MBQIP Update Presentation for TASC 90 Webinar | July 20 th , 2020 Natalia Vargas, MPH Lead, MBQIP Program 8/25/2020 1 1
Discussion Points Part I: MBQIP Data Overview and Discussion 1. Updates on MBQIP Quarterly Data Reports 2. Q&A related to MBQIP Report Updates 3. Discussion Questions: Feedback to FORHP Part II: MBQIP Refresh: Follow‐up on Pool‐side Chat 1. Overview of Pool‐side Chat: Analysis and Results 2. Overview of MBQIP Refresh Timeline & Next Steps 3. Final Questions & Answers 8/25/2020 2 2
8/25/2020 3 3
Webinar Part I: MBQIP Data Overview and Discussion 8/25/2020 4 4
MBQIP Refresh Quarterly Report Updates • FORHP welcomes the Flex Monitoring Team at the University of Minnesota • RQITA will remain the point of contact for TA related to these reports • The FMT reports are similar to the quarterly reports produced by Telligen Reports will include national, state, and CAH‐level data • A 3‐phase approach for producing FMT reports Changes in report timelines as FMT re‐launches the process: we will review timelines today for context 8/25/2020 5 5
Reporting Channels for CAHs 3 2 1 Quality NHSN Net State Flex Office HCAHPS Survey (Submitted via vendor or self- administered) Antibiotic HCP/IMM-3 Stewardship (formerly (submitted via OP-27, submitted Annual Facility EDTC CMS Outpatient Measures CMS Outpatient Measures to NHSN) Survey) (Submitted via CART or (Submitted via QualityNet vendor) directly) OP-2, OP-3, OP-18 OP-22 *Na�onal Healthcare Safety Network †Emergency Department Transfer Communica�on Note: After CAHs report measures, CMS/CDC collect data & send to FORHP and FMT 8/25/2020 6 6
Timeline: From CAH Reporting to Distributing MBQIP Data Reports CAHs Collect CMS/FORHP CMS/CDC/SFCs Data Within Submission Send Data to Encounter Deadline FORHP/FMT Period FMT Develops FORHP POs FMT Receives & Reports and Distribute Validates Data Sends to FORHP Reports to SFCs 8/25/2020 7 7
Data Lags: Vary by Report Hospital CMS/CDC/SFCs Encounter Total Lag 6 Submission Send Data to weeks to 8 Period Deadline FORHP & FMT months 1 month (EDTC) to 10 days (EDTC) to 7 3‐4 months months (HCAHPS) (HCAHPS/IP/OP) FMT Develops FORHP Data Shared Reports and Distributes Total Lag with FMT Sends to Reports to 5 weeks FORHP SFCs 3 Weeks 2 Weeks 8/25/2020 8 8
Updated Quarterly Reports‐ What to Expect • There will be five types of reports (based on current MBQIP measures): 1) Patient Experience (11 Measures: HCAHPS Composite 1‐7; Q‐8; Q‐9; Q‐21; Q‐ 22) 2) Care Transitions (9 Measures: EDTC 1 – EDTC 8 + ALL EDTC) 3) Patient Safety/Inpatient and Outpatient (14 Measures: HCP/IMM‐3; ED‐2b; OP‐2; OP‐3; OP‐18; OP‐22; 8 Antibiotic Stewardship Measures) 4) Additional HAI report: (6 Measures: CLABSI; CAUTI; CDI; MRSA; SSIC; SSIH) 5) Annual report (to be discussed in upcoming slides) 8/25/2020 9 9
Report Contents A cover page that contains a non‐technical introduction to how the report was created and a description of how to interpret results Data for the most recent reporting period and previous reporting period(s) Numerator and denominator values, where relevant Comparison values for state and national data for each measure 8/25/2020 10 10
Phases & Milestones • Phase 1 (Late May 2020 through Fall 2020) Internal negotiations with FMT and discussions with Federal partners FMT develops and sets up production of initial set of Quarterly Reports • Phase 2 (Late Summer 2020 through Summer 2021; slight overlap with Phase 1) Rapid cycle learning with opportunities for SFCs to provide feedback Process development for MBQIP quarterly reports Return to a consistent report delivery schedule by early 2021 Interim 2019 Annual Report produced by FMT • Phase 3 (Fall 2021) 2020 Annual Report produced with additional elements added Development of Benchmarks for each measure Exploratory implementation of MBQIP Performance Score (developed by RQITA) at the CAH level, in partnership with FMT and RQITA 8/25/2020 11 11
Phase 1 (Late May 2020‐through Fall 2020) 8/25/2020 12 12
Phase 1: Temporary Report Timeline • This is a temporary, or “catch‐up” timeline to deliver initial set of MBQIP reports. • The intent is to transition to a consistent quarterly report delivery schedule in Phase 2 • Time frames indicate when states can expect the MBQIP data reports Antibiotic Care Transitions Patient Safety & Inpatient‐ *Patient Experience Stewardship‐ Raw (EDTC) Report Outpatient Report (HCAHPS) Report Data Spreadsheet Q1 2020 (Jan 1‐ Mar Q4 2019 (Oct 1‐ Dec 31) & Q4 2019 (Oct 1‐ Dec (2019 Annual Facility 31) & Q2 2020 (Apr 1‐ Q1 2020 (Jan 1‐ Mar 31) 31) & Q1 2020 (Jan 1‐ Survey Data) Jun 30) Mar 31) August 20 September 28 November 13 December 3 Dates Reports will be Delivered to SFCs Note: these are anticipated release dates for State Flex Coordinators. *HCAHPS timeline is currently under final negotiation with CMS & FMT, and may vary slightly from date listed 8/25/2020 13 13
Help Available to SFCs During Phase 1 Transition While FORHP strives to align with previous processes, we acknowledge that change/delays are unavoidable, and will need to take time into consideration as FMT transitions into this new role How can we help? • Statement from FORHP to Hospitals to alleviate burden for SFCs • RQITA available for consultations, tools, and resource development that can assist hospitals in the transition Pause for Questions 8/25/2020 14 14
Phase 2 (Late Summer 2020 ‐ through Summer 2021) 8/25/2020 15 15
Rapid Cycle Learning (RCL) Phase RCL Objectives • Apply and optimize learnings before the reports are created and a new process is implemented— a year of active learning • Understand limitations through a scan of our Apply Implement resources (CMS, FMT), and end‐user needs (SFCs, CAHs) to help close the gap in “what we know” and “what we do” • Inform prototype changes intended to prepare Learn us for launching the consistent quarterly report timeline and a 2020 Annual Report 8/25/2020 16 16
Phase 2: Quarterly Reports Timeline • In phase 2, FORHP expects to have a consistent quarterly report release timeline REPORT NAME Q1 (Jan 1‐ Mar 31) Q2 (Apr 1‐ Jun 30) Q3 (Jul 1 – Sept 30) Q4 (Oct 1‐ Dec 31) End of Sept Early Jan Early Apr Early Jul Patient Safety/Inpatient and Outpatient Early Jul Early Oct Early Jan Early Apr Care Transitions (EDTC) Patient Experience Early Dec Early Apr Early Jul Mid Aug (HCAHPS) Note: these are anticipated release dates for State Flex Coordinators. 8/25/2020 17 17
RCL Completed in Phase II: Fielded Survey for SFCs Format • Likes: 90 th percentile data; state and national averages • Dislikes: Reports not timely; don’t like 3 separate reports; PDF format (prefer data in spreadsheet); don’t have visual representation over time Data • Likes: State and national averages; 90 th percentile; inclusion of data from previous quarters • Dislikes: Timeliness of data Use of Reports • Top 6: Send reports to hospitals; do own data analyses; use for benchmarking; use to prioritize projects; use to plan site visits; do not use/reports not useful 8/25/2020 18 18
Key Recommendations from Survey Respondents requested that FORHP: • Explains data collection and submission process • Provides a detailed timeline of quarterly reports Apply Implement • Explains why we have 3 different MBQIP quarterly reports instead of a combined report that includes all 3 measure areas combined Accomplished by July 20 Webinar Learn • Next RCL to begin today with your input! 8/25/2020 19 19
Short‐Term Opportunities for RCLs in Phase 2 • Responses on the 2 discussion questions will be analyzed and discussed with FMT Can also send us a follow‐up email @ MBQIP@hrsa.gov • October, 2020: Open Office Hours with MBQIP Coordinator After receiving the Care Transitions (EDTC) Report for Q1 2020 and Q2 2020; FORHP will collect feedback on reports to address with FMT • January, 2021: FORHP Fireside Chat to Check‐in with SFCs Will allow for discussion of impact of MBQIP report changes Feedback collected as FORHP develops MBQIP Strategic Plan The goal is to wrap up the RCL before we are back on the regular report delivery schedule Other Opportunities May be Formulated Based on Feedback Received (Before Phase 3) 8/25/2020 20 20
Group Discussion Questions What would be helpful for states now or after reports come out? This can be resources, tools, communication points, etc What would be helpful for CAHs, and how can FORHP assist them in this transition? 8/25/2020 21 21
Phase 3 (Fall 2021) 8/25/2020 22 22
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