Hospital Metrics TAG January 12, 2016 Welcome and Introductions 2 - - PowerPoint PPT Presentation

▶
hospital metrics tag
SMART_READER_LITE
LIVE PREVIEW

Hospital Metrics TAG January 12, 2016 Welcome and Introductions 2 - - PowerPoint PPT Presentation

May 29, 2023 144 likes •506 views

Hospital Metrics TAG January 12, 2016 Welcome and Introductions 2 Agenda Overview Updates Presentation on Potentially Preventable Readmissions Measure Year 2 submissions Continue review of draft Year 3 measure specifications

slide-1
SLIDE 1

Hospital Metrics TAG

January 12, 2016

slide-2
SLIDE 2

Welcome and Introductions

2

slide-3
SLIDE 3

Agenda Overview

  • Updates
  • Presentation on Potentially Preventable

Readmissions Measure

  • Year 2 submissions
  • Continue review of draft Year 3 measure

specifications

– Sharing ED info (EDIE) – Warfarin – C-sections – Opioid – C-diff

  • Wrap-up

3

slide-4
SLIDE 4

Updates

  • Year 3 CMS discussions
  • Committee updates

– Last met 18 December

  • Agreed straw model (next slide)
  • H-TAG feedback requested:

– Threshold for opioid measure (to discuss later in agenda) – Identify which medication safety measure would drop (if any) – Thoughts for hospitals without L&D

– Next meeting 22 January

  • Discussion of Years 3 and strategies moving forward

4

slide-5
SLIDE 5

Updates

5

slide-6
SLIDE 6

Updates (cont)

  • Miscellaneous

– Follow-up after hospitalization for mental illness Year 2 clarification – HTPP evaluation

6

slide-7
SLIDE 7

Updates (cont)

  • CCO Metrics Update

– Upcoming Reports – Cigarette smoking prevalence measure – January CCO Metrics & Scoring Committee meeting

7

slide-8
SLIDE 8

Potentially Preventable Readmissions

8

slide-9
SLIDE 9

Potentially Preventable Readmissions

  • Committee recommended shifting from All Cause

Readmissions to Potentially Preventable Readmissions Measure beginning in Year 3 (2016)

  • Subject to CMS approval
  • Benefits:

– Addresses hospital concerns regarding all-cause measure

  • Cons:

– Uses proprietary 3M methodology

9

slide-10
SLIDE 10

3M Potentially Preventable Readmissions (PPR) Overview

January 2016

slide-11
SLIDE 11

Overview of PPR

  • Developed and maintained using a panel of

physicians

  • Chains

– a series of potentially preventable readmissions related to one initial admission

  • Clinical Relatedness

– Based on APR DRGs

  • Exclusions
  • Severity Adjustment

11

slide-12
SLIDE 12

Index Readmission Jan 1 Jan 15 Feb 10 March 15

transfer

Readmission Index

Chaining

Discharged: Admitted: Admitted: Admitted:

Heart Failure Heart Failure Heart Failure Heart Failure

slide-13
SLIDE 13

Index Index Jan 1 Jan 15

Clinical Relatedness

Discharged: Admitted:

Gastric Bypass Broken Arm

slide-14
SLIDE 14

Exclusions

  • Patients – problems with one or more records for the

same patient (i.e.. mismatched birthdates)

  • Admissions
  • Death during index stay
  • LAMA
  • Palliative care
  • Planned readmissions – discharge status codes are critical
  • Most HIV admissions
  • Certain metastatic malignancies
  • Optional – certain mental health DRGs

– Excludes Schizophrenia, Depression, Bipolar disorder, etc. – Mental health diagnosis codes with substance abuse DRGs will NOT be excluded

14

slide-15
SLIDE 15

Severity Adjusted Rate

Accounts for differences in case-mix across hospitals

  • Expected rates are calculated for each DRG/SOI level
  • Aggregated up to an Observed to Expected Ratio
  • Hospital OE Ratio * State Rate = Severity Adjusted Rate

Result is the hospital’s rate at the state case-mix Allows comparison across hospitals

15

slide-16
SLIDE 16

Severity Adjustment Calculation

State Data for APRDRG 344 Primary Calculation Severity Of Illness Readmission Chains At Risk Admissions State Rate 1 9 124 7.3% 2 71 777 9.1% 3 95 862 11.0% 4 30 165 18.2% Totals 205 1,928 10.6%

Hospital XYZ- APRDRG 344

Severity Of Illness Readmission Chains At Risk Admissions Hospital Observed Rate (Chains/At risk) State Rate (Chains/At Risk) Expected Number of Chains (Hospital at Risk*State Rate) Expected Rate (Expected Number/Hospital At Risk) OE Ratio Hospital Severity Adjusted Rate (Statewide Rate * Hospital OE Ratio) 1 1 15 6.7% 7.3% 1.1 7.3% 0.92 2 5 28 17.9% 9.1% 2.6 9.1% 1.95 3 2 35 5.7% 11.0% 3.9 11.0% 0.52 4 11.0% 0.0 Totals 8 78 10.3% 10.6% 7.5 9.6% 1.07 11.3%

slide-17
SLIDE 17

Questions

17

slide-18
SLIDE 18

Contacts

Kelly Price

Senior Director, DataGen Group (518) 431-7629 kprice@hanys.org

Melissa Bauer

Senior Informatics Analyst, DataGen Group (518) 431-7810 mbauer@hanys.org

18

slide-19
SLIDE 19

Years 1 & 2 Data Submission Timeline Reminders

19

slide-20
SLIDE 20

OVERALL DATA SUBMISSION TIMELINE

1/11/2016 20

Oregon Association of Hospitals & Health Systems

  • Year 2: Performance period data submission

Date What must be completed? Feb 15, 2016 All final data and changes submitted on Apprise reporting platform. System will be locked for review, and no additional data will be accepted. March 31, 2016 Apprise completed review and corrections of data and make final submission to OHA. Apprise received checklist with attestation of data adhering to specs, accuracy in data, and sign off from each hospital. June 30, 2016 Payments to hospitals by OHA completed.

slide-21
SLIDE 21

DATA SUBMISSION CHECKLIST

  • Year 2 final review checklist
  • As part of the formal submission of the Year 2 data to

the OHA, hospital submissions will include a checklist

  • Hospitals will attest to each item on the checklist as

part of the formal submission; does not apply for Follow Up to Mental Health Hospitalization (OHA) and Readmissions (Apprise)

  • This is to ensure the accuracy of the data submitted,

and adherence to the official HTPP measure specifications

1/11/2016 21

Oregon Association of Hospitals & Health Systems

slide-22
SLIDE 22

YEAR 2 DATA SUBMISSION CHECKLIST EXAMPLE

1/11/2016 22

Oregon Association of Hospitals & Health Systems

Measure Performance Data period Verified that data submitted meets measure specification Verified that data entered at HTPP reporting platform is accurate Verified that backup documentation is assembled and available if asked All verifications completed 1 Catheter associated urinary tract infections (CAUTI) in all tracked units Apr 1, 2015- Sep 30, 2015 2 Central line associated bloodstream infections (CLABSI) in all tracked units Oct 1, 2014- Sep 30, 2015 3 Adverse drug events due to opioids Oct 1, 2014- Sep 30, 2015 4 Excessive anticoagulation with Warfarin Oct 1, 2014- Sep 30, 2015

slide-23
SLIDE 23

DATA SUBMISSION TIMELINE – CAUTI

1/11/2016 23

Oregon Association of Hospitals & Health Systems

  • Baseline data re-submission
  • Timeframe: Jan 1, 2015-Mar 31, 2015 – due Oct 16,

2015 (Completed)

  • Performance year
  • Timeframe: Apr 1, 2015-Sep 30, 2015 – due Feb 15
  • Seeing discrepancies between NHSN and HTPP

reporting platform

  • Barbara and Diane will share discrepancies with

hospitals during monthly calls in Jan

  • Hospitals need to take action and ensure correct

data is on HTPP platform

slide-24
SLIDE 24

DATA SUBMISSION TIMELINE – CLABSI

1/11/2016 24

Oregon Association of Hospitals & Health Systems

  • Baseline data
  • Timeframe: Oct 1, 2013-Sep 30, 2014
  • No resubmission unless approved by OHA
  • Performance year
  • Timeframe: Oct 1, 2014-Sep 30, 2015 – due Feb 15
  • Seeing discrepancies between NHSN and HTPP

reporting platform

  • Barbara and Diane will share discrepancies with

hospitals during monthly calls in Jan

  • Hospitals need to take action and ensure correct

data is on HTPP platform

slide-25
SLIDE 25

DATA SUBMISSION TIMELINE – MED SAFETY

1/11/2016 25

Oregon Association of Hospitals & Health Systems

  • Baseline data
  • Timeframe: Oct 1, 2013-Sep 30, 2014
  • No resubmission unless approved by OHA
  • Performance year
  • Timeframe: Oct 1, 2014-Sep 30, 2015 – due Feb 15
  • Self-reported by hospitals on HTPP reporting

platform

  • Hospitals need to take action and ensure correct

data is on HTPP platform

slide-26
SLIDE 26

DATA CALCULATION ISSUE - HCAHPS

1/11/2016 26

Oregon Association of Hospitals & Health Systems

  • HCAHPS – Explain meds

Q16: Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? Q17: Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?

  • Hospital HCAHPS Calculation

Q16 ‘Always’ + Q17 ‘Always’ Q16 ‘Total’ + Q17 ‘Total’

  • CMS HCAHPS Calculation

Q16 ‘Always’ Q17 ‘Always’ Q16 ‘Total’ Q17 ‘Total’ 2

slide-27
SLIDE 27

DATA SUBMISSION TIMELINE – HCAHPS

1/11/2016 27

Oregon Association of Hospitals & Health Systems

  • Baseline data
  • Timeframe: Oct 1, 2013-Sep 30, 2014 – due Feb 15
  • Hospitals to send monthly vendor report to Elyssa or

HTPP@apprisehealthinsights.com for re-calculation

  • Performance year data
  • Timeframe: Oct 1, 2014-Sep 30, 2015 – due Feb 15
  • Hospitals to send monthly vendor report to Elyssa or

HTPP@apprisehealthinsights.com for re-calculation

  • Re-submission needed for both HCAHPS measures
  • Apprise will re-calculate per CMS methodology and send

back to hospitals for sign-off.

slide-28
SLIDE 28

DATA SUBMISSION TIMELINE – HCAHPS

1/11/2016 28

Oregon Association of Hospitals & Health Systems

  • Sample of a vendor report
slide-29
SLIDE 29

DATA SUBMISSION TIMELINE – READMISSIONS

1/11/2016 29

Oregon Association of Hospitals & Health Systems

  • Baseline data
  • Timeframe: Oct 1, 2013-Sep 30, 2014
  • No resubmission – administrative data
  • Performance year
  • Timeframe: Oct 1, 2014-Sep 30, 2015 – due Feb 15
  • Apprise will enter data on HTPP reporting platform

by Feb 1 for hospitals to view

  • Hospitals need to complete review by Feb 15
  • Apprise responsible for signing off on meeting

measure specification and documentation

slide-30
SLIDE 30

DATA SUBMISSION TIMELINE – FU TO MENTAL HEALTH HOSPITALIZATION

1/11/2016 30

Oregon Association of Hospitals & Health Systems

  • Baseline data
  • Timeframe: Oct 1, 2013-Sep 30, 2014
  • No resubmission – administrative data
  • Performance year
  • Timeframe: Oct 1, 2014-Sep 30, 2015 – due Mar 31
  • OHA shares data with hospital by Feb 15 via

Apprise secure portal

  • Hospitals to review and approve directly with OHA

by Mar 31

slide-31
SLIDE 31

DATA SUBMISSION TIMELINE – SBIRT

1/11/2016 31

Oregon Association of Hospitals & Health Systems

  • Baseline data re-submission due to de-duplication
  • Nine hospitals resubmitted
  • Timeframe: Varies among hospitals – due Dec 31,

2015 (Completed)

  • Performance period
  • Timeframe: Varies among hospitals; look at your

checklist to see your hospital’s data timeframe – due Feb 15

  • Self-reported by hospitals on HTPP reporting

platform

  • Hospitals need to ensure that total across all months
  • f performance period is de-duplicated
slide-32
SLIDE 32

DATA SUBMISSION TIMELINE – EDIE

1/11/2016 32

Oregon Association of Hospitals & Health Systems

  • Baseline data re-submission
  • Hospitals to review CMT Feb 1 report and determine

if resubmission is needed

  • Timeframe: Varies among hospitals – due Feb 15
  • Send revised baseline data if needed to Elyssa or

HTPP@apprisehealthinsights.com

  • Performance period
  • Timeframe: Varies among hospitals; use checklist to

see your hospital’s data timeframe – due Feb 15

  • Self-reported by hospitals on HTPP reporting

platform

  • Hospitals need to take action and ensure correct

data is on HTPP platform

slide-33
SLIDE 33

Review Draft Year 3 Specifications (see drafts in supplementary materials)

  • 1. Sharing ED information (EDIE)
  • decision to continue including those without PCPs
  • 2. Excessive anticoagulation with Warfarin
  • excludes those on argatroban and those receiving Warfarin >72 hrs prior
  • 3. Reducing C-sections
  • balancing measure of NQF 716, unexpected newborn complications
  • 4. Reducing opioid use
  • please circulate to ED docs; question on threshold number of pills as well

as benchmarking

  • 5. C-difficile

33

slide-34
SLIDE 34

Wrap-up

  • Next meeting

– Tuesday, February 9, 10am – 12pm

  • H-TAG webpage (for meeting materials, future meeting

dates, etc.)

  • http://www.oregon.gov/oha/analytics/Pages/Hospital-

Metrics-Technical-Advisory-Group.aspx

34

slide-35
SLIDE 35

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

35