S

Intermountain HEN Measurement

April 12, 2013

Introduction

Lucy Savitz, PhD, MBA

Overview of: Changes in CMS requirement for reporting Criteria for measure selection

S

HEN Data Collection Process

Amy Wuthrich

Data Collection Process:behind the scenes

The data template is generated using the COGNOS system and the data tables in the electronic data warehouse (EDW)

This allows for a extremely large amount of data to be condensed into a coherent document, for the entire HEN, rather than having to do it manually for each site

Data Collection Process: generating contact

The body of the email is entered into the COGNOS system

SQL query connects the appropriate hospital/system ID to the appropriate contact email

It takes several hours for the program to run

Emails are sent from the system to the data contact at the HEN hospitals approximately three weeks prior to data submission deadline

Data Collection Process: once we have data

Completed data requests are emailed back to Jesse Gygi

Data is entered into the data tables which are stored on the EDW

Internal validity is established 2 person accuracy checks

If possible, run charts are sent back to hospital data contact to double check

Data Collection Process: once we have data

Preliminary run charts are created

HEN team meets to review the run charts Looks for questions/concerns in the data reported Correct any inconsistencies

Charts are prepared for CMS reports/feedback reports

Remaining 2013 Data Collection Milestones

May 20th – January through March data

August 20th – April through June data

November 20th – July through September data

S

HEN Data Process and Feedback

Reports

Tom Belnap

Monthly Progress Reports

Progress reports are submitted to CMS monthly

These include: Narrative highlighting progress and successes Data contribution and reporting from members Data showing current rates on metrics Barriers to continued improvement

Data Reporting Process

Data submission

Data entry

Data validation

Report generationOverall HEN metrics

Month 1 Month 2 Month 3

Report GenerationHEN Metrics by Hospital

Size

Report GenerationHEN Metrics by Metric Adoption (Z5) Status

HEN reporting meeting

Reporting changes as needed

Report generation

Monthly

Work with hospital data contacts to resolve any

data questions

Incorporate data updates into reports

Generate and send feedback reports to

hospital primary contacts

Compile and organize feedback report results

Send reminders and requests for next data

submission

Collect information on use and utility of feedback reports

Incorporate data updates into reports

Select reports for monthly report

Report generation

Report writing and submission

Work with sites to get updated data metrics

Feedback Reports

Feedback reports will be sent out to each site quarterly

Sent to data contacts first and then other contacts

Hospital data will be compared to the HEN average rate

Feedback Reports

Purpose of feedback reports: Benchmark performance against HEN Track hospital progress over time Ensure data completeness and accuracy Encourage dialog within hospitals and greater

involvement/communication across the HEN

We welcome feedback on the feedback and any suggestions

S

Reporting to CMS

Jason Scott

What we report to CMS

HEN level run charts

Run charts stratified by hospital bed size

large – 331+ bedsmedium – 140 to 330 bedssmall – 1 to 139 beds

Hospital specific success stories with your approval

HEN level run charts

Stratified run charts

Hospital success stories http://www.henlearner.org/additional-resources/success-stor

ies/