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April 2017‐March 2018 BCBSM Peer Group 5 Hospital Pay‐for‐Performance Program Contact: [email protected] 1

Blue Cross Blue Shield of Michigan (BCBSM) designates small, rural acute care facilities that provide

access to care in areas where no other care is available as peer group 5 facilities (PG 5). Additionally,

many of these hospitals are also classified as Critical Access Hospitals (CAH) by Medicare. The BCBSM

PG5 Hospital Pay‐for‐Performance (P4P) program provides these hospitals with an opportunity to

demonstrate value to their communities and customers by meeting expectations for access,

effectiveness and quality of care.

The PG 5 Hospital P4P program described in this document is effective April 1st, 2017 through March

31st, 2018. Performance in the program determines up to six percentage points of a rural hospital’s

payment rate, effective October 1st, 2018.

The PG5 hospital community can provide valuable feedback about the P4P program through the PG5

P4P Advisory Group. This group is dedicated to collaboratively discuss each year’s P4P program and

evaluate program measures to ensure each positively challenges rural hospitals to deliver the most

value to the communities they serve. The PG5 P4P Advisory group includes representatives from

BCBSM, the Michigan Health & Hospital Association (MHA), and members of the PG5 hospital

community – membership and contact information can be found in Appendix A. PG5 hospitals may

contact these representatives to provide comments related to the P4P program, and any comments

received will be presented at future Advisory Group meetings for consideration.

Program Enhancements in 2017‐2018

Although the overall structure of the PG5 P4P program remains largely unchanged, notable

enhancements in the 2017‐2018 PG5 P4P program year include:

Retirement of individual MHA Keystone Initiatives and introduction of MHA‐sponsored Great

Lakes Partners for Patients Hospital Improvement Innovation Network (HIIN)

Different program weights for non‐CAH

Program Overview

2017‐2018 Peer Group 5 Hospital Pay‐for‐Performance Program

April 2017 through March 2018


2017‐2018 P4P Program Structure

Pre‐Qualifying Condition & CEO Attestation Form

In order for hospitals to participate in the PG5 P4P program, each much first meet the culture of patient

safety survey pre‐qualifying condition. PG5 hospitals must conduct a hospital‐wide patient safety

assessment survey at least once every two years, in either 2016 or 2017. There are three eligible surveys:

Hospital Survey on Patient Safety Culture (HSOPSC)

Safety Assessment Questionnaire (SAQ)

MHA SCORE Survey

The survey can be assessed by a vendor, online assessment tool or a hospital self‐assessment process, but

the assessment process must provide guidance on how to make improvements in patient safety culture.

A hospital wishing to use an alternative survey may contact BCBSM for review and consideration.


CEO Attestation Form

The P4P also requires hospitals to submit a yearly CEO attestation to BCBSM, certifying that the

information being sent to BCBSM for the PG5 P4P program is true and to the best of the knowledge of

each hospital. This form also provides documentation for each of the individual program components,

outlines information on the results of the patient safety assessment, and describes any activities the

hospital plans to implement to address findings from the assessment. Completed CEO attestation forms

should be submitted to BCBSM by fax or email at [email protected] by June 1, 2018.

Health of the Community (CAH 30%; Non‐CAH 40%)

The Health of the Community component maintains the same program structure from the 2016‐2017

program year. In order to support Michigan’s rural providers in being national leaders in collecting and

reporting patient experience information1, HCAHPS survey submission will remain a mandatory

requirement for all participating‐sites. Hospitals will have the option to select two additional activities to

earn the remaining incentive.

2017‐2018 Health of the Community requirements include:

Measure Name Program Weight

CAH Program Weight

Non‐CAH

HCAHPS Survey Submission 10% 15%

Choose two of the following:

Community Service Plan (CSP)

10% each (Choose Two)

12.5% each (Choose Two)

Population Health Management Champion Attestation

Admission, Discharge and Transfer (ADT) notification service

HCAHPS Survey

Hospitals will also be required to collect HCAHPS survey information, at a minimum, for the following four

questions:

Question 3 – During this hospital stay, how often did nurses explain things in a way you could

understand?

Question 7 – How often did doctors explain things in a way you could understand?

Question 19 – Did hospital staff talk with you about whether you would have the help you

needed when you left the hospital?

Question 20 – Did you get the information in writing about what symptoms or health problems

to look out for after you left the hospital?

1 http://www.flexmonitoring.org/wp‐content/uploads/2015/04/Michigan.pdf


Hospitals can either submit HCAHPS data directly to BCBSM or attest that HCAHPS data has been

submitted to the CMS Hospital Compare website via CEO attestation form.

Please note: beginning with the 2014‐2015 program year, HCAHPS survey submission is no longer

accepted as an alternative to participation in one or more MHA Keystone quality initiatives.

Population Health Management Activities

PG5 hospitals are required to select two of the following measures:

1. Community Service Plan

In order to offer hospitals credit for the investments that each is already making to improve the health

of their communities, BCBSM has included the Community Service Plan (CSP) dimension to the P4P.

The goal of the CSP is for each hospital to provide a high‐level narrative of their community service

initiatives. As with years past, hospitals will receive full credit for submitting at least one CSP proposal

(Appendix C). With the approval of individual P4P‐participating hospitals, BCBSM will compile CSP

responses into a single Community Benefit Information Booklet with the intent to share best practices

for improving population health within rural hospital communities.

2. Population Health Management Champion Attestation

In an effort to continue to increase awareness of population‐health management within Michigan

rural hospital communities, the 2017‐2018 program year will continue to offer PG5 hospitals the

opportunity to designate a “Population Health Champion”. These champions are intended to be the

point of contact for all population‐health management activities and collaboration efforts with other

healthcare providers in the community and across care settings.

For the 2017‐2018 program year, BCBSM will continue to encourage champions to review BCBSM’s

Population Insights Reporting and share insights with appropriate representatives within their

hospitals and other care providers. Additionally, champions will be required to fill out an attestation

form (Appendix D) analyzing Population Insights Reporting and explaining current population health

management activities taking place within their organization.

3. Admission, Discharge and Transfer (ADT) notification service

In the 2017‐2018 program year, hospitals will have the opportunity to engage in Health Information

Exchange (HIE) activities, including the statewide Admission, Discharge and Transfer (ADT) notification

service. This program measure is an option to PG5 hospitals to assist rural providers in joining the

existing HIE efforts that PG1‐4 acute care hospitals and Skilled Nursing Facility post‐acute providers

have been required to make in their own incentive programs. With the unique care that PG5 hospitals

provide, those sites who are successful in engaging in these new HIE activities may find themselves

better able to improve care transitions and reduce readmissions for the patients they serve. Early

adopters may also find themselves better positioned to take advantage of HIE activities in future P4P

program years.


This measure will require hospitals to electronically transmit all patient, all payer admission,

discharge and transfer data, on a daily basis, into the statewide notification service established

through the Michigan Health Information Network Shared Services (MiHIN) for distribution to

practitioners who have a care relationship with each patient (Appendix E).

Clinical Quality Indicators (CAH 30%; Non‐CAH 40%)

The Clinical Quality Indicator program component of the 2017‐2018 program year will maintain all five

measures from the prior program year. Each quality indicator will be worth 6% for CAH and 8% for Non‐

CAH and program weights for measures with less than 20 cases will be equally redistributed across

remaining eligible measures.

CMS Indicator Program Weight

CAH Program Weight

Non‐CAH

OP ‐ 4a Aspirin at arrival ‐ overall (AMI & chest pain) 6% 8%

OP ‐ 5a Median time to ECG ‐ overall (AMI & chest pain) 6% 8%

OP ‐ 20 Door to Diagnostic Evaluation by a Qualified Medical Personnel 6% 8%

OP ‐ 27 Influenza Vaccination Coverage among Healthcare Personnel 6% 8%

IMM ‐ 2 Immunization for Influenza 6% 8%

Scoring Thresholds

Hospitals will be scored on the above clinical quality indicator measures by comparing actual performance

against scoring thresholds. BCBSM encourages that thresholds increase each year or that measures be

retired when nearly all hospitals meet > 95% compliance. Each June, representatives from BCBSM, MHA

and the hospital community meet to review the prior year’s hospital performance on these measures and

establish new scoring thresholds. Because the quality data from the previous program year is not

available until June 1st, thresholds are established during the first quarter of current program year and

communicated to hospitals no later than June 30, 2017.

For scoring thresholds that include a range, such as the thresholds for OP‐4a and IMM‐2, hospitals earn

full points for scoring above the range, zero points for scoring below the range, or points equal to

performance falling within the range. For example, for a scoring threshold of 93‐95%, a score greater than

95% will earn a hospital 100%, a score less than 93% will earn the hospital 0%, and hospitals performing

within the range will earn points equal to the performance rate.


Quality Initiatives (CAH 40%; Non‐CAH 20%)

The Quality Indicator program component requires hospitals to participate in the following initiatives:

Michigan Critical Access Hospital Quality Network (MICAHQN) Participation

MHA Great Lakes Partners for Patients Hospital Improvement Innovation Network (HIIN)

Participation in the MICAHQN and attendance at quarterly meetings is mandatory for all CAH facilities.

Great Lakes Partners for Patients Hospital Improvement Innovation Network (HIIN)

For the 2017‐2018 program year, the MHA, in partnership with the Illinois Health and Hospital Association

and Wisconsin Hospital Association, has combined Keystone collaborative efforts into a single, two‐year

long Hospital Improvement Innovation Network (HIIN) initiative, named Great Lakes Partners for Patients

HIIN. In 2017‐2018, all targeted improvement work will occur under the Great Lakes Partners for Patients

HIIN and as such, the MHA Keystone center will not be enrolling hospitals in individual collaboratives.

In 2017‐2018, Hospital participation in the HIIN is required and will be weighted at 40% of the overall

program for CAH and 20% for non‐CAH.

The HIIN will focus on implementing person and family engagement practices, enhancing antimicrobial

stewardship, building cultures of high reliability, reducing readmissions and addressing 11 types of

inpatient harm. A HIIN Performance Index scorecard outlining measure requirements can be found in at

the end of this program guide.

Although enrollment in the HIIN closed on November 10th, 2016, hospitals that desire to join for BCBSM

purposes may still do so. In addition, hospitals planning to participate in a HIIN other than the Great Lakes

Partners for Patients may still be eligible for points and should contact the MHA Keystone Center for more

information at [email protected].

Quality Initiative Performance Index

A hospital’s quality initiative score is determined by its performance on specific measures related to

MICAHQN and MHA HIIN initiative and will each be worth up to 20%. Performance Index scores will be

shared with hospitals prior to their submission to BCBSM. Hospitals should contact either the MHA

Keystone or MICAHQN representative if interested in obtaining performance status at any time during the

program period.

P4P Incentive Payments

BCBSM will communicate P4P payment rates to hospitals by July 31st, 2018 with rates becoming effective

October 1st, 2018. The BCBSM Peer Group 5 P4P program, established by the BCBSM Participating

Hospital Agreement for Peer Group 5 facilities, determines up to six percentage points of a participating

hospital’s inpatient and outpatient payment rate. Regardless of a hospital’s fiscal year end, the P4P

payment rate is effective for a twelve month period beginning on October 1st.


Pay‐for‐Performance payment rates are calculated by multiplying a facility’s final P4P score by the 6

percent maximum payment rate that each peer group 5 hospital is eligible to receive. For those hospitals

earning a P4P score less than 100%, the difference between the corresponding P4P payment rate and six

percent maximum is subtracted from your overall reimbursement rate. If applicable, any rate adjustments

made for the 2016‐2017 P4P program year will be added back at this time. In October, hospital’s earning

less than the full six percentage points attributed to P4P performance can expect to receive a revised rate

sheet from BCBSM’s Facility Reimbursement department.

Appendix A PG5 Advisory Group Representatives


PG5 Hospital Representatives

Chris Wilhelm Barb Cote Lee Gascho

COO Director, Total Quality Management

Quality Improvement System Leader

Charlevoix Area Hospital Spectrum Health Reed City Scheurer Hospital

14700 Lake Shore Dr 300 North Patterson Rd 170 N Caseville Rd

Charlevoix, MI 48720 Reed City, MI 49677 Pigeon, MI 48755

(231) 547‐4024 (231) 832‐7159 (989) 453‐4475

[email protected] barb.cote@spectrum‐health.org [email protected]

Brenda Bolsby Rodney Nelson Tiffany Friar

QA/Risk Management CEO Director of Clinical Integration

Marlette Regional Hospital Mackinac Straits Health System Hayes Green Beach Memorial Hospital

2270 Main Street 1140 North State Street 321 East Harris Street

Marlette, MI 48452 St. Ignace, MI 49781 Charlotte, MI 48813

(989) 635‐4009 (906) 643‐0456 (517) 543‐1050 Ext. 1208

[email protected] [email protected] [email protected] [email protected]

William Roeser Joanne Schroeder Debbie Smith

CEO President & CEO Senior Director of Quality Risk Management

Sparrow Ionia Hospital South Haven Community Hospital South Haven Community Hospital

479 Lafayette St 955 South Bailey Ave 955 South Bailey Ave

Ionia, MI 48846 South Haven, MI 49090 South Haven, MI 49090

(616) 527‐4200 (269) 639‐2806 (269) 639‐2806

[email protected] jschroeder@sh‐hs.org dsmith@sh‐hs.org

[email protected]

Carolyn Vanwert

Case Management & Quality Analyst

MidMichigan ‐ Gladwin

515 Quarter St

Gladwin, MI 48624

(989) 246‐9426

[email protected]

Appendix A PG5 Advisory Group Representatives


MHA Representatives

Bill Jackson Sam Watson Jason Jorkasky

Senior Vice President Senior Vice President Senior Director, Policy

MHA MHA Keystone Center MHA

2112 University Park Drive 2112 University Park Drive 2112 University Park Drive

Okemos, MI 48864 Okemos, MI 48864 Okemos, MI 48864

(517) 323‐3443 (517) 886‐8362 (517) 703‐8649


Marilyn Litka‐Klein Brittany Bogan Ewa Panetta

Vice President, Health Finance Vice President, Patient Safety and Quality Project Coordinator

MHA MHA Keystone Center MHA Keystone Center

2112 University Park Drive 2112 University Park Drive 2112 University Park Drive

Okemos, MI 48864 Okemos, MI 48864 Okemos, MI 48864

(517) 703‐8603 (517) 886‐8313 (517) 886‐8364

[email protected] [email protected] [email protected]

[email protected]

BCBSM Representatives

Kristen Frey Lauren Rossi Michael Andreshak

Hospital Incentive Programs Hospital Incentive Programs Hospital Contracting and Policy

BCBSM BCBSM BCBSM

600 E. Lafayette 600 E. Lafayette 600 E. Lafayette

Detroit, MI 48226 Detroit, MI 48226 Detroit, MI 48226

(313) 448‐4746 (313) 448‐6090 (313) 448‐3905


Appendix B Quality Initiative Scoring Index


Michigan Critical Access Hospital Quality Network (MICAHQN)

Measure Name Weight Measure Performance Points Earned

Participation in Meetings

100

All four meetings (in‐person or teleconference)

100

Two or three meetings 75

One meeting 25

Did not attend any meeting 0

Hospitals with questions regarding MICAH Quality Network measure performance may contact Crystal Barter, Email: [email protected]; Phone: (517) 432‐0006

Appendix C Community Benefit Information – Community Service Program


Peer Group 5 Hospital Pay‐for‐Performance Program Community Service Program April 2017 through March 2018

Hospital Name: _____________________________________________________________

Completed Community Service Program(s) must be returned to BCBSM with a signed, PG5 P4P CEO

Attestation form by June 1, 2018.

Identify Program

Counties Served

Health Status of Population

Monitoring/Measurements of

population (baseline and re‐

measurement)

Communication of

program/interventions

Participation/Partnerships

Rate of success

Appendix D Population Health Champion Attestation


BCBSM Peer Group 5 Pay‐for‐Performance Program (P4P) Population Health Champion Attestation

4/1/2017 – 3/31/2018 P4P (Due June 1, 2018)

I certify that I have reviewed the Population Insights Report and Population Profiling Tool for Peer Group 5 Pay‐for‐Performance Program, and it is true to the best of my knowledge.

_________________________________________ Printed Name – Population Health Champion _________________________________________ Signature _________________________________________ Facility

_________________________________________ Title _________________________________________ Email _________________________________________ Facility Code

PGIP Physician Organizations (PO) with whom Hospital has a shared patient population:

Physician Organization (PO) Sub‐Physician Organization (SubPO)

Using BCBSM’s Population Insights Report, identify partnering PGIP PO utilization measures showing opportunity for improvement, if applicable:

Utilization Metrics

For the above, identify any interventions currently in place to improve utilization rates (if none, explain how your hospital intends on working on the issue):

Appendix D Population Health Champion Attestation


Fill out the table below according to current population health management activities your hospital is participating in:

Population Health Activities

Does your hospital currently participate in an Accountable Care Organization (ACO)? If yes, which one?

ACO Participants

What population health activities does your hospital participate in as part of an ACO?

What are your long term goals of ACO participation?

Are there any programs or population health management activities your hospital participates in outside of ACO‐related activities?

Non‐ACO Participants

What are your barriers to entry in participating in an ACO?

Are you participating in any population health management activities? (i.e. actively engaging with physician partners to better coordinate care)

Appendix E Health Information Exchange – ADT Measure


PG5 P4P Program – Health Information Exchange (HIE) Activity:

Admission, Discharge and Transfer (ADT) notification service

Overview

The BCBSM Hospital Pay‐for‐Performance Health Information Exchange (HIE) Daily Hospital Census

Reporting Admit, Discharge, Transfer (ADT) and ED Visit measure will reward hospitals who participate in

the statewide notification service established by the Michigan Health Information Network (MiHIN).

Participation in the notification service is expected to improve care transitions and reduce readmissions.

In 2017‐2018, the P4P weight for the HIE ADT measure is 10 points and will be based on the successful

implementation of the admission, discharge, transfer and emergency room visit use case.

Background

The population‐based model of health promotes a team‐based approach and a commitment to caring for

the patient across time and settings of care. Despite the need for this longitudinal approach, there are

many obstacles that prevent consistent communication across the care continuum. A primary issue is the

number of individuals and organizations involved in managing a patient’s health. This includes hospitals,

primary care physicians, specialists, mental health providers, skilled nursing facilities, pharmacists, care

coordinators, other care givers and public and private insurers. Caregivers need to receive timely

notification of their patients’ ADT and ER visits so they can improve the care coordination process and

reduce the likelihood of an unplanned readmission.

Many health systems have a process in place, but the communications are generally limited to a narrow

set of affiliated providers. For most hospitals, a large proportion of their patients have primary caregivers

who are not affiliated with the hospital. In these situations, the patient’s primary care physician and other

caregivers are often unaware of the ADT or ER event until the patient calls for a follow‐up appointment.

For some patients this delayed notification can result in a sub‐optimal transition from the acute care

setting and insufficient follow‐up during the critical first days following discharge.

The Michigan Health Information Network – Statewide Notification Service

To address the need for more timely information, MiHIN established a statewide notification service to

give practitioners daily all‐payer ADT and ER census reports for their patients. The goal is to help

practitioners better prepare for and support their patients when they are discharged from an acute care

hospital or ER into the home or another care setting. This should improve the transition process, result in

a better health outcome for the patient and reduce the likelihood of an unplanned readmission.

The MiHIN notification service routes ADT and ER visit information from hospitals to a patient’s caregivers,

regardless of where the patient has been admitted or whether his or her primary caregivers have an

affiliation with the hospital. The MiHIN service uses existing HIE infrastructure to receive hospital ADT and

ER visit data, identify the physicians who have a care relationship with each patient, and transmit a



notification to the relevant physician organization. Each PO determines for itself how it wants to receive

these notifications and how it will distribute the information to its practice units or care coordinators.

In addition to its technical role in Michigan’s HIE infrastructure, an important function provided by MiHIN

is to ensure all parties participating in the service adhere to the necessary HIPAA and legal requirements

that govern the sharing of data. Each party transmitting or receiving data through the notification service

must sign an ADT Use Case Agreement. The agreement establishes a “chain of trust” across all users by

clearly specifying who has access to the data, how it will be routed across participants, and how it can be

used by recipients. The Use Case Agreement also requires MiHIN to discard data for which there is no

identified recipient with an applicable care relationship. MiHIN does not function as a data repository and

discards all data after 30 days.

Principles of the statewide notification service

To ensure maximum effectiveness and ease of use, the MiHIN statewide notification service is designed

around the following four principles:

Hospitals should only need to communicate ADT and ER visit information once, regardless of the

number of recipients.

Hospitals should be able to send the information through the electronic channel of their choice,

as long as it connects to the appropriate clinical process for managing transitions.

Practitioners should be able to receive the information in the manner they choose to support their

clinical processes.

Report information should meet standard expectations related to common data definitions, fields

etc.

In addition to improved transitions, timely ADT notification can help improve the care provided to patients

while they are still in the hospital. For example, physicians may have information about a patient that will

improve the care provided during a hospitalization. A daily ADT report will alert physicians of these

hospitalized patients and help ensure relevant information is shared with the hospital on a timely basis.

The statewide notification service is an all‐payer, all‐patient solution. A statewide group of stakeholders,

including MiHIN, sub‐state HIEs, BCBSM, hospitals and physicians provided input and guidance on the

design and implementation of the service.

Other Benefits of the MiHIN Statewide Notification System

The architecture of the statewide notification service is also designed to allow expansion into other

services. For example, the same technical platform is used to send discharge medication information to

providers, which significantly impacts their ability to perform care transitions. The transmission of

additional types of data, such as laboratory and imaging results, is currently in development.



Criteria for Participation in the MiHIN Notification Service

In order to be considered as successfully participating in the MiHIN statewide notification service for the

purpose of BCBSM’s P4P program, a hospital must meet the following criteria:

Agree to all respective data use case agreements associated with the notification service

Agree to meet timelines associated with the project

Electronically transmit the MiHIN required minimum ADT data elements on a daily basis (data

conformance will be required prior to hospital onboarding)

A hospital will be considered fully participating when it is transmitting all‐payer, all‐patient, validated ADT

data into the MiHIN service. A hospital will NOT be considered fully participating if only a limited subset

of its ADT data (e.g., BCBSM member data only) is transmitted into the service.

MiHIN will notify BCBSM of the status of the on‐boarding process for each hospital and whether there are

issues related to a hospital being able to meet the P4P Health Information Exchange ADT measure

expectations. If there are implementation issues that are beyond a hospital’s ability to resolve, BCBSM

will take this into account when scoring the measure.

Contact Information

For questions regarding data specifications and to schedule an implementation kick‐off meeting, please

contact Marty Woodruff at MiHIN, [email protected].

For questions regarding the BCBSM Pay‐for‐Performance Health Information Exchange ADT measure,

please contact Jen Cerre at [email protected].

2017-18 BCBSM Peer Group 5 P4P Scoring Index – MHA Keystone Center HIIN – CAH ONLY Updated 2/6/2017

MHA Keystone Center Great Lakes Partners for Patients Hospital Improvement Innovation Network (HIIN) Scoring Index

2017-18 BCBSM Peer Group 5 Pay-for-Performance Program Critical Access Hospitals (CAH) ONLY

Table 1: MHA Keystone / Great Lakes Partners for Patients HIIN Requirements

Component Weight Scoring Frequency Reporting Timeframe Data submission: Outcome Measures (Appendix A)

40% Monthly April 2017 – March 2018

Performance: Improvement on CAUTI, EDTC-1, and EDTC-4 measures (individual improvement from designated baselines)

25% Once Varies by measure

(see Table 3)

Person & Family Engagement: Patient & Family Advisory Councils

(PFAC)/ inclusion of patient advisors

20% Twice 1: April 2017 - September 2017 2: October 2017 – March 2018

Antimicrobial Stewardship: Current practices assessment

15% Once

Due by April 30, 2017

Pay for Performance Program Peer Group 5 Critical Access Hospital (CAH) ONL


Table 3: MHA Keystone / Outcomes Performance

Measure Baseline Performance

Period for Mid-year Score

Performance Period –

Final Score

CAUTI (Hospital wide): Urinary Catheter Utilization (KDS-HIIN-CAUTI-3a and KDS-HIIN-CAUTI-3b) OR

CAUTI Rate (KDS-HIIN-CAUTI-2a (all units))

Q1 2014

Apr. 2017 – Sept. 2017

Apr. 2017 – Mar. 2018

EDTC-1: Administrative Communication Element 1: Healthcare facility to healthcare facility (MBQIP) OR Element 2: Physician to physician communication (MBQIP)

Q1 2016 Apr. 2017 – Sept. 2017

Apr. 2017 – Mar. 2018

Table 2: MHA Keystone / Great Lakes Partners for Patients HIIN Scoring Index

Component Description Available Points

Data Submission*

o At least 90% of outcome data submitted across 12-month period o 70 – 89% of all outcome data submitted across 12-month period o Less than 70% of all outcome data submitted across 12-month period

40 points

25 points

15 points

Performance on outcomes for CAUTI, EDTC-1, and EDTC-4** (see table 3 for additional detail)

o Improvement from baseline on 3 of 3 measures o Improvement from HIIN baseline on 2 of 3 measures o Improvement from HIIN baseline on 1 of 3 measures

30 points (5 bonus) 25 points 10 points

Launch of Patient & Family Advisory Council (PFAC) and/or Inclusion of Patient Advisor on Existing Quality Improvement Team***

o PFAC / inclusion of patient advisors - Fully implemented o PFAC / inclusion of patient advisors - Partially implemented o PFAC / inclusion of patient advisors - Not implemented

20 points 10 points 5 points

Antimicrobial Stewardship (AMS)**** o Completion of AMS assessment by April 30, 2017 o No completion of AMS assessment by April 30, 2017

15 points

0 points

Total Possible Points

100 points


EDTC-4: Medication Information Element 1: Medications administered in ED (MBQIP) OR Element 2: Allergies (MBQIP) OR Element 3: Home medications (MBQIP)

Q1 2016 Apr. 2017 – Sept. 2017

Apr. 2017 – Mar. 2018

* Hospitals will only be scored for the submission of outcome data they are eligible to collect. Please reference

Appendix A (HIIN Encyclopedia of Measures) for a complete list of the required measures.

General HIIN Participation Requirements

Completion of an enrollment assessment to identify primary contacts including quality and risk leaders, executive, physician and nursing champions, data lead, PFE contact, pharmacy contact and infection prevention lead.

Participate in HIIN-wide quality improvement activities and/or site-specific activities related to the achieving the aims of the HIIN (20% reduction in all-cause harm and 12% reduction in preventable readmissions over a two-year period).

In addition to the required components above, hospitals may also be invited to:

Participate in Improvement Action Networks (IANs), Safe Tables, or Site Visits (Maximum requests = 4 per year)

** Hospitals will be scored on their own performance over time, and whether they are demonstrating

improvement in CAUTI (Urinary Catheter Utilization Ratio OR CAUTI Rate), EDTC 1 (Element 1 OR Element 2), and

EDTC 4 (Element 1 OR Element 2 OR Element 3) rates from the designated (hospital-specific) baseline to the

listed performance period (Table 3). The highest performing metric/element under the designated measure will

be selected. Hospitals that maintain rates in the top quartile among all participating CAH hospitals will receive

full points for improvement (please see Appendix A & Appendix B for measure definition).

*** The goal of this component is to implement a PFAC and/or include patient advisors on existing quality

improvement teams by the end of the program year (if not currently implemented). Hospitals would be asked to

report on this component minimally twice during the program year, by simply indicating fully implemented,

partially implemented, or not implemented in KDS. Please reference the MHA Community Website – Keystone

Center Quality Initiatives – HIIN Foundational Concepts – Person & Family Engagement (PFE) folder for

additional information on the launch of Patient & Family Advisory Councils and/or inclusion of patient advisors

on existing quality improvement committees.

**** Completion of the NHSN Patient Safety Annual Survey (which contains AMS questions) during 2017 will

meet this requirement if the hospital has conferred rights to MHA Keystone Center. Hospitals who do not submit

to NHSN, MHA Keystone Center will provide HIIN infection prevention contacts a link to complete the AMS

assessment. Hospitals have designated these contacts upon enrollment in the HIIN.

http://community.mha.org/communities/community-home/librarydocuments?communitykey=4ab0331c-9624-41ad-8c6c-83734e9baf08&tab=librarydocuments


2017-18 BCBSM Peer Group 5 P4P Scoring Index – MHA Keystone Center HIIN – Non-CAH ONLY Updated 2/6/2017

MHA Keystone Center Great Lakes Partners for Patients Hospital Improvement Innovation Network (HIIN) Scoring Index

2017-18 BCBSM Peer Group 5 Pay-for-Performance Program

Non-Critical Access Hospitals ONLY

Table 1: MHA Keystone / Great Lakes Partners for Patients HIIN Requirements

Component Weight Scoring Frequency Reporting Timeframe Data submission: Outcome Measures (Appendix A)

40% Monthly April 2017 – March 2018

Performance: Improvement on CAUTI, sepsis, and pain management measures (individual improvement from HIIN baselines)

25% Once Varies by measure

(see Table 3)

Person & Family Engagement: Patient & Family Advisory Councils

(PFAC)/ inclusion of patient advisors

20% Twice 1: April 2017 - September 2017 2: October 2017 – March 2018

Antimicrobial Stewardship: Current practices assessment

15% Once

Due by April 30, 2017

Pay for Performance Program Peer Group 5 Critical Access Hospital (CAH) ONL


Table 2: MHA Keystone / Great Lakes Partners for Patients HIIN Scoring Index

Component Description Available Points

Data Submission*

o At least 90% of outcome data submitted across 12-month period o 70 – 89% of all outcome data submitted across 12-month period o Less than 70% of all outcome data submitted across 12-month period

40 points

25 points

15 points

Performance on outcomes for CAUTI, Sepsis and Opioid Adverse Events** (see Table 3 for additional detail)

o Improvement from HIIN baseline on 3 of 3 measures o Improvement from HIIN baseline on 2 of 3 measures o Improvement from HIIN baseline on 1 of 3 measures

30 points (5 bonus) 25 points 10 points

Launch of Patient & Family Advisory Council (PFAC) and/or Inclusion of Patient Advisor on Existing Quality Improvement Team***

o PFAC / inclusion of patient advisors - Fully implemented o PFAC / inclusion of patient advisors - Partially implemented o PFAC / inclusion of patient advisors - Not implemented

20 points 10 points 5 points

Antimicrobial Stewardship (AMS)**** o Completion of AMS assessment by April 30, 2017 o No completion of AMS assessment by April 30, 2017

15 points

0 points

Total Possible Points 100 points

Table 3: MHA Keystone / Great Lakes Partners for Patients HIIN Outcomes Performance

Measure Baseline Performance

Period for Mid-year Score

Performance Period –

Final Score

CAUTI (ICUs): Urinary Catheter Utilization (KDS-HIIN-CAUTI-3b) OR CAUTI SIR (KDS-HIIN-CAUTI-1b)

Q1 2014

Q1 2015

Apr. 2017 – Sept. 2017

Apr. 2017 – Mar. 2018

Sepsis: Post-op Sepsis (KDS-HIIN-SEP-1) OR Sepsis Mortality (KDS-HIIN-SEP-2)

Q4 2015 Apr. 2017 – Sept. 2017

Apr. 2017 – Mar. 2018

Opioid Adverse Drug Events: Use of naloxone among inpatients receiving opioids (KDS-HIIN-ADE-4)

Q4 2016 Apr. 2017 – Sept. 2017

Apr. 2017 – Mar. 2018


* Hospitals will only be scored for the submission of outcome data they are eligible to collect. Please reference

Appendix A (HIIN Encyclopedia of Measures) for a complete list of the required measures

General HIIN Participation Requirements

Completion of an enrollment assessment to identify primary contacts including quality and risk leaders, executive, physician and nursing champions, data lead, PFE contact, pharmacy contact and infection prevention lead.

Participate in HIIN-wide quality improvement activities and/or site-specific activities related to the achieving the aims of the HIIN (20% reduction in all-cause harm and 12% reduction in preventable readmissions over a two-year period).

In addition to the required components above, hospitals may also be invited to:

Participate in Improvement Action Networks (IANs), Safe Tables, or Site Visits (Maximum requests = 4 per year)

** Hospitals will be scored on their own performance over time, and whether they are demonstrating improvement in CAUTI (Urinary Catheter Utilization OR CAUTI SIR), Sepsis (Post-op Sepsis OR Sepsis Mortality) and Opioid ADE rates from the designated (hospital-specific) baseline to the listed performance period (Table 3). The highest performing metric under the designated measure will be selected. This aligns with how the MHA Keystone Center will track performance of hospitals in the HIIN for all measures. Hospitals that maintain rates in the top quartile among all participating hospitals will receive full points for improvement. *** The goal of this component is to implement a PFAC and/or include patient advisors on existing quality improvement teams by the end of the program year (if not currently implemented). Hospitals would be asked to report on this component minimally twice during the program year, by simply indicating fully implemented, partially implemented, or not implemented in KDS. Please reference the MHA Community Website – Keystone Center Quality Initiatives – HIIN Foundational Concepts – Person & Family Engagement (PFE) folder for additional information on the launch of Patient & Family Advisory Councils and/or inclusion of patient advisors on existing quality improvement committees. **** Completion of the NHSN Patient Safety Annual Survey (which contains AMS questions) during 2017 will meet this requirement if the hospital has conferred rights to MHA Keystone Center. Hospitals who do not submit to NHSN, MHA Keystone Center will provide HIIN infection prevention contacts a link to complete the AMS assessment. Hospitals have designated these contacts upon enrollment in the HIIN.



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