Post on 06-Oct-2020
8/15/2019
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4Q18 Core Measures 2Q19 MBQIP Data Promoting Interoperability Stage 3
August 16, 2019
Joshua Salander, MBA, PMP
Consultant
Conflict of Interest / Disclaimer
• Conflict of Interest: I, Joshua Salander, am employed by Scheurer Hospital. Any content or opinion in this presentation shall not be construed as an opinion or representation of Scheurer Hospital.
• Disclaimer: This presentation is informational only. You should review requirements to determine specific impacts to your hospital. Persevion, LLC is not liable for the accuracy of this information or how it pertains to your hospital.
• Disclaimer: Any information included in this presentation or the Reports Appendix is intended for quality improvement and benchmarking purposes only.
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Reports delivery
• 4Q18 reports were sent via email on August 11, 2019
• Quarterly Reports
• Quarterly Trend Charts
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MICAHQN Reports Schedule
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Qtr CMS Data Deadline* Data Provided By*
1st Qtr August 15 August 31
2nd Qtr November 15 November 30
3rd Qtr February 15 February 28
4th Qtr May 15 May 31
Summary of 4Q18 MICAHQN Core Measures Performance
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Measure # Hospitals Denominator Current Rate/Value
Top Performer(s)
IMM-2 34/40 2959 94.4% See IMM-2 Slide
OP-1 11/40 17 26 Schoolcraft Memorial Hospital
OP-2 12/40 23 56.5% See OP-2 Slide
OP-3a 23/40 62 117.5 Spectrum Health Reed City Hospital
OP-3b 15/40 42 134.5 Spectrum Health Reed City Hospital
OP-3c 14/40 20 91.5 Carson City Hospital
OP-4a 32/40 563 95.4% See OP-4a Slide
OP-4b 32/40 236 95.8%
OP-4c 32/40 327 95.1%
OP-5a 37/40 736 7 Helen Newberry Joy Hospital
OP-5b 37/40 329 7 Helen Newberry Joy Hospital
OP-5c 37/40 407 6 Borgess - Lee Memorial Hospital
4Q18 – OP-2: Fibrinolytic Therapy Received Within 30 Minutes (100%)
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Hospitals
Aspirus Grand View
Helen Newberry Joy Hospital
Mackinac Straits Health System, Inc.
Munson Healthcare Manistee
Schoolcraft Memorial Hospital
St. Mary's of Michigan Standish Hospital
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4Q18 – IMM-2: Influenza Immunization – Overall Rate (100%)
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Hospitals
Aspirus Iron River Hospital and Clinics
Baraga County Memorial Hospital
Borgess - Lee Memorial Hospital
Caro Community Hospital
Eaton Rapids Medical Center
Kalkaska Memorial Health Center
Mercy Health Lakeshore Campus
4Q18 - OP-4a: Aspirin at Arrival (100%)
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Hospitals
Allegan General Hospital Helen Newberry Joy Hospital
Aspirus Ontonagon Hospital Hills & Dales General Hospital
Borgess - Lee Memorial Hospital Mackinac Straits Health System, Inc.
Caro Community Hospital Schoolcraft Memorial Hospital
Deckerville Community Hospital Sheridan Community Hospital
Harbor Beach Community Hospital, Inc. Spectrum Health Gerber Memorial
Hayes Green Beach Memorial Hospital
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93.0%
94.0%
95.0%
96.0%
97.0%
98.0%
99.0%
100.0%
Rat
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OP4a - Aspirin at Arrival - Overall Rate
MICAHQN Overall UCL LCL
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Summary of 4Q18 MICAHQN Core Measures Performance
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Measure # Hospitals Denominator Current Rate/Value
Top Performer(s)
OP-18a 37/40 4030 121 Mercy Health Lakeshore Campus
OP-18b 37/40 3521 112 Mercy Health Lakeshore Campus
OP-18c 36/40 142 191.5 Mid Michigan Medical Center – Clare
OP-18d 37/40 383 204 Bronson LakeView Hospital
OP-20 32/40 3181 13 Paul Oliver Memorial Hospital
ED-1a 34/40 2609 228 St. Mary's of Michigan Standish Hospital
ED-1b 34/40 2573 227 Harbor Beach Community Hospital, Inc.
ED-1c 17/40 36 252.5 Schoolcraft Memorial Hospital
ED-2a 33/40 2436 62 Deckerville Community Hospital
ED-2b 33/40 2402 62 Deckerville Community Hospital
ED-2c 13/40 34 58 Eaton Rapids Medical Center
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95
100
105
110
115
120
125
130
135
Me
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OP18a - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Overall
MICAHQN Overall UCL LCL
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100
105
110
115
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125
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OP18b - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Reporting Measure
MICAHQN Overall UCL LCL
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0
50
100
150
200
250
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OP18c - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Psychiatric/Mental Health Patients
MICAHQN Overall UCL LCL
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0
50
100
150
200
250
Me
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OP18d - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Transfer Patients
MICAHQN Overall UCL LCL
OP-18b -Median Time from ED Arrival to ED Departure for Discharged ED Patients
• What benchmarks are you using for this measure?
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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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.
OP-18b -Median Time from ED Arrival to ED Departure for Discharged ED Patients
• Factors contributing to higher times than desired • Volume during peak hours • Waiting for test results • Waiting for Psychiatric/Behavioral Health evaluation • Med/Surg nurses cover the ED when no patients on the floor,
so when there is an admission it slows the process down • Workforce cuts • Changes in ED Providers (changed companies or had
providers come and go) • Variability in the productivity of ED Providers • Use of Paper T-sheets (documentation not readily available
and needs to be scanned)
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.
OP-18b -Median Time from ED Arrival to ED Departure for Discharged ED Patients
• Steps being taken to reduce the time
• Hired more staff for peak hours
• Phasing out providers with low productivity
• Moving providers to EMR and using Dragon (medical record immediately available)
• ED Physicians covering as Hospitalists or at least able to admit
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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50.0
52.0
54.0
56.0
58.0
60.0
62.0
64.0
66.0
Me
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ED-2a - Admit Decision Time to ED Departure Time for Admitted Patients - Overall Rate
MICAHQN Overall UCL LCL
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50.0
52.0
54.0
56.0
58.0
60.0
62.0
64.0
66.0
Me
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ED-2b - Admit Decision Time to ED Departure Time for Admitted Patients - Reporting Measure
MICAHQN Overall UCL LCL
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
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ED-2c - Admit Decision Time to ED Departure Time for Admitted Patients - Psychiatric/Mental Health Patients
MICAHQN Overall UCL LCL
Summary of 2Q19 MBQIP Performance
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Measure # Hospitals Current Rate/Value
Notes
EDTC-1 36/36 96% 22 @ 100%
EDTC-2 36/36 95% 25 @ 100%
EDTC-3 36/36 97% 22 @ 100%
EDTC-4 36/36 96% 19 @ 100%
EDTC-5 36/36 96% 19 @ 100%
EDTC-6 36/36 93% 14 @ 100%
EDTC-7 36/36 97% 26 @ 100%
EDTC-Overall 36/36 87% 7 @ 100%
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2Q19 - EDTC-Overall (100%)
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Hospitals
Bronson LakeView Hospital
Eaton Rapids Medical Center
Mackinac Straits Health System, Inc.
McKenzie Health System
Mercy Health Lakeshore Campus
Sparrow Clinton Hospital
Spectrum Health Gerber Memorial
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Me
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All EDTC Measure
MICAHQN Overall UCL LCL
Promoting Interoperability Stage 3: Public Health and Clinical Data Exchange
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IT & Quality Collaboration
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Promoting Interoperability Stage 3: Public Health and Clinical Data Exchange
Objectives Description
Electronic Prescribing Generate and transmit permissible discharge prescriptions electronically
Health Information Exchange Encourage and leverage interoperability on a broader scale and promote health IT-based care coordination
Provider to Patient Exchange Provide patients electronic access to their health information
Public Health & Clinical Data Exchange • Syndromic Surveillance • Immunization Registry • Electronic Case Reporting • Public Health Registry • Clinical Data Registry • Electronic Reportable Laboratory Result Reporting
Measures that an eligible hospital or CAH attests yes to being in active engagement with a public health agency (PHA) or clinical data registry (CDR) to submit electronic public health data in a meaningful way using certified electronic health record technology (CEHRT) for two measures within the objective.
26 https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/TableofContents_EH_Medicare_2019.pdf
Promoting Interoperability Stage 3: Public Health and Clinical Data Exchange
Measure Points
Electronic Prescribing 10
Query of Prescription Drug Monitoring Program (PDMP) (optional) 5 bonus
Verify Opioid Treatment Agreement (optional) 5 bonus
Support Electronic Referral Loops by Sending Health Information 20
Support Electronic Referral Loops by Receiving and Incorporating Health Information 20
Provide Patients Electronic Access to their Health Information 40
Public Health & Clinical Data Exchange (attest to two measures) 10
27 https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/
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Promoting Interoperability Stage 3: Public Health and Clinical Data Exchange
28 https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/MedicareEH_2019_Obj2-.pdf
Promoting Interoperability Stage 3: Public Health and Clinical Data Exchange
29 https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/MedicareEH_2019_Obj2-.pdf
Promoting Interoperability Stage 3: Public Health and Clinical Data Exchange
• Measures that an eligible hospital or CAH attests yes to being in active engagement with a public health agency (PHA) or clinical data registry (CDR) to submit electronic public health data in a meaningful way using certified electronic health record
technology (CEHRT) for two measures within the objective.
• Make sure you’re familiar with the exclusions for each of the above measures!
30 https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/MedicareEH_2019_Obj2-.pdf
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Promoting Interoperability Stage 3: Public Health and Clinical Data Exchange
31 https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/MedicareEH_2019_Obj2-.pdf
Thank you!
Joshua Salander, MBA, PMP
Consultant
jsalander@persevion.com
(989) 666-7033