QIP Page 5

7 Summary of Measures Table 3. Summary of Measures Measure Target ADT Interface with Community HIE (Required for participation) Hospitals must complete Admission, Submissions: Discharge, and Transfer (ADT) interface with a community HIE by the end of the measurement year, June 30, 2017 Part I: Implementation Plan, due October 31, 2016 Part II: Attestation of Completion of ADT Interface, due August 31, 2017 Readmissions (20 points) 1. All-Cause 30-day Adult Readmission Rate for all hospitalized PHC patients Full Points: 12.0% = 20 points Partial Points: >12.0% % = 10 points Conditional Measure: Measure 1a applies only if Measure 1 not met by June 30, 2017: 1a. Percentage of member hospital discharges with a physician office followup visit within 4 calendar days of discharge Full Points: 30.0% of members with a physician office visit within 4 calendar days of discharge = 20 points Advance Care Planning (15 points) 2. Option 1: Percentage of admitted patients 65 years of age and older with an Advance Directive status recorded as Structured Data (Documentation of Inquiry) Option 1: Documentation of Inquiry Full Points: 90.0% = 15 points Partial Points: 80.0% - <90.0% = 7.5 points Option 2: Percentage of admitted patients 65 years of age and older with Advance Care Planning documentation in the patients medical record (Obtained Advance Care Planning Documentation) Option 2: Obtained Advance Care Planning Documentation Full Points: 50.0% = 15 points Partial Points: 40.0% - <50.0% = 7.5 points Hospital QIP Page 6

8 Clinical Quality: OB/Newborn/Pediatrics (40 points) 3. Rate of Elective Delivery Before 39 Weeks Full Points: 3.0% = 10 points Partial Points: >3.0% - 5.0% = 5 points 4. Exclusive Breast Milk Feeding Rate at Time of Discharge from Hospital for all Newborns Full Points: 70.0% = 10 points Partial Points: 65.0% - < 70.0% = 5 points 5. VBAC Rate, Uncomplicated Full Points: 5.0% VBAC Uncomplicated = 10 points No Partial Points available for this measure 6. Timely Participation in CPQCC Data Reporting Full Points: Six or more months participating in CPQCC and submitting data to CPQCC for at least 6 months of the measurement year = 5 points Partial Points: Join CPQCC and submit data by June 30, 2017 (end of the measurement year) = 2.5 points Hospital QIP Page 7

9 7. Timely Participation in CMQCC Data Reporting Full Points: For hospitals new to the Hospital QIP: 6 or more months of Active Track participation during the measurement year = 5 points For hospitals participating prior to : 12 months of Active Track participation during the measurement year = 5 points Partial Points: For all hospitals: Establish Active Track participation in CMQCC or active participation in the CMQCC QI Collaborative to Support Vaginal Births and Reduce Unnecessary Cesareans during the measurement year = 2.5 points *Active track participation is defined by hospital submission of data to the Maternal Data Center by the end of the measurement year. Patient Safety (15 points) 8. VTE Prophylaxis: VTE-5 VTE Warfarin Therapy Discharge Instructions VTE-6 Hospital-Acquired Potentially- Preventable VTE STK-4 Thrombolytic Therapy Full Points: VTE % = 5 points VTE-6 5.0% = 5 points STK % = 5 points No Partial Points available for these components Operations and Efficiency (10 points) 9. Percentage of Inpatient Treatment Authorization Requests submitted electronically (etars) within one business day of an inpatient admission Full Points: 85.0% = 10 points Partial Points: 80.0% - <85.0% = 5 points Hospital QIP Page 8

10 Large Hospital Measurement Set Specifications- Readmissions Domain Measurement Set Specifications Measure 1. All-Cause 30 Day Adult Readmission Rate In healthcare, a readmission occurs when a patient is discharged from a hospital, and then admitted back into the hospital within a short period of time. Increased re-admissions are often associated with increased rates of complications and infections, and some studies even suggest that readmissions are commonly preventable. High rates of hospital readmissions not only indicate an opportunity for improving patient experience, safety, and quality of care, but they are also recognized by policymakers and providers as an opportunity to reduce overall healthcare system costs through quality improvement. As such, this measure is prioritized by organizations such as the NCQA to help inform and guide health care providers in their quality efforts, and is a HEDIS plan measure. 3,4 Measure Summary Percentage of acute hospital admissions that are within 30 days of a discharge. Target Full Points: 13.0% = 20 points Partial Points: >13.0% % = 10 points Target thresholds determined based on 2014 average HEDIS data for commercial HMO. July 1, 2016 June 30, Measurement Period Specifications Numerator: The total number of adult acute inpatient stays that were followed by an unplanned acute readmission for any diagnosis within 30 days of discharge. Denominator: Total number of adult acute inpatient discharges from July 1- May 31 during the measurement year. Patient Population PHC members 18 or older who are admitted to the hospital, and for whom PHC is the primary coverage. Exclusions Stays at the following facility types: Long Term Care, Intermediate Care, Sub-acute, rehabilitation, and behavioral health. Excludes acute stays for maternity care and newborn nursery days (OB, Nursery, and NICU stays) as identified by revenue code. PHC members for whom Medicare is the primary coverage Hospital QIP Page 9

11 Large Hospital Measurement Set Specifications- Readmissions Domain No reporting by hospital to PHC is required. Reporting PHC will provide an interim report in April for the period of July December, for participating hospitals to monitor performance. Methodology for extracting data at PHC Using claims and capitated encounter data, PHC will identify all acute inpatient stays not subject to the exclusion criteria, with a discharge date within the measurement period. The denominator is the count of all continuous stays for members continuously enrolled with PHC 90 days prior to the index admission date, through 30 days after index admission date. The numerator is the count of all 30-day readmissions of those in the denominator. For acute-to-acute transfers, the original admission date is the admission date for the entire stay, and the transfer s discharge date is the discharge date for the entire stay. Transfers to rehabilitation, subacute, or nursing facilities will be counted as discharges Hospital QIP Page 10

12 Large Hospital Measurement Set Specifications- Readmissions Domain Measure 1a. Post Discharge Follow-up Visits (Conditional measure*) *Points can only be earned for this measure if All-Cause Readmissions target not met (Measure 1). Considerable amount of national health care spending is spent on recurrent hospitalizations, even though studies have shown that a substantial portion of readmissions are preventable through effective pre-discharge planning and post-discharge follow-up after the initial visit. 4 Some studies suggest that up to 50% of readmissions are not associated with post-discharge follow-up procedures, although it has been shown that follow-up within 7 days is associated with meaningful reductions in readmission risk for some populations. As a backup measure to All-Cause 30 Day Adult Readmission, this measure will serve to guide improvement efforts surrounding the timeliness of post-discharge follow-up, with the ultimate goal of reducing overall readmissions. 5,6 Measure Summary Percentage of PHC patient discharges with a follow-up visit within 4 calendar days of discharge, based on claims and encounter data. Target 30.0% of members who have a physician office visit within 4 calendar days of discharge = 20 Points. Target threshold determined based on literature reviews and inter-departmental discussions. July 1, 2016 June 30, Measurement Period Specifications Numerator: Number of adult acute inpatient discharges with a qualifying follow-up visit within 4 days of discharge. Denominator: Total number of adult acute inpatient discharges from July 1 - May 31 during the measurement year. Patient Population PHC members 18 or older who are admitted to the hospital, and for whom PHC is the primary coverage. Exclusions Stays at the following facility types: Long Term Care, Intermediate Care, Sub-acute, rehabilitation, and behavioral health. Excludes acute stays for maternity care and newborn nursery days (OB, nursery and NICU stays) as identified by revenue code. PHC members for whom Medicare is the primary coverage Hospital QIP Page 11

13 Large Hospital Measurement Set Specifications- Readmissions Domain Reporting No reporting by hospital to PHC is required. A final report will be provided to the hospital by October 31, 2017, only if the hospital does not meet the full or partial points target for the Readmissions measure. Methodology for extracting data at PHC Using claims and encounter data, PHC will identify all inpatient discharges from hospital for all members during the measurement period. A follow-up visit will be counted if there is an outpatient office visit billed by a physician indicating a date of service within 4 calendar days of discharge Hospital QIP Page 12

14 Large Hospital Measurement Set Specifications- Advance Care Planning Domain Measure 2. Advance Directive for Patients 65 Years of Age or Older An advance directive is a document by which a person makes provision for health care decisions in the event that, in the future, he/she becomes unable to make those decisions for his/herself. The Hospital QIP s Advance Care Planning (ACP) measure aligns with similar measures established by many reputable healthcare quality improvement organizations, and is supported by national trends and data showing the importance of ACP in an individual s end of life care. 7, 8 ACP discussions increase the likelihood that a patient s wishes will be respected at end of life, and also eases sharing of medical information. 9 Measure Summary Among all unique patients 65 years old or older admitted to Hospital between July 01, 2016 and June 30, 2017, report on either: Percentage of admitted patients 65 years of age and older with an indication of Advance Directive status recorded as structured data. OR Percentage of admitted patients 65 years of age and older with Advance Care Planning documentation in the patients medical record (i.e. POLST/ Advance Directive). Option 1: Documentation of Inquiry Target Full Points: 90.0% = 15 points Partial Points: 80.0% - < 90.0% = 7.5 points Option 2: Obtained Advance Care Planning Documentation Full Points: 50.0% = 15 points Partial Points: 40.0% - < 50.0% = 7.5 points Target thresholds determined based on AARA Stage 2 Meaningful Use CMS Medicaid HER Incentive Program. July 1, 2016 June 30, Measurement Period Specifications PHC uses Meaningful Use Stage 2 specifications for this measure. For detailed specifications, follow this link: ospitalmenu_1_advancedirective.pdf Hospital QIP Page 13

15 Large Hospital Measurement Set Specifications- Advance Care Planning Domain Numerator: Option 1- Documentation of Inquiry: The number of patients in the denominator who have an indication of an Advance Directive status entered using structured data. Option 2- Obtained Advance Care Planning Documentation: The number of patients in the denominator who have Advance Care Planning documentation in the medical record. Denominator: The number of unique patients age 65 or older admitted during the measurement year. Patient Population All-hospital patient population ages 65 years or older, regardless of payer. N/A. Exclusions Reporting Annual reporting. Hospital will EMR report (all formats will be accepted) to Hospital QIP team at: or fax to (707) Hospital QIP Page 14

16 Large Hospital Measurement Set Specifications- Clinical Quality Domain: OB/Newborn/Pediatrics Measure 3. Elective Delivery before 39 Weeks Elective delivery is defined as a non-medically indicated, scheduled cesarean section or induction of labor before the spontaneous onset of labor or rupture of membranes. 10 It has been found that compared to spontaneous labor, elective deliveries result in more cesarean births and longer maternal lengths of stay. 11 Repeated elective cesarean births before 39 weeks gestation also result in higher rates of adverse respiratory outcomes, mechanical ventilation, sepsis, and hypoglycemia for the newborns. 12 The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) has consistently placed a standard requiring 39 completed weeks gestation prior to elective delivery, either vaginal or operative, for over 30 years Even with these standards in place, a 2007 survey of almost 20,000 births in HCA hospitals throughout the U.S. estimated that 1/3 of all babies delivered in the United States are electively delivered, with an estimated 5% of all deliveries in the U.S. delivered in a manner violating ACOG/AAP guidelines. Most of these are for convenience, and can result in significant short term neonatal morbidity. 16 Measure Summary Percent of patients with newborn deliveries at 37 to < 39 weeks gestation completed, where the delivery was elective. Full Points: 3.0% = 10 points Partial Points: > 3.0% - 5.0% = 5 points Target Target thresholds determined based on Joint Commission National Quality Measures, and PHC Hospital QIP participant data. January 1, 2016 December 31, Measurement Period Specifications Joint Commission National Quality Care Measures Specifications used for this measure (Perinatal Care Measure PC-1). For detailed specifications, follow this link: Numerator: The number of patients in the denominator who had elective deliveries. Denominator: Patients delivering newborns with 37 and < 39 weeks of gestation completed during the measurement year Hospital QIP Page 15

17 Large Hospital Measurement Set Specifications- Clinical Quality Domain: OB/Newborn/Pediatrics Patient Population All-hospital newborns, regardless of payer. Exclusions Exclusion list retrieved from v2016a Specifications Manual for Joint Commission National Quality Measures PC-01: ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for conditions possibly justifying elective delivery prior to 39 weeks gestation as defined in Appendix A, Table Less than 8 years of age Greater than or equal to 65 years of age Length of stay > 120 days Gestational Age < 37 or 39 weeks For hospitals with a denominator of 30 or less, elective deliveries for a medical reason not listed under Joint Commission s PC-01 exclusions may be submitted for PHC s review and, if approved, be excluded from the denominator. If the hospital does not have maternity services, this measure does not apply. Reporting Annual reporting. Hospitals will report (all formats will be accepted) to Hospital QIP team at: HQIP@partnershiphp.org or fax to (707) Hospital QIP Page 16

18 Large Hospital Measurement Set Specifications- Clinical Quality Domain: OB/Newborn/Pediatrics Measure 4. Exclusive Breast Milk Feeding Rate Exclusive breast milk feeding for the first 6 months of neonatal life has been a goal of the World Health Organization (WHO), and is currently a 2025 Global Target to improve maternal, infant, and young child nutrition. Other health organizations and initiatives such as the Department of Health and Human Services (DHHS), American Academy of Pediatrics (AAP), and American College of Obstetricians and Gynecologists (ACOG), Healthy People 2010, and the CDC have also been active in promoting this goal Measure Summary Exclusive breast milk feeding rate for all newborns during the newborn s entire hospitalization. Target Full Points: 70.0% = 10 points Partial Points: 65.0% - < 70.0% = 5 points Target thresholds determined based on Joint Commission National Quality Measures, and PHC Hospital QIP participant data. July 1, 2016 June 30, Measurement Period Specifications Joint Commission National Quality Care Measures Specifications used for this measure (Perinatal Care Measure PC-05) For detailed specifications of the measure, follow this link: Numerator: The number of newborns in the denominator that were fed breast milk only since birth. Denominator: Single term newborns discharged alive from the hospital during the measurement year. Patient Population All-hospital newborns, regardless of payer. Exclusions Exclusions retrieved from v2016a Specifications Manual for Joint Commission National Quality Measures, PC-05 specifications: Admitted to the Neonatal Intensive Care Unit (NICU) at this hospital during the hospitalization ICD-10 Other Diagnosis Codes for galactosemia as defined in Appendix A, Table ICD-10 Principal Procedure Code or ICD-10 Other Procedure Codes for parenteral nutrition as defined in Appendix A, Table Experienced death Hospital QIP Page 17

19 Large Hospital Measurement Set Specifications- Clinical Quality Domain: OB/Newborn/Pediatrics Length of Stay >120 days Patients transferred to another hospital Patients who are not term or with < 37 weeks gestation completed If the hospital does not have maternity services, this measure does not apply. Reporting Annual reporting. Hospitals will report (all formats will be accepted) to Hospital QIP team at: or fax to (707) Hospital QIP Page 18

20 Large Hospital Measurement Set Specifications- Clinical Quality Domain: OB/Newborn/Pediatrics Measure 5. Vaginal Birth after Cesarean (VBAC) Rate, Uncomplicated Vaginal birth after cesarean (VBAC) is used to describe a vaginal delivery of a child when the mother has delivered a baby through cesarean delivery in a previous pregnancy. Measure Summary Percent of patients who had a previous cesarean delivery who deliver vaginally. Target Full Points: 5.0% VBAC Uncomplicated = 10 points. No partial points available for this measure. Target threshold determined by AHRQ Quality Indicators and PHC Hospital QIP participant data. July 1, 2016 June 30, Measurement Period Specifications This measure is an AGRQ Inpatient Quality Indicator, #22. For detailed specifications, follow this link: rth_after_cesarean_(vbac)_rate_uncomplicate.pdf Numerator: Number of vaginal deliveries among cases meeting inclusion criteria for the denominator. Denominator: All deliveries with any listed ICD-9 or IDC-10 diagnosis code for previous Cesarean delivery. Patient Population All deliveries at the hospital where the mother had a prior cesarean section. Exclusions Exclusions retrieved from AHRQ Inpatient Quality Indicators #22. Exclusions include abnormal presentation, preterm, fetal death, multiple gestation, or procedure codes for breech delivery. If the hospital does not have maternity services, this measure does not apply. This measure does not apply to hospitals with 200 deliveries during the measurement year. Reporting Annual reporting. Hospitals will report (all formats will be accepted) to Hospital QIP team at: HQIP@partnershiphp.org or fax to (707) Hospital QIP Page 19

21 Large Hospital Measurement Set Specifications- Clinical Quality Domain: OB/Newborn/Pediatrics Measure 6. Timely Participation in California Perinatal Quality Care Collaborative (CPQCC) Data Reporting The California Perinatal Quality Care Collaborative is a quality improvement organization with the goal of improving health care outcomes for mothers and babies in California. Using the Institute for Healthcare Improvement ( collaborative quality improvement model, participating sites will focus on improving practices relative to their own baseline data. As a result of participating in this collaborative quality improvement process, facilities can expect the following benefits: Access to an evidence-based change package. The opportunity to benchmark, track, and compare data between the hospital site and other participating sites. Access to a multidisciplinary Expert Panel, which will actively support participating sites in their implementation of best practices. Credit for participating neonatologists toward the QI requirements of the American Board of Pediatrics (ABP) maintenance of certification (MOC) program. Measure Summary Participation in the California Perinatal Quality Care Collaborative. Target Full Points: Six or more months participating in CPQCC and submitting data to CPQCC for at least 6 months of the measurement year = 5 points Partial Points: Join CPQCC and submit data by June 30, 2017 (end of the measurement year) = 2.5 points July 1, 2016 June 30, Measurement Period Specifications All hospitals with maternity services and a Neonatal Intensive Care Unit would report data, per CPQCC parameters. Patient Population All newborns admitted to a nursery in the hospital. Exclusions If the hospital does not have a Neonatal Intensive Care Unit, this measure does not apply. Reporting No reporting by hospital to PHC is required. CPQCC will send report to PHC by July 31, 2017, noting participating hospitals and their start date for submitting data. PHC will validate the report with the participating hospitals Hospital QIP Page 20

22 Large Hospital Measurement Set Specifications- Clinical Quality Domain: OB/Newborn/Pediatrics Measure 7. Timely Participation in California Maternal Quality Care Collaborative (CMQCC) Data Reporting CMQCC works to improve maternal and infant outcomes through 3 primary focus areas: Aggregate, analyze and present data Create quality metrics and tools Implement large-scale QI projects and inform policy Measure Summary Participation in the California Maternal Quality Care Collaborative. Full Points: Target For hospitals new to the Hospital QIP: six or more months of Active Track participation during the measurement year = 5 points For hospitals participating prior to : 12 months of Active Track participation during the measurement year = 5 points Partial Points: For all hospitals: Establish Active Track participation in CMQCC = 2.5 points *Active track participation is defined by hospital submission of data to the Maternal Data Center by the end of the measurement year. July 1, 2016 June 30, Measurement Period Specifications All hospitals with maternity services would report data, per CMQCC parameters. Patient Population All newborns admitted to a nursery in the hospital. Exclusions If the hospital does not have maternity services, this measure does not apply. Reporting No reporting by hospital to PHC is required. CMQCC will send report to PHC by July 31, 2017, noting participating hospitals and their start date for submitting data. PHC will validate the report with the participating hospitals Hospital QIP Page 21

23 Large Hospital Measurement Set Specifications- Patient Safety Domain Measure 8. VTE Prophylaxis Rates for Stroke, Surgery, ICU, and Non ICU Patients The incidence of preventable venous thromboembolism (VTE) among hospitalized patients is overwhelming, and contributes to extended hospital stays and the rising cost of health care. VTE is considered by many as one of the most common medical complications of postoperative patients, and one of the most common causes of excess length of stay, excess charges, and even excess mortality. In spite of formal guidelines, and recommendations for increased preventive care, pulmonary embolism is still considered one of the most common preventable causes of death among hospitalized patients. 24 Measure Summary 1) VTE-5: Venous Thromboembolism Warfarin Therapy Discharge This measure assesses the number of patients diagnosed with confirmed VTE that are discharged to home, home care, court/law enforcement or home on hospice care on warfarin with written discharge instructions that address all four criteria: compliance issues, dietary advice, follow-up monitoring, and information about the potential for adverse drug reactions/interactions. 2) VTE-6: Hospital Acquired Potentially-Preventable Venous Thromboembolism This measure assesses the number of patients diagnosed with confirmed VTE during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date. 3) STK-4: Thrombolytic Therapy This measure assess the number of acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well, and for whom IV t-pa was initiated at this hospital within 3 hours of time last known well. Full Points: Target VTE % = 5 points VTE-6 5.0% = 5 points STK % = 5 points No partial points are available for the individual components of this measure. Target thresholds determined based on Joint Commission National Hospital Inpatient Quality Measures. January 1, 2016 December 31, Measurement Period Hospital QIP Page 22

24 Large Hospital Measurement Set Specifications- Patient Safety Domain Specifications Joint Commission National Hospital Inpatient Quality Measures Specifications used for this measure. For detailed specifications, follow this link: measures.aspx Numerator: 1) VTE-5: Venous Thromboembolism Warfarin Therapy Discharge Patients with documentations that they or their caregivers were given written discharge instructions or other educational material about warfarin that addressed all of the following: Compliance issues Dietary advice Follow-up monitoring Potential for adverse drug reactions and interactions 2) VTE-6: Hospital Acquired Potentially-Preventable Venous Thromboembolism Patients who received no VTE prophylaxis prior to the VTE diagnostic test order date. 3) STK-4 (Stroke Patients): Thrombolytic Therapy Acute ischemic stroke patients for whom IV thrombolytic therapy was initiated at this hospital within 3 hours (less than or equal to 180 minutes) of time last known well. Denominator: VTE-5: Venous Thromboembolism Warfarin Therapy Discharge Patients with confirmed VTE discharged on warfarin therapy. VTE-6: Hospital Acquired Potentially-Preventable Venous Thromboembolism Patients who developed confirmed VTE during hospitalization. STK-1 (Stroke Patients): Thrombolytic Therapy Acute ischemic stroke patients whose time of arrival is within 2 hours (less than or equal to 120 minutes) of time last known well. Patient Population All-hospital patient population, regardless of payer Hospital QIP Page 23

25 Large Hospital Measurement Set Specifications- Patient Safety Domain Refer to the following link: Exclusions easures.aspx Annual reporting. Reporting Hospitals will report (all formats will be accepted) to Hospital QIP team at: or fax to (707) Hospital QIP Page 24

26 Large Hospital Measurement Set Specifications- Operations and Efficiency Domain Measure 9. Inpatient Treatment Authorization Requests - Electronic Submission (etars) Electronic TAR (etar) is a web-based direct data entry system used by Medi-Cal providers. Medi-Cal providers have the ability to use etar for the purpose of submitting most TARs and inquiring about TAR decisions. Using the etar submissions process, providers can create, update, inquire, and view responses for TARs online. In addition, providers have access to the Code Search tool for code inquiries. Using etar eliminates mail and paper processing time. Measure Summary Percentage of all Inpatient Treatment Authorization Requests (TARs) submitted electronically within one business day of an inpatient admission. Target Full Points: 85.0% = 10 points Partial Points: 80.0% - < 85.0% = 5 points Target thresholds determined based on PHC Hospital QIP participant data. July 1, 2016 June 30, Measurement Period Specifications Numerator: Total number of Inpatient TARs submitted electronically by Hospital by 11:59 pm of the next business day following admission during the measurement period. Denominator: All Inpatient TARs received from Hospital by PHC during the measurement period. Patient Population PHC members who are admitted to the Hospital, and for whom PHC is the primary coverage. Exclusions Dual eligible beneficiaries (Medi-Medi patients), members for whom PHC is not primary coverage, members transferred to in- house swing-bed facilities, I-TARS (newborns without member ID numbers), duplicate TAR submissions (same patient, same admission date), TARS with retroactive timeframes. Reporting No reporting by hospital to PHC is required. PHC will provide monthly reports for participating hospitals to monitor performance. Methodology for extracting data at PHC PHC will extract all manual and electronic TAR data submitted by Hospital to PHC and compare the submittal date to the date of admission. The manual and electronic TAR submissions will be compared Hospital QIP Page 25

27 Large Hospital Measurement Set Specifications- Operations and Efficiency Domain to determine the percentage of all TARs submitted electronically within one business day of an inpatient admission Hospital QIP Page 26

28 Appendix I: HIE Participation Forms The following submission forms are required to participate in the Hospital QIP, with the Implementation Plan due by October 31, 2016 and the Attestation Form due by August 31, all material to or fax to (707) , Attention: Hospital QIP Project Coordinator. Should you have any questions, please us at Please find the following forms in this appendix: - Part I: ADT Interface Implementation - Part II: HIE Attestation Form Hospital QIP Page 27

29 Partnership HealthPlan of California Hospital Quality Improvement Program 4665 Business Center Drive, Fairfield, CA Tel (707) Fax (707) HIE Participation Part I: ADT interface implementation Please complete the following and submit to our office via fax or no later than October 31, Please include the following: Attestation of membership of community HIE in good standing, with a detailed ADT interface implementation plan, including date of implementation before June 30, Hospital: (e.g. Lakeside Hospital) Community Health Information Exchange: Start date for ADT interface: (e.g. February 1, 2017) Please describe any additional information for participation in the community HIE. This may include onboarding budget approval, anticipated date of completion of BAA, Network Participation Agreement, installation proposal details, etc Hospital QIP Page 28

30 Partnership HealthPlan of California Hospital Quality Improvement Program 4665 Business Center Drive, Fairfield, CA Tel (707) Fax (707) HIE Participation Part II: Attestation Form Dear Hospital QIP Participants, As part of the participation criteria for the 2016/2017 PHC Hospital QIP Program, your organization was required to participate with a community Health Information Exchange (HIE) by implementing a participation plan, as noted in your Implementation Form submitted in October Please fill out the attestation form below to confirm the implementation of your participation plan, and return it to our office via fax or no later than August 31 st, I (name, title) do hereby attest that (name of hospital) in the city of (name of city) has completed all the necessary steps to be considered compliant with the PHC 2016/2017 Hospital QIP gateway requirement of implementing a community HIE plan for our hospital. I attest to the following: Our community HIE has received a total of ADT files from our organization as of June 30, Contact: Hospital: Position: Date: Phone: Hospital QIP Page 29

31 Appendix II: Hospital QIP Submission Forms The following submission forms and the required attachments are due by August 31, 2017, with exceptions noted below. all material to or fax to (707) , Attention: Hospital QIP Project Coordinator. Should you have any questions, please us at Please find the following forms in this appendix: - Measure 2. Advance Care Planning - Measure 3. Elective Delivery before 39 Weeks - Measure 4. Exclusive Breast Milk Feeding Rate - Measure 5. VBAC Rate - Measure 8. VTE Prophylaxis Rates for Stroke, Surgery, ICU, and Non-ICU Patients Hospital QIP Page 30

32 Partnership HealthPlan of California Hospital Quality Improvement Program 4665 Business Center Drive, Fairfield, CA Tel (707) Fax (707) Measure 2. Advance Care Planning Complete the following table and attach a hospital EMR report to this submission form. Target population data is reported on All-hospital patients Option Selected (Select One) Option 1: Inquiry Option 2: Documentation Denominator Numerator Percentage (Num/Den) Definitions: Denominator: Total number of unique patients 65 years of age or older admitted between 7/1/2016 6/30/2017. (Exclusions apply. Please refer to measure specifications.) Numerator: Option 1: Patients in the denominator with an indication of an advance directive status entered using structured data. Option 2: Patients in the denominator with Advance Care Planning documentation in medical record Hospital QIP Page 31

33 Partnership HealthPlan of California Hospital Quality Improvement Program 4665 Business Center Drive, Fairfield, CA Tel (707) Fax (707) Measure 3. Elective Delivery before 39 Weeks Complete the following table and attach a hospital EMR report to this submission form. Please submit the completed form and attachment(s) to our office via fax or no later than August 31, Target population data is reported on Denominator Numerator Percentage (Num/Den) All-hospital deliveries Definitions: Denominator: Patients delivering newborns with 37 and < 39 weeks of gestation completed between 1/1/2016 and 12/31/2016. (Exclusions apply. Please refer to measure specifications.) Numerator: Patients in the denominator with elective deliveries Hospital QIP Page 32

34 Partnership HealthPlan of California Hospital Quality Improvement Program 4665 Business Center Drive, Fairfield, CA Tel (707) Fax (707) Measure 4. Exclusive Breast Milk Feeding Rate Complete the following table and attach a hospital EMR report to this submission form. Include specifications used to collect data and a brief description of the data collection system in place at your hospital. Please submit the completed form and attachment(s) to our office via fax or no later than August 31, Target population data is reported on Denominator: Numerator: Percentage: (Num/Den) All-hospital deliveries Definitions: Denominator: Single term newborns discharged alive from the hospital between 7/1/2016 6/30/2017. (Exclusions apply. Please refer to measure specifications.) Numerator: Newborns in the denominator that were fed breast milk only since birth Hospital QIP Page 33

35 Partnership HealthPlan of California Hospital Quality Improvement Program 4665 Business Center Drive, Fairfield, CA Tel (707) Fax (707) Measure 5. VBAC Rate Complete the following table and attach a hospital EMR report to this submission form. Include specifications used to collect data and a brief description of the data collection system in place at your hospital. Please submit the completed form and attachment(s) to our office via fax or no later than August 31, Target population data is reported on Denominator: Numerator: Percentage: (Num/Den) All-hospital deliveries Definitions: Denominator: All deliveries between July 1, 2016 and June 30, 2017 with any ICD-9 or ICD-10 previous diagnosis of where at least one prior delivery was by cesarean section. (Exclusions apply. Please refer to measure specifications.) Numerator: Vaginal deliveries meeting inclusion criteria Note: Any reported rate is eligible for full points Hospital QIP Page 34

36 Partnership HealthPlan of California Hospital Quality Improvement Program 4665 Business Center Drive, Fairfield, CA Tel (707) Fax (707) Measure 8. VTE Prophylaxis Rates for Stroke, Surgery, ICU, and Non-ICU Patients Complete the following table and attach a hospital EMR report to this submission form. Please submit completed form and attachment(s) to our office via fax or no later than August 31, Measure: Denominator : Numerator: Percentage: (Num/Den) VTE-5 VTE Warfarin Therapy Discharge VTE-6 Hospital-Acquired Potentially-Preventable VTE STK-4 Thrombolytic Therapy Definitions: Denominator: Unique to each measure measurement period between 1/1/ /31/2016 (Exclusions apply. Please refer to measure specifications) Numerator: Unique to each measure- measurement period between 1/1/ /31/ Hospital QIP Page 35

37 Works Cited 1. Selke, Curt. "Using ADTs as a Starting Point for Valuable Insights into Accountable Care Delivery Insights." Using ADTs as a Starting Point for Valuable Insights into Accountable Care Delivery. Accountable Care News, 10 Apr Web. 24 May Evidence Report/ Technology Assessment: Health Information Exchange. Rep. no Agency for Healthcare Research and Quality, Dec Web. 24 May Plan All-Cause Readmissions. National Committee for Quality Assurance State of Health Care Quality Report October 21, May 11, Benbassat, Jochanan, and Mark Taragin. "Hospital Readmissions as a Measure of Quality of Health Care." Arch Intern Med Archives of Internal Medicine (2000): Web. May 17, Jackson, C., M. Shahsahebi, T. Wedlake, and C. A. Dubard. "Timeliness of Outpatient Follow-up: An Evidence-Based Approach for Planning After Hospital Discharge." The Annals of Family Medicine 13.2 (2015): Web. May 17, "Rehospitalizations among Patients in the Medicare Fee-for-Service Program." New England Journal of Medicine N Engl J Med (2009): Web. May 17, California HealthCare Foundation, Final Chapter: Californians Attitudes and Experiences With Death and Dying (2012), May 17, Institute of Medicine, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life, (Washington, DC: National Academies Press, 2014), 3 4. May 11, Karen M. Detering et al., The Impact of Advance Care Planning on End-of-Life Care in Elderly Patients: Randomized Controlled Trial, BMJ 340 (2010): 4 5, doi: /bmj.c Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age. March of Dimes, California Maternal Quality Care Collaborative, Maternal, Child and Adolescent Health Division; Center for Family Health. California Department of Public Health. EliminationOfNon-MedicallyIndicatedDeliveries.pdf 11. Glantz, J. (Apr.2005). Elective induction vs. spontaneous labor associations and outcomes. [Electronic Version]. J Reprod Med. 50(4): Hospital QIP Page 36