Medicare Beneficiary Quality Improvement Program (MBQIP)

Stephen Njenga, Director of Performance Measurement ComplianceMarch 2018

Housekeeping Handouts Location of restrooms Instead of reimbursing for mileage during the

regional meetings funds were diverted to cover the following offerings that were open to all participating CAHs:Population HealthHigh Reliable Organizations/Culture of SafetyTeamSTEPPSSecondary Data Analysis for CHNA Each hospital was eligible for $3,500

SHIP Deadlines

2017 Grant Period: June 1, 2017 to May 31, 2018 Invoices no later than Thursday, May 31 Award Amount: $8,717

2018 Grant Period: June 1, 2018 to May 31,2019 Not yet awarded Award Amount: $9,000

FLEX Grant Activities

• Patient safety, patient engagement, care transitions, outpatient careQuality

• Financial and operational assessments and actions, revenue cycle management, operational improvement

Financial and Operational

• Identify specific health needs of CAH communities and implement activities

Population Health

NHSN Agreement to Participate

NHSN Annual Surveys

2017 NHSN survey is due Thursday, March 1Hospitals are always encouraged to submit in

advance to avoid last minute issues. Annual surveys are used for your risk adjustment

for SIR and may change year to year based on your responses. Currently, facilities are using 2016 or 2017 surveys. These surveys will be used to calculate 2016 and 2017

SIRs.

Core Measures Data Submission –CART Tool

New Deadlines for MBQIP Measures

FLEX Grant Overview

National Logic Model — Inputs

Federal Office of Rural Health Policy

$23 Million

45 States

Resources – toolkits, publications, reports

State Logic Model — Inputs

33 Critical Access Hospitals

Collaboration with DHSS

Resources – toolkits, publications, data

State — Level Core Areas

Quality Improvement (MBQIP)

Operational and Financial Improvement

Population Health Improvement

Program GoalsSh

ort

Term

• Staff understands the program requirements, indicators and strategies

Med

ium

Ter

m • Staff reports measures, adopts projects and best practices

Long

Ter

m • CAHs improve their quality of care, stabilize finances and adjust to changing community needs

Core Area Improvement Activities

CAH Needs Assessments Training and technical assistance Consultations Information sharing Collaboration and networking ROI tracking Scholarships and education reimbursement Data analysis

State Logic Model — Outputs

Quality• Quality Reporting – How many hospitals report? • Quality Improvement – Are hospitals improving the care they provide?

Operational• Operational and financial state measures

• State – standard measures monitored at the state level • Individual – unique measures by hospital

Population Health

• CHNA Compliance – Are all hospitals conducting an assessment that are mandated?

• CHNA Improvement – Are the assessments and action plans making an impact?

Game Changers in Health Care

Changing Landscape in Health Care The Triple Aim To improve health care delivery To improve population health To lower costs — improve efficiencies

– Affordability– Quality/outcomes– Patient experience – Population management

Achieving Triple Aim

Greater efficiencies: Improved access/ outcomes; reduced variability;

reduced costs Characteristics:

– Patient/ family engagement and satisfaction– Measurable results– Implementation, spread and sustainability of evidence-based

best practices– Continuous measurement– Differential rewards: pay for performance and outcomes– Mitigate risk

Performance Improvement

Multiple Opportunities: Clinical

– Consistent implementation of evidence - based practices– Fidelity to recommend models (process measures)– Seamless care transitions

Operational– LEAN Six Sigma — reduce waste, increase efficiency– Throughput improvements– Seamless care transitions

Administrative– Revenue enhancement — coding/billing accuracy– Supply/purchasing management– Seamless care transitions

Quality Improvement Efforts

Convene experts (clinical domain, quality, patient experience) Identify and disseminate best practices (collaboratives) Manage and evaluate programs and grants to transform

care (measure processes, cost, benefit, outcomes) Breakdown/cross silos Work across/share clinical practice

Partner with internal and external stakeholders (Community partners, providers, payers, policymakers)

Payment Rates: decline Quality and Efficiency:

rewarded Readmissions and Low

Quality: penalized Population Health:

important

What to Expect in the Future

The Premise

Important Considerations for CAHs

Improve/ document efficiency and quality Partner with local primary care providers Improve care coordination and transitions Prepare for population health management Consider participation in an ACO, community

care organization, medical home or other value-based models

To Achieve Value

To achieve excellent performance and success in a value-based system, CAHs must ensure: Leadership alignment Vision and strategy Partnerships, care coordination and community Use of data and information Change-ready adaptable workforce Highly efficient, business-oriented processes Customers, partners and community Staff and culture Efficient processes and operations Information and knowledge Documentation of outcomes and value

Leadership Educate and engage hospital trustees and boards

about the critical role of value-based purchasing and population health Form meaningful partnerships with local

physicians and health care providers Align hospital leaders and managers behind

value and population health

Leadership

Strategic Planning

Patients, Partners and Communities

Processes and Operations

Maximize the efficiency of clinical, financial and operation processes Develop effective care coordination teams and

processes, and ensure safe and timely transitions of careMaximize the effectiveness of health information,

social media and telehealth technology

Use Data Effectively

Always Remember that…

The health care market is undergoing transformational change. Leadership awareness/support is critical in helping rural

health providers stay relevant during market transformation. The Performance Excellence Blueprint is a tool to help

rural leaders manage system – wide improvement and navigate change. The framework is flexible and can be used in multiple

ways – a starting point is just reviewing the key success factors and taking a critical look at your organization.

New Reporting Requirements for FY18-21

Antibiotic Stewardship - MBQIP

This addition would allow CAHs four years to fully implement an antibiotic stewardship program by FY2021. (September 1, 2018 to August 31, 2022)

Background Information

Former President Obama’s Executive Order and National Strategy (Sept. 2014) PCAST Report to the

President (Sept. 2014) National Action Plan for

Combating Antibiotic-Resistant Bacteria (Mar. 2015)

PCAST-President’s Council of Advisors on Science and Technology

Elements for Antibiotic Stewardship Programs

Leadership Commitment Accountability Drug Expertise Action Tracking Reporting Education

http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html

Antimicrobial Management Team

• Selecting physician champion• Complete gap assessment and

action plan as a team• Determine staffing needs to

adequately resource ASP activities

• Create competency/training plan for all disciplines based on current knowledge and involvement

• Invite CEO to ASP team meeting to discuss plan, resources and support

Basic ASP Foundation

• M.D./ PharmD champion• Multidisciplinary team• Gap assessment• Assess staff resources• Competency/training planning• Communication plan for facility • CEO support of ASP — approval

of gap and action plan

Missouri – Antibiotic Stewardship

The state legislature enacted SB579 requiring that by August 28, 2017, each Missouri hospital, excluding mental health facilities, and each ambulatory surgical center, must establish an antimicrobial stewardship program. Hospitals are required to use CDC’s Antimicrobial Use and

Resistance Module when regulations concerning Stage 3 of the Medicare and Medicaid Electronic Health Records Incentive Program take effect. This has been delayed, but hospitals should keep the

program going as they await for the necessary infrastructure to be available for reporting.

Reporting Requirements for ASP

Utilization of the AUR Module specifically requires eMAR and some form of clinical document architecture. The vendor system has to have the service and software

that will allow participating in the AUR pharmacy option through direct reporting. Vendors who have the software and services and are

actively reporting include EPIC, Asolva, MedMinded, Bacter (ICNet), Intelligent Medical Systems (Meditab), RL Solutions, Sentri7, TheraDoc and VigiLanz. Although you may utilize one of these vendors, you may

not have the specific software needed to begin reporting

Measuring Antibiotic Usage

Standardized antimicrobial administration ratio Observed-to-expected/predicted rate Serves as a starting point for antimicrobial use

evaluations by stewardship teams A statistically significant SAAR >1.0 indicates

more antimicrobial use than expected.

Missouri Hospitals IT Survey Results (146 Hospital Responses)

133 have fully implemented the ability to review laboratory results across all units 132 have fully implemented eMAR across all units 105 have fully implemented bar coding or radio

frequency identification for closed-loop medication administration across all units 131 have fully implemented record-preferred

language for communication with providers of care as part of meaningful use

Missouri Hospitals IT Survey Results(146 Hospital Responses)

117 can automatically generate hospital-specific, meaningful use quality measures by extracting data from EHR without additional manual processes 111 have some level of clinical document

architecture to send clinical/summary of care records

ED Throughput Measures

ED Throughput Measures Final rule additions to MBQIP FY18-21

(September 2018 to August 2022) ED-1 – Median Time from ED Arrival to ED Departure

for Admitted ED Patients ED-2 – Admit Decision Time to ED Departure Time for

Admitted Patients

Background Information

The first quarter of required reporting was 3Q17(Submission deadline was February 15, 2018)

CY2016 — 47 persent reported these measures nationallyMissouri’s current reporting rate is 51 perecent. Chart-abstracted and reported to QualityNet on a

quarterly basis Reported using CART tool or approved vendor Patients included in ED-1 and ED-2 measures are

admitted for an inpatient stay from the ED

ED-1 and ED-2 Core Measures Participation

Dashboard Report – All Measures

Hospital Consumer Assessment of Healthcare Providers and

Systems Analytics

HCAHPS

Standardized survey tool to measure patient’s perception of quality of care by physicians and hospital staff during hospital stayWhy? Consumers – provide information helpful in choosing a

hospital Hospitals – offer incentives to improve quality of care

How? A way to compare hospitals Provides meaningful data for improvement efforts

HCAHPS

HCAHPS

The epicenter of these experiences for patients is generally focused on the patient room and five different types of human interactions during the patient stay When the patient is alone in the room When the patient and a visitor are together in the room When the patient and nurse interact in the room When the patient and physician interact in the room When the patient and support services interact in the room These different human interactions create the paradigm for

defining the patient experience … the people, the process and the place. These three interactions need to work well collaboratively in

order to yield a satisfactory patient experience and quality HCAHPS scores.

HCAHPS

People — the physical space of the patient room can contribute to engaging the caregiver by providing plenty of natural light, giving caregivers adequate space to work, and planning spaces that combine multiple functions. Process — Lean design principles should be used to

improve the caregiver’s workflow and limit the number of value-wasted movements. By making their job more efficient, they can save energy and leverage opportunities for rest and respite. Place — The physical space needs to be quiet and clean.

Using easy-to-clean flooring materials and designing patient rooms to limit room-to-room and corridor-to-room noise transfer enables the space to address typical areas for satisfaction shortfalls.

What Works?

Improving patient experience involves the following: Front-line staff need to be involved with creating the

experience. Focus on two to three interventions that are done with

excellence and consistency. The focus MUST be on creating a healing experience

for the patient. Create a process for continuous accountability and staff

recognition.

Intention - Connection - Action

1. Intention What is my intention going into the patient’s room?

2. Connect Build a relationship with the patient before doing

anything to them.

3. Action After I’m clear about my intention and I have

connected with the patient, only then do I carry out any tasks of the job such as checking vitals, administering medications, or even their diagnosis and treatment

Use Five Ps to Anticipate Needs

Pain Potty Positioning Personal needs Patient Priority

Decrease falls and call lights Use language that suggests what they might need,

rather than just asking if they have a need.

Making Five Ps Proactive

Typical question: Do you need to use the restroom?

Proactive language: “I’m about to give you pain medication which might

make you sleepy. Would you like me to help you to the restroom first so that you won’t have to get back up?”

“I know you are used to getting up on your own, but since you are connected to an IV, let me go ahead and help you to the bathroom while I am here so that I can make sure you are safe.”

Outpatient Measures Analytics

Quality Reporting Channels

Importance of Documentation

Communicates to others what was done Facilitates patient care Supports data collection Reflects quality of decision - making Justifies legal defense Supports regulatory compliance Supports fair payment /reimbursement

Documentation is Important

ED physician and nursing documentation in some cases is weak or missing. The documentation does not fully support patient care, correct coding and accurate charging. Examples: Length of laceration is not always documented. IV start and stop time is often not documented. Critical care nursing time is not documented. Physicians’ charts are not always complete. Documentation does not always comply with payer and

regulatory guidelines.

Emergency Department Transfer Communication Analytics

Quality Reporting Process

Spotlight Hospital

Internal Quality Monitoring Tool

OP-1 Median Time to Fibrinolysis

OP-2 Fibrinolytic Therapy Received Within 30 Minutes

OP-3b: Median Time to Transfer to Another Facility for Acute Coronary Intervention

OP-4: Aspirin at Arrival

OP-5: Median Time to ECG

OP-18: Median Time from ED Arrival to ED Departure for Discharged ED Patients

OP-20: Door to Diagnostic Evaluation by a Qualified Medical Professional

OP-21: Median Time to Pain Management for Long Bone Fracture

OP-22: Patient Left Without Being Seen

OP-27: Influenza Vaccination Coverage Among Health Care Personnel

IMM-2: Immunization for Influenza

ALL EDTC – Composite Score

Food for Thought“Even if you’re on the right track,

you’ll get run over if you just sit there.”-Will Rogers

Resources

Care Learning

Online program Orientation FLEX program overview Quality reporting and improvement Financial and operational excellence Population health management

Cost is covered by FLEX program

MHA https://web.mhanet.com/mbqip.aspx

Resources HCAHPS http://www.hcahpsonline.org/home.aspx MBQIP Measures Fact Sheets

http://web.mhanet.com/SQI/mbqip/MBQIP-Measures-Fact-Sheets-Final_2015-11-10.pdf Federal Office of Rural Health Policy

http://www.hrsa.gov/ruralhealth/ FLEX Monitoring Team http://www.flexmonitoring.org/ QualityNet https://www.qualitynet.org/ CDC Antibiotic Stewardship Program

https://www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdf#page=14

References

MHA http://web.mhanet.com/mbqip.aspxMHA https://web.mhanet.com/chna.aspx QualityNet https://www.qualitynet.org Hospital Compare

https://www.medicare.gov/hospitalcompare/search.html National Rural Health Resource Center

https://www.ruralcenter.org/tasc/mbqip

Stephen Njenga, MPH, MHA, CPHQ, CPPSDirector of Performance Measurement Compliance

Missouri Hospital Associationsnjenga@mhanet.com

573/893-3700, ext. 1325