Hospital Metrics TAG September 8, 2015
Welcome and Introductions 2
Updates • CMS discussions • Committee updates – Next meeting 24 September – Behavioral health learning session, with CCO Metrics & Scoring Committee (tentatively 30 Oct) – Year 4 survey, open until 7 October 2015 3
Updates Year 3 Survey Results please see supplementary materials 4
Year 2 - CAUTI • Timing issues HTPP Year Period Specifications Year 1 Oct. 2013 – Old NHSN (baseline) Sep. 2014 specifications Year 2 Oct. 2014 – • First quarter – (performance Sep. 2015 consistent with year) baseline • Last 3 quarters – new NHSN specifications (not comparable to baseline) 5
Year 2 - CAUTI • Possible measurement/benchmarking solutions – Entire baseline year compared to data covering just the first quarter of Year 2 (common specifications) – Year 2 payments based on benchmark only (no improvement target) – The H-TAG ideas was consulted on these and asked to submit alternative solutions 6
Year 2 - CAUTI • Decision – Only use data with new CDC specifications – Baseline: January 1, 2015 – March 31, 2015 (3 months) – Performance Period: April 1, 2015 – September 30, 2015 (6 months) – Benchmark remains at HTPP baseline 50 th percentile, but absolute number changes to 1.10 per 1000 catheter days (excluding hospitals with no CAUTIs) 7
Year 3 CAUTI / CLABSI • Recap: Committee has expressed concern with basing rate on device days • As of 2015 the risk-adjusted Standardized Infection Ratio (SIR) is available for all tracked units. • SIRs compare the number of infections in a facility to the number of infections that would be expected to have occurred based on previous years of reported data. • Committee decided to switch to SIRs, which will be available from the CDC for all tracked units beginning in 2015 8
Year 3 CAUTI / CLABSI • CDC calculating two SIRs – Interim , available July 2015; based on 2009 baselines – Rebased , available ~Jan. 2017, based on 2015 baselines • HTPP decision - hold off on switch to SIRs until Year 4 (2017) 9
EDIE – Year 3 • Notification to primary care providers currently included in the denominator (as not technically possible to exclude them from the baseline year) • Could exclude in Year 3 – Pros: Would exclude patients for whom hospitals would be unable to get numerator credit – Cons: Not completely clean; potential lack of clarity on which patients require primary care notifications • H-TAG opinions? 10
Additional Discussion of EDIE- based Measure 11
Sepsis (Healthcare-Associated Infections Domain) Description: Mortality rate for patients admitted with severe sepsis and septic shock per 1,000 discharges from HRET HEN (OPT-HEN-SEPSIS-1). National benchmark: HEN goal was to reduce mortality by 25% Alignment w/ CCOs? No. Risk adjustment? No. Considerations: • There is an NQF endorsed process measure bundle associated with Sepsis (NQF 0500 ) – one composite measure for all bundle elements. • The HRET has 4 process measures (ED screening; Inpt screening; compliance with 3-hr and 6-hr bundles). • Hospitals could implement the bundle components to help with quality improvement, but only report on the mortality measure. 12
Future Agenda Items? 13
Wrap up / next meeting Tuesday, October 13, 10am – 12pm 14
Questions? Sara Kleinschmit, OHA sara.kleinschmit@state.or.us Diane Waldo, OAHHS diane.waldo@oahhs.org Elyssa Tran, Apprise Health Insights elyssa.tran@apprisehealthinsights.com Barbara Wade, OAHHS/Apprise Barbara.wade@apprisehealthinsights.com 15
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