2020 Quality Measure Development CHASE Board August 27, 2019 - PowerPoint PPT Presentation

HQIP 2019 Scoring and 2020 Quality Measure Development CHASE Board August 27, 2019 Nancy Dolson Department of Health Care Policy & Financing

Agenda 1. 2019 CO HQIP Scoring 2. 2020 CO HQIP Proposed Quality Measures Review of 2019 Measures • Proposed Changes for 2020 • 2

2019 Scoring: Cesarean Section The HQIP Subcommittee has voted to apply the 2018 bounds to this year’s distribution. Healthy People 2020’s benchmark of 23.9% was used as the cutoff for scoring eligibility. C-section Lower Bound Upper Bound Points No. of facilities 1st Tercile (lowest) 0.0% 17.2% 4 17 2nd Tercile 17.3% 20.8% 2 10 3rd Tercile 20.9% 23.8% 1 7 ≥ 23.9% (highest) 23.9% 100.0% 0 12 Ineligible* 36 Total 82 * Ineligible facilities (those that do not provide obstetric services or do not meet the minimum number of qualified deliveries) will have their scores normalized for this measure. 3

2019 Scoring: Falls with Injury Falls with Injury (rate per 1000 inpatient days) Lower Bound Upper Bound Points No. of facilities 1st Quartile (lowest) 0.00 0.08 5 41 2nd Quartile 0.09 0.21 3 13 3rd Quartile 0.22 0.64 1 14 4th Quartile (highest) 0.65 38.96 0 14 Total 82 4

2019 Scoring: Advance Care Planning The HQIP Subcommittee has voted to apply the 2018 bounds to this year’s distribution. The 2018 method excluded those with 0% ACP from calculation and awarded maximum points for those greater than or equal to 99.5%. Advance Care Planning Lower Bound Upper Bound Points No. of facilities 4th Quartile (highest) 99.5% 100.0% 3 26 3rd Quartile 86.4% 99.4% 2 32 2nd Quartile 75.0% 86.3% 1 3 1st Quartile (lowest) 0% 74.9% 0 21 Total 82 5

2019 Scoring: HCAHPS, Composite 5 The Communication about Medicines measure reflects patients’ feedback on how often hospital staff explained the purpose of any new medicine and what side effects that medicine might have. ‘Always’ Percentage Lower Bound Upper Bound Points No. of facilities 4th Quartile (highest) 70% 86% 4 15 3rd Quartile 67% 69% 2 11 2nd Quartile 65% 66% 1 16 1st Quartile (lowest) 0% 64% 0 20 Not Available* 20 Total 82 * Not Available group includes those with suppressed scores due to insufficient responses and rehabilitation facilities that are not required to implement the HCAHPS survey. Scores will be normalized. 6

2019 Scoring: HCAHPS, Composite 6 The Discharge Information measure summarizes how well the hospital staff communicated with patients about the help they would need at home after leaving the hospital. The measure also summarizes how often patients reported that they were given written information about symptoms or health problems to watch for during their recovery. ‘Yes’ Percentage Lower Bound Upper Bound Points No. of facilities 4th Quartile (highest) 91% 95% 4 14 3rd Quartile 90% 90% 2 12 2nd Quartile 89% 89% 1 9 1st Quartile (lowest) 0% 88% 0 27 Not Available* 20 Total 82 * Not Available group includes those with suppressed scores due to insufficient responses and rehabilitation facilities that are not required to implement the HCAHPS survey. Scores will be normalized. 7

2019 Scoring: HCAHPS, Composite 7 The Care Transition measure evaluates the degree to which patients understood their care when they left the hospital. ‘Strongly Agree’ Percentage Lower Bound Upper Bound Points No. of facilities 4th Quartile (highest) 59% 71% 4 14 3rd Quartile 56% 58% 2 14 2nd Quartile 53% 55% 1 17 1st Quartile (lowest) 0% 52% 0 17 Not Available* 20 Total 82 * Not Available group includes those with suppressed scores due to insufficient responses and rehabilitation facilities that are not required to implement the HCAHPS survey. Scores will be normalized. 8

2020 Quality Measures Review of 2019 Measures Proposed Changes for 2020 9

2019 Quality Measures Measure Group Measure Status Data Goal Breast Feeding Existing Hospital Reported Process C-Section Existing Hospital Reported Outcome Perinatal and Maternal Care Pregnancy related depression New Hospital Reported Process Maternal Emergencies New Hospital Reported Process Family Planning New HCPF/Hospital Report Process Clostridium difficile (C-Diff) Existing HCPF/Hospital Report Outcome Adverse Event Existing Hospital Reported Process Patient Safety Falls w/Injury Existing Hospital Reported Outcome Culture of Safety Survey Existing Hospital Reported Process HCAHPS New HCPF Outcome Patient Experience Advanced Care Plan Existing Hospital Reported Process Follow-Up after Hospitalization for Mental Illness New HCPF Outcome Behavioral Health ED Utilization MH New HCPF Outcome ED Utilization SUD New HCPF Outcome SUB Composite New Hospital Reported Outcome Substance Use ALTO and Post-Surg New Hospital Reported Process Addressing Cost of Care Hospital Index New HCPF Outcome 10

2020 Quality Measures Measure Group Measure Status Data Goal Breast Feeding Existing Hospital Reported Process C-Section Existing Hospital Reported Outcome Pregnancy related depression Existing Hospital Reported Process Perinatal and Maternal Care Maternal Emergencies Existing Hospital Reported Process Family Planning Existing HCPF/Hospital Report Process Incidence of Episiotomy New HCFP Process Clostridium difficile (C-Diff) Existing HCPF/Hospital Report Outcome Adverse Event Existing Hospital Reported Process Culture of Safety Survey Existing Hospital Reported Process Patient Safety Sepsis New Hospital Reported Process Antibiotics Stewardship New Hospital Reported Process Handoffs and Signouts New Hospital Reported Process HCAHPS Existing HCPF Outcome Patient Experience Advanced Care Plan Existing Hospital Reported Process 11

2020 Proposed Changes: Retired Measures Three measure groups are being removed. These areas are going to be addressed in the Hospital Transformation Program. One measure (falls with injury) is being retired as the measure has topped out. A total of 9 measures are being retired. ❖ Behavioral Health Follow-up appointments within 7 days after hospital discharge for a mental health condition • • Follow-up appointments within 7 days after hospital discharge for a mental health condition Emergency department utilization for mental health condition • Emergency department utilization for substance use condition • ❖ Substance use Using Alternatives to Opioids (ALTOs) in Hospital Emergency Departments • • Post surgical Opioid Prescribing Tobacco and Substance Use Screening and Intervention • ❖ Addressing Cost of Care • Addressing cost of care ❖ Patient Safety • Falls with injury 12

2020 Proposed Changes: New Measures Four new measures are being proposed: ❖ Maternal Health and Perinatal Care • Incidence of episiotomy ❖ Patient Safety • Sepsis • Antibiotics Stewardship • Handoffs and Signouts 13

Incidence of Episiotomy Area: Maternal Health and Perinatal Care NQF #0470 Incidence of Episiotomy - Percentage of vaginal deliveries (excluding those coded with shoulder dystocia) during which an episiotomy is performed. Numerator Statement: • Number of episiotomy procedures (ICD-9 code 72.1, 72.21, 72.31, 72.71, 73.6; ICD-10 PCS:0W8NXZZ performed on women undergoing a vaginal delivery (excluding those with shoulder dystocia ICD-10; O66.0) during the analytic period- monthly, quarterly, yearly etc. Denominator Statement: • All vaginal deliveries during the analytic period- monthly, quarterly, yearly etc. excluding those coded with a shoulder dystocia ICD-10: O66.0). Exclusions: • Women who have a coded complication of shoulder dystocia. In the case of shoulder dystocia, an episiotomy is performed to free the shoulder and prevent/mitigate birth injury to the infant. 14

Sepsis Area: Patient Safety Sepsis Process Measure: • Describe the protocols and alerts your facility has in place for identifying sepsis and for treating sepsis. If the protocols are different for different levels of care (e.g. ED vs inpatient), please describe the protocols and their differences. • Describe and provide evidence of the training that your facility has in place for orienting new providers and staff to your facility’s systems and protocols for addressing suspected sepsis cases • Describe and provide evidence of the process of providing regular feedback to providers on sepsis identification and treatment results. • Provide process measures and/or outcome measures your facility uses for tracking sepsis identification and treatment as well as any results for the purposes of quality improvement 15