MBQIP Activities : Data & Resources

Transcription

1 MBQIP Activities : Data & Resources Alex Evenson Communications Coordinator Flex Monitoring Team University of Minnesota RHRC November 18, 2015 TASC 90 Webinar

2 Required MBQIP Activities Outpatient Measures: Emergency Department (ED) measures Patient Safety: Influenza vaccinations for all health care personnel and eligible patients Care Transitions: Emergency Department Transfer Communication (EDTC) measures Patient Engagement: HCAHPS survey

3 Critical Access Hospitals (CAHs) Reporting at Least One Inpatient Measure, % % of CAHs Reporting Data 80% 60% 73.5% 79.7% 87.3% 86.4% 40% 20% 0% Q Q Q Q1 2014

4 CAHs Reporting at Least One Outpatient Measure, % % of CAHs Reporting Data 80% 60% 40% 54.4% 54.0% 20% 21.2% 27.3% 0% Q Q Q Q1 2014

5 Oupatient ED Measures: Reporting % of CAHs Reporting Data Median Min. to ECG 47.2% Median Min. before Transfer Median Min. to Pain Mgmt. for Bone Fracture Door to Diagnostic Evaluation 20.9% 21.5% 27.6% Fibrinolytic within 30 Mins. 22.0% Patient Left without Being Seen 25.6% 0% 10% 20% 30% 40% 50%

6 Outpatient ED Measures: Performance CAHs All Hospitals Median Min. to ECG Median Min. before Transfer Median Min. to Pain Mgmt. for Bone Fracture Door to Diagnostic Evaluation Median Time in Minutes Fibrinolytic within 30 Mins. Patient Left without Being Seen 1.2% 2.0% Percent of Patients 50.0% 60.0%

7 Outpatient ED Measure Takeaway Points Only about one-quarter or fewer CAHs reported data on most ED measures, Among reporting CAHs, performance on ED measures is comparable or better than other hospitals, except for fibrinolytic measure

8 What Can State Flex Programs Do? Encourage CAHs to report data Reporting on ED measures needs to improve Technical assistance to improve performance Particular attention to fibrinolytic measure Learn from states doing well

9 Patient Safety Measures Influenza Vaccination for Patients Reporting: 32.6% of CAHs nationwide Performance: 90.1% of CAH patients received influenza vaccination Influenza Vaccination for Health Care Personnel (HCP) Reporting: 25% of CAHs nationwide Performance: 86.3% of HCPs received influenza vaccination

10 What can State Flex Programs do? Encourage CAH reporting & use of resources to improve influenza vaccination rates Health care personnel (CDC NHSN Manual (Centers for Disease Control, National Healthcare Safety Network)) Educate HCPs re: benefits of HCP vaccination Convenient worksite access to free influenza vaccinations Signed declinations for non-medical refusals Patients (FMT Policy Brief on Pneumonia QI) Baseline data on hospital performance, data feedback, and benchmarking Provider reminders to check vaccination status at admission; automatic reminders when due Standing orders to immunize patients

11 Care Transitions Emergency Department Transfer Communications (EDTC) Reporting: 28.8% of CAHs reported EDTC data to MBQIP in Q State reporting rates ranged from 0% (10 states) to 100% of CAHs

12 Care Transitions EDTC Performance Q4 2014

13 What Can State Flex Programs Do? Encourage CAHs to use EDTC resources Stratis Health: Rural EDTC Resources MBQIP Quality Guide Learn from states doing well

14 Patient Engagement HCAHPS Reporting % of CAHs reported HCAHPS data 48.7% of reporting CAHs had <100 completed surveys 12.7% of reporting CAHs had survey response rate of less than 25% Variation across states in reporting and response rates

15 Patient Engagement CAHs (n=867) and All U.S. Hospitals (n=4143) Reporting Data to HCAHPS,

16 HCAHPS Takeaway Points Number of CAHs reporting HCAHPS data has increased BUT completed surveys per CAH & response rates have decreased CAHs continue to perform better than other hospitals on all HCAHPS measures Lowest scores for CAHs and all hospitals are on new transition of care composite measure

17 What Can State Flex Programs Do? Encourage 1/3 of CAHs not reporting HCAHPS to report Examine reasons for low survey response rates Provide TA to improve performance, especially care transitions University of Colorado Care Transitions Program Learn from states doing well

18 FMT State CAH Quality Reports Available on Use Hospital Compare data for all reporting CAHs Includes data CMS suppresses from Hospital Compare website due to small volume

19 Thank You! Alex Evenson, MA flexmonitoring.org rhrc.umn.edu This work was supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS) under cooperative agreement # U27RH The information, conclusions and opinions expressed in this presentation are those of the authors and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred.