Medicare Beneficiary Quality Improvement Project (MBQIP)

Medicare Beneficiary Quality Improvement Project (MBQIP) Karla Weng, MPH, CPHQ November 14, 2017 Nebraska CAH Conference on Quality Kearney, NE

Stratis Health Independent, nonprofit, Minnesota-based organization founded in 1971 Lead collaboration and innovation in health care quality and safety, and serve as a trusted expert in facilitating improvement for people and communities Work at intersection of research, policy, and practice Long history of working with rural providers, CAHs, and the Flex Program Rural Quality Improvement Technical Assistance (RQITA) is a FORHP funded program of Stratis Health 1

Rural Quality Improvement Technical Assistance Center (RQITA) Three-year cooperative agreement awarded to Stratis Health starting September 2015 from the Health Resources and Services Administration Federal Office of Rural Health Policy (HRSA FORHP). Improve quality and health outcomes in rural communities through TA for FORHP quality initiatives Flex/MBQIP Small Health Care Provider Quality Improvement Grantees (SCHPQI) Focus on quality reporting and improvement

Overview MBQIP Summary/Measures Current state of MBQIP Your MBQIP Journey MBQIP Going Forward Tools and Resources

MBQIP Overview 4

MBQIP Overview Quality improvement (QI) activity under the Medicare Rural Hospital Flexibility (Flex) grant program through the Federal office of Rural Health Policy (FORHP) Improve the quality of care provided in CAHs by increasing quality data reporting and then driving improvement activities based on the data Aligned with other Federal quality programs 5

Goals of MBQIP CAHs report common set of ruralrelevant measures Measure and demonstrate improvement Help CAHs prepare for value-based reimbursement 6

Benefits of MBQIP Participation Improved patient care Improved quality outcomes Increased capacity for participation in Federal reporting programs Access to full scope of Flex resources

MBQIP Core/Required Measures Patient Safety/Inpatient Care OP-27: Influenza vaccination coverage among health care personnel IMM-2: Influenza immunization New for FY 2018: Antibiotic Stewardship ED-1 and ED-2: ED measures for admitted patients Patient Engagement Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS): Patient Experience Survey

MBQIP Core/Required Measures Care Transitions EDTC: Emergency department transfer communication* Outpatient Acute myocardial infarction (AMI)/Chest Pain OP-1: Median Time to Fibrinolysis OP-2: Fibrinolytic Therapy Received Within 30 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 *Not currently a CMS Hospital Measure

MBQIP Core/Required Measures Outpatient (cont.) ED throughput OP-18 : Median Time from ED Arrival to ED Departure for Discharged ED Patients OP-20: Door to Diagnostic Evaluation by a Qualified Medical Professional OP-22: Pain management OP-21: Left Without Being Seen Median Time to Pain Management for Long Bone Fracture 10

MBQIP Additional Measures Patient Safety Healthcare Acquired Infections (HAIs), Stroke care, Venous Thromboembolism (VTE), Perinatal care, Surgical care, Pneumonia, Falls, Adverse Drug Events (ADEs), Readmissions, Safety Culture Survey Care Transitions Discharge Planning, Medication Reconciliation, Swing Bed Care Outpatient OP-23: Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI Scan Interpretation Within 45 Minutes of ED Arrival

MBQIP Reporting Processes QualityNet via Centers for Medicare and Medicaid Services (CMS) Abstraction and Reporting Tool (CART) or vendor QualityNet via online tool QualityNet via approved HCAHPS surveyor National Healthcare Safety Network (NHSN) EDTC template via state Flex Program

Quality Data Reporting Channels for MBQIP Core Measures Quality Net NHSN * State Flex Coordinator CMS Inpatient Measures (Submitted via CART or vendor tool) ED-1, ED-2, IMM-2 CMS Outpatient Measures (Submitted via CART or vendor tool) OP-1, OP-2, OP-3, OP-4, OP-5, OP-18, OP-20, OP-21 HCAHPS Survey (Vendor or selfadministered) CMS Outpatient Measures (Submitted through QualityNet Secure Portal) OP-22 Measure OP-27 ABX Annual Facility Survey EDTC *National Healthcare Safety Network Antibiotic Stewardship Emergency Department Transfer Communication 13

MBQIP Reporting and Performance 14

Current State of MBQIP 99% of CAHs have signed MOUs to participate in MBQIP 93.5% reported data in at least one quarter in at least two domains in the past year Significant increases in CAH reporting in recent years. 15

1,000 CAHs Reporting IMM-2 and OP-27 for MBQIP 950 968 953 900 850 858 840 800 750 2015-2016 Influenza Season 2016-2017 Influenza Season IMM-2 OP-27 National Performance IMM-2: 2015-2016: 87% 2016-2017: 87% OP-27: 2015-2016: 86% 2016-2017: 88% Source: MBQIP quarterly data 16

Emergency Department Communication Transfer (EDTC)* MBQIP Domain Description Care Transitions 7 Sub Measures (Percent) 1. Administrative Communication (2 elements) 2. Patient Information (6 elements) 3. Vital Signs (6 elements) 4. Medication Information (3 elements) 5. Physician/Practitioner Generated Information (2 elements) 6. Nurse Generated Information (6 elements) 7. Procedures and Tests (2 elements) Reporting Process EDTC All or None Composite (27 elements) EDTC Template to State Flex Office* Importance Timely, accurate and direct communication facilitates the handoff to the receiving facility provides continuity of care and avoids medical errors and redundant tests. *EDTC is the only required MBQIP measure that is not a CMS Hospital Measure 17

1,400 Number of Critical Access Hospitals reporting EDTC-All measure (national) 1,200 1,000 800 600 400 200 0 Q1 2015 Q2 2015 Q3 2015 Q4 2015 Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 Q2 2017 Q1 2015: 479 CAHs reporting Q2 2017: 1,150 CAHs reporting Source: MBQIP quarterly data 18

100% Critical Access Hospital EDTC measure performance (national) 90% 80% 70% 60% 50% 40% 30% 20% Q1 2015: 51.8% EDTC-All Q2 2017: 78.5% EDTC-All 10% 0% Q1 2015 Q2 2015 Q3 2015 Q4 2015 Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 Q2 2017 EDTC-1 Percent EDTC-2 Percent EDTC-3 Percent EDTC-4 Percent EDTC-5 Percent EDTC-6 Percent EDTC-7 Percent EDTC-All Percent Source: MBQIP quarterly data 19

Nebraska vs National Room for improvement in EDTC 86% of Nebraska CAHs reported EDTC for Q2 2017 Over time, Nebraska generally has a statewide average performance slightly lower than the nation 20

1,250 CAHs Reporting Data for At Least One MBQIP Outpatient Quality Measure 1,200 1,189 1,150 1,133 1,115 1,100 1,050 1,021 1,056 1,070 1,000 950 900 2015 Q4* 2016 Q1** 2016 Q2 2016 Q3 2016 Q4* 2017 Q1** *Reporting time period includes OP-22, reported once per year **Reporting time period includes OP-27, reported once per year Source: MBQIP Non-Submission Reports 21

Outpatient Performance Q1 2012 Q1 2017: AMI/chest pain (OP-1-5) no notable change Q1 2015 Q1 2017: ED Throughput (OP-18 & 20) no notable change Long Bone Pain (OP-21) no notable change Source: http://www.flexmonitoring.org/wp-content/uploads/2016/12/dsr20.pdf 22

Nebraska vs National Consistently better than the nation in OP-18 and OP-20 (ED measures) OP-18: Nebraska averages under 91 minutes; Nation averages about 104 minutes OP-20: Nebraska averages 15 to 16 minutes; Nation consistently about 17 minutes 23

90% of Nebraska CAHs reported HCAHPs in 2015. Source: http://www.flexmonitoring.org/wp- content/uploads/2017/01/dsr-21-hcahps- 2017.pdf 24

HCAHPS Performance From Q1 2012 Q4 2015: Quarterly trends in CAH national performance showed significant improvement in nearly all measures. The cleanliness of hospital environment measure did not show significant change over this time. Care transitions composite measure, added in Q2 2014, is lower than for the other HCAHPS measures and did not change significantly over time. Source: http://www.flexmonitoring.org/wp-content/uploads/2016/12/dsr20.pdf 25

Source: http://www.flexmonitoring.org/wp-content/uploads/2017/01/nebraska-hcahps-2017.pdf 26

Source: http://www.hcahpsonline.org/summaryanalyses.aspx 27

HCAHPS: Updated Pain Questions CMS is replacing the current HCAHPS Pain Management questions with three new questions that will comprise a new composite measure Communication About Pain New survey questions will be used beginning with patients discharged in January 2018 To access the updated survey: http://www.hcahpsonline.org/surveyinstrument.aspx 28

HCAHPS: Updated Pain Questions 29

MBQIP Current State Assessment Significant increases in CAH quality reporting (consistency still a challenge) To date, improvement on individual metrics is mixed Seeing a shift in conversations - from a focus on reporting to more focus on improvement Growing set of resources to support reporting and improvement 30

Discussion How has your MBQIP journey been going? Successes: How have you operationalized reporting? What improvements/strategies are working? Challenges: Where do you get stuck: Reporting? Improvement? Opportunities: What areas still need work? What tools, resources, or support would help you in that journey? 31

Future of MBQIP 32

MBQIP Going Forward Ongoing focus on measures that align with other Federal programs and priorities While advocating for increased availability of rural-relevant measures Anticipate continued step-wise approach to increasing minimum MBQIP participation criteria for Flex participation 33

New MBQIP Measures FORHP has announced additional required measures starting in 2018: ED-1 and ED-2: ED measures for admitted patients Antibiotic Stewardship (NHSN Annual Facility Survey) Continues to monitor other areas of interest, and policy challenges that impact implementation 34

ED Measures Admitted Patients ED-1: Median Time from ED Arrival to ED Departure for Admitted ED Patients ED-2: Admit Decision Time to ED Departure Time for Admitted Patients Note: CMS considers ED-1 and ED-2 Inpatient measures, since the population for the measures is patients with an inpatient stay 35

ED Measures Admitted Patients Reporting Route: QualityNet via CART or a vendor tool More than 40% of CAHs reported these measures in 2015 Why? Aligns other improvement efforts related to timeliness of care in the ED Incorporate communication and alignment of processes with inpatient units for timely transfer Majority of CAHs likely to have cases to report 36

Antibiotic Stewardship Adding an antibiotic stewardship program requirement to MBQIP for the next Flex grant program project period (starting in Fall 2018) FORHP is currently exploring options for how this activity will be evaluated Data source will be CDC NHSN Annual Facility Survey Aligns with proposed CMS updates to CAH Conditions of Participation (CoP) which includes an antibiotic stewardship program requirement 37

Why Antibiotic Stewardship? Improving antibiotic use in hospitals is imperative to improving patient outcomes, decreasing antibiotic resistance, and reducing healthcare costs 20-50% of all antibiotics prescribed in U.S. acute care hospitals are either unnecessary or inappropriate, which leads to serious side effects such as adverse drug reactions and Clostridium difficile infection Overexposure to antibiotics contributes to antibiotic resistance, making antibiotics less effective Federal priority and alignment with a variety of federal programs 38

Core Elements of Hospital Antibiotic Stewardship Leadership Commitment: Dedicate human, financial and IT resources Accountability: Leader responsible for outcomes (physician recommended) Drug Expertise: Pharmacist leader Action: Implement recommended action(s) such as antibiotic time-out Tracking: monitor prescribing and resistance patterns Reporting: regular information to doctors, nurses, and relevant staff Education: focus on resistance and optimal prescribing with clinicians Source: https://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html 39

Antibiotic Stewardship and MBQIP FORHP working closely with CDC More than 200 CAHs (26%) in successfully implemented all seven core elements in 2015 Current CDC focus goes beyond hospitals: CDC Core elements for Outpatient and Nursing Homes Opportunity for collaboration and alignment locally and/or regionally Resources: CDC: Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals JUMP START STEWARDSHIP: Implementing Antimicrobial Stewardship in a Small, Rural Hospital 40

Other Areas of Interest FORHP considered moving three HAI measures to MBQIP Required: HAI 2: CAUTI (Catheter Associated Urinary Tract Infection) HAI 5: MRSA (Methicillin-Resistant Staphylococcus Aureus Infection) HAI 6: CDI (Clostridium Difficile Infection) Decision to leave as additional for MBQIP due to lack of meaningful data feedback (SIR) HAI reporting continues to be strongly encouraged as appropriate for CAH services 41

HAI Metric: SIR Publically reported measure is a Standardized Infection Ratio (SIR) Calculated by CDC, and are risk adjusted for facility and patient characteristics Compares the number of reported HAIs to the number of predicted HAIs: (OBSERVED/PREDICTED = SIR) Hospitals that have less than one (1) predicted HAI in a given timeframe do not have a SIR calculated. Few CAHs will have a SIR calculated for any of the HAIs in a single quarter. https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/nhsn-sir-guide.pdf 42

Other areas of interest Swing Bed Quality Need to show value Exploratory efforts related to Functional Improvement Metrics ED-CAHPs (patient experience) CMS working on Emergency Department Patient Experiences with Care (EDPEC) Survey Testing supplemental HCAHPS questions for inpatients admitted from the ED Feasibility discussions for survey focused on patients discharged to the community National implementation unclear (if/when) https://www.cms.gov/research-statistics-data-and-systems/research/cahps/ed.html 43

Other areas of interest Appropriate Use Measures Readmissions Ambulatory Sensitive Admissions Inappropriate ED Use ecqms (electronic Clinical Quality Measures) 44

ecqms We believe that in the near future, collection and reporting of data elements through EHRs will greatly simplify and streamline reporting for various CMS quality reporting programs, and that hospitals will be able to switch primarily to EHR-based data reporting for many measures that are currently manually chart abstracted and submitted to CMS for the Hospital IQR Program. Federal Register / Vol. 81, No. 81 / Wednesday, April 27, 2016 / IPPS Proposed Rules/page 25174 45

ecqm Reporting Inpatient Quality Reporting (IQR) 2016: Submit 4 of 28 available ecqms for one CY quarter. 2017: Submit 4 of 15 available ecqms for one self-selected quarter. Due 2/28/2018 2018: Submit 4 of 15 available ecqms for one self-selected quarter. Due 2/28/2019 NOTE: The 2018 IPPS final rule significantly reduced the ecqm reporting requirements from what was previously outlined. Medicare EHR Incentive Program 2016: Submit at least 4 ecqms OR attest to 16 ecqms. 2017: Submit 4 of the16 available ecqms OR attest to all 16 ecqms* Due 2/28/2018 2018: Eligible hospitals and CAHs must electronically submit 4 of the 16 available ecqms using CEHRT when feasible. Due 2/28/2019 Attestation will no longer be an option except in circumstances where electronic reporting is not feasible. *Requirements vary slightly based on level of MU attained the prior year. Source: http://www.qualityreportingcenter.com/inpatient/iqr/tools/ 46

More Changes? FORHP works to align MBQIP measures with other Federal programs. OPPS Final Rule retires several current MBQIP core measures: OP-1: Median Time to Fibrinolysis (redundant to OP-2: Received Within 30 Minutes) OP-4: Aspirin on Arrival OP-20: Door to Diagnostic Evaluation by a Qualified Medical Professional OP-21:Median Time to Pain Management for Long Bone Fracture FORHP will provide guidance on impact for MBQIP reporting. 47

Process for CMS Quality Measure Identification CMS measures are identified and updated through the annual rule-making process IPPS Rule (Inpatient Prospective Payment System) defines IQR (Inpatient Quality Reporting Program) OPPS Rule (Outpatient Prospective Payment System) defines OQR (Outpatient Quality Reporting Program) Measures must be endorsed by the National Quality Forum (NQF), and reviewed by the NQF Measures Application Partnership (MAP) Measures are regularly topped-out and retired 48

National Quality Forum (NQF) Rural Health Project 20-member multi-stakeholder committee Committee Charge: Consider how to mitigate low-volume and resource challenges in payment incentive programs Identify which measures are most appropriate for those programs Recommend how future development resources are best directed to address particular measurement gaps areas. Final report September 2015 www.qualityforum.org/rural_health.aspx 49

NQF Rural Health Project (cont.) 14 recommendations, including: Mandatory participation in CMS QI programs for all rural providers using a phased approach Encourage voluntary groupings of rural providers for payment incentive purposes Fund development of rural-relevant measures. Suggested areas: Patient hand-offs/ transitions Alcohol/drug treatment Telehealth/telemedicine Access to care and timeliness of care Cost Population health at the geographic level Advance directives/ end-of-life

New! NQF Rural MAP Workgroup Timeline: Late 2017 Summer 2018 Provide recommendations on issues related to measurement challenges in the rural population to the NQF MAP Coordinating Committee Identify a core set of the best available (i.e., rural relevant ) measures and identify rural-relevant gaps in measurement. For more information or to track progress: http://www.qualityforum.org/map_rural_health_workgroup.aspx 51

Provide Input! Your input is needed to improve quality measurement and reporting: Provide comments in proposed rules and regulations Participate in discussions at a state and national level National Quality Forum Rural Recommendations as framework Watch for opportunities for input to the NQF Rural MAP Workgroup Share what works (or doesn t) for your CAH 52

Resources 53

Tools and Resources Key Resource Collection online: www.ruralcenter.org/tasc/mbqip/keyresource-list See handout/resource list 54

MBQIP Resources Reporting: Data Deadlines Chart MBQIP Reporting Guide Recorded Abstraction Training Series Improvement: QI Basics for Rural Healthcare Professionals CAH Improvement Guide and Toolkit Interpreting MBQIP Hospital Reports for Improvement HCAHPS Best Practices in CAHs 55

Need Help? For CMS Measures: Jackie Trojan (jackie.trojan@area-a.hcqis.org) or (402) 476-1399 For EDTC: Nancy Jo Hansen (Nancyjo.Hansen@nebraska.gov) or (402) 471-4616 Connect to RQITA Team as needed for additional support Questions can also go to: tasc@ruralcenter.org 56

Stratis Health RQITA MBQIP Team Robyn Carlson Quality Reporting Specialist Jodi Winters Administrative Support Sarah Brinkman Program Manager Karla Weng Program Lead Laura Grangaard Johnson Data Analyst 57

Rural places matter every patient counts! 58

Questions? Karla Weng, Senior Program Manager Stratis Health 952-853-8570 or 877-787-2847 kweng@stratishealth.org www.stratishealth.org 59

Stratis Health is a nonprofit organization that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities. This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U1RRH29052, Rural Quality Improvement Technical Assistance Cooperative Agreement, $500,000 (0% financed with nongovernmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.