8.17.2018 Performance Measurement for Rural Low Volume Providers - - PowerPoint PPT Presentation

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8.17.2018 Performance Measurement for Rural Low Volume Providers - - PowerPoint PPT Presentation

Jan 25, 2024 180 likes •481 views

Data Management 8.17.2018 Performance Measurement for Rural Low Volume Providers Recommendations (2015) Make participation in Centers for Medicare and Medicaid Services (CMS) quality measurement and quality improvement programs mandatory

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Data Management 8.17.2018

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Performance Measurement for Rural Low Volume Providers Recommendations (2015)

 Make participation in Centers for Medicare and Medicaid

Services (CMS) quality measurement and quality improvement programs mandatory for all rural providers

  • Allow a phased approach for full participation across program

types and explicitly address low-case volume

 Development of rural-relevant measures

  • Fund development of rural-relevant measures
  • Develop and/or modify measures so as to explicitly address low

case-volume

  • Alignment of measurement efforts
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 Measure selection

  • Use guiding principles for selecting quality measures that

are relevant for rural providers

  • Create a Measures Applications Partnership (MAP)

workgroup to advise CMS on the selection of rural- relevant measures  Payment considerations

  • For rural providers, create payment programs that include

incentive payments, but not penalties

  • Offer rewards for rural providers based on achievement or

improvement

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 Identifying core sets of the best available rural-

relevant measures

 Recommendations regarding measuring and

improving access to care for the rural population

 Identifying gaps in measurement and alignment

and coordination of measurement efforts

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 Eight measures for the hospital setting  Thirteen measures for ambulatory setting  Apply to majority of rural patients and providers

  • Cross cutting
  • Resistant to low-case volume

 Includes process and outcome measures  Includes measures based on patient report

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 See Handout  Measurement Gaps

  • Access to care
  • Disparities in care
  • Balancing access and cost with health outcomes
  • Outcome measures, particularly patient-reported
  • utcomes

 Implications…..

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 Federal Office of Rural Health Policy – Division

  • f Health Resources Services Administration

(HRSA) Award

 Top 10 States – Highest reporting rates and

levels of improvement over the last year

 Improvement from #7 to #2

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 See Handout

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KDS & NHSN - monthly Quarter 3 Data

  • MBQIP due to Crystal by October 24th
  • Outpatient due to QNet/Quantros by November 1st
  • Inpatient due to QNet/Quantros by November 15th
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 Does anyone have any questions or

comments regarding measure specifications?

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http://www.mcrh.msu.edu/programs/CAH/Quality%20Improvement%20NEW.html MICAH QN Measures – Excel Sheet

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 Hospital Compare has information on over

4,000 Medicare-certified hospitals

 Overall rating displayed on about 80%  7 measure groups  57 quality measures

Link to Inpatient Hospital Compare Report Guide

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Overall Rating Number of Hospitals 5 stars 337 (7.36%) 4 stars 1155 (25.22%) 3 stars 1187 (25.92%) 2 stars 753 (16.44%) 1 star 260 (5.68%) Volume too low 887 (19.37%)

0% 5% 10% 15% 20% 25% 30% 35% 5 4 3 2 1

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Measure Group Number of Potential Measures within Each Group Number of Measures for Your Hospital Standard Measure Group Weight Measure Group Score National Group Score Performance Category Mortality 7 2 22.0% 0.37 0.0004 N/A Readmission 9 4 22.0% 0.22

  • 0.06

Same as the national average Safety of Care 8 2 22.0% 1.15

  • 0.04

N/A Patient Experience 10 10 22.0% 1.55

  • 0.0004

Above the national average Efficient Use of Medical Imaging 5 4 4.0% 0.64 0.003 Same as the national average Timeliness of Care 7 4 4.0% 0.77

  • 0.02

Same as the national average Effectiveness of Care 11 4 4.0% 0.12 0.03 Same as the national average

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July 2018 (May Preview) December 2017 October 2017 July 2017 December 2016 October 2016 July 2016 National Average

Overall Hospital Rating Results

Temp Hold

  • n Stars

4 out of 5 Stars 4 out of 5 Stars 4 out of 5 Stars 4 out of 5 Stars 4 out of 5 Stars 4 out of 5 Stars 3 out of 5 Stars

Summary Score 0.79 0.44 0.42 0.42 0.44 0.5 0.46 0.02 Measure Group Column1 Column13 Column12 Column122 Column4 Column42 Column422

Performance Category Potential Measures within Each Group Measures for Your Hospital Measure Group Weight

Total Score Mortality 0.37 0.30 0.30 0.30 0.31 0.31 0.31 N/A 7 2 22.0% 0.0814 Readmission 0.22

  • 0.12
  • 0.12

0.04 0.55 0.55 0.55 Same as the national average 8 4 22.0% 0.0484 Safety of Care 1.15

  • 0.03
  • 0.03
  • 0.03
  • 0.10
  • 0.10
  • 0.10

N/A 8 2 22.0% 0.253 Patient Experience 1.55 1.88 1.88 1.59 1.23 1.53 1.32 Above the national average 10 10 22.0% 0.341 Efficient Use of Medical Imaging 0.64

  • 0.94
  • 0.94
  • 0.92
  • 0.50
  • 0.50
  • 0.50

Same as the national average 5 4 4.0% 0.0256 Timeliness of Care 0.77 0.74 0.74 0.82 0.98 0.92 0.89 Same as the national average 7 4 4.0% 0.0308 Effectiveness of Care 0.12

  • 0.01
  • 0.007

0.09

  • 0.36
  • 0.42
  • 0.27

Same as the national average 11 4 4.0% 0.0048 56 30 0.785

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Measure Group Measure ID Measure Name July 2018 (May Preview) Standardized Measure Score Jan 2018 July 2017 Jan 2017 National Mean July 2018 National Mean July 2017

Mortality

MORT-30-AMI

Acute Myocardial Infarction (AMI) 30-Day Mortality Rate

N/A N/A N/A N/A 13.2% 13.6%

Mortality

MORT-30-CABG Coronary Artery Bypass Graft (CABG) 30-

Day Mortality Rate

N/A N/A N/A N/A 3.2% 3.2%

Mortality

MORT-30-COPD Chronic Obstructive Pulmonary Disease

(COPD) 30-Day Mortality Rate

8.1% 0.27 7.6% 7.6% 8.1% 8.4% 8.1%

Mortality

MORT-30-HF

Heart Failure (HF) 30-Day Mortality Rate

N/A N/A N/A N/A 11.8% 12.2%

Mortality

MORT-30-PN

Pneumonia (PN) 30-Day Mortality Rate

13.4% 1.25 14.2% 14.2% 14.0% 15.9% 16.0%

Mortality

MORT-30-STK

Acute Ischemic Stroke (STK) 30-Day Mortality Rate

N/A N/A N/A N/A 14.3% 14.9%

Mortality

PSI-4-SURG- COMP

Death Rate Among Surgical Inpatients with Serious Treatable Complications

N/A N/A N/A N/A 161.80 136.70

Readmission

READM-30-AMI

Acute Myocardial Infarction (AMI) 30-Day Readmission Rate

N/A N/A N/A N/A 13.2% 16.9%

Readmission

READM-30-CABG Coronary Artery Bypass Graft (CABG) 30-

Day Readmission Rate

N/A N/A N/A N/A 14.4% 14.4%

Readmission

READM-30- COPD

Chronic Obstructive Pulmonary Disease (COPD) 30-Day Readmission Rate

18.6% 0.92 19.2% 19.2% 19.0% 19.6% 19.8%

Readmission

READM-30-HF

Heart Failure (HF) 30-Day Readmission Rate

N/A N/A N/A N/A 4.5%

Readmission

READM-30-Hip- Knee

Hospital-Level 30-Day All-Cause Risk- Standardized Readmission Rate (RSRR) Following Elective Total Hip Arthroplasty (THA)/Total Knee Arthroplasty (TKA)

3.8% 0.79 4.0% 4.0% 4.9% 4.2% 4.4%

Readmission

READM-30-PN

Deleted Pneumonia (PN) 30-Day Readmission Rate

D/C 15.1% 15.1% 15.0% 17.1%

Readmission

READM-30-STK

Stroke (STK) 30-Day Readmission Rate

N/A 12.6% 12.6%

Readmission

READM-30-STK

Stroke (STK) 30-Day Readmission Rate

N/A N/A N/A N/A 11.9% 12.2%

Readmission

EDAC-30-PN

New Excess Days in Acute Care after Hospitalization for Pneumonia (PN)

  • 26.7

1.28 N/A N/A N/A 4.7

Readmission

READM-30-HOSP- WIDE

HWR Hospital-Wide All-Cause Unplanned Readmission

15.1% 0.25 15.4% 15.4% 15.0% 15.3% 15.3%

Readmission

OP-32

Facility Seven-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy

N/A N/A N/A N/A 0.2% 0.2%

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Safety of Care

HAI-1

Central-Line Associated Bloodstream Infection (CLABSI)

N/A N/A N/A N/A 0.808 0.995

Safety of Care

HAI-2

Catheter-Associated Urinary Tract Infection (CAUTI)

N/A N/A N/A N/A 0.885 0.928

Safety of Care

HAI-3

Surgical Site Infection from colon surgery (SSI- colon)

N/A N/A N/A N/A 0.850 0.914

Safety of Care

HAI-4

Surgical Site Infection from abdominal hysterectomy (SSI-abdominal hysterectomy)

N/A N/A N/A N/A 0.820 0.962

Safety of Care

HAI-5

MRSA Bacteremia

N/A N/A N/A N/A 0.898 1.011

Safety of Care

HAI-6

Clostridium Difficile (C.difficile)

0.000 1.55 N/A N/A N/A 0.822 0.955

Safety of Care

COMP-HIP-KNEE

Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA)

2.0% 1.16 2.9% 2.9% 4.1% 2.6% 2.8%

Safety of Care

PSI-90-Safety

Patient Safety for Selected Indicators (PSI)

NA N/A N/A N/A 0.99 0.89

Patient Experience

H-CLEAN-HSP

Cleanliness of Hospital Environment

93 1.34 94 94 94 88 88

Patient Experience

H-COMP-1

Nurse Communication

96 1.82 96 95 95 91 92

Patient Experience

H-COMP-2

Doctor Communication

93 0.54 95 93 94 92 92

Patient Experience

H-COMP-3

Responsiveness of Hospital Staff

94 1.95 95 94 93 86 85

Patient Experience

H-COMP-4

Deleted Pain management

D/C 93 90 89 87

Patient Experience

H-COMP-5

Communication About Medicines

89 1.42 89 84 80 79 79

Patient Experience

H-COMP-6

Discharge Information

95 0.47 92 91 88 87 87

Patient Experience

H-HSP-RATING

Overall Rating of Hospital

95 1.96 95 94 93 89 89

Patient Experience

H-QUIET-HSP

Quietness of Hospital Environment

87 0.84 89 87 86 83 83

Patient Experience

H-COMP-7

HCAHPS 3 Item Care Transition Measure

83 0.45 83 83 84 82 81

Patient Experience

H-RECMND

Willingness to Recommend Hospital

97 2.05 97 96 94 88 88 Measure Group Measure ID Measure Name July 2018 (May Preview) Standardized Measure core Jan 2018 July 2017 Jan 2017 National Mean July 2018 National Mean July 2017

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Measure Group Measure ID Measure Name July 2018 (May Preview) Standardized Measure Score Jan 2018 July 2017 Jan 2017 National Mean July 2018 National Mean July 2017

Efficient Use of Medical Imaging

OP-8

MRI Lumbar Spine for Low Back Pain

NA N/A N/A N/A 40.4% 40.5%

Efficient Use of Medical Imaging

OP-10

Abdomen CT Use of Contrast Material

2.9% 0.65 14.9% 14.9% 12.7% 7.7% 8.0%

Efficient Use of Medical Imaging

OP-11

Thorax CT Use of Contrast Material

0.0% 0.53 6.0% 6.0% 8.2% 2.2% 2.6%

Efficient Use of Medical Imaging

OP-13

Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac Low-Risk Surgery

3.8% 0.34 2.9% 2.9% 2.3% 4.5% 4.7%

Efficient Use of Medical Imaging

OP-14

Simultaneous Use of Brain Computed Tomography (CT) and Sinus CT

0.4% 0.64 0.4% 0.4% 0.7% 0.9% 1.3%

Timeliness of Care

ED-1b

Median Time from ED Arrival to ED Departure for Admitted ED Patients

NA N/A N/A N/A 275 300

Timeliness of Care

ED-2b

Admit Decision Time to ED Departure Time for Admitted Patients

NA N/A N/A N/A 102 119

Timeliness of Care

OP-3b

Median Time to Transfer to Another Facility for Acute Coronary Intervention

NA N/A N/A N/A 64 57

Timeliness of Care

OP-5

Median Time to ECG

6 0.38 5 5 6 8 8

Timeliness of Care

OP-18b/ED-3

Median Time from ED Arrival to ED Departure for Discharged ED Patients

102 0.94 106 106 96 141 142

Timeliness of Care

OP-20

Door to Diagnostic Evaluation by a Qualified Medical Professional

14 0.62 12 12 13 23 24

Timeliness of Care

OP-21

ED-Median Time to Pain Management for Long Bone Fracture

N/A 53 53

Timeliness of Care

OP-3b

Median Time to Transfer to Another Facility for Acute Coronary Intervention

N/A 58 58

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Timeliness of Care

OP-21

Median Time to Pain Management for Long Bone Fracture

47 0.17 45 45 NA 50 52

Effectiveness of Care

OP-4

Chest Pain Aspirin at Arrival

97% 0.35 97% 97% 93% 95% 95%

Effectiveness of Care

IMM-2

Influenza Immunization

89%

  • 0.19

91% 91% 91% 91% 92%

Effectiveness of Care

IMM-3/OP-27

Healthcare Personnel Influenza Vaccination

N/A 85% 85%

Effectiveness of Care

IMM-3/OP-27

Healthcare Personnel Influenza Vaccination

93% 0.50 93% 93% N/A 86% 86%

Effectiveness of Care

OP-22

ED-Patient Left Without Being Seen

0% 0.98 0% 0% 0% 2% 2%

Effectiveness of Care

OP-23

ED-Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke who Received Head CT or MRI Scan Interpretation Within 45 Minutes of Arrival

NA N/A N/A N/A 74% 71%

Effectiveness of Care

OP-29

Endoscopy/Polyp Surveillance: Appropriate Follow- up Interval for Normal Colonoscopy in Average Risk Patients

NA N/A N/A N/A 85% 80%

Effectiveness of Care

OP-30

Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use

NA N/A N/A N/A 89% 86%

Effectiveness of Care

OP-33

External Beam Radiotherapy for Bone Metastases

NA N/A N/A N/A 82% 82%

Effectiveness of Care

PC-01

Elective Delivery Prior to 39 Completed Weeks Gestation: Percentage of Babies Electively Delivered Prior to 39 Completed Weeks Gestation

NA N/A N/A N/A 1% 2%

Effectiveness of Care

SEP-1

Severe Sepsis and Septic Shock

NA N/A N/A N/A 49%

Effectiveness of Care

VTE-6

Hospital Acquired Potentially-Preventable Venous Thromboembolism

NA N/A N/A N/A 2% 2% Measure Group Measure ID Measure Name July 2018 (May Preview) Standardized Measure Score Jan 2018 July 2017 Jan 2017 National Mean July 2018 National Mean July 2017

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