data management 5.18
TRANSCRIPT
Data Management5.18.2018
BCBSM Attestation Due June 1st
KDS & NHSN - monthlyQuarter 2 Data
MBQIP due to Crystal by July 24th
Outpatient due to QNet/Quantros by August 1st
Inpatient due to QNet/Quantros by August 15th
ED-1 and ED-2 Initial population is the same as IMM-2
▪ Inpatient hospitalization for acute medical/surgical care
▪ Does not include Observation patients
▪ Does not include Swing Bed patients
▪ Does not include Inpatient Hospice patients
▪ No, it’s not specifically defined In the Specs Manual
Tip from Josh: If you are sampling your total population for the ED measures, make sure to remove cases before you sample.
Questions
EDTC Composite Measure Report only for the current BCBSM P4P PG5
Program year (Q2 2018 through Q1 2019)
http://www.mcrh.msu.edu/programs/CAH/Quality%20Improvement%20NEW.html
MICAH QN Measures – Excel Sheet
BLHED-1b Median Time from ED Arrival to ED Department for Admitted
Patients VARIANCE REPORT
299
268
290
285
280
247
256254
240
232
230
259
243242
255257
250
260
270
300
310
January February March April May June July August September October November December
Axi
sTi
tle
BLH meets target 247 min
BLH - Rapid Triage and Pull
until FullGoal-door to room < 6min
BLH - Collaboration and goal
sharing with IP and HouseSupervisors orders received to
depart < 15min
BLH - New charge nurse
role posted and hired to
facilitate throughputBLH - Phlebotomistin ED
BLH - Standard work for pt.
room prep
BLH - Triage Lean standardwork developed and trained
BLH - Registration standard
work and improvement in
communication
From our last meeting
Sherri’s use of a Run Chart that includes:• Target line• Initiatives/Action taken
Current
Reporting
Period
Average TargetMeasure
1.4%1.9%since
Q2 14
Average
<=3%
Bad Debt/Charity Care
Write-off Percentage
Trend - When 6 or more data points are all going up or down. A trend suggests the process needs to be reviewed because something has changed which is causing a significant effect. This usually indicates a process in transition.
Shift – When 8 or more consecutive data points are all either above or below the center line. Values on the line can be ignored. A shift can be positive or negative, but likely comes as a result of a significant change.
Redlines are set at 3 Standard Deviation - 99.7% of the data points will fall within 3 standard deviations. We are perfectly designed to score between the red lines.
Q4 2017BC P4P Year
Q2 17 - Q1 18Target
Hospital Compare and Blue Cross Blue Shield of Michigan (BCBSM)
Pay for Performance MeasuresMeasure
Emergency
Department
Throughput
Times
Time from Door to
Physician Evaluation
14Minutes
15
< 33
BC P4P full
payment
Trend
Davis BalestracciHarmony Consulting, LLCPortland, ME(207)-899-0962www.davisdatasanity.com
For an interesting approach to data…
Mini-lessons can be found on YouTube (posted by QIO/CMS)- Bite-Size Learning: Run Charts (Davis Balestracci)- Bite-Size Learning: Red-Yellow-Green (Davis Balestracci)- Bite-Size Learning: Commons Cause (Davis Balestracci)
The EDTC Technical Expert Panel in conjunction with the University of Minnesota Rural Health Research Center are recommending the NQF make modifications to the EDTC measures.
If the recommendations are endorsed by the NQF, we will see the changes take effect in the Spring of 2019.
Keep
Medications administered in the ED
Allergies
Home Medications
Provider note
Mental status/orientation
Reason for transfer and/or plan of care
Tests and procedures done
Tests and procedures sent
Administrative communication - remove nurse to nurse and physician to physician communication
Patient information - remove name, address, age, gender, significant other contact info, and insurance
Vital Signs – remove P, RR, BP, Temp, O2 Sat and modify neuro status
Nurse generated info – remove immobilizations, cath’s, respiratory support, oral limitations, and modify sensory status
EDTC Next Steps
U of MN “measure owner and steward”
submits revisions to National Quality
Forum to update endorsement.
With NQF endorsement…
• EDTC and MBQIP
• Data collection and submission
• CMS Outpatient Prospective Payment
System (OPPS) measures
21
RQITA Overview: Tools andResources
RQITA Overview: Tools and ResourcesNew or recently updated
– Patient and Family Engagement in Critical Access Hospitals: A Flex ProgramStory (new)
– Quality Improvement Implementation Guide and Toolkit for CAHs (updated)
– Flex Program Resources: Inpatient and Outpatient Measure ComparisonTemplate (updated)
– Interpreting MBQIP Hospital Data Reports for Quality Improvement (updated)
Ongoing:
– MBQIP Monthly
– MBQIP Data Reporting Reminders
https://www.ruralcenter.org/ to get to these resources - use the search feature