MHA Keystone Center Update MICAH QN Meeting – August 18, 2017

BCBSM P4P – Keystone Lead Kristy Swadley - KeystoneP4P@mha.org

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

MHA Keystone / GLPP HIIN Requirements Critical Access Hospitals PG5 Updated Scoring Index 8/16/2017 Non-Critical Access Hospitals PG5

MHA Keystone / GLPP HIIN Requirements – Data Submission Monthly data submission of ALL 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 in KDS (no other data sources available)

MHA Keystone / GLPP HIIN Requirements – Data Submission GLPP HIIN EOM v. 2.1 – Updated 8/16/2017 To Do: Review EOM Cover page for updates under v. 2.1 Review FAQ

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) Baseline will be select based on data submission during outlined timeframes 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 NON-CAH PG: Please watch for updated scoring index identifying baselines for performance measures! Questions: keystonep4p@mha.org

MHA Keystone / GLPP HIIN Requirements – Performance – Baseline Data MHA Keystone is reviewing baseline data submission and will be reaching out to PG 5 participants to discuss: missing data baseline selection Questions? keystonep4p@mha.org

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.

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! Update: ALL PG5 hospitals have met this requirement!

PFE Mid-Year Data Update

PFE Mid-Year Data Update Status update on the five PFE metrics by verifying the data in the H-2 survey in the Keystone Data System (KDS) by Aug. 25 [report updates for any measure(s) that is now “Partially” or “Fully-implemented”] Reminder: PFE Metric 4 (BCBS P4P Requirement) needs to show “Fully Implemented” by the end of the 2017-18 program year

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: Sep. 19: MHA Keystone Fall Conference – HAIs (Dearborn) Oct. 11 & 12: QuEST Training (Gaylord) Reminders: Submit your data!!

Health Equity Series – Save the Date Webinar 1 – Setting the Stage for Success: PFE and Health Equity Thursday, September 21, 10:00 am - 11:00 am ET / 9:00 am - 10:00 am CT Webinar 2 - Collecting and Using REAL Data to Improve Quality and Safety Thursday, October 19, 10:00 am - 11:00 am ET / 9:00 am - 10:00 am CT Webinar 3 - Examples from the Field: How to Use REAL Data to Improve Quality and Safety

MHA Keystone PSO Updates & Reminders

PSO – Updates & Reminders Upcoming Training Opportunities: Sep. 12: Safe Table: Behavioral Health (Livonia) Sep. 20: RCA² Training (Livonia) Oct. 23-Nov. 10: Culture Survey Kickoff webinar #1: Aug. 28 Kickoff webinar #2: Sep. 6 Nov. 28: Safe Table: Rural Health (Petoskey) Nov. 29: RCA² Training (Petoskey) PSO Questions? Contact Adam Novak (anovak@mha.org)

Ewa K. Panetta epanetta@mha.org