Michigan Critical Access

Hospital Quality Network

STRATEGY GROUP #2 DATA MANAGEMENT AND ANALYSIS

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Strategy Group #2 Data Management and Analysis

Goal: Michigan CAHs consistently submit timely and accurate data and are knowledgeable about how to utilize the data to identify gaps. No CAH left behind!

•Update members on current clinical quality measures and track on new and retired measures (including eCQMs, Star Ratings, and potential new areas of focus).

•Provide education regarding when and how to report on measures.

•Drive sharing of ideas on how to share results and scorecard examples while encouraging transparency, promoting professional development, offering opportunities for networking and inspiring change.

•Work with consultants to present the data in a meaningful way, including benchmarking and comparison data.

•Provide best practices on specific measures related to data collection and reporting.

•Be proactive – identify measures that we want to be held accountable for and recommend they be used by agencies like MHA, FORH and payors like BCBSM for VBP. Go toward them, not wait for them.

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Measure Spreadsheet Update

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

MICAH QN Measures – Excel Sheet

http://www.mcrh.msu.edu/programs/CAH/Quality%20Improvement%20NEW.html

RemindersMonthly – Submit to KDS & NHSN Quarterly – Q2 2019 data◦ July 24th - Email MBQIP results to Crystal ◦August 1st - Outpatient results due to QNet (Most use Quantros) ◦August 15th - Inpatient due to QNet

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

ED-1 Median Time from ED Arrival to ED Departure for Admitted ED Patients- Retired by CMS for their P4P programs- Retired by MBQIP- Retired by MICAH QN

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

ED-2 Admit Decision Time to ED Departure Time for Admitted Patients- Retired by CMS for their P4P programs- MBQIP will continue using this measure at

least through 2019- MICAH QN will continue reporting on

this measure at least through 2019

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

EDTC Population

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Only patients that are transferred/discharged to another

facility are included

EDTC Population - continued

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Patients admitted to observation at your hospital and then transferred

are included

Patients discharged to a Long Term Care Facility attached to your hospital

are included

EDTC Population - continued

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

OP-18b – Median Time from ED Arrival to ED Departure for Discharged ED PatientsJOSH – make sense of this

- Which patients are in the population?

- Guidance for selecting Arrival Time – this has surfaced a couple of times. Departure time is also in the guideline

- Hospitals with improvement

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

OP-18bArrival Time – What time should I use?

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Excerpts from the OQR Arrival Time GuidelinesRemember the definition of Arrival Time is “the earliest documented time (military time) the patient arrived at the outpatient or emergency department.”If the time on the face/registration sheet is not labeled “arrival,” “registration,” or “admit” time, or is labeled simply “time,” then the time can be considered a nondescript time and should not be used as Arrival Time.

Arrival Time can be the time the patient first sees triage, registration, or the volunteer who puts her/his name on a page with a time. It does not have to be a professional who documents the arrival time.

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Excerpts - continuedDo not use a time stamp unless it is clear that it is used specifically for patient arrival time.

Do not use pre-printed times on a vital sign graphic record.

Do not use a stamp or label that has a consistent time on every page. QUESTION: If the patient enters the ED, is signed in by a volunteer at 1950, and then sits in the waiting room until called by triage at 2012, what is the correct Arrival Time?

ANSWER: The earliest documented time the patient arrived in the ED – 1950.

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Excerpts - continuedQUESTION: The patient arrives by ambulance and has an ECG, IV, and O2 that are all recorded as 1300. A Nurses Note is documented as 12:55. A note in the ambulance run sheet indicates that the patient arrived at 1240. What is the correct Arrival Time?

ANSWER: The earliest documented time the patient arrived in the ED – 1255. You cannot use the ambulance run sheet as a time of arrival; you may only use the run sheet (if you must) to substantiate that the patient was not in the ED at 1240.

QUESTION: The record indicates a non-labeled/non-descript time of 1840 on the registration sheet, the time is not labeled “Admit” or “Registered,” there is a time of 1850 on the triage note, an ECG time of 1845, and a lab collection time of 0000. What is the Arrival Time?

ANSWER: The earliest documented time the patient arrived in the ED – 1845. Unless there is other documentation to substantiate that the patient was present at 0000, ignore that time and use the next earliest time – 1845. The 1840 time is not valid to use since it was not labeled “arrival,” registration,” or “admit.”

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Excerpt from the OQR Departure Time GuidelinesRemember the intent of abstraction “…is to capture the latest time at which the patient was receiving care in the emergency department, under the care of emergency department services, or awaiting transport to service/care.” Go to QNet and enjoy reading the rest of this guideline

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Hospital with decreases in OP-18b

Mercy Health Lakeshore Campus (decrease – top performer)

Paul Oliver Memorial Hospital (decrease – top performer)

Carson City Hospital (decrease)

Deckerville Community Hospital (decrease)

Borgess - Lee Memorial Hospital (decrease)

Hills & Dales General Hospital (decrease)

Spectrum Health Kelsey Hospital (decrease)

Kalkaska Memorial Health Center (consistent)

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.