Data Management 8.17.2018
Performance Measurement for Rural Low Volume Providers Recommendations (2015) Make participation in Centers for Medicare and Medicaid Services (CMS) quality measurement and quality improvement programs mandatory for all rural providers Allow a phased approach for full participation across program types and explicitly address low-case volume Development of rural-relevant measures Fund development of rural-relevant measures Develop and/or modify measures so as to explicitly address low case-volume Alignment of measurement efforts
Measure selection Use guiding principles for selecting quality measures that are relevant for rural providers Create a Measures Applications Partnership (MAP) workgroup to advise CMS on the selection of rural- relevant measures Payment considerations For rural providers, create payment programs that include incentive payments, but not penalties Offer rewards for rural providers based on achievement or improvement
Identifying core sets of the best available rural- relevant measures Recommendations regarding measuring and improving access to care for the rural population Identifying gaps in measurement and alignment and coordination of measurement efforts
Eight measures for the hospital setting Thirteen measures for ambulatory setting Apply to majority of rural patients and providers Cross cutting Resistant to low-case volume Includes process and outcome measures Includes measures based on patient report
See Handout Measurement Gaps Access to care Disparities in care Balancing access and cost with health outcomes Outcome measures, particularly patient-reported outcomes Implications…..
Federal Office of Rural Health Policy – Division of Health Resources Services Administration (HRSA) Award Top 10 States – Highest reporting rates and levels of improvement over the last year Improvement from #7 to #2
See Handout
KDS & NHSN - monthly Quarter 3 Data MBQIP due to Crystal by October 24 th Outpatient due to QNet/Quantros by November 1 st Inpatient due to QNet/Quantros by November 15 th
Does anyone have any questions or comments regarding measure specifications?
http://www.mcrh.msu.edu/programs/CAH/Quality%20Improvement%20NEW.html MICAH QN Measures – Excel Sheet
Hospital Compare has information on over 4,000 Medicare-certified hospitals Overall rating displayed on about 80% 7 measure groups 57 quality measures Link to Inpatient Hospital Compare Report Guide
Overall Rating Number of Hospitals 5 stars 337 (7.36%) 35% 4 stars 1155 (25.22%) 30% 25% 3 stars 1187 (25.92%) 20% 15% 2 stars 753 (16.44%) 10% 5% 1 star 260 (5.68%) 0% 5 4 3 2 1 Volume too low 887 (19.37%)
Number of Number of Potential Standard Measures Measure Group National Measure Group Measures Measure Group Performance Category for Your Score Group Score within Each Weight Hospital Group Mortality 7 2 22.0% 0.37 0.0004 N/A Same as the national Readmission 9 4 22.0% 0.22 -0.06 average Safety of Care 8 2 22.0% 1.15 -0.04 N/A Patient Experience 10 10 22.0% 1.55 -0.0004 Above the national average Efficient Use of Medical Same as the national 5 4 4.0% 0.64 0.003 Imaging average Same as the national Timeliness of Care 7 4 4.0% 0.77 -0.02 average Same as the national Effectiveness of Care 11 4 4.0% 0.12 0.03 average
July 2018 December October July December October July National (May 2017 2017 2017 2016 2016 2016 Average Preview) Temp Hold Overall Hospital 4 out of 5 4 out of 5 4 out of 5 4 out of 5 4 out of 5 4 out of 5 3 out of 5 Stars Rating Results on Stars Stars Stars Stars Stars Stars Stars Summary Score 0.79 0.44 0.42 0.42 0.44 0.5 0.46 0.02 Potential Measures Measures Measure Total Performance Measure Group Column1 Column13 Column12 Column122 Column4 Column42 Column422 within for Your Group Category Score Each Hospital Weight Group Mortality 0.37 0.30 0.30 0.30 0.31 0.31 0.31 N/A 7 2 22.0% 0.0814 Same as the Readmission 0.22 -0.12 -0.12 0.04 0.55 0.55 0.55 national 8 4 22.0% 0.0484 average Safety of Care 1.15 -0.03 -0.03 -0.03 -0.10 -0.10 -0.10 N/A 8 2 22.0% 0.253 Above the Patient 1.55 1.88 1.88 1.59 1.23 1.53 1.32 national 10 10 22.0% 0.341 Experience average Same as the Efficient Use of 0.64 -0.94 -0.94 -0.92 -0.50 -0.50 -0.50 national 5 4 4.0% 0.0256 Medical Imaging average Same as the Timeliness of 0.77 0.74 0.74 0.82 0.98 0.92 0.89 national 7 4 4.0% 0.0308 Care average Same as the Effectiveness of 0.12 -0.01 -0.007 0.09 -0.36 -0.42 -0.27 national 11 4 4.0% 0.0048 Care average 56 30 0.785
Standardized National National July 2018 Measure Group Measure ID Measure Name (May Measure Jan 2018 July 2017 Jan 2017 Mean Mean Preview) Score July 2018 July 2017 Acute Myocardial Infarction (AMI) 30-Day MORT-30-AMI N/A N/A N/A N/A 13.2% 13.6% Mortality Mortality Rate MORT-30-CABG Coronary Artery Bypass Graft (CABG) 30- Mortality N/A N/A N/A N/A 3.2% 3.2% Day Mortality Rate MORT-30-COPD Chronic Obstructive Pulmonary Disease 8.1% 0.27 7.6% 7.6% 8.1% 8.4% 8.1% Mortality (COPD) 30-Day Mortality Rate MORT-30-HF N/A N/A N/A N/A 11.8% 12.2% Mortality Heart Failure (HF) 30-Day Mortality Rate MORT-30-PN 13.4% 1.25 14.2% 14.2% 14.0% 15.9% 16.0% Mortality Pneumonia (PN) 30-Day Mortality Rate Acute Ischemic Stroke (STK) 30-Day MORT-30-STK N/A N/A N/A N/A 14.3% 14.9% Mortality Mortality Rate PSI-4-SURG- Death Rate Among Surgical Inpatients with N/A N/A N/A N/A 161.80 136.70 Mortality COMP Serious Treatable Complications Acute Myocardial Infarction (AMI) 30-Day READM-30-AMI N/A N/A N/A N/A 13.2% 16.9% Readmission Readmission Rate READM-30-CABG Coronary Artery Bypass Graft (CABG) 30- N/A N/A N/A N/A 14.4% 14.4% Readmission Day Readmission Rate READM-30- Chronic Obstructive Pulmonary Disease 18.6% 0.92 19.2% 19.2% 19.0% 19.6% 19.8% Readmission COPD (COPD) 30-Day Readmission Rate Heart Failure (HF) 30-Day Readmission READM-30-HF N/A N/A N/A N/A 4.5% Readmission Rate Hospital-Level 30-Day All-Cause Risk- READM-30-Hip- Standardized Readmission Rate (RSRR) 3.8% 0.79 4.0% 4.0% 4.9% 4.2% 4.4% Readmission Knee Following Elective Total Hip Arthroplasty (THA)/Total Knee Arthroplasty (TKA) Deleted Pneumonia (PN) 30-Day READM-30-PN D/C 15.1% 15.1% 15.0% 17.1% Readmission Readmission Rate READM-30-STK N/A 12.6% 12.6% Readmission Stroke (STK) 30-Day Readmission Rate READM-30-STK N/A N/A N/A N/A 11.9% 12.2% Readmission Stroke (STK) 30-Day Readmission Rate New Excess Days in Acute Care after EDAC-30-PN -26.7 1.28 N/A N/A N/A 4.7 Readmission Hospitalization for Pneumonia (PN) READM-30-HOSP- HWR Hospital-Wide All-Cause Unplanned 15.1% 0.25 15.4% 15.4% 15.0% 15.3% 15.3% Readmission Readmission WIDE Facility Seven-Day Risk-Standardized OP-32 N/A N/A N/A N/A 0.2% 0.2% Readmission Hospital Visit Rate after Outpatient Colonoscopy
July 2018 Standardized National National Measure Group Measure ID Measure Name (May Measure Jan 2018 July 2017 Jan 2017 Mean Mean July Preview) core July 2018 2017 Central-Line Associated Bloodstream Infection HAI-1 N/A N/A N/A N/A 0.808 0.995 Safety of Care (CLABSI) HAI-2 N/A N/A N/A N/A 0.885 0.928 Safety of Care Catheter-Associated Urinary Tract Infection (CAUTI) Surgical Site Infection from colon surgery (SSI- HAI-3 N/A N/A N/A N/A 0.850 0.914 Safety of Care colon) Surgical Site Infection from abdominal hysterectomy HAI-4 N/A N/A N/A N/A 0.820 0.962 Safety of Care (SSI-abdominal hysterectomy) HAI-5 N/A N/A N/A N/A 0.898 1.011 Safety of Care MRSA Bacteremia Safety of Care HAI-6 Clostridium Difficile (C.difficile) 0.000 1.55 N/A N/A N/A 0.822 0.955 Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip COMP-HIP-KNEE 2.0% 1.16 2.9% 2.9% 4.1% 2.6% 2.8% Safety of Care Arthroplasty (THA) and Total Knee Arthroplasty (TKA) PSI-90-Safety NA N/A N/A N/A 0.99 0.89 Safety of Care Patient Safety for Selected Indicators (PSI) Patient Experience H-CLEAN-HSP Cleanliness of Hospital Environment 93 1.34 94 94 94 88 88 H-COMP-1 96 1.82 96 95 95 91 92 Patient Experience Nurse Communication H-COMP-2 93 0.54 95 93 94 92 92 Patient Experience Doctor Communication H-COMP-3 94 1.95 95 94 93 86 85 Patient Experience Responsiveness of Hospital Staff Patient Experience H-COMP-4 Deleted Pain management D/C 93 90 89 87 H-COMP-5 89 1.42 89 84 80 79 79 Patient Experience Communication About Medicines H-COMP-6 95 0.47 92 91 88 87 87 Patient Experience Discharge Information H-HSP-RATING 95 1.96 95 94 93 89 89 Patient Experience Overall Rating of Hospital Patient Experience H-QUIET-HSP Quietness of Hospital Environment 87 0.84 89 87 86 83 83 H-COMP-7 83 0.45 83 83 84 82 81 Patient Experience HCAHPS 3 Item Care Transition Measure H-RECMND 97 2.05 97 96 94 88 88 Patient Experience Willingness to Recommend Hospital
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