2016 Hospital Measures
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1 2016 Hospital Measures Vicki Tang Olson, Stratis Health Statewide Quality Reporting and Measurement System (SQRMS) Annual Forum June 22, 2015
2 Objectives Share the process used for 2016 hospital measures recommendations Review recommended changes to the 2016 hospital slate of measures 1
3 2016 Hospital Measures Recommendation Process 2
4 Changes to Process Steering committee will convene throughout the year and will consider feedback from expert groups Preliminary slate of measures will be developed by April 15 each year to match the clinic measures recommendation process 3
5 Recommendations Process MDH focus Final Slate of Measures Identify potential measures Added step Preliminary Slate of Measures Convene team Team discussion Enhanced step Request feedback from expert groups Enhanced step 4
6 Process after Recommendations Final Recommendations Public Forum Proposed Rule Formal Comment Period Final Rule 5
7 2016 Hospital Slate of Measure Changes 6
8 Topic areas for potential new/added measures Federal alignment CMS and HRSA Cost/Spending Readmissions End of Life Patient Safety Mental/Behavioral Health 7
9 Alignment 8
10 Alignment Historically looked at every measure that was part of the CMS inpatient and outpatient programs Over time there has been variation between the SQRMS slate of measures for PPS hospitals and Critical Access Hospital (CAH) measures 9
11 Current Slate of Measures PPS Hospital Slate of Measures Inpatient Quality Reporting Program (IQR) Outpatient Quality Reporting Program (OQR) Additional Measures for MN CAH Hospital Slate of Measures 10
12 Relationship of National Programs Readmission Reduction (RRP) Program Value- Based Purchasing (VBP) Program Inpatient Quality Reporting Program (IQR) Medicare Beneficiary Quality Improvement Program (MBQIP) Hospital Acquired Condition (HAC) Program Outpatient Quality Reporting Program (OQR) ED Transfer Communication Additional Measures for MN 11
13 Future Slate of Measures Readmission Reduction (RRP) Program Value- Based Purchasing (VBP) Program PPS Hospitals Medicare Beneficiary Quality Improvement Program (MBQIP) Hospital Acquired Condition (HAC) Program CAH Hospitals Additional Measures for MN 12
14 Value-based Purchasing FY2016 Total Performance Score Unweighted and weighted domain score for clinical process of care, patient experience of care, outcome and efficiency Measure scores 13
15 Hospital Acquired Conditions Program Score FY2016 Total HAC score Domain 1 score Domain 2 score Measure scores 14
16 Readmissions Reduction Program Composite Score FY2016 Total Readmissions score (Number of 30 day readmission measures with excess readmissions) Excess readmissions for AMI Excess readmissions for Heart Failure Excess readmissions for Pneumonia Excess readmission for total knee/total hip arthroplasty Excess readmission for Chronic Obstructive Pulmonary Disease 15
17 Composite MBQIP score Does not currently exist Recommendation that we develop a methodology to report one score for CAH 16
18 Alignment of Individual Measures 17
19 Measures Added - PPS PN-6 Initial antibiotic selection for communityacquired pneumonia (CAP) in immunocompetent patients 18
20 Measures Added - PPS SCIPInf-2a Prophylactic antibiotic selection for surgical patients SCIP-Inf-3a Prophylactic antibiotics discontinued within 24 hours after surgery end time * (SCIP-Inf-3a) SCIP-Inf-9 Urinary catheter removed on postoperative day 1 or postoperative day 2 with day surgery being day zero 19
21 Measures Added - PPS SCIP- Card-2 Surgery patients on beta-blocker therapy prior to arrival who received a beta-blocker during the perioperative period SCIP-VTE-2 Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery 20
22 Measures Added - PPS Central line-associated bloodstream infection (CLABSI) event Catheter associated Urinary Tract Infection (CAUTI) event Surgical Site infections (SSI) event following colon surgery Surgical Site infections (SSI) event following abdominal hysterectomy surgery Medicare Spending per Beneficiary outcome measure for applicable hospital discharge dates 21
23 Measures Removed - PPS ED-1a Median time from ED arrival to ED departure for admitted ED patients ED-2a Median time from admit decision time to ED departure time for admitted patients PC-01 Early Elective Deliveries All outpatient measures 22
24 Measures Added - CAH VTE-1 Venous Thromboembolism prophylaxis ED-1a Median time from ED arrival to ED departure for admitted ED patients ED-2a Median time from admit decision time to ED departure time for admitted patients Catheter associated Urinary Tract Infection (CAUTI) event Healthcare personnel influenza immunization and OP-27 (inpatient and outpatient combined) 23
25 Measures Added - CAH OP-1 Median time to fibrinolysis 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 ED-median time to pain management for long bone fracture 24
26 Measures Added - CAH OP-22 ED-patient left without being seen OP-23 ED-head CT scan results for acute ischemic stroke or hemorrhagic stroke who received head CT scan interpretation within 45 minutes of arrival. OP-25 Safe surgery checklist OP-27 Influenza Vaccination Coverage among Healthcare Personal (combined with HCP) 25
27 Measures Removed - CAH Mortality measures Acute myocardial infarction Heart failure Pneumonia PSI-90 26
28 30 Day Readmissions Acute Myocardial Infarction PPS Heart Failure PPS CAH Pneumonia PPS CAH Total Hip /Total Knee Arthroplasty PPS Chronic Obstructive Pulmonary Disease PPS CAH 27
29 Current readmissions workgroup Looking at what we can learn from All payor claims database Work continues 28
30 Measures Removed All adult - PPS & CAH MN stroke registry measures AHRQ measures Children s measures 29
31 Measures Removed PPS/CAH MN Stroke Registry Door-to-imaging performed time Door-to-needle time to intravenous thrombolytic therapy 30
32 Measures Removed PPS/CAH AHRQ measures Mortality for selected conditions composite measure (IQI-91) Death among surgical inpatients with serious treatable complications (PSI 4) Obstetric trauma vaginal delivery with instrument (PSI 18) Obstetric trauma vaginal delivery without instrument (PSI 19) 31
33 Measures Removed PPS/CAH AHRQ measures AHRQ measures Pediatric Heart Surgery Mortality Rate measure (PDI 6) Pediatric Heart Surgery Volume measure (PDI 7) Pediatric patient safety for selected indicators composite measure. (PDI-19) 32
34 Measures for Children s hospitals - removed Peds AHRQ measures Late Sepsis or Meningitis in Neonates (Vermont Oxford Network) Central line-associated bloodstream infection (CLABSI) event in NICU/PICU 33
35 Data Submission of VBP, RRP and HAC results Results in summer Final results in October Hospital Compare in December Required for MN in January 34
36 FY2016 VBP Fact Sheet 35
37 FY2016 Readmissions 36
38 FY2016 HAC Fact Sheet 37
39 CAH Inpatient (IQR) Data Submission Third Quarter, 2015: July 1 September 30; February 15, 2016 Fourth Quarter, 2015: October 1 December 31; May 15, 2016 First Quarter, 2016: January 1 March 31; August 15, 2016 Second Quarter, 2016: April 1 June 30; November 15,
40 CAH Outpatient (OQR) Data Submission Third Quarter, 2015: July 1 September 30; February 1, 2016 Fourth Quarter, 2015: October 1 December 31; May 1, 2016 First Quarter, 2016: January 1 March 31; August 1, 2016 Second Quarter, 2016: April 1 June 30; November 1,
41 CAH ED Transfer Communication Data Submission Fourth Quarter, 2015: January 31, 2016 First Quarter, 2016: April 20, 2016 Second Quarter, 2016: July 31, 2016 Third Quarter, 2016: October 31,
42 End of Life 41
43 End of Life Measure Stage 3 meaningful use Advance Directives measure More than 50 percent of all unique patients 65 years old or older admitted to the eligible hospital's or CAH's inpatient department (POS 21) during the EHR reporting period have an indication of an advance directive status recorded as structured data Reported through question on Health Information Technology (HIT) 42
44 Future Measures 43
45 Topic areas for potential new/added measures Federal alignment CMS and HRSA Cost/Spending Readmissions End of Life Patient Safety Mental/Behavioral Health 44
46 Patient Safety Recommended development of a composite measure for PPS and CAH hospitals Focus would be on cultural/structural areas as well as patient harm Next steps would be for MNCM to convene a workgroup 45
47 Questions? Vicki Olson, Program Manager or
48 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. Prepared by Stratis Health under contract with Minnesota Community Measurement funded by the Minnesota Department of Health.
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FY X Time (48 hrs for cardiac surgery) SCIP-Inf-4 Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Blood
Valuebased 2013 Hospital Measure Summary Data Collection for Inpatient Quality Reporting FY2015 and Outpatient Reporting CY2014 January 2013 Key: = Required by both CMS and State of Minnesota = Required
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Denom Observed VBP Standard VBP Benchmark Denom Observed VBP Standard VBP Benchmark N Percent x/n N Percent x/n Value Based Purchasing-Clinical Process of Care Measures (%) SCIP-Inf-9 Urinary catheter
The Centers for Medicare & Medicaid Services (CMS) Acute Care Hospital Fiscal Year (FY) 2018 Quality Improvement Program Measures
ID M easure Name NQF # H os pital M easurement Period H os pital H os pital Value-Bas ed Purchas ing M easurement Period H os pital H ealth Record (EH R) Incentive M easurement Period H os pital H os pital-
Core = Core required measures for all CAH nationally r = Required by State of Minnesota X = Additional for MBQIP
Key: 2016 Hospital Measure Summary Minnesota Statewide Quality eporting and Measurement System (SQMS) and FY2018 for Center for Medicare and Medicaid Services () January 2016 = equired by Core = Core required
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