4Q17 Core Measures and 2Q18 MBQIP Data August 17, 2018 Joshua Salander, MBA, PMP Consultant
Reports delivery 4Q17 reports were sent via email on August 12, 2018 Quarterly Reports Quarterly Trend Charts 2
MICAHQN Reports Schedule Qtr CMS Data Deadline* Data Provided By* 1st Qtr August 15 August 31 2nd Qtr November 15 November 30 3rd Qtr February 15 February 28 4th Qtr May 15 May 31 3
FY2019 IPPS Final Rule Issued on 8/2/18 Home Page: https://www.cms.gov/medicare/medicare-fee-for- Service-Payment/AcuteInpatientPPS/FY2019-IPPS-Final-Rule- Home-Page.html Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fiscalyear-fy-2019-medicare-hospital-inpatient-prospective-paymentsystem-ipps-and-long-term-acute-0 Disclaimer: This is informational only. You should review the Final Rule to determine specific impacts to your hospital. Persevion LLC is not liable for the accuracy of this information or how it pertains to your hospital. 4
FY2019 IPPS Final Rule Interoperability Meaningful Use (MU) = Promoting Interoperability (PI) 90 Day Reporting periods for CY19 & CY20 Performance Based Scoring Methodology New e-prescribing Measures Query of PDMP (optional in 2019, required in 2020) Verify Opioid Treatment Agreement (optional in 2019 and 2020) Changes/removal of existing measures 2015 Edition of CEHRT required effective in 2019 Removal of eight ecqms effective in 2020 2019 submission deadline is 2/29/20 Disclaimer: This is informational only. You should review the Final Rule to determine specific impacts to your hospital. Persevion LLC is not liable for the accuracy of this information or how it pertains to your hospital. 5
FY2019 IPPS Final Rule Transparency Online posting of standard charges in machine readable format Update information at least annually Request for information regarding challenges that exist for patients due to insufficient price transparency Disclaimer: This is informational only. You should review the Final Rule to determine specific impacts to your hospital. Persevion LLC is not liable for the accuracy of this information or how it pertains to your hospital. 6
FY2019 IPPS Final Rule Meaningful Measures Hospital Inpatient Quality Reporting (IQR) Program Removal of 18 measures, de-duplicate 21 measures Chart abstracted, ecqms, Claims-based, Structural, etc. Value-Based Purchasing Hospital-Acquired Conditions (HAC) Reduction Readmissions Reduction Programs Disclaimer: This is informational only. You should review the Final Rule to determine specific impacts to your hospital. Persevion LLC is not liable for the accuracy of this information or how it pertains to your hospital. 7
FY2019 IPPS Final Rule Burden Reduction easing burden by easing documentation requirements and providing flexibility in several areas, while maintaining important patient and program integrity protections. https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2019-medicare-hospital-inpatientprospective-payment-system-ipps-and-long-term-acute-0 Disclaimer: This is informational only. You should review the Final Rule to determine specific impacts to your hospital. Persevion LLC is not liable for the accuracy of this information or how it pertains to your hospital. 8
FY2019 IPPS Final Rule Next Steps Determine how the rule affects you (only 2593 pages ) Consult with stakeholders (internal & external) Perform gap analysis Implement changes for new requirements Disclaimer: This is informational only. You should review the Final Rule to determine specific impacts to your hospital. Persevion LLC is not liable for the accuracy of this information or how it pertains to your hospital. 9
CY2019 Medicare PFS Proposed Rule Published on 7/27/18 Comment Period Closing Date 9/10/18 Fact sheet: https://www.cms.gov/newsroom/fact-sheets/proposed-policypayment-and-quality-provisions-changes-medicare-physician-fee-schedulecalendar-year-3 Home Page: https://www.cms.gov/medicare/medicare-fee-for-service- Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS- 1693-P.html Disclaimer: This is informational only. You should review the Rule to determine specific impacts to your hospital. Persevion LLC is not liable for the accuracy of this information or how it pertains to your hospital. 10
CY2019 OPPS Proposed Rule Published on 7/31/18 Comment Period Closing Date 9/24/18 Fact sheet: https://www.cms.gov/newsroom/fact-sheets/cmsproposes-medicare-hospital-outpatient-prospective-paymentsystem-and-ambulatory-surgical-center Home Page: https://www.cms.gov/medicare/medicare-fee-for- Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient- Regulations-and-Notices-Items/CMS-1695-P.html Disclaimer: This is informational only. You should review the Final Rule to determine specific impacts to your hospital. Persevion LLC is not liable for the accuracy of this information or how it pertains to your hospital. 11
Summary of 4Q17 MICAHQN Core Measures Performance Source for National CAH, National CAH 90th Percentile, and National performances: Telligen Reports IMM2 (highest 4Q performance since trending started in 1Q13, better than national) OP1 (consistent performance, better than national) OP2 (consistent performance, better than national, slightly lower than CAH national) OP3 (unexpected performance in 4Q17 (increase in time), worse than national) OP4 (consistent performance, better than national) OP5 (consistent performance, better than national) OP18 (adjusted expected performance ranges) a and b five quarters unexpected performance (increase in time), worse than CAH national, better than National) c and d are consistent with expected ranges based on adjustments OP20 (three quarters consecutively decreased time, better than national) ED1 (decrease in time, worse than CAH national, better than national) ED2 (a and b both showed increase in time, worse than national) 12
Median Time 135 OP18a - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Overall 130 125 120 115 110 105 100 MICAHQN Overall UCL LCL 13
Median Time 125 OP18b - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Reporting Measure 120 115 110 105 100 95 MICAHQN Overall UCL LCL 14
OP18b Data Comparison 4Q15 4Q17 Dx Code Description Denominator Median Dx Code Description Denominator Median R07.89 Chest Pain 119 136 J20.9 Acute Bronchitis 69 84 R07.9 Chest Pain 69 164 J06.9 Upper Respiratory Infection 62 42 N39.0 UTI 62 74 R07.89 Chest Pain 131 193 R07.9 Chest Pain 82 224 J06.9 Upper Respiratory Infection 78 67 N39.0 UTI 59 115 J20.9 Acute Bronchitis 55 93 15
OP18b Data Comparison Principal Dx Code Dx Code Description 4Q15 4Q17 % Change R07.89 R07.9 J06.9 N39.0 J20.9 Chest Pain 136 193 30% Chest Pain 164 224 27% Upper Respiratory Infection 42 67 37% UTI 74 115 36% Acute Bronchitis 84 93 10% 16
Summary of 2Q18 MBQIP Performance Source for National CAH, National CAH 90 th Percentile, and National performances: Telligen Reports EDTC-1 (consistent performance) Best Quarter 4Q17 98% EDTC-2 (four quarters consecutively that rate has increased) Best Quarter 3Q16, 4Q16 98% EDTC-3 (two quarters that rate has increased) Best Quarter 2Q18 98% EDTC-4 (three quarters that rate has increased) Best Quarter 2Q18 97% EDTC-5 (consistent performance) Best Quarter 2Q18 96% EDTC-6 (consistent performance) Best Quarter 1Q18, 2Q18 95% EDTC-7 (two quarters that rate has increased) Best Quarter 4Q16, 2Q18 98% EDTC-Overall (consistent performance) Best Quarter 4Q17, 2Q18 88% 17
MBQIP Graphs
20 28 22 24 30 12 7 9 21 37 38 39 5 6 8 10 11 13 14 15 16 17 18 19 23 25 26 27 29 31 32 33 34 35 36 40 67% 69% 93% 93% 93% 95% 96% 96% 96% 96% 98% 98% EDTC-1 Administrative Communication 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% Hospital Q2 2018 MICAHQN (97%) Q2 2017-Q1 2018 National (96%) Q2 2017-Q1 2018 90th Percentile National () Source for National CAH, National CAH 90 th Percentile, and National performances: Telligen Reports 19
EDTC-1: Administrative Communication 95.0% 90.0% 85.0% 80.0% 75.0% MICAHQN Overall UCL LCL 20
76% 79% 80% 87% 91% 91% 93% 93% 93% 96% 98% 98% 98% EDTC - 2 Patient Information 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 22 15 36 37 21 24 12 31 33 13 7 10 18 5 6 8 9 11 39 14 16 17 19 20 23 25 26 27 28 29 30 32 34 35 38 40 Hospital Q2 2018 MICAHQN (97%) Q2 2017-Q1 2018 National (95%) Q2 2017-Q1 2018 90th Percentile National () Source for National CAH, National CAH 90 th Percentile, and National performances: Telligen Reports 21
EDTC-2: Patient Information 95% 90% 85% 80% 75% MICAHQN Overall UCL LCL 22
84% 87% 89% 93% 93% 93% 95% 96% 96% 98% 98% 98% 98% 98% 98% 98% 98% 98% EDTC - 3 Vital Signs 95% 90% 85% 80% 75% 22 37 15 13 33 36 12 21 24 7 8 9 10 39 14 30 38 25 5 6 11 16 17 18 19 20 23 26 27 28 29 31 32 34 35 40 Hospital Q2 2018 MICAHQN (98%) Q2 2017-Q1 2018 National (95%) Q2 2017-Q1 2018 90th Percentile National () Source for National CAH, National CAH 90 th Percentile, and National performances: Telligen Reports 23
Median Time EDTC-3: Vital Signs 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% MICAHQN Overall UCL LCL 24
76% 82% 87% 89% 93% 93% 93% 93% 93% 93% 95% 96% 96% 96% 98% 98% 98% EDTC - 4 Medication Information 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 18 22 37 30 6 13 24 33 36 40 12 21 29 15 7 10 26 5 8 9 11 39 14 16 17 19 20 23 25 27 28 31 32 34 35 38 Hospital Q2 2018 MICAHQN (97%) Q2 2017-Q1 2018 National (93%) Q2 2017-Q1 2018 90th Percentile National () Source for National CAH, National CAH 90 th Percentile, and National performances: Telligen Reports 25
Median Time EDTC-4: Medication Information 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% MICAHQN Overall UCL LCL 26
68% 76% 87% 90% 93% 93% 93% 93% 93% 95% 98% 98% 98% 98% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% EDTC - 5 Physician or Practitioner Generated Information 25 22 37 36 13 18 21 30 33 12 7 10 34 28 5 6 8 9 11 39 14 15 16 17 19 20 23 24 26 27 29 31 32 35 38 40 Hospital Q2 2018 MICAHQN (96%) Q2 2017-Q1 2018 National (94%) Q2 2017-Q1 2018 90th Percentile National () Source for National CAH, National CAH 90 th Percentile, and National performances: Telligen Reports 27
Rate EDTC-5: Practitioner Information 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% MICAHQN Overall UCL LCL 28
71% 80% 82% 87% 87% 89% 89% 90% 91% 93% 93% 93% 96% 98% 98% 98% 98% 98% 98% 98% 98% 98% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% EDTC - 6 Nurse Generated Information 22 36 15 24 37 39 21 12 30 13 18 33 6 7 9 10 14 17 38 5 28 25 8 11 16 19 20 23 26 27 29 31 32 34 35 40 Hospital Q2 2018 MICAHQN (95%) Q2 2017-Q1 2018 National (90%) Q2 2017-Q1 2018 90th Percentile National () Source for National CAH, National CAH 90 th Percentile, and National performances: Telligen Reports 29
Rate EDTC-6: Nurse Information 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% MICAHQN Overall UCL LCL 30
80% 87% 93% 93% 95% 96% 98% 98% 98% EDTC - 7 Procedures and Tests 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% 78% 76% 74% 72% 70% 68% 66% 64% 62% 60% 58% 56% 54% 52% 50% 22 37 13 36 12 21 7 10 33 5 6 8 9 11 39 14 15 16 17 18 19 20 23 24 25 26 27 28 29 30 31 32 34 35 38 40 Hospital Q2 2018 MICAHQN (98%) Q2 2017-Q1 2018 National (96%) Q2 2017-Q1 2018 90th Percentile National () Source for National CAH, National CAH 90 th Percentile, and National performances: Telligen Reports 31
Rate EDTC-7: Procedures and Tests 95.0% 90.0% 85.0% 80.0% 75.0% MICAHQN Overall UCL LCL 32
62% 64% 65% 66% 67% 67% 69% 70% 71% 82% 87% 87% 89% 90% 91% 93% 93% 93% 93% 93% 96% 96% 96% 98% 98% 98% 98% 98% 98% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% All EDTC Measures 22 15 28 25 30 20 18 36 24 37 39 21 6 12 9 7 13 31 33 40 14 29 38 8 10 17 26 34 5 11 16 19 23 27 32 35 Hospital Q2 2018 MICAHQN (88%) Q2 2017-Q1 2018 National (81%) Q2 2017-Q1 2018 90th Percentile National () Source for National CAH, National CAH 90 th Percentile, and National performances: Telligen Reports 33
Median Time All EDTC Measure 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% MICAHQN Overall UCL LCL 34
Core Measure Graphs
Rate 90.0% OP AMI/CP Rate Based Measures - 4Q17 97.2% 97.0% 98.3% 97.1% 97.2% 96.4% 97.3% 96.9% 80.0% 70.0% 60.0% 50.0% 52.9% 56.3% 40.0% 30.0% 20.0% 10.0% 0.0% Fibrinolytic Therapy Received Within 30 Minutes Aspirin at Arrival - Overall Rate Aspirin at Arrival - AMI Aspirin at Arrival - Chest Pain MICAHQN Rate CAH Only Rate Rural Only Rate 36
Rate OP2 - Fibrinolytic Therapy Received Within 30 Minutes 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% MICAHQN Overall UCL LCL 37
Rate OP4a - Aspirin at Arrival - Overall Rate 99.0% 98.0% 97.0% 96.0% 95.0% 94.0% 93.0% MICAHQN Overall UCL LCL 38
Rate OP4b - Aspirin at Arrival - AMI 99.0% 98.0% 97.0% 96.0% 95.0% 94.0% 93.0% 92.0% 91.0% MICAHQN Overall UCL LCL 39
Rate OP4c - Aspirin at Arrival - Chest Pain 99.0% 98.0% 97.0% 96.0% 95.0% 94.0% MICAHQN Overall UCL LCL 40
0.0% 25.0% 33.3% 50.0% 66.7% 95.0% 90.0% 85.0% 80.0% 75.0% 70.0% 65.0% 60.0% 55.0% 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% OP-2: Fibrinolytic Therapy Received Within 30 Minutes 4 38 10 9 23 8 11 36 1 3 2 5 6 7 39 12 13 14 15 16 17 18 19 20 21 22 24 25 26 27 28 29 30 31 32 33 34 35 37 40 Hospital Q4 2017 MICAHQN (52.9%) Q1 2017-Q4 2017 CAH National (51%) Q1 2017-Q4 2017 CAH 90th Percentile National () Q1 2017-Q4 2017 National (57%) Source for National CAH, National CAH 90 th Percentile, and National performances: Telligen Reports 41
75.0% 85.7% 88.2% 89.7% 92.3% 92.9% 93.8% 94.1% 95.7% 96.2% 96.4% 97.6% 98.2% OP-4a: Aspirin at Arrival - Overall Rate 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 25 19 35 34 5 20 16 9 3 40 33 28 38 1 2 4 6 7 8 10 11 39 12 13 14 15 17 18 21 22 23 24 26 29 30 31 32 36 37 27 Hospital Q4 2017 MICAHQN (97.2%) Q1 2017-Q4 2017 CAH National (95%) Q1 2017-Q4 2017 CAH 90th Percentile National () Q1 2017-Q4 2017 National (95%) Source for National CAH, National CAH 90 th Percentile, and National performances: Telligen Reports 42
71.4% 80.0% 81.8% 85.7% 91.3% OP-4b: Aspirin at Arrival - AMI 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 25 5 35 9 3 1 2 4 6 7 8 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 26 28 29 30 31 32 33 34 36 37 38 40 39 27 Hospital Q4 2017 MICAHQN (97.2%) 43
81.8% 85.7% 87.0% 92.3% 93.3% 94.7% 95.7% 96.3% OP-4c: Aspirin at Arrival - Chest Pain 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 19 20 34 16 40 33 38 28 1 3 2 4 5 6 7 8 9 10 11 39 13 14 15 18 21 22 23 24 25 26 29 30 31 32 35 36 37 12 17 27 Hospital Q4 2017 MICAHQN (97.3%) 44
OP AMI/CP Continuous Measures - 4Q17 Median Time to ECG - Chest Pain Median Time to ECG - AMI Median Time to ECG - Overall Rate 4 7 6 4.5 8 7 4 7 7 Median Time to Transfer to Another Facility for Acute Coronary Intervention - QI Measure 69 83 126 Median Time to Transfer to Another Facility for Acute Coronary Intervention - Reporting Measure 56 99.5 120 Median Time to Transfer to Another Facility for Acute Coronary Intervention - Overall 69 99 112 Median Time to Fibrinolysis 30 30 61 0 20 40 60 80 100 120 140 Rural Only Values CAH Only Values MICAHQN Values Median Time 45
Median Time 45 OP1 - Median Time to Fibrinolysis 40 35 30 25 20 15 10 5 0 MICAHQN Overall UCL LCL 46
Median Time 120 OP3a - Median Time to Transfer to Another Facility for Acute Coronary Intervention - Overall 100 80 60 40 20 0 MICAHQN Overall UCL LCL 47
Median Time 120 OP3b - Median Time to Transfer to Another Facility for Acute Coronary Intervention - Reporting Measure 100 80 60 40 20 0 MICAHQN Overall UCL LCL 48
Median Time 120 OP3c - Median Time to Transfer to Another Facility for Acute Coronary Intervention - QI Measure 100 80 60 40 20 0 MICAHQN Overall UCL LCL 49
Median Time 9 OP5a - Median Time to ECG - Overall Rate 8 7 6 5 4 3 2 1 0 MICAHQN Overall UCL LCL 50
Median Time 9 OP5b - Median Time to ECG - AMI 8 7 6 5 4 3 2 1 0 MICAHQN Overall UCL LCL 51
Median Time 9 OP5c - Median Time to ECG - Chest Pain 8 7 6 5 4 3 2 1 0 MICAHQN Overall UCL LCL 52
7 19.5 25 30 35 36 41 61 70 OP-1: Median Time to Fibrinolysis 60 50 40 30 20 10 0 11 36 23 8 9 10 38 4 1 3 2 5 6 7 39 12 13 14 15 16 17 18 19 20 21 22 24 25 26 27 28 29 30 31 32 33 34 35 37 40 Hospital Q1 2017-Q4 2017 CAH National (32 minutes) Q1 2017-Q4 2017 National (34 minutes) Q4 2017 MICAHQN (30 minutes) Q1 2017-Q4 2017 CAH 90th Percentile National (17 minutes) Source for National CAH, National CAH 90 th Percentile, and National performances: Telligen Reports 53
18 31 32 33 37 41 42 43 45 46 49 55 56 63.5 66 67 90 100 109.5 147.5 150 206 250 OP-3a: Median Time to Transfer to Another Facility for Acute Coronary Intervention - Overall 200 150 100 50 0 1 14 34 6 29 28 30 25 2 35 40 20 24 9 32 15 26 3 19 13 36 38 4 5 7 8 10 11 39 12 16 17 18 21 22 23 27 31 33 37 Hospital Q4 2017 MICAHQN (99 minutes) 54
18 33 34 35 41 42 43 45 46 49 56 66 67 85 90 90 109.5 150 205 250 OP-3b: Median Time to Transfer to Another Facility for Acute Coronary Intervention - Reporting Measure 200 150 100 50 0 1 29 20 34 28 30 25 2 35 40 24 32 15 13 3 26 19 36 38 4 5 6 7 8 9 10 11 39 12 14 16 17 18 21 22 23 27 31 33 37 Hospital Q1 2017-Q4 2017 CAH National (65 minutes) Q1 2017-Q4 2017 National (61 minutes) Q4 2017 MICAHQN (99.5 minutes) Q1 2017-Q4 2017 CAH 90th Percentile National (34 minutes) Source for National CAH, National CAH 90 th Percentile, and National performances: Telligen Reports 55
29 31 33 44 63.5 92 97 152 210 248 300 OP-3c: Median Time to Transfer to Another Facility for Acute Coronary Intervention - QI Measure 250 200 150 100 50 0 34 14 6 29 9 1 20 3 13 38 2 4 5 7 8 10 11 39 12 15 16 17 18 19 21 22 23 24 25 26 27 28 30 31 32 33 35 36 37 40 Hospital Q4 2017 MICAHQN (83 minutes) 56
0 3 3 3 4 4 4.5 4.5 5 5 5 5 5.5 5.5 5.5 6 6 6 6 6.5 6.5 6.5 6.5 7 7 7 7.5 8 9 9 9 10 11 11 11 12 13 18 44 50 OP-5a: Median Time to ECG - Overall Rate 45 40 35 30 25 20 15 10 5 0 12 3 4 20 6 35 2 31 10 15 22 37 39 32 34 9 21 25 33 1 13 18 36 5 11 28 24 29 16 19 38 8 14 30 40 26 23 17 7 27 Hospital Q1 2017-Q4 2017 CAH National (8 minutes) Q1 2017-Q4 2017 National (8 minutes) Q4 2017 MICAHQN (7 minutes) Q1 2017-Q4 2017 CAH 90th Percentile National (3 minutes) Source for National CAH, National CAH 90 th Percentile, and National performances: Telligen Reports 57
0 1.5 2 2 3 3 3 3.5 4 4 4 5 5.5 6 6 6 6.5 7 7 7 7.5 7.5 8 8 8 8 9 9 9 9.5 10 12 12 13 16 18 28.5 40 45 OP-5b: Median Time to ECG - AMI 40 35 30 25 20 15 10 5 0 12 3 10 14 4 5 6 20 2 11 31 34 35 15 25 32 36 1 9 13 24 29 16 28 30 40 21 33 38 18 22 8 23 26 37 17 19 7 39 27 Hospital Q4 2017 MICAHQN (7 minutes) 58
0 1 2 2.5 3 3 3.5 3.5 4 4 4 4.5 4.5 5 5 5 5.5 6 6 6 6 6 6.5 6.5 7 7.5 8 8 8 8 9 9 11 12 12 13 30 44 50 OP-5c: Median Time to ECG - Chest Pain 45 40 35 30 25 20 15 10 5 0 12 4 35 20 3 25 9 22 6 15 32 2 21 10 31 37 39 1 8 13 33 34 18 36 28 5 11 19 24 29 16 38 30 26 40 14 23 7 17 27 Hospital Q4 2017 MICAHQN (6 minutes) 59
OP Emergency Department Throughput - 4Q17 Door to Diagnostic Evaluation by a Qualified Medical Professional Median Time from ED Arrival to ED Departure for Discharged ED Patients - Transfer Patients Median Time from ED Arrival to ED Departure for Discharged ED Patients - Psychiatric/Mental Health Patients Median Time from ED Arrival to ED Departure for Discharged ED Patients - Reporting Measure Median Time from ED Arrival to ED Departure for Discharged ED Patients - Overall 0 50 100 150 200 250 Rural Only Values CAH Only Values MICAHQN Values Median Time 60
Median Time 135 OP18a - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Overall 130 125 120 115 110 105 100 MICAHQN Overall UCL LCL 61
Median Time 125 OP18b - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Reporting Measure 120 115 110 105 100 95 MICAHQN Overall UCL LCL 62
Median Time 250 OP18c - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Psychiatric/Mental Health Patients 200 150 100 50 0 MICAHQN Overall UCL LCL 63
Median Time 250 OP18d - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Transfer Patients 200 150 100 50 0 MICAHQN Overall UCL LCL 64
Median Time 30 OP20 - Door to Diagnostic Evaluation by a Qualified Medical Professional 25 20 15 10 5 0 MICAHQN Overall UCL LCL 65
74 75 83 87 87 92.5 95 99 103.5 104.5 109 112 112 114 119.5 119.5 120.5 120.5 121 121 123 124 125 126 126 132 135 136.5 137 140 141 145.5 146 147 148.5 168 183 185.5 187 225 250 OP-18a: Median Time from ED Arrival to ED Departure for Discharged ED Patients - Overall 200 150 100 50 0 23 5 11 2 22 37 20 32 33 17 18 12 26 21 24 36 6 10 25 40 4 1 13 14 34 19 39 35 3 9 27 31 28 8 29 15 38 30 16 7 Hospital Q4 2017 MICAHQN (126 minutes) 66
70 71 73 85 85 87 88 94 95.5 98 98.5 100 100.5 104.5 111 112 112 113.5 114 117 118 118 118.5 119.5 120 120 122 129 133 136.5 137 141 142 143 143 157.5 160.5 169 170 217 250 OP-18b: Median Time from ED Arrival to ED Departure for Discharged ED Patients - Reporting Measure 200 150 100 50 0 23 11 5 2 22 20 37 32 26 33 18 21 6 17 25 12 36 40 10 1 14 24 19 4 9 13 34 3 35 39 27 29 8 28 31 16 15 30 38 7 Hospital Q1 2017-Q4 2017 CAH National (105 minutes) Q1 2017-Q4 2017 National (134 minutes) Q4 2017 MICAHQN (116 minutes) Q1 2017-Q4 2017 CAH 90th Percentile National (78 minutes) Source for National CAH, National CAH 90 th Percentile, and National performances: Telligen Reports 67
64 68 79 83 91 110 116 118 118.5 121 137 142 145.5 154.5 156 163.5 171 176 188 190 191 196 203 207 240.5 247.5 262 286.5 347.5 357 457.5 550 553.5 668 755 800 OP-18c: Median Time from ED Arrival to ED Departure for Discharged ED Patients - Psychiatric/Mental Health Patients 700 600 500 400 300 200 100 0 5 11 24 32 17 27 33 23 12 4 37 35 6 10 21 15 1 29 18 26 28 34 22 20 38 36 9 25 3 16 8 30 7 40 13 2 39 14 19 31 Hospital Q4 2017 MICAHQN (191 minutes) 68
110 112.5 122 127.5 129 139 151 167 177 181 190.5 191 192 197 197.5 203 203 206 209 210 210 213 220 223 228 233.5 233.5 236 247 253 262 269 273 278 279 292 294 295.5 318 333.5 400 OP-18d: Median Time from ED Arrival to ED Departure for Discharged ED Patients - Transfer Patients 350 300 250 200 150 100 50 0 17 23 39 5 12 22 13 19 33 6 21 14 34 10 9 2 37 27 4 11 35 26 16 31 8 3 40 38 24 20 29 7 28 1 30 15 36 18 25 32 Hospital Q4 2017 MICAHQN (216 minutes) 69
1.5 7 7.5 8 9 9 10 10 10 10 10 11 11 11.5 11.5 12 13 14 14 14 14 14 15 15 16 16 17 18 18 19 20 20.5 21 21.5 22 23 23 24 32 35 OP-20: Door to Diagnostic Evaluation by a Qualified Medical Professional 30 25 20 15 10 5 0 39 31 4 5 9 28 6 16 17 23 26 2 20 19 40 24 3 13 15 21 33 37 1 11 27 32 18 29 34 22 8 25 10 35 7 14 36 12 30 38 Hospital Q1 2017-Q4 2017 CAH National (16 minutes) Q1 2017-Q4 2017 National (19 minutes) Q4 2017 MICAHQN (14 minutes) Q1 2017-Q4 2017 CAH 90th Percentile National (7 minutes) 70
IP Emergency Department - 4Q17 Admit Decision Time to ED Departure Time for Admitted Patients - Psychiatric/Mental Health Patients 139 148 168 Admit Decision Time to ED Departure Time for Admitted Patients - Reporting Measure 160 146 148 Admit Decision Time to ED Departure Time for Admitted Patients - Overall Rate 160 147 148 Median Time from ED Arrival to ED Departure for Admitted ED Patients - Psychiatric/Mental Health Patients 215 247 239 Median Time from ED Arrival to ED Departure for Admitted ED Patients - Reporting Measure 230 231 231 Median Time from ED Arrival to ED Departure for Admitted ED Patients - Overall Rate 230 231 231 0 50 100 150 200 250 300 Rural Only Values CAH Only Values MICAHQN Values Median Time 71
Median Time 260 ED-1a - Median Time from ED Arrival to ED Departure for Admitted ED Patients - Overall Rate 250 240 230 220 210 200 1Q17 2Q17 3Q17 4Q17 CAH Only Rural Only MICAHQN 72
Median Time 260 ED-1b - Median Time from ED Arrival to ED Departure for Admitted ED Patients - Reporting Measure 250 240 230 220 210 200 1Q17 2Q17 3Q17 4Q17 CAH Only Rural Only MICAHQN 73
Median Time 300 ED-1c - Median Time from ED Arrival to ED Departure for Admitted ED Patients - Psychiatric/Mental Health Patients 250 200 150 100 50 0 1Q17 2Q17 3Q17 4Q17 CAH Only Rural Only MICAHQN 74
Median Time 180 ED-2a - Admit Decision Time to ED Departure Time for Admitted Patients - Overall Rate 160 140 120 100 80 60 40 20 0 1Q17 2Q17 3Q17 4Q17 CAH Only Rural Only MICAHQN 75
Median Time 180 ED-2b - Admit Decision Time to ED Departure Time for Admitted Patients - Reporting Measure 160 140 120 100 80 60 40 20 0 1Q17 2Q17 3Q17 4Q17 CAH Only Rural Only MICAHQN 76
Median Time 250 ED-2c - Admit Decision Time to ED Departure Time for Admitted Patients - Psychiatric/Mental Health Patients 200 150 100 50 0 1Q17 2Q17 3Q17 4Q17 CAH Only Rural Only MICAHQN 77
100 160 166 175 180 182 184 190 192 197 200 208 208 209 218 220 221 225 230 231 236 239 249 252 253 270 283 297 307 350 ED-1a: Median Time from ED Arrival to ED Departure for Admitted ED Patients - Overall Rate 300 250 200 150 100 50 0 14 16 12 11 9 2 23 8 19 6 10 17 40 18 3 33 21 31 27 22 28 26 34 36 29 38 1 7 30 4 5 39 13 15 20 24 25 32 35 37 Hospital Q4 2017 MICAHQN (231 minutes) 78
100 160 168 175 180 182 184 190 192 197 203 208 208 209 219 220 221 226 230 231 236 239 249 253 255 270 285 293 307 350 ED-1b: Median Time from ED Arrival to ED Departure for Admitted ED Patients - Reporting Measure 300 250 200 150 100 50 0 14 16 12 11 9 2 23 8 19 6 10 17 40 18 3 33 21 31 27 22 28 26 34 29 36 38 1 7 30 4 5 39 13 15 20 24 25 32 35 37 Hospital Q1 2017-Q4 2017 CAH National (189 minutes) Q1 2017-Q4 2017 National (253 minutes) Q4 2017 MICAHQN (231 minutes) Q1 2017-Q4 2017 CAH 90th Percentile National (110 minutes) Source for National CAH, National CAH 90 th Percentile, and National performances: Telligen Reports 79
78 138 154 164 199 203 222 230 230 247 256 262 266 287 369 382 387 627 700 ED-1c: Median Time from ED Arrival to ED Departure for Admitted ED Patients - Psychiatric/Mental Health Patients 600 500 400 300 200 100 0 12 10 21 23 3 28 31 1 27 36 34 26 22 40 7 30 8 38 2 4 5 6 9 11 39 13 14 15 16 17 18 19 20 24 25 29 32 33 35 37 Hospital Q4 2017 MICAHQN (239 minutes) 80
24 38 74 75 86 100 105 126 127 136 137 143 147 150 155 156 161 162 163 165 167 169 170 173 177 181 183 191 195 214 250 ED-2a: Admit Decision Time to ED Departure Time for Admitted Patients - Overall Rate 200 150 100 50 0 9 38 37 23 30 14 12 11 2 19 22 7 31 6 16 3 26 18 8 21 28 40 36 34 17 29 10 33 1 27 4 5 39 13 15 20 24 25 32 35 Hospital Q4 2017 MICAHQN (148 minutes) 81
24 38 74 77 86 100 106 126 127 136 137 139 147 150 155 157 161 162 163 165 167 167 170 172 177 181 185 191 195 208 250 ED-2b: Admit Decision Time to ED Departure Time for Admitted Patients - Reporting Measure 200 150 100 50 0 9 38 37 23 30 14 12 11 2 19 22 7 31 6 16 3 26 18 8 21 36 28 40 34 17 29 10 33 1 27 4 5 39 13 15 20 24 25 32 35 Hospital Q1 2017-Q4 2017 CAH National (44 minutes) Q1 2017-Q4 2017 National (85 minutes) Q4 2017 MICAHQN (148 minutes) Q1 2017-Q4 2017 CAH 90th Percentile National (6 minutes) Source for National CAH, National CAH 90 th Percentile, and National performances: Telligen Reports 82
14 22 90 116 128 130 133 145 148 151 185 193 218 231 249 277 300 ED-2c: Admit Decision Time to ED Departure Time for Admitted Patients - Psychiatric/Mental Health Patients 250 200 150 100 50 0 23 12 10 30 22 40 3 1 31 28 26 34 27 36 7 8 2 4 5 6 9 11 39 13 14 15 16 17 18 19 20 21 24 25 29 32 33 35 37 38 Hospital Q4 2017 MICAHQN (148 minutes) 83
Thank you! Joshua Salander, MBA, PMP Consultant jsalander@persevion.com (989) 666-7033