MHA Keystone Center MICAH QN Meeting - May 19, 2017

Introduction Kristy Swadley

2017-18 BCBSM P4P Pg5 Program – GLPP HIIN Quality Initiative Updates & Reminders

2016-17 BCBSM P4P PG5 program ended March 31, 2017 Reminder: 2016-17 BCBSM P4P PG5 program ended March 31, 2017 MHA Keystone Center Final Score Performance Reports (2016-17 program) Delivery Date: by June 16 To: BCBS P4P Primary Contacts From: KeystoneP4P@mha.org Questions/Concerns: respond by June 30

Critical Access Hospitals 2017-18 MHA Keystone / Great Lakes Partners for Patients (GLPP) HIIN Scoring Index Critical Access Hospitals CAUTI, EDTC-1, EDTC-4

Non-Critical Access Hospitals 2017-18 MHA Keystone / Great Lakes Partners for Patients (GLPP) HIIN Scoring Index Non-Critical Access Hospitals CAUTI, Sepsis, PM

MHA Keystone / GLPP HIIN Requirements Critical Access Hospitals PG5 Non-Critical Access Hospitals PG5

MHA Keystone / GLPP HIIN Requirements – Data Submission Monthly data submission of HIIN Measures will be reported from April 2017 – March 2018 (entire program year) Hospitals will only be scored for the submission of outcome data they are eligible to collect. Please reference Appendix A (HIIN Encyclopedia of Measures) for a complete list of the required measures. Data Submission (Manual data entry ONLY) Goal = Monthly (15th after each month submit previous months data) Minimally = Quarterly

MHA Keystone / GLPP HIIN Requirements – Data Submission EOM Cover Page – Administrative Claims Measures Keystone Data System (KDS) Location NOTE: These measures are automatically uploaded for hospitals who submit to MIDB (Michigan Inpatient Data Base) Confirm with your claims person or check KDS (6 month data lag)

MHA Keystone / GLPP HIIN Requirements – Data Submission NOTE: NHSN Users If you submit ALL HAI measures in NHSN, have conferred rights to Keystone, these measures will be automatically uploaded for your facility in KDS Keystone Data System (KDS) Location EOM Cover Page – NHSN Measures NOTE: If you DO NOT submit ALL HAI measures in NHSN, you will have to directly submit these measures in KDS!

MHA Keystone / GLPP HIIN Requirements – Data Submission NHSN Users Confer rights to MHA Keystone If unit name changes, re- confer rights

MHA Keystone / GLPP HIIN Requirements – Data Submission EOM Cover Page – Manual Entry Measures Keystone Data System (KDS) Location NOTE: These are manual entry measures (no other data sources available)

MHA Keystone / GLPP HIIN Requirements – Data Submission Updated EOM v. 2.0 – Updated 3/30/2017 Review EOM Cover page for updates under v. 2.0 Review FAQ Swing bed clarification

MHA Keystone / GLPP HIIN Requirements – Performance Critical Access Hospitals PG5 2 = FULL Points Bonus points can ONLY be used towards Keystone HIIN Quality Initiative section Non-Critical Access Hospitals PG5 2 = FULL Points

MHA Keystone / GLPP HIIN Requirements – Performance – CAH ONLY Hospitals will be scored on their own performance over time, and whether they are demonstrating improvement in: CAUTI (Urinary Catheter Utilization Ratio OR CAUTI Rate), EDTC 1 (Element 1 OR Element 2), and EDTC 4 (Element 1 OR Element 2 OR Element 3) rates from the designated (hospital-specific) baseline to the listed performance period (Table 3) The highest performing metric/element under the designated measure will be selected at the end of the program year Hospitals that maintain rates in the top quartile among all participating CAH hospitals will receive full points for improvement Please see Appendix A & Appendix B for measure definition

MHA Keystone / GLPP HIIN Requirements - Performance - NON-CAH ONLY Hospitals will be scored on their own performance over time, and whether they are demonstrating improvement in CAUTI (Urinary Catheter Utilization OR CAUTI SIR), Sepsis (Post-op Sepsis OR Sepsis Mortality) and Opioid ADE rates from the designated (hospital-specific) baseline to the listed performance period (Table 3). The highest performing metric under the designated measure will be selected. This aligns with how the MHA Keystone Center will track performance of hospitals in the HIIN for all measures. Hospitals that maintain rates in the top quartile among all participating hospitals will receive full points for improvement. Please see Appendix A for measure definition

MHA Keystone / GLPP HIIN Requirements – Performance Baseline & Performance Period Calculation Example  Urinary Catheter Utilization Baseline (Q1-2014) = 𝑆𝑈𝑀 𝑜𝑓 Numerator (𝑄1.2014) 𝑆𝑈𝑀 𝑜𝑓 Denominator(𝑄1.2014) Performance Period (Apr. 2017- Mar. 2018) = 𝑆𝑈𝑀 𝑜𝑓 Numerator (𝐴𝑝𝑟. 17−𝑀𝑎𝑟.18) 𝑆𝑈𝑀 𝑜𝑓 Denominator(𝐴𝑝𝑟. 17−𝑀𝑎𝑟.18)

MHA Keystone / GLPP HIIN Requirements – PFE The goal of this component is to implement a PFAC and/or include patient advisors on existing quality improvement team(s) by the end of the program year (if not currently implemented) Hospitals would be asked to report on this component minimally twice during the program year, by simply indicating fully implemented, partially implemented, or not implemented in Keystone Data System Please reference the MHA Community Website – Keystone Center Quality Initiatives – HIIN Foundational Concepts – Person & Family Engagement (PFE) folder for additional information on the launch of Patient & Family Advisory Councils and/or inclusion of patient advisors on existing quality improvement committees. NOTE: MHA Board of Directors Goal = JUNE 2017

MHA Keystone / GLPP HIIN Requirements – AMS Completion of the NHSN Patient Safety Annual Survey (which contains AMS questions) during 2017 will meet this requirement if the hospital has conferred rights to MHA Keystone Center Hospitals who do not submit to NHSN must complete the MHA Keystone Center AMS assessment. Survey link sent back in late March to HIIN Infection & Primary Contacts!

Submission of PFE Metrics in KDS PFE Data Submission Submission of PFE Metrics in KDS

Submission of PFE Metrics in KDS PFE Data Submission Submission of PFE Metrics in KDS

PFE Data Submission H2-2017 – PFE Status Update H1-2017 data locks at the end of June H1-2017 data will be automatically uploaded for ALL hospitals who submitted the data to H2-2017 survey period Come late June, you will be asked to UPDATE status under 2017/H2 for any “Non-Implemented” or “Partially Implemented” PFE measures that you have implemented! Note: THE PFE survey is live. You can update your status at any time during the ‘half year’ survey period!

BCBSM P4P Questions regarding BCBSM P4P GLPP HIIN requirements: KeystoneP4P@mha.org

MHA Keystone GLPP HIIN Updates & Reminders

GLPP HIIN Updates & Reminders Upcoming Training Opportunities: May 24: MHA Keystone Spring Workshop – HRO (East Lansing) Sep. 19: MHA Keystone Fall Conference – HAIs (Dearborn) Oct. 11 & 12: QuEST Training (Gaylord) Reminders: Data submission through Q1-2017 (manual entry) Resources: MHA Community - Keystone Center Quality Initiatives CMS PfP Webinars – available to all HIIN participants (national participation)

MHA Keystone PSO Updates & Reminders

Benefits of PSO Membership Comparative data reports Compare your hospital to other Keystone PSO member CAHs, as well as our national database Educational Programs and Activities RCA² Training May 31 (Grand Rapids), Sep. 20 (Livonia), Nov. 29 (Petoskey) Human Factors Engineering Training Safe Tables June 22 (Grand Rapids), Sep. (TBD), Nov. 28 (Petoskey)

Benefits of PSO Membership Culture Survey (Fall start date: Oct. 23) Included in PSO membership Administer either the SCORE or AHRQ HSOPS (both fulfill requirements for P4P PG5) Speak-up! Award and Toolkit Acknowledges frontline staff who speak-up! Toolkit has simple instructions and ready-to-use templates A culture of speaking-up can lead to: higher culture scores, lower costs to the hospital, increases in near-miss reporting

Ewa K. Panetta epanetta@mha.org