2020 Quality Measure Development CHASE Board August 27, 2019 - - PowerPoint PPT Presentation
HQIP 2019 Scoring and 2020 Quality Measure Development CHASE Board August 27, 2019 Nancy Dolson Department of Health Care Policy & Financing Agenda 1. 2019 CO HQIP Scoring 2. 2020 CO HQIP Proposed Quality Measures Review of 2019
CHASE Board August 27, 2019
Nancy Dolson Department of Health Care Policy & Financing
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The HQIP Subcommittee has voted to apply the 2018 bounds to this year’s distribution. Healthy People 2020’s benchmark of 23.9% was used as the cutoff for scoring eligibility.
C-section Lower Bound Upper Bound Points
1st Tercile (lowest) 0.0% 17.2% 4 17 2nd Tercile 17.3% 20.8% 2 10 3rd Tercile 20.9% 23.8% 1 7 ≥ 23.9% (highest) 23.9% 100.0% 12 Ineligible* 36 Total 82
*Ineligible facilities (those that do not provide obstetric services or do not meet the minimum number of qualified deliveries)
will have their scores normalized for this measure.
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Falls with Injury (rate per 1000 inpatient days) Lower Bound Upper Bound Points
1st Quartile (lowest) 0.00 0.08 5 41 2nd Quartile 0.09 0.21 3 13 3rd Quartile 0.22 0.64 1 14 4th Quartile (highest) 0.65 38.96 14 Total 82
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The HQIP Subcommittee has voted to apply the 2018 bounds to this year’s distribution. The 2018 method excluded those with 0% ACP from calculation and awarded maximum points for those greater than or equal to 99.5%.
Advance Care Planning Lower Bound Upper Bound Points
4th Quartile (highest) 99.5% 100.0% 3 26 3rd Quartile 86.4% 99.4% 2 32 2nd Quartile 75.0% 86.3% 1 3 1st Quartile (lowest) 0% 74.9% 21 Total 82
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The Communication about Medicines measure reflects patients’ feedback on how often hospital staff explained the purpose of any new medicine and what side effects that medicine might have.
‘Always’ Percentage Lower Bound Upper Bound Points
4th Quartile (highest) 70% 86% 4 15 3rd Quartile 67% 69% 2 11 2nd Quartile 65% 66% 1 16 1st Quartile (lowest) 0% 64% 20 Not Available* 20 Total 82
*Not Available group includes those with suppressed scores due to insufficient responses and rehabilitation facilities that are
not required to implement the HCAHPS survey. Scores will be normalized.
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The Discharge Information measure summarizes how well the hospital staff communicated with patients about the help they would need at home after leaving the hospital. The measure also summarizes how
symptoms or health problems to watch for during their recovery.
‘Yes’ Percentage Lower Bound Upper Bound Points
4th Quartile (highest) 91% 95% 4 14 3rd Quartile 90% 90% 2 12 2nd Quartile 89% 89% 1 9 1st Quartile (lowest) 0% 88% 27 Not Available* 20 Total 82
*Not Available group includes those with suppressed scores due to insufficient responses and rehabilitation facilities that are
not required to implement the HCAHPS survey. Scores will be normalized.
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The Care Transition measure evaluates the degree to which patients understood their care when they left the hospital.
‘Strongly Agree’ Percentage Lower Bound Upper Bound Points
4th Quartile (highest) 59% 71% 4 14 3rd Quartile 56% 58% 2 14 2nd Quartile 53% 55% 1 17 1st Quartile (lowest) 0% 52% 17 Not Available* 20 Total 82
*Not Available group includes those with suppressed scores due to insufficient responses and rehabilitation facilities that are
not required to implement the HCAHPS survey. Scores will be normalized.
Review of 2019 Measures Proposed Changes for 2020
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Measure Group Measure Status Data Goal Perinatal and Maternal Care Breast Feeding Existing Hospital Reported Process C-Section Existing Hospital Reported Outcome Pregnancy related depression New Hospital Reported Process Maternal Emergencies New Hospital Reported Process Family Planning New HCPF/Hospital Report Process Patient Safety Clostridium difficile (C-Diff) Existing HCPF/Hospital Report Outcome Adverse Event Existing Hospital Reported Process Falls w/Injury Existing Hospital Reported Outcome Culture of Safety Survey Existing Hospital Reported Process Patient Experience HCAHPS New HCPF Outcome Advanced Care Plan Existing Hospital Reported Process Behavioral Health Follow-Up after Hospitalization for Mental Illness New HCPF Outcome ED Utilization MH New HCPF Outcome ED Utilization SUD New HCPF Outcome Substance Use SUB Composite New Hospital Reported Outcome ALTO and Post-Surg New Hospital Reported Process Addressing Cost of Care Hospital Index New HCPF Outcome
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Measure Group Measure Status Data Goal Perinatal and Maternal Care Breast Feeding Existing Hospital Reported Process C-Section Existing Hospital Reported Outcome Pregnancy related depression Existing Hospital Reported Process Maternal Emergencies Existing Hospital Reported Process Family Planning Existing HCPF/Hospital Report Process Incidence of Episiotomy New HCFP Process Patient Safety Clostridium difficile (C-Diff) Existing HCPF/Hospital Report Outcome Adverse Event Existing Hospital Reported Process Culture of Safety Survey Existing Hospital Reported Process Sepsis New Hospital Reported Process Antibiotics Stewardship New Hospital Reported Process Handoffs and Signouts New Hospital Reported Process Patient Experience HCAHPS Existing HCPF Outcome Advanced Care Plan Existing Hospital Reported Process
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Three measure groups are being removed. These areas are going to be addressed in the Hospital Transformation Program. One measure (falls with injury) is being retired as the measure has topped out. A total of 9 measures are being retired. ❖ Behavioral Health
❖ Substance use
❖ Addressing Cost of Care
❖ Patient Safety
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Four new measures are being proposed: ❖ Maternal Health and Perinatal Care
❖ Patient Safety
Area: Maternal Health and Perinatal Care
NQF #0470 Incidence of Episiotomy - Percentage of vaginal deliveries (excluding those coded with shoulder dystocia) during which an episiotomy is performed. Numerator Statement:
PCS:0W8NXZZ performed on women undergoing a vaginal delivery (excluding those with shoulder dystocia ICD-10; O66.0) during the analytic period- monthly, quarterly, yearly etc. Denominator Statement:
coded with a shoulder dystocia ICD-10: O66.0). Exclusions:
an episiotomy is performed to free the shoulder and prevent/mitigate birth injury to the infant.
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Area: Patient Safety
Sepsis Process Measure:
treating sepsis. If the protocols are different for different levels of care (e.g. ED vs inpatient), please describe the protocols and their differences.
new providers and staff to your facility’s systems and protocols for addressing suspected sepsis cases
sepsis identification and treatment results.
identification and treatment as well as any results for the purposes of quality improvement
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Area: Patient Safety
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This measure has four levels corresponding to a tiered point structure. The levels are cumulative, e.g a hospital must achieve Level I to potentially achieve Level II. This measure is based on the work that the Colorado Department of Public Health and Environment (CDPHE), the Colorado Hospital Association (CHA), Colorado Health Care Association (CHCA), and Telligen have done on antibiotic stewardship working towards developing an Antibiotic Stewardship Honor Roll. Level 1, Commitment: The hospital demonstrates leadership support for antibiotic stewardship and has an antibiotic stewardship committee that includes a physician and pharmacist that meets at least quarterly. Level 2, Education: The hospital meets criteria for Level 1, as well as the following:
urinary tract infection, and skin and soft-tissue infection,
Level 3, Guidance: The hospital meets criteria for Level 1 and Level 2, as well as the following:
with feedback, antibiotic time-outs, or pharmacy-driven interventions designed for the antibiotic stewardship program, such as automatic alerts for, and de-escalation of, unnecessarily duplicative therapy, or time-sensitive automatic stop orders,
Level 4, Collaboration: The hospital meets criteria for Level 1, Level 2, and Level 3 as well as the following during the measurement period:
stewardship, and
Area: Patient Safety
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Each level is cumulative, a hospital has to meet the conditions and provide documentation and supporting evidence for the highest level it wishes to obtain as well as those below it. (e.g. to achieve level 3 hospitals must meet the criteria and submit documentation that meets levels 1 – 3). Measure details: Level 1 ❖ Hospitals must answer yes to the following questions and provide supporting documentation:
efforts to improve antibiotic use (antibiotic stewardship)?
❖ Documentation: Document dates of antibiotic stewardship committee meetings and include the names and position descriptions of attendees (e.g., “physician leader”). ❖ Letter of support: The letter must indicate support for improving antibiotic stewardship and attest that there is an antibiotic stewardship committee that includes physician and pharmacist leaders and meets at least quarterly.
Area: Patient Safety
Measure details: Level 2 ❖ Does your hospital have facility-specific treatment recommendations, based on national guidelines and local susceptibility, to assist with antibiotic selection for the following common conditions (must answer yes to all)?
❖ Does your hospital produce an antibiogram (cumulative antibiotic susceptibility report) and distribute the antibiogram to prescribers annually or every other year? ❖ Does your stewardship program provide education to clinicians and other relevant staff on improving antibiotic prescribing at least annually? ❖ Documentation:
acquired pneumonia, urinary tract infection, and skin and soft-tissue infection
(e.g., Infectious Diseases Society of America).
measurement period.
clinicians and staff on antibiotic stewardship at least annually.
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Area: Patient Safety
Measure details: Level 3 ❖ Does your hospital conduct any of the following broad interventions to improve antibiotic use? (yes to one or more)
prior to dispensing (i.e., pre-authorization) at your hospital?
antibiotic agents and provide verbal or written feedback to prescribers with 72 hours after the initial orders (i.e., prospective audit with feedback) at your hospital?
appropriateness of antibiotics within 72 hours after the initial orders?
following:
unnecessarily duplicative
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Area: Patient Safety
Measure details: Level 3 Continued ❖ Does your hospital monitor antibiotic use (consumption) at the unit and/or hospital-wide level by one of the following metrics? (yes to one or more)
aggregate sum of days for which any amount of a specified antimicrobial agent is administered or dispensed to a particular patient (numerator) divided by a standardized denominator (e.g., patient-days, days present, or admissions).
number of grams of each antibiotic purchased, dispensed, or administered during a period of interest divided by the World Health Organization-assigned DDD and divided by a standard denominator (e.g., patient-days, days present, or admissions). ❖ Does your hospital report information to staff on improving antibiotic use and resistance? (yes to one or more)
prescribing at least once every 6 months?
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Area: Patient Safety
Measure details: Level 3 Continued ❖ Documentation:
with feedback, antibiotic time-out, or pharmacy-driven intervention), including:
improve antibiotic use (antibiotic pre-authorization, prospective audit with feedback, antibiotic time-out, or pharmacy interventions), the tracking of antibiotic days of therapy or defined daily doses, and the report of antibiotic use data to prescribers at least once every six months.
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Area: Patient Safety
Measure details: Level 4 In order to achieve this level, the hospital must complete both activities. ❖ Has your hospital collaborated with one or more facilities, such as other hospitals or long-term care facilities, to implement coordinated antibiotic stewardship?
stewardship activities among multiple facilities, implementation of broad interventions to improve antibiotic use as defined for Level 3, Guidance, to multiple facilities, multi-facility efforts to track and report antibiotic use, or participation in a state or national public health collaborative. ❖ Does your hospital regularly report antibiotic use data to NHSN via the Antibiotic Use and Resistance Module (3 or more months during the measurement period)? ❖ Documentation:
facilities, and a description of the coordinated intervention.
participation in collaborative antibiotic stewardship efforts with other healthcare facilities and report of ≥3 months of antibiotic use data to NHSN.
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Area: Patient Safety
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Hospitals had identified this area in their patient safety surveys as an area that needed
different hospitals may have different areas where they need to improve handoffs and signouts. Based on this feedback this process measure was developed. Three-step Process Measure: Step 1: Hospitals must identify the areas of handoffs and signouts that they need to improve on and focus on the area that has the most need. Hospitals should look at both areas that have the greatest need for improvement and areas with the highest severity of potential harm. This can be accomplished by reviewing the results of their patient safety survey or other means. These handoffs and signouts can be between different levels of care, between departments, or other areas where providers transition care between themselves or other hospital staff. Step 2: Hospitals must describe the process they are using to address handoffs and transitions Step 3: Hospitals must describe how they will measure the implementation and performance of the programs and complete the following tasks:
Area: Patient Safety
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Three-step Process Measure: Step 1: Hospitals must identify the areas of handoffs and signouts that they need to improve on and focus on the area that has the most need. Hospitals should look at both areas that have the greatest need for improvement and areas with the highest severity of potential harm. This can be accomplished by reviewing the results of their patient safety survey or other means. These handoffs and signouts can be between different levels of care, between departments, or other areas where providers transition care between themselves or other hospital staff.
needs to be improved in this area. Examples of transitions include:
Step 2: Hospitals must describe the process they are using to address handoffs and transitions
Area: Patient Safety
Process Measure: Step 3: Hospitals must describe how they will measure the implementation and performance of the programs and complete the following tasks:
intervention vs post intervention
asking important clinical questions etc.)
barriers to improvements in the handoff process
hospital staff to facilitate continuous improvement.
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Area: Patient Safety
Step 3 Examples Based on Care Settings: ❖ Operating Room (OR) to Intensive Care Unit (ICU):
receiving ICU team)
circulation/hemodynamics, inputs, outputs, drains/lines, complications, plan, team contact information, and family information
question asking. ❖ Transfer to ICU:
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Matt Haynes Special Finance Projects Manager Department of Health Care Policy & Financing Matt.haynes@state.co.us