Reports delivery. MICAHQN Reports Schedule 5/15/ Q17 Core Measures and 1Q18 MBQIP Data. May 18, Joshua Salander, MBA, PMP Consultant

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1 /1/21 Q1 Core Measures and 1Q1 MBQIP Data May 1, 21 Joshua Salander, MBA, PMP Consultant Reports delivery Updated Q1 reports were sent via on May 1, 21 Quarterly Reports Quarterly Trend Charts Please delete reports that were went on Sunday, May 1, 21 2 MICAHQN Reports Schedule Qtr CMS Data Deadline* Data Provided By* 1st Qtr August 1 August 1 2nd Qtr November 1 November rd Qtr February 1 February 2 th Qtr May 1 May 1 1

2 /1/21 Summary of Q1 MICAHQN Core Measures Performance OP1 (three quarters consecutively that has time decreased) OP2 (two quarters consecutively that rate has increased) OP (consistent performance) OP (consistent performance, AMI increased (all but one hospital at ) OP (overall measure decreased below lower control limit to five minutes) OP1 a and b five quarters above overall time c and d seven quarters above overall time; time to adjust overall time OP2 (two quarters consecutively that time has decreased) ED1 and ED2 (both showed increase in time) Summary of Q1 MBQIP Performance EDTC-1 (nine quarters consecutively that rate has been above %) Best Quarter Q1 EDTC-2 (three quarters consecutively that rate has increased) Best Quarter Q1, Q1 EDTC- (nine quarters consecutively that rate has been above %) Best Quarter 2Q1, Q1, 1Q1 EDTC- (seven quarters consecutively that rate has been above %) Best Quarter Q1, Q1, 1Q1, 1Q1 % EDTC- (six quarters consecutively that rate has been above %) Best Quarter Q1, Q1, Q1 % EDTC- (six quarters consecutively that rate has been above %) Best Quarter 1Q1 % EDTC- (nine quarters consecutively that rate has been above %) Best Quarter Q1 EDTC-Overall (six quarters consecutively that rate has been above 1%) Best Quarter Q1 % Project Management Processes Initiation Planning Executing Closure 2

3 /1/21 Portfolio vs Program vs Project Project Management A project is a temporary endeavor undertaken to create a unique product, service, or result (PMBOK Guide th Edition) Achieving objectives! Knowledge, Skills, Tools, Techniques Program Management Optimize utilization of resources Group of related projects Portfolio Management Larger scope and objectives Centralized management identify, prioritize, and authorize Portfolio vs Program vs Project Portfolio Management Program Management Quality & Regulatory Nursing Ancillary Departments Project Management Core Measures MBQIP BCBSM PP HIPAA Promoting Interoperability And so on

4 /1/21 Project Initiation Phase Project Charter The WHY! Authorizes the project to begin Identify Stakeholders / Resource Allocation Who is affected (Employees, patients, community, volunteers) Resources allocated to support project 1 Project Charter Scope Objectives Goals or Measurement Project Name Milestones Executive Sponsor Assumptions Project Manager Revision Date Stakeholders Project Charter Attachments 12

5 Rate % % % % % % % 1% 1% 2% % % % 2 2 Q1 21 MICAHQN Q 21 National 1 Q 21 MICAHQN Q 21 MICAHQN Q2 21 MICAHQN Q1 21 MICAHQN Q 21 MICAHQN Q1 21 MICAHQN Q 21 MICAHQN Q1 21 MICAHQN Q 21 MICAHQN Q2 21 MICAHQN 1 1 Q 21 MICAHQN /1/21 MBQIP Graphs EDTC-1 Administrative Communication - 1Q1 % % % % % % % 2% 1% % Q1 21 MICAHQN () 1 EDTC-1: Administrative Communication.%.%.%.%.% 1

6 % 22 Q1 21 MICAHQN Q 21 National 2 Q2 21 MICAHQN Q 21 MICAHQN Q 21 MICAHQN 12 Q 21 MICAHQN Q 21 MICAHQN Q1 21 MICAHQN Q1 21 MICAHQN Q1 21 MICAHQN Q2 21 MICAHQN Q 21 MICAHQN Q 21 MICAHQN % 22 Q1 21 MICAHQN 1 Q 21 National 1 12 Q 21 MICAHQN Q 21 MICAHQN Q 21 MICAHQN 21 Q 21 MICAHQN Q2 21 MICAHQN Q1 21 MICAHQN Q 21 MICAHQN Q1 21 MICAHQN Q1 21 MICAHQN Q 21 MICAHQN Q2 21 MICAHQN % % % % % % % % % % % % 2% % % % % % % % % /1/21 EDTC - 2 Patient Information - 1Q1 % % % % % % % 2% 1% % Q1 21 MICAHQN () 1 EDTC-2: Patient Information % % % % % 1 EDTC - Vital Signs - 1Q1 % % % % % % % 2% 1% % Q1 21 MICAHQN () 1

7 % 22 1 Q1 21 MICAHQN Q 21 National 1 1 Q2 21 MICAHQN Q 21 MICAHQN Q1 21 MICAHQN 21 2 Q 21 MICAHQN Q2 21 MICAHQN Q 21 MICAHQN Q 21 MICAHQN Q1 21 MICAHQN Q 21 MICAHQN 12 Q1 21 MICAHQN Q 21 MICAHQN % % 1% % % % % % 1% % % % % % % % % % % % % % % % /1/21 EDTC-: Vital Signs % % % % % % % 2% 1% % 1 EDTC - Medication Information - 1Q1 % % % % % % % 2% 1% % Q1 21 MICAHQN (%) 2 EDTC-: Medication Information % % % % % % % 2% 1% % 21

8 Rate % 2 22 Q1 21 MICAHQN 1 21 Q 21 National Q2 21 MICAHQN Q 21 MICAHQN 1 Q1 21 MICAHQN Q 21 MICAHQN Q 21 MICAHQN Q1 21 MICAHQN Q1 21 MICAHQN Q2 21 MICAHQN Q 21 MICAHQN Q 21 MICAHQN Q 21 MICAHQN % 22 Q1 21 MICAHQN 21 Q 21 National 1 Q2 21 MICAHQN Q 21 MICAHQN Q1 21 MICAHQN 1 1 Q 21 MICAHQN Q 21 MICAHQN Q 21 MICAHQN Q2 21 MICAHQN 12 Q 21 MICAHQN Q1 21 MICAHQN Q 21 MICAHQN 2 Q1 21 MICAHQN % % % % % % % % % % % % % % % % % % % % % % % 2% % % % % % % % % % % % 1% 2% % % % % % % /1/21 EDTC - Physician or Practitioner Generated Information - 1Q1 % % % % % % % % % % % % % % 2% 2% 1% 1% % % Q1 21 MICAHQN (%) 22 EDTC-: Practitioner Information.%.%.%.%.%.%.% 2.% 1.%.% 2 % % % % % % % % % % % % % % 2% 2% 1% 1% % % EDTC - Nurse Generated Information - 1Q1 Q1 21 MICAHQN (%) 2

9 Rate 22 Q1 21 MICAHQN 1 1 Q 21 National 21 Q 21 MICAHQN Q 21 MICAHQN Q1 21 MICAHQN Q 21 MICAHQN Q1 21 MICAHQN Q 21 MICAHQN Q2 21 MICAHQN Q2 21 MICAHQN Q1 21 MICAHQN Q 21 MICAHQN Q 21 MICAHQN % % % % % 1% 2% % % Rate /1/21 EDTC-: Nurse Information.%.%.%.%.%.%.% 2.% 1.%.% 2 EDTC - Procedures and Tests - 1Q1 % 2% % % % % 2% % % % % 2% % % % % 2% % % % % 2% % Q1 21 MICAHQN () 2 EDTC-: Procedures and Tests.%.%.%.%.% 2

10 % % % % % % % % 1% % % % % % % % % % 1% 2% % % % % % % % % % % % 1% 1% % 2 22 Q1 21 MICAHQN Q 21 National Q 21 MICAHQN 1 2 Q 21 MICAHQN 1 Q2 21 MICAHQN 1 21 Q 21 MICAHQN Q1 21 MICAHQN 2 Q 21 MICAHQN Q2 21 MICAHQN Q1 21 MICAHQN Q 21 MICAHQN Q1 21 MICAHQN Q 21 MICAHQN /1/21 % % % % % % % % % % % % % % 2% 2% 1% 1% % % All EDTC Measures - 1Q1 Q1 21 MICAHQN (%) 2 All EDTC Measure % % % % % % % 2% 1% % 2 Core Measure Graphs 1

11 Rate Rate Rate /1/21.% OP AMI/CP Rate Based Measures - Q1.1%.%.%.%.%.%.%.%.2%.%.%.% 1.%.%.%.%.% 2.% 1.%.% Fibrinolytic Therapy Received Within Minutes Aspirin at Arrival - Overall Rate Aspirin at Arrival - AMI Aspirin at Arrival - Chest Pain MICAHQN Rate CAH Only Rate Rural Only Rate 1 OP2 - Fibrinolytic Therapy Received Within Minutes.%.%.%.%.%.%.% 2.% 1.%.% 2 OPa - Aspirin at Arrival - Overall Rate.%.%.%.%.%.%.%

12 Rate Rate.%.%.%.%.%.% /1/21 OPb - Aspirin at Arrival - AMI.%.%.%.%.%.%.% 2.% 1.% OPc - Aspirin at Arrival - Chest Pain.%.%.%.%.%.% OP-2: Fibrinolytic Therapy Received Within Minutes.%.%.%.%.%.%.%.%.%.%.%.%.%.% 2.% 2.% 1.% 1.%.%.% Q 21 MICAHQN (1.%) 12

13 .% 2.%.%.% 2.%.% 1.%.% 2.%.%.%.%.1% 2.%.% 2.%.%.%.%.%.%.%.% /1/21 OP-a: Aspirin at Arrival - Overall Rate.%.%.% 2.%.%.%.%.% Q 21 MICAHQN (.%) OP-b: Aspirin at Arrival - AMI.%.%.% 2.%.%.% Q 21 MICAHQN (.1%) OP-c: Aspirin at Arrival - Chest Pain.%.%.%.%.% Q 21 MICAHQN (.%) 1

14 /1/21 OP AMI/CP Continuous Measures - Q1 to ECG - Chest Pain to ECG - AMI to ECG - Overall Rate to Transfer to Another Facility for Acute Coronary Intervention - QI Measure. to Transfer to Another Facility for Acute Coronary Intervention - Reporting Measure to Transfer to Another Facility for Acute Coronary Intervention - Overall 1. to Fibrinolysis Rural Only Values CAH Only Values MICAHQN Values OP1 - to Fibrinolysis OPa - to Transfer to Another Facility for Acute Coronary Intervention - Overall

15 /1/21 OPb - to Transfer to Another Facility for Acute Coronary Intervention - Reporting Measure 2 1 OPc - to Transfer to Another Facility for Acute Coronary Intervention - QI Measure OPa - to ECG - Overall Rate 2 1 1

16 /1/21 OPb - to ECG - AMI 2 1 OPc - to ECG - Chest Pain 2 1 OP-1: to Fibrinolysis Q 21 MICAHQN (2 minutes) 1

17 /1/21 OP-a: to Transfer to Another Facility for Acute Coronary Intervention - Overall Q 21 MICAHQN (. minutes) OP-b: to Transfer to Another Facility for Acute Coronary Intervention - Reporting Measure Q 21 MICAHQN ( minutes) OP-c: to Transfer to Another Facility for Acute Coronary Intervention - QI Measure Q 21 MICAHQN ( minutes) 1 1

18 /1/21 OP-a: to ECG - Overall Rate Q 21 MICAHQN ( minutes) 2 OP-b: to ECG - AMI Q 21 MICAHQN ( minutes) OP-c: to ECG - Chest Pain Q 21 MICAHQN ( minutes) 1

19 /1/21 OP Emergency Department Throughput - Q1 1 Door to Diagnostic Evaluation by a Qualified Medical Professional 1 1 from ED Arrival to ED Departure for Discharged ED Patients - Transfer Patients from ED Arrival to ED Departure for Discharged ED Patients - Psychiatric/Mental Health Patients from ED Arrival to ED Departure for Discharged ED Patients - Reporting Measure from ED Arrival to ED Departure for Discharged ED Patients - Overall Rural Only Values CAH Only Values MICAHQN Values OP1a - from ED Arrival to ED Departure for Discharged ED Patients - Overall OP1b - from ED Arrival to ED Departure for Discharged ED Patients - Reporting Measure

20 /1/21 2 OP1c - from ED Arrival to ED Departure for Discharged ED Patients - Psychiatric/Mental Health Patients OP1d - from ED Arrival to ED Departure for Discharged ED Patients - Transfer Patients OP2 - Door to Diagnostic Evaluation by a Qualified Medical Professional

21 /1/21 OP-1a: from ED Arrival to ED Departure for Discharged ED Patients - Overall Q 21 MICAHQN (12 minutes) 1 OP-1b: from ED Arrival to ED Departure for Discharged ED Patients - Reporting Measure Q 21 MICAHQN ( minutes) 2 OP-1c: from ED Arrival to ED Departure for Discharged ED Patients - Psychiatric/Mental Health Patients Q 21 MICAHQN (212. minutes) 21

22 /1/21 OP-1d: from ED Arrival to ED Departure for Discharged ED Patients - Transfer Patients Q 21 MICAHQN (2. minutes) OP-2: Door to Diagnostic Evaluation by a Qualified Medical Professional Q 21 MICAHQN (1 minutes) IP Emergency Department - Q1 Admit Decision Time to ED Departure Time for Admitted Patients - Psychiatric/Mental Health Patients Admit Decision Time to ED Departure Time for Admitted Patients - Reporting Measure Admit Decision Time to ED Departure Time for Admitted Patients - Overall Rate from ED Arrival to ED Departure for Admitted ED Patients - Psychiatric/Mental Health Patients from ED Arrival to ED Departure for Admitted ED Patients - Reporting Measure from ED Arrival to ED Departure for Admitted ED Patients - Overall Rate Rural Only Values CAH Only Values MICAHQN Values 22

23 /1/21 2 ED-1a - from ED Arrival to ED Departure for Admitted ED Patients - Overall Rate Q1 2Q1 Q1 CAH Only Rural Only MICAHQN 2 ED-1b - from ED Arrival to ED Departure for Admitted ED Patients - Reporting Measure Q1 2Q1 Q1 CAH Only Rural Only MICAHQN ED-1c - from ED Arrival to ED Departure for Admitted ED Patients - Psychiatric/Mental Health Patients Q1 2Q1 Q1 CAH Only Rural Only MICAHQN 2

24 /1/21 1 ED-2a - Admit Decision Time to ED Departure Time for Admitted Patients - Overall Rate Q1 2Q1 Q1 CAH Only Rural Only MICAHQN 1 ED-2b - Admit Decision Time to ED Departure Time for Admitted Patients - Reporting Measure Q1 2Q1 Q1 CAH Only Rural Only MICAHQN 1 2 ED-2c - Admit Decision Time to ED Departure Time for Admitted Patients - Psychiatric/Mental Health Patients Q1 2Q1 Q1 CAH Only Rural Only MICAHQN 2 2

25 /1/21 ED-1a: from ED Arrival to ED Departure for Admitted ED Patients - Overall Rate Q 21 MICAHQN (2 minutes) ED-1b: from ED Arrival to ED Departure for Admitted ED Patients - Reporting Measure Q 21 MICAHQN (2 minutes) ED-1c: from ED Arrival to ED Departure for Admitted ED Patients - Psychiatric/Mental Health Patients Q 21 MICAHQN (2 minutes) 2

26 /1/21 ED-2a: Admit Decision Time to ED Departure Time for Admitted Patients - Overall Rate Q 21 MICAHQN ( minutes) ED-2b: Admit Decision Time to ED Departure Time for Admitted Patients - Reporting Measure Q 21 MICAHQN ( minutes) ED-2c: Admit Decision Time to ED Departure Time for Admitted Patients - Psychiatric/Mental Health Patients Q 21 MICAHQN (1 minutes) 2

27 /1/21 Thank you! Joshua Salander, MBA, PMP Consultant () - 2