Michigan STRATEGY GROUP #2 Critical Access DATA M A MANA NAGEMENT NT AND ND A ANAL ALYSI SIS S Hospital Quality NOVEMBER 7, 7, 201 2019 Network AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
Measure Spreadsheet Update http://www.mcrh.msu.edu/programs/CAH /Quality%20Improvement%20NEW.html MICAH QN Measures – Excel Sheet AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
Reminders Monthly – Submit to KDS & NHSN Quarterly – Q3 2019 data ◦ January 24 th - Email MBQIP results to Crystal ◦ December 1 st - Email HCAHPS results to Crystal ◦ February 1 st - Outpatient results due to QNet (Most use Quantros) ◦ February 15 th - Inpatient due to QNet AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
Reminders Alternative Readmission Activity for BCBSM ◦ Narrative is Due June 1 ◦ See Appendix E of the 2019-2020 Peer Group 5 Hospital Pay-for-Performance Program (Copy on the MICAH QN Website) (Readmission Activity Sharing Google Document) Don’t wait until it’s too late to get started AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
Opt ptions ns 1. Development of a post-acute network strategy 2. Collaboration plan with local social service agencies to better understand and address patients’ social determinants of care 3. Establish process to identify potentially preventable readmissions 4. Develop process to use PG 1-4 P4P Health Information Exchange (HIE) activities meaningfully for the purposes of improving care transitions and readmission reduction 5. Other: Please describe any current readmission-reducing efforts in place that do not fall into one of the above categories AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
High gh-level n el nar arrativ ive d e describin ing p plan an or inter erven entio ion, including (but n t not l t limited to) t the b below e elements ts: 1. Activity purpose, priorities and goals 2. Descriptions of internal roles and responsibilities 3. Process for external stakeholder engagement, if applicable 4. Core measures and measurement processes: • Baseline readmission measurement • Targeted performance goal • Populations and/or service lines affected • Expected milestone dates and/or completion date 5. Communication and evaluation plan AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
HCAHPS Scores – Q2 2019 MICAH Michigan National National Top 90 th Percentile QN Average Average Care Transitions Composite Score 58.22% 54% 53% 63% Discharge Information Composite Score 91.23% 89% 87% 92% Overall Rating 81.84% 74% 73% 84% Would you Recommend 80.86% 71% 72% 84% * MI and National Average is from Hospital Compare 10.1.2017-9.30-2018 * Three CAHs did not submit, and 3 do not participate in HCAHPS AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
Or Organ anization onal S Scorec ecard S Showcase Katie Stewart - Allegan General Hospital AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
All Measure Spreadsheet Purpose: Give MI CAH quality leaders a tool to assess and share quality metrics monitored in various hospital departments (outside of mandated measures which can be found on the MICAH QN Measures Excel Sheet) Cross Department HIM Maintenance Rehab Acute (Med Surg) Human Resources Purchasing Respiratory Care Billing Imaging Nutrition Services Safety Cardio Infection Prevention PAS (Registration) Social Work Clinics Infusion Patient Satisfaction Surgical Services Emergency Services IT Pharmacy Swing Bed Employee Health Lab Promoting Telemedicine Interoperability Long-Term Care EVS Utilization Review AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
All Measure Spreadsheet Update http://www.mcrh.msu.edu/programs/CAH /Quality%20Improvement%20NEW.html MICAH QN All Measures – Google Document AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
Quick Reminder - IHI Institute for Healthcare Improvement – Basic Certificate in Quality and Patient Safety • Still tickets available • Can complete through March 2020 AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
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