Medicare Beneficiary Quality Improvement Program (MBQIP) Stephen Njenga, Director of Performance Measurement Compliance March 2018
Housekeeping Handouts Location of restrooms Instead of reimbursing for mileage during the regional meetings funds were diverted to cover the following offerings that were open to all participating CAHs: Population Health High Reliable Organizations/Culture of Safety TeamSTEPPS Secondary Data Analysis for CHNA Each hospital was eligible for $3,500
SHIP Deadlines 2017 Grant Period: June 1, 2017 to May 31, 2018 Invoices no later than Thursday, May 31 Award Amount: $8,717 2018 Grant Period: June 1, 2018 to May 31,2019 Not yet awarded Award Amount: $9,000
FLEX Grant Activities Quality Patient safety, patient engagement, care transitions, outpatient care Financial and Operational Financial and operational assessments and actions, revenue cycle management, operational improvement Population Health Identify specific health needs of CAH communities and implement activities
NHSN Agreement to Participate
NHSN Annual Surveys 2017 NHSN survey is due Thursday, March 1 Hospitals are always encouraged to submit in advance to avoid last minute issues. Annual surveys are used for your risk adjustment for SIR and may change year to year based on your responses. Currently, facilities are using 2016 or 2017 surveys. These surveys will be used to calculate 2016 and 2017 SIRs.
Core Measures Data Submission CART Tool
New Deadlines for MBQIP Measures
FLEX Grant Overview
National Logic Model Inputs Federal Office of Rural Health Policy $23 Million 45 States Resources toolkits, publications, reports
State Logic Model Inputs 33 Critical Access Hospitals Collaboration with DHSS Resources toolkits, publications, data
State Level Core Areas Quality Improvement (MBQIP) Operational and Financial Improvement Population Health Improvement
Program Goals Short Term Staff understands the program requirements, indicators and strategies Medium Term Staff reports measures, adopts projects and best practices Long Term CAHs improve their quality of care, stabilize finances and adjust to changing community needs
Core Area Improvement Activities CAH Needs Assessments Training and technical assistance Consultations Information sharing Collaboration and networking ROI tracking Scholarships and education reimbursement Data analysis
State Logic Model Outputs Quality Quality Reporting How many hospitals report? Quality Improvement Are hospitals improving the care they provide? Operational Operational and financial state measures State standard measures monitored at the state level Individual unique measures by hospital Population Health CHNA Compliance Are all hospitals conducting an assessment that are mandated? CHNA Improvement Are the assessments and action plans making an impact?
Game Changers in Health Care
Changing Landscape in Health Care The Triple Aim To improve health care delivery To improve population health To lower costs improve efficiencies Affordability Quality/outcomes Patient experience Population management
Achieving Triple Aim Greater efficiencies: Improved access/ outcomes; reduced variability; reduced costs Characteristics: Patient/ family engagement and satisfaction Measurable results Implementation, spread and sustainability of evidence-based best practices Continuous measurement Differential rewards: pay for performance and outcomes Mitigate risk
Performance Improvement Multiple Opportunities: Clinical Consistent implementation of evidence - based practices Fidelity to recommend models (process measures) Seamless care transitions Operational LEAN Six Sigma reduce waste, increase efficiency Throughput improvements Seamless care transitions Administrative Revenue enhancement coding/billing accuracy Supply/purchasing management Seamless care transitions
Quality Improvement Efforts Convene experts (clinical domain, quality, patient experience) Identify and disseminate best practices (collaboratives) Manage and evaluate programs and grants to transform care (measure processes, cost, benefit, outcomes) Breakdown/cross silos Work across/share clinical practice Partner with internal and external stakeholders (Community partners, providers, payers, policymakers)
What to Expect in the Future Payment Rates: decline Quality and Efficiency: rewarded Readmissions and Low Quality: penalized Population Health: important
The Premise
Important Considerations for CAHs Improve/ document efficiency and quality Partner with local primary care providers Improve care coordination and transitions Prepare for population health management Consider participation in an ACO, community care organization, medical home or other valuebased models
To Achieve Value To achieve excellent performance and success in a value-based system, CAHs must ensure: Leadership alignment Vision and strategy Partnerships, care coordination and community Use of data and information Change-ready adaptable workforce Highly efficient, business-oriented processes Customers, partners and community Staff and culture Efficient processes and operations Information and knowledge Documentation of outcomes and value
Leadership Educate and engage hospital trustees and boards about the critical role of value-based purchasing and population health Form meaningful partnerships with local physicians and health care providers Align hospital leaders and managers behind value and population health
Leadership
Strategic Planning
Patients, Partners and Communities
Processes and Operations Maximize the efficiency of clinical, financial and operation processes Develop effective care coordination teams and processes, and ensure safe and timely transitions of care Maximize the effectiveness of health information, social media and telehealth technology
Use Data Effectively
Always Remember that The health care market is undergoing transformational change. Leadership awareness/support is critical in helping rural health providers stay relevant during market transformation. The Performance Excellence Blueprint is a tool to help rural leaders manage system wide improvement and navigate change. The framework is flexible and can be used in multiple ways a starting point is just reviewing the key success factors and taking a critical look at your organization.
New Reporting Requirements for FY18-21
Antibiotic Stewardship - MBQIP This addition would allow CAHs four years to fully implement an antibiotic stewardship program by FY2021. (September 1, 2018 to August 31, 2022)
Background Information Former President Obama s Executive Order and National Strategy (Sept. 2014) PCAST Report to the President (Sept. 2014) National Action Plan for Combating Antibiotic- Resistant Bacteria (Mar. 2015) PCAST-President s Council of Advisors on Science and Technology
Elements for Antibiotic Stewardship Programs Leadership Commitment Accountability Drug Expertise Action Tracking Reporting Education http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html
Antimicrobial Management Team
Basic ASP Foundation M.D./ PharmD champion Multidisciplinary team Gap assessment Assess staff resources Competency/training planning Communication plan for facility CEO support of ASP approval of gap and action plan Selecting physician champion Complete gap assessment and action plan as a team Determine staffing needs to adequately resource ASP activities Create competency/training plan for all disciplines based on current knowledge and involvement Invite CEO to ASP team meeting to discuss plan, resources and support
Missouri Antibiotic Stewardship The state legislature enacted SB579 requiring that by August 28, 2017, each Missouri hospital, excluding mental health facilities, and each ambulatory surgical center, must establish an antimicrobial stewardship program. Hospitals are required to use CDC s Antimicrobial Use and Resistance Module when regulations concerning Stage 3 of the Medicare and Medicaid Electronic Health Records Incentive Program take effect. This has been delayed, but hospitals should keep the program going as they await for the necessary infrastructure to be available for reporting.
Reporting Requirements for ASP Utilization of the AUR Module specifically requires emar and some form of clinical document architecture. The vendor system has to have the service and software that will allow participating in the AUR pharmacy option through direct reporting. Vendors who have the software and services and are actively reporting include EPIC, Asolva, MedMinded, Bacter (ICNet), Intelligent Medical Systems (Meditab), RL Solutions, Sentri7, TheraDoc and VigiLanz. Although you may utilize one of these vendors, you may not have the specific software needed to begin reporting
Measuring Antibiotic Usage Standardized antimicrobial administration ratio Observed-to-expected/predicted rate Serves as a starting point for antimicrobial use evaluations by stewardship teams A statistically significant SAAR >1.0 indicates more antimicrobial use than expected.
Missouri Hospitals IT Survey Results (146 Hospital Responses) 133 have fully implemented the ability to review laboratory results across all units 132 have fully implemented emar across all units 105 have fully implemented bar coding or radio frequency identification for closed-loop medication administration across all units 131 have fully implemented record-preferred language for communication with providers of care as part of meaningful use
Missouri Hospitals IT Survey Results (146 Hospital Responses) 117 can automatically generate hospital-specific, meaningful use quality measures by extracting data from EHR without additional manual processes 111 have some level of clinical document architecture to send clinical/summary of care records
ED Throughput Measures
ED Throughput Measures Final rule additions to MBQIP FY18-21 (September 2018 to August 2022) 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
Background Information The first quarter of required reporting was 3Q17 (Submission deadline was February 15, 2018) CY2016 47 persent reported these measures nationally Missouri s current reporting rate is 51 perecent. Chart-abstracted and reported to QualityNet on a quarterly basis Reported using CART tool or approved vendor Patients included in ED-1 and ED-2 measures are admitted for an inpatient stay from the ED
ED-1 and ED-2 Core Measures Participation
Dashboard Report All Measures
Hospital Consumer Assessment of Healthcare Providers and Systems Analytics
HCAHPS Standardized survey tool to measure patient s perception of quality of care by physicians and hospital staff during hospital stay Why? Consumers provide information helpful in choosing a hospital Hospitals offer incentives to improve quality of care How? A way to compare hospitals Provides meaningful data for improvement efforts
HCAHPS
HCAHPS The epicenter of these experiences for patients is generally focused on the patient room and five different types of human interactions during the patient stay When the patient is alone in the room When the patient and a visitor are together in the room When the patient and nurse interact in the room When the patient and physician interact in the room When the patient and support services interact in the room These different human interactions create the paradigm for defining the patient experience the people, the process and the place. These three interactions need to work well collaboratively in order to yield a satisfactory patient experience and quality HCAHPS scores.
HCAHPS People the physical space of the patient room can contribute to engaging the caregiver by providing plenty of natural light, giving caregivers adequate space to work, and planning spaces that combine multiple functions. Process Lean design principles should be used to improve the caregiver s workflow and limit the number of value-wasted movements. By making their job more efficient, they can save energy and leverage opportunities for rest and respite. Place The physical space needs to be quiet and clean. Using easy-to-clean flooring materials and designing patient rooms to limit room-to-room and corridor-to-room noise transfer enables the space to address typical areas for satisfaction shortfalls.
What Works? Improving patient experience involves the following: Front-line staff need to be involved with creating the experience. Focus on two to three interventions that are done with excellence and consistency. The focus MUST be on creating a healing experience for the patient. Create a process for continuous accountability and staff recognition.
Intention - Connection - Action 1. Intention What is my intention going into the patient s room? 2. Connect Build a relationship with the patient before doing anything to them. 3. Action After I m clear about my intention and I have connected with the patient, only then do I carry out any tasks of the job such as checking vitals, administering medications, or even their diagnosis and treatment
Use Five Ps to Anticipate Needs Pain Potty Positioning Personal needs Patient Priority Decrease falls and call lights Use language that suggests what they might need, rather than just asking if they have a need.
Making Five Ps Proactive Typical question: Do you need to use the restroom? Proactive language: I m about to give you pain medication which might make you sleepy. Would you like me to help you to the restroom first so that you won t have to get back up? I know you are used to getting up on your own, but since you are connected to an IV, let me go ahead and help you to the bathroom while I am here so that I can make sure you are safe.
Outpatient Measures Analytics
Quality Reporting Channels
Importance of Documentation Communicates to others what was done Facilitates patient care Supports data collection Reflects quality of decision - making Justifies legal defense Supports regulatory compliance Supports fair payment /reimbursement
Documentation is Important ED physician and nursing documentation in some cases is weak or missing. The documentation does not fully support patient care, correct coding and accurate charging. Examples: Length of laceration is not always documented. IV start and stop time is often not documented. Critical care nursing time is not documented. Physicians charts are not always complete. Documentation does not always comply with payer and regulatory guidelines.
Emergency Department Transfer Communication Analytics
Quality Reporting Process
Spotlight Hospital
Internal Quality Monitoring Tool
OP-1 Median Time to Fibrinolysis
OP-2 Fibrinolytic Therapy Received Within 30 Minutes
OP-3b: Median Time to Transfer to Another Facility for Acute Coronary Intervention
OP-4: Aspirin at Arrival
OP-5: Median Time to ECG
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-21: Median Time to Pain Management for Long Bone Fracture
OP-22: Patient Left Without Being Seen
OP-27: Influenza Vaccination Coverage Among Health Care Personnel
IMM-2: Immunization for Influenza
ALL EDTC Composite Score
Food for Thought Even if you re on the right track, you ll get run over if you just sit there. -Will Rogers
Resources
Care Learning Online program Orientation FLEX program overview Quality reporting and improvement Financial and operational excellence Population health management Cost is covered by FLEX program
MHA https://web.mhanet.com/mbqip.aspx
Resources HCAHPS http://www.hcahpsonline.org/home.aspx MBQIP Measures Fact Sheets http://web.mhanet.com/sqi/mbqip/mbqip-measures- Fact-Sheets-Final_2015-11-10.pdf Federal Office of Rural Health Policy http://www.hrsa.gov/ruralhealth/ FLEX Monitoring Team http://www.flexmonitoring.org/ QualityNet https://www.qualitynet.org/ CDC Antibiotic Stewardship Program https://www.cdc.gov/getsmart/healthcare/pdfs/coreelements.pdf#page=14
References MHA http://web.mhanet.com/mbqip.aspx MHA https://web.mhanet.com/chna.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
Stephen Njenga, MPH, MHA, CPHQ, CPPS Director of Performance Measurement Compliance Missouri Hospital Association snjenga@mhanet.com 573/893-3700, ext. 1325