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WYOMING MEDICARE RURAL HOSPITAL FLEXIBILITY (FLEX)
PROGRAM
WY Quality Improvement RoundtableJanuary 16, 2020Facilitated By: Rochelle Schultz Spinarski,Rural Health Solutions
AGENDA
MBQIP Updates
EDTC Changes
Upcoming Evaluations and Needs Assessment
QHi data and next steps - discussion
HCAHPS:
Communication about Nurses Communication about Doctors Responsiveness of Staff Communication about Meds Cleanliness of Hospital Quietness of Hospital Discharge Information Care Transitions Overall Rating Willingness to Recommend
*HCAHPS: EDTC-1: Administrative Communication (2 data elements)
EDTC-2: Patient Information (6 data elements)
EDTC-3: Vital Signs (6 data elements)
EDTC-4: Medication Information (3 data elements)
EDTC-5: Physician or Practitioner Generated Information (2 data elements)
EDTC-6: Nurse Generated Information (6 data elements)
EDTC-7: Procedures and Tests (2 data elements)
All Data Elements
* OP-2: Fibrinolytic Therapy Received within 30 minutes
* OP-3: Median Time to Transfer to another Facility for Acute Coronary Intervention
* OP-18: Median time ED to discharge
* OP-22: Patient left without being seen (once a year)
2020 MBQIP MEASURES
*Immunizations
*EDTC:
*Outpatient:• IMM-3: Influenza vaccination
coverage among healthcare personnel
• ED-2: Admit Decision Time to ED Departure Time for Admitted Patients
Note: ED-2 - CAHs should continue to report this measure through 4Q 2019 encounters (due 5/15/2020.
*Inpatient:
Antibiotic stewardship program established based on CDC guidelines
*Antibiotics:
MBQIP: UPCOMING REPORTING REMINDERS
Healthcare Personnel Influenza Vaccination –HCP/IMM-3 (formerly OP-27)
•For data October 1, 2018 – March 31, 2019
•Submitted through the National Healthcare Safety Network (NHSN)
Inpatient – February 15 for 3Q2019ED-2
EDTC – January 30 for 4Q2019
Outpatient - February 1 for 3Q2019:AMI-OP-2AMI-OP-3ED_OP-18
EDTC MEASURES & POPULATION FOR 2020
Eight Measures:
Home Medications
Allergies and/or Reactions
Medications Administered in ED
ED Provider Note
Mental Status/Orientation Assessment
Reason for Transfer and/or Plan of Care
Tests and/or Procedures Performed
Tests and/or Procedures Results
Population Inclusions:
Acute Care Facility
Hospice – healthcare facility
Other health care facility*, including discharge, transfer or return to: Extended or Intermediate Care Facility
(ECF/ICF) o Long Term Acute Care Hospital (LTACH) o
Long Term Care Facility Nursing Home or Facility, including Veteran’s
Administration Nursing Facility Psychiatric Hospital or Psychiatric Unit of a
Hospital Rehabilitation Facility, including Inpatient
Rehabilitation Facility/Hospital or Rehabilitation Unit of a Hospital o Skilled Nursing Facility (SNF), Sub-Acute Care, or
Swing Bed Transitional Care Unit (TCU)
Observation status not included in population
EDTC DATA REPORTING
QHi Same process as in year’s past:
Download reporting tool via link that starts on the Data Submission Page
Use this tool for data reporting
Create report from within tool and upload into QHi
Stratis Same Process as in year’s past:
Go to website: http://www.stratishealth.org/providers/EDTC-Resources-Q12020.html
Download tool
Use this tool for data reporting
Create report and send to Shanelle Van Dyke and Kyle Cameron by reporting deadline
RESOURCES AND TOOLS
www.wyqim.com
http://www.stratishealth.org/providers/EDTC-Resources-Q12020.html
www.qualityhealthindicators.org
FYI Webinar will be coming out shortly Updates and training will be posted on Stratis website as well as www.wyqim.comRefer to the Data Specifications ManualContinue to report all transfers or random sample depending on population size
This Photo by Unknown Author is licensed under CC BY-NC-ND
UPCOMING NEEDS ASSESSMENT AND EVALUATIONS
Evaluations
Initiative or activity specific
Targeted to participating CAH staff members
Used to report impact or outcomes to FORHP
Used for overall program planning and decision-making
Have some catch-up to do but working towards streamlining and real-time
PLEASE PARTICIPATE
QI Needs Assessment
• Annual (January/February)
• All CAHs – one per hospital
• Need 100% response rate
• Used to report changes and updates to FORHP
• Used for overall program planning and decision-making
• Used to determine allocation of QI funding across CAHs
OPPORTUNITIES Discussion
QHI USE & MEASURESCody – No QI data, all financial data (Nov)
Crook County – All core, EDTC, LTC falls, all HIIN, NHSN, all financial data (Nov - all)
Hot Springs – No data
Johnson County – No QI data, most financial data (Nov)
Niobrara – All core, HIIN (Nov)
North Big Horn – All core (missing readmissions and falls Nov) , EDTC, all HIIN, NHSN (Nov), all financial data (Nov)
Powell Valley – All core (Nov), EDTC, HIIN (Nov), financial (all but 1 – Nov)
South Big Horn – No QI data, financial (Dec 2018)
South Lincoln – EDTC, all financial (Nov)
Star Valley – All core (Oct), HIIN (Sept), financial (Nov)
Weston County – All core (Dec), ED, EDTC, LTC falls, financial (Dec but data missing here and there)
Core measures: • HAIs• Unassisted falls• Readmissions w/in 30
days all causes• Percent of return ER
visits w/in 72 hours same/similar diagnosis
WHO
Crook County Medical Services
Johnson County Healthcare
Center
Memorial Hospital of
Converse CountyNorth Big Horn
Hospital
Powell Valley Hospital
South Big Horn County Hospital
South Lincoln Medical Center
Star Valley Hospital
Cody Regional Medical Center
Weston County Health Services
Niobrara
Not Reporting
ROUNDTABLE
Who is using data and how?
Is there anything we should be doing to
support you in data use?
FINANCIAL MEASURES SELECTED
Benefits as a % of salary
Staff turnover
Nurse staff turnover
Salary to operating expenses
Days cash on hand
Gross days in A/R
Cost/adjusted patient day
Labor hours per adjusted patient day
Labor cost per adjusted patient day
Cost per patient day
Labor hours per patient day
Operating profit margin
EBIDTA margin (Earnings before interest, taxes, depreciation and amortization)
Acute occupancy/day
Swing bed occupancy/day
Payer Mix Commercial
Medicaid
Medicare
Self/Private
Other
Financial/HR• 10 CAHs reporting
monthly• 20 measures reported
(incl 4 core)• CAH selected• New reporting page
NEW FINANCIAL DATA SUBMISSION PAGE
Option to change QI submissions to something similar – if it would increase involvement/participation and support increased benchmarking and use of the data internally.
DISCUSSION
Do we want to consider expanding the current QHI core measure set to include a set of measures specific to WY?
Would access to a revised data entry screen be helpful?
Sample Additions:
EDTC measure set
Unassisted falls that result in injury
LTC Falls – for those with LTC
Left without being seen
ED wait time
Others…
Next QI Roundtable:March 18, 10:00 am – 11:30amAgenda – Antibiotic Stewardship
SHIP Grants:2-3 months noticeUpdate from Kyle
FLEX & OTHER CONTACTSKyle Cameron, Flex Program Coordinator
Rochelle Spinarski, Rural Health Solutions
Shanelle VanDyke, Quality Reporting Services
Eric Boley, WHA
Brandon Kelley, WY EMS
Deb Anderson, QIO – Mountain Pacific