Michigan STRATEGY GROUP #2 Critical Access DATA MANAGEMENT AND ANALY LYSIS Hospital Quality AUGUST 16, 2019 Network AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
Strategy Group #2 Data Management and Analysis Goal: Michigan CAHs consistently submit timely and accurate data and are knowledgeable about how to utilize the data to identify gaps. No CAH left behind! • Update members on current clinical quality measures and track on new and retired measures (including eCQMs, Star Ratings, and potential new areas of focus). • Provide education regarding when and how to report on measures. • Drive sharing of ideas on how to share results and scorecard examples while encouraging transparency, promoting professional development, offering opportunities for networking and inspiring change. • Work with consultants to present the data in a meaningful way, including benchmarking and comparison data. • Provide best practices on specific measures related to data collection and reporting. • Be proactive – identify measures that we want to be held accountable for and recommend they be used by agencies like MHA, FORH and payors like BCBSM for VBP. Go toward them, not wait for them. AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
Measure Spreadsheet Update http://www.mcrh.msu.edu/programs/CAH /Quality%20Improvement%20NEW.html MICAH QN Measures – Excel Sheet AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
Reminders Monthly – Submit to KDS & NHSN Quarterly – Q2 2019 data ◦ October 24 th - Email MBQIP results to Crystal ◦ September 15 th - Email HCAHPS results to Crystal ◦ November 1 st - Outpatient results due to QNet (Most use Quantros) ◦ November 15 th - Inpatient due to QNet AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
Scorecard Showcase Feature Using a Cumulative Total Most FY 2019 Performance Measure Recent Target Result 50 39.4 Market Share FY 2109 26.8 39.4 Primary Care Office Target 25 26.8 Yearly total Encounters Cumulative Total (Thousands) 0 AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
Scorecard Showcase Feature Most FY 2019 Performance Measure Recent Target Result 50 39.4 Market Share 35.1 39.4 Primary Care Office 25 FY 2109 35.1 Target Yearly total Encounters Cumulative (Thousands) Total 0 AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
Scorecard Showcase Feature Using a Rolling 12 Months Most FY 2019 Performance Measure Recent Target Result 90% 86.4% 86.6% FY 2019 86.4% 85% Target 86.6% Patient Satisfaction June 2019 Combined Rolling 12 Months 80% AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
HCAHPS Scores – Q1 2019 MICAH Michigan National National Top 90 th Percentile QN Average Average Care Transitions Composite Score 58% 54% 53% 63% Discharge Information Composite Score 91% 89% 87% 92% Overall Rating 81% 74% 73% 84% Would you Recommend 80% 71% 72% 84% * MI and National Average is from Hospital Compare 10.1.2017-9.30-2018 * Three CAHs did not submit, and 3 do not participate in HCAHPS AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
GLPP HIIN Update MICAH Quality Network meeting August 16, 2019
GLPP HIIN Dashboard
ADE-Opioids ADE-Opioids 6 5 5 5 4 3 3 3 3 3 2 2 2 2 2 2 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 July 2018 - June 2019
Falls with Injury Falls 6 5 5 5 4 4 4 3 3 3 3 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 July 2018 - June 2019
Post-Operative Sepsis (PSI-13) *AHRQ software update not available yet, only data till Sept 2018 available for this measure
Sepsis Mortality Rate
MICAH QN now using Google Docs • Use Google Chrome if you have it • You can login through your Gmail account • Make sure to not include any PHI • Links will come from Crystal • First round – Alternative Readmission Activities AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE .
AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
Organizational Scorecard Showcase Schoolcraft Memorial Hospital AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
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