MBQIP Update Presentation for TASC 90 Webinar | July 20 th , 2020 - - PowerPoint PPT Presentation

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MBQIP Update

Presentation for TASC 90 Webinar | July 20th, 2020 Natalia Vargas, MPH Lead, MBQIP Program

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Discussion Points

Part I: MBQIP Data Overview and Discussion

• 1. Updates on MBQIP Quarterly Data Reports
• 2. Q&A related to MBQIP Report Updates
• 3. Discussion Questions: Feedback to FORHP

Part II: MBQIP Refresh: Follow‐up on Pool‐side Chat

• 1. Overview of Pool‐side Chat: Analysis and Results
• 2. Overview of MBQIP Refresh Timeline & Next Steps
• 3. Final Questions & Answers

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Webinar Part I: MBQIP Data Overview and Discussion

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MBQIP Refresh Quarterly Report Updates

• FORHP welcomes the Flex Monitoring Team at the University of Minnesota
• RQITA will remain the point of contact for TA related to these reports
• The FMT reports are similar to the quarterly reports produced by Telligen
• Reports will include national, state, and CAH‐level data
• A 3‐phase approach for producing FMT reports
• Changes in report timelines as FMT re‐launches the process: we will review timelines

today for context

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Reporting Channels for CAHs

6 *Naonal Healthcare Safety Network †Emergency Department Transfer Communicaon

Quality Net

CMS Outpatient Measures (Submitted via CART or vendor) OP-2, OP-3, OP-18 CMS Outpatient Measures (Submitted via QualityNet directly) OP-22 HCAHPS Survey (Submitted via vendor or self- administered)

NHSN

HCP/IMM-3 (formerly OP-27, submitted to NHSN) Antibiotic Stewardship (submitted via Annual Facility Survey)

State Flex Office

EDTC

Note: After CAHs report measures, CMS/CDC collect data & send to FORHP and FMT

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Timeline: From CAH Reporting to Distributing MBQIP Data Reports

CAHs Collect Data Within Encounter Period CMS/FORHP Submission Deadline CMS/CDC/SFCs Send Data to FORHP/FMT

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FMT Receives & Validates Data FMT Develops Reports and Sends to FORHP FORHP POs Distribute Reports to SFCs

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Data Lags: Vary by Report

Encounter Period Hospital Submission Deadline CMS/CDC/SFCs Send Data to FORHP & FMT

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Data Shared with FMT FMT Develops Reports and Sends to FORHP FORHP Distributes Reports to SFCs

1 month (EDTC) to 3‐4 months (HCAHPS/IP/OP) 3 Weeks 2 Weeks

Total Lag 6 weeks to 8 months Total Lag 5 weeks

10 days (EDTC) to 7 months (HCAHPS)

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Updated Quarterly Reports‐ What to Expect

• There will be five types of reports (based on current MBQIP measures):

1) Patient Experience (11 Measures: HCAHPS Composite 1‐7; Q‐8; Q‐9; Q‐21; Q‐ 22) 2) Care Transitions (9 Measures: EDTC 1 – EDTC 8 + ALL EDTC) 3) Patient Safety/Inpatient and Outpatient (14 Measures: HCP/IMM‐3; ED‐2b; OP‐2; OP‐3; OP‐18; OP‐22; 8 Antibiotic Stewardship Measures) 4) Additional HAI report: (6 Measures: CLABSI; CAUTI; CDI; MRSA; SSIC; SSIH) 5) Annual report (to be discussed in upcoming slides)

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Report Contents

• A cover page that contains a non‐technical introduction to how the report

was created and a description of how to interpret results

• Data for the most recent reporting period and previous reporting period(s)
• Numerator and denominator values, where relevant
• Comparison values for state and national data for each measure

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Phases & Milestones

• Phase 1 (Late May 2020 through Fall 2020)
• Internal negotiations with FMT and discussions with Federal partners
• FMT develops and sets up production of initial set of Quarterly Reports
• Phase 2 (Late Summer 2020 through Summer 2021; slight overlap with Phase 1)
• Rapid cycle learning with opportunities for SFCs to provide feedback
• Process development for MBQIP quarterly reports
• Return to a consistent report delivery schedule by early 2021
• Interim 2019 Annual Report produced by FMT
• Phase 3 (Fall 2021)
• 2020 Annual Report produced with additional elements added
• Development of Benchmarks for each measure
• Exploratory implementation of MBQIP Performance Score (developed by RQITA) at the

CAH level, in partnership with FMT and RQITA

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Phase 1

(Late May 2020‐through Fall 2020)

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Phase 1: Temporary Report Timeline

• This is a temporary, or “catch‐up” timeline to deliver initial set of MBQIP

reports.

• The intent is to transition to a consistent quarterly report delivery schedule

in Phase 2

• Time frames indicate when states can expect the MBQIP data reports

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Antibiotic Stewardship‐ Raw Data Spreadsheet (2019 Annual Facility Survey Data) Care Transitions (EDTC) Report Q1 2020 (Jan 1‐ Mar 31) & Q2 2020 (Apr 1‐ Jun 30) Patient Safety & Inpatient‐ Outpatient Report Q4 2019 (Oct 1‐ Dec 31) & Q1 2020 (Jan 1‐ Mar 31) *Patient Experience (HCAHPS) Report Q4 2019 (Oct 1‐ Dec 31) & Q1 2020 (Jan 1‐ Mar 31) Dates Reports will be Delivered to SFCs August 20 September 28 November 13 December 3

Note: these are anticipated release dates for State Flex Coordinators. *HCAHPS timeline is currently under final negotiation with CMS & FMT, and may vary slightly from date listed

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Help Available to SFCs During Phase 1 Transition

While FORHP strives to align with previous processes, we acknowledge that change/delays are unavoidable, and will need to take time into consideration as FMT transitions into this new role

How can we help?

• Statement from FORHP to Hospitals to alleviate burden for SFCs
• RQITA available for consultations, tools, and resource development that

can assist hospitals in the transition

Pause for Questions

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Phase 2

(Late Summer 2020 ‐ through Summer 2021)

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Rapid Cycle Learning (RCL) Phase

Implement Learn Apply

RCL Objectives

• Apply and optimize learnings before the reports

are created and a new process is implemented— a year of active learning

• Understand limitations through a scan of our

resources (CMS, FMT), and end‐user needs (SFCs, CAHs) to help close the gap in “what we know” and “what we do”

• Inform prototype changes intended to prepare

us for launching the consistent quarterly report timeline and a 2020 Annual Report

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Phase 2: Quarterly Reports Timeline

• In phase 2, FORHP expects to have a consistent quarterly report release timeline

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REPORT NAME Q1 (Jan 1‐ Mar 31) Q2 (Apr 1‐ Jun 30) Q3 (Jul 1 – Sept 30) Q4 (Oct 1‐ Dec 31) Patient Safety/Inpatient and Outpatient End of Sept Early Jan Early Apr Early Jul Care Transitions (EDTC) Early Jul Early Oct Early Jan Early Apr Patient Experience (HCAHPS) Early Dec Early Apr Early Jul Mid Aug

Note: these are anticipated release dates for State Flex Coordinators.

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RCL Completed in Phase II: Fielded Survey for SFCs

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Format

• Likes: 90th percentile data; state and national averages
• Dislikes: Reports not timely; don’t like 3 separate reports; PDF format (prefer data in

spreadsheet); don’t have visual representation over time

Data

• Likes: State and national averages; 90th percentile; inclusion of data from previous quarters
• Dislikes: Timeliness of data

Use of Reports

• Top 6: Send reports to hospitals; do own data analyses; use for benchmarking; use to

prioritize projects; use to plan site visits; do not use/reports not useful

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Key Recommendations from Survey

Respondents requested that FORHP:

• Explains data collection and submission process
• Provides a detailed timeline of quarterly reports
• Explains why we have 3 different MBQIP

quarterly reports instead of a combined report that includes all 3 measure areas combined Accomplished by July 20 Webinar

• Next RCL to begin today with your input!

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Implement Learn Apply

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Short‐Term Opportunities for RCLs in Phase 2

• Responses on the 2 discussion questions will be analyzed and discussed

with FMT

• Can also send us a follow‐up email @ MBQIP@hrsa.gov
• October, 2020: Open Office Hours with MBQIP Coordinator
• After receiving the Care Transitions (EDTC) Report for Q1 2020 and Q2 2020;

FORHP will collect feedback on reports to address with FMT

• January, 2021: FORHP Fireside Chat to Check‐in with SFCs
• Will allow for discussion of impact of MBQIP report changes
• Feedback collected as FORHP develops MBQIP Strategic Plan
• The goal is to wrap up the RCL before we are back on the regular report delivery

schedule

Other Opportunities May be Formulated Based on Feedback Received (Before Phase 3)

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What would be helpful for states now or after reports come out?

This can be resources, tools, communication points, etc

What would be helpful for CAHs, and how can FORHP assist them in this transition?

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Group Discussion Questions

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Phase 3

(Fall 2021)

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New 2020 Annual Reports

• In 2021, FMT will produce 2 annual reports (new)
• A 2019 Interim Annual Report—to be released in Spring 2021; and
• A 2020 Annual Report—to be released in Fall 2021
• As previously requested by states, the 2020 Annual Report will capture data

from all of the measures from the quarterly reports (Patient Safety/Inpatient and Outpatient, Patient Experience, Care Transitions, HAI measures) at the state and national levels

• 2020 Annual Report components:
• Data for each state (and U.S.) for this year compared to the previous year
• Summary analyses for each measure
• Trend visualizations for each measure
• Benchmarks for each measure (to be developed in the first year)

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Questions on MBQIP Quarterly Report Update

(Phases 1‐3)

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Webinar Part II: MBQIP Refresh: Follow‐up

• n Poolside Chat

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MBQIP Poolside Chat: Where we are now

• Process will continue to keep State Flex

Coordinators (SFCs) as key partners that inform our work

• Pool‐side chat launched the MBQIP strategic

planning pull/push approach

• FORHP primary aims in this process are to use

evidence to drive decision‐making

Examples: New projects from FMT on measure feasibility; evidence‐based approach encouraged by MBQIP coordinator; future RQITA work with Rural Quality Council

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State Flex Coordinators Feedback MBQIP Coordinator FMT, POs & HSD Director RQITA & TASC FORHP Guidance or Products

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MBQIP Refresh: Timeline

FORHP Internal Meeting (Aug 2019) Strategic planning FORHP‐ RQITA (Dec 2019‐Mar 2020) FORHP internal discussions (Apr‐Jun 2020) Poolside Chat with SFCs (Jun 2020)

FORHP presents input results to SFCs (Jul 2020)

Strategic planning relaunched (Aug‐Dec 2020) FORHP Check‐ in with SFCs (Jan 2021) MBQIP refresh strategic plan (SP) developed (Mar 2021) Second Poolside Chat (May 2021)

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MBQIP Poolside Chat: Analysis

• Analysis of typed

responses (qualitative attitudinal data)

• Developed deductive

thematic approach

• rganized by the three

questions on the chat pods

• Thematic structure

evaluated for good fit to develop key findings

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MBQIP Poolside Chat: Preliminary Results

• FORHP will produce a final report of findings to share in Fall, 2020
• Themes organized around the questions that guided the pool‐side chat discussion:
• 1. Challenges in states for meeting MBQIP participation and reporting

requirements?

• 12 sub‐themes* identified
• 2. Measures/measure topic areas most relevant to CAHs
• 10 sub‐themes* identified
• 3. Priorities/areas of need related to quality improvement for CAHs
• 10 sub‐themes* identified

*sample of relevant themes presented in next slide

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Example of Preliminary Results

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Primary Theme: Challenges for MBQIP Participation

QI Staff in CAHs overburdened, have competing priorities Staff turnover in CAHs and need for targeted training on MBQIP for CAHs Meaningfulness & relevance of measures for QI Reporting burden/need for streamlined reporting C‐suite/leadership support

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MBQIP Refresh Pull/Push Approach: Data‐Driven Decisions

FORHP Internal Meeting (Aug 2019) Strategic planning FORHP‐ RQITA (Dec 2019‐ Mar 2020) FORHP internal discussions (Apr‐Jun 2020) Poolside Chat with SFCs (Jun 2020) FORHP presents input results to SFCs (Jul 2020) Strategic planning relaunched; MBQIP Open Office Hours (Aug‐Dec 2020) FORHP Check‐in with SFCs (Jan 2021) MBQIP refresh strategic plan (SP) developed (Mar 2021) Second Poolside Chat (May 2021)

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Red Circles = FOHRP Pull from States (input gathering from SFCs). = FOHRP to Disseminate Qualitative Report to States (reflecting all input from poolside chat).

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Thank you, Let’s Talk!

Contact:

Natalia Vargas, MPH: nvargas@hrsa.gov MBQIP Coordinator

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