Hospital Metrics TAG September 8, 2015 Welcome and Introductions 2 - - PowerPoint PPT Presentation

Hospital Metrics TAG

September 8, 2015

Welcome and Introductions

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Updates

• CMS discussions
• Committee updates

– Next meeting 24 September – Behavioral health learning session, with CCO Metrics & Scoring Committee (tentatively 30 Oct) – Year 4 survey, open until 7 October 2015

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Updates

Year 3 Survey Results

please see supplementary materials

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Year 2 - CAUTI

• Timing issues

HTPP Year Period Specifications Year 1 (baseline)

• Oct. 2013 –
• Sep. 2014

Old NHSN specifications Year 2 (performance year)

• Oct. 2014 –
• Sep. 2015
• First quarter –

consistent with baseline

• Last 3 quarters –

new NHSN specifications (not comparable to baseline)

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Year 2 - CAUTI

• Possible measurement/benchmarking solutions

– Entire baseline year compared to data covering just the first quarter of Year 2 (common specifications) – Year 2 payments based on benchmark only (no improvement target) – The H-TAG ideas was consulted on these and asked to submit alternative solutions

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Year 2 - CAUTI

• Decision

– Only use data with new CDC specifications – Baseline: January 1, 2015 – March 31, 2015 (3 months) – Performance Period: April 1, 2015 – September 30, 2015 (6 months) – Benchmark remains at HTPP baseline 50th percentile, but absolute number changes to 1.10 per 1000 catheter days (excluding hospitals with no CAUTIs)

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Year 3 CAUTI / CLABSI

• Recap: Committee has expressed concern with

basing rate on device days

• As of 2015 the risk-adjusted Standardized Infection

Ratio (SIR) is available for all tracked units.

• SIRs compare the number of infections in a facility

to the number of infections that would be expected to have occurred based on previous years of reported data.

• Committee decided to switch to SIRs, which will be

available from the CDC for all tracked units beginning in 2015

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Year 3 CAUTI / CLABSI

• CDC calculating two SIRs

– Interim, available July 2015; based on 2009 baselines – Rebased, available ~Jan. 2017, based on 2015 baselines

• HTPP decision - hold off on switch to SIRs

until Year 4 (2017)

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EDIE – Year 3

• Notification to primary care providers currently

included in the denominator (as not technically possible to exclude them from the baseline year)

• Could exclude in Year 3

– Pros: Would exclude patients for whom hospitals would be unable to get numerator credit – Cons: Not completely clean; potential lack of clarity on which patients require primary care notifications

• H-TAG opinions?

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Additional Discussion of EDIE- based Measure

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Sepsis (Healthcare-Associated Infections Domain)

Description: Mortality rate for patients admitted with severe sepsis and septic shock per 1,000 discharges from HRET HEN (OPT-HEN-SEPSIS-1). National benchmark: HEN goal was to reduce mortality by 25% Alignment w/ CCOs? No. Risk adjustment? No.

Considerations:

• There is an NQF endorsed process measure bundle associated with

Sepsis (NQF 0500) – one composite measure for all bundle elements.

• The HRET has 4 process measures (ED screening; Inpt screening;

compliance with 3-hr and 6-hr bundles).

• Hospitals could implement the bundle components to help with

quality improvement, but only report on the mortality measure.

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Future Agenda Items?

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Wrap up / next meeting Tuesday, October 13, 10am – 12pm

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Questions?

Sara Kleinschmit, OHA sara.kleinschmit@state.or.us Diane Waldo, OAHHS diane.waldo@oahhs.org Elyssa Tran, Apprise Health Insights elyssa.tran@apprisehealthinsights.com Barbara Wade, OAHHS/Apprise Barbara.wade@apprisehealthinsights.com

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