1 Quality Health Indicators Brought to you by… Left click mouse or use down arrow to proceed through this presentation

2 About QHi The PiHQ Portal Defining your facility Selecting Measures Entering Data Dashboards Reports How we use the data Select any menu item above to go directly to a topic or click to continue through the presentation. Main Menu

3 Quality Health Indicators  The Quality Health Indicator (QHi) web site was developed through the Kansas Hospital Association, KHA, and KRHOP the Kansas Rural Health Options Project to facilitate a benchmarking project for rural Kansas hospitals.  The goal of QHi is to provide hospitals an economical instrument to evaluate internal processes of care and to seek ways to improve practices by comparing specific measures of quality with like hospitals.  Using QHi as a tool, regional networks of hospitals and individual facilities can select from a library of indicators to determine which measures meet their unique needs.

4 Quality Health Indicators  More than 700 users in over 200 Critical Access and other small rural hospitals in Alaska, Arizona, California, Colorado, Kansas, Louisiana, Michigan, Minnesota, Missouri, Nebraska, New Mexico, Oklahoma and Wyoming use QHi as a data collection and benchmarking tool.  As a user-driven multi-state project, QHi is well-positioned to serve as a significant repository of information on quality of care and performance in rural hospitals nationwide.

5 Four Pillars Of Measurement Quality Health Indicators Clinical Quality Employee Contribution Patient Satisfaction Financial Operational

6 QHi Core Measures Set Clinical Quality Hospital Associated Infections per 100 inpatient days Unassisted Patient Falls per 1000 inpatient days Inpatients Receiving Pneumonia Immunization (CMS PN-2) Pneumonia Patients Given Antibiotics within 6 hours of admission (CMS PN-5c) Employee Contribution Benefits as a Percentage of Salary Staff Turnover All participating hospitals are asked to collect and report the 8 QHi Core Measures: Financial Operational Days Cash on Hand Gross Days in AR

7 Clinical Quality Measures  Inpatients Screened for Pneumonia (not a CMS measure)  Medication Omissions Resulting in Medication Error  Medication Errors Resulting from Transcription Errors  ER Provider Response Times  Return ER Visits within 72 hours with same/similar diagnosis  Readmits Within 30 Days with Same or Similar Diagnosis  Hospital Associated Infections per 100 inpatient days*  Unassisted Patient Falls per 1000 inpatient days* CMS Pneumonia Measures  Inpatients Receiving O2 Assessment within 24 hours of admission - CMS Pn-1 (retired)  Inpatients Receiving Pneumonia Immunization - CMS PN-2*  Pneumonia Patients Given Antibiotics within 6 hours of admission - CMS PN-5c * CMS OP Transfer Measures  Percentage of eligible patients who received thrombolytic therapy - CMS OP-1 and OP-2  Median Time from Emergency Dept Arrival to Time of Transfer to another Facility for Acute Coronary Intervention - CMS OP-3  Number of AMI patients without aspirin contraindications who received aspirin within 24 hours - CMS OP-4  Percentage of AMI or Chest Pain patients receiving ECG within 10 minutes of arrival (prior to transfer) - CMS OP-5 *Part of the 8 Core Measure Set Additionally, facilities can select from over 90 measures in the QHi library of indicators:

Clinical Quality Measures (continued ) HF Measures  Discharge Instructions provided to HF patients – CMS HF-1  Evaluation of LVS Function – CMS HF-2  ACEI or ARB for LVSD – CMS HF-3  Adult Smoking Cessation Advice/Counseling – CMS HF-4 SCIP Measures  Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision – CMS SCIP-Inf-1a  Prophylactic Antibiotic Selection for Surgical Patients – CMS SCIP-Inf-2a  Prophylactic Antibiotics Discontinued Within 24 Hours after Surgery End Time – CMS SCIP-Inf-3a  Surgery Patients with Appropriate Hair Removal – CMS SCIP-Inf-6  Urinary Catheter Removed on Postop Day 1 or Postop Day 2 with Day of Surgery being Day 0 – CMS SCIP-Inf-9  Surgery Patients with Periop Temperature Management – CMS SCIP-Inf-10  Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Periop Period – CMS SCIP-Card-2  Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered – CMS SCIP-VTE-1  Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery – CMS SCIP-VTE-2 8

9 Employee Contribution Measures  Non-Nursing Staff Turnover  Average Time to Hire (All Staff)  Nursing Staff Turnover  Average Time to Hire (Nursing)  Average Time to Hire (Non-Nursing)  Salary to Operating Expenses Comparison  Benefits as a Percentage of Salary*  Staff Turnover* Patient Satisfaction Measures  How well staff worked together to care for the patient (QHi1)  The extent to which the patient felt ready for discharge (QHi2) In addition to these original QHi patient satisfaction measures, 22 HCAHPS measures are now in the library of indicators. *Part of the 8 Core Measure Set Hospital Characteristic Measures  Average Inpatient Days  Monthly Inpatient Census  Multi-State ALOS (in hours) Comparison  ALOS (in hours) Comparison

10 Financial  Bad Debt Expense  Charity Care  Cost per Patient Day  Labor Hours per Patient Day  Operating Profit Margin  Current Ratio  Net Patient Revenue per Patient Days  Payer Mix – Commercial  Payer Mix – Medicaid  Payer Mix – Medicare  Payer Mix – Other  Payer Mix – Other Government  Payer Mix – Self/Private Pay  Days Cash on Hand *  Gross Days in AR * Financial & Operational Measures Operational  Physical Therapy Labor Hours per Unit of Service  Laboratory Labor Hours per Unit of Service  X-ray Labor Hours per Unit of Service  Mammogram Labor Hours per Unit of Service  Ultrasound Labor Hours per Unit of Service  CT Labor Hours per Unit of Service  MRI Labor Hours per Unit of Service  Pharmacy Labor Hours per Unit of Service  Nursing Hours per Patient Day  Rural Health Clinic Encounters per FTE  Long Term Care Hours per LTC Patient Day  Laboratory Hours per Billed Service *Part of the 8 Core Measure Set

11 Web Site Access An address and password are required to enter this secure web site. The level of access is determined by the User type : System Administrator – maintains the site – KHA/KHERF State Administrator –provides support to Hospital Contacts in their State Network Administrator – maintains Network profiles & provides support Hospital Contact – maintains Hospital profiles, adds users & enters data Hospital User – enters data and runs reports View Only – views data and runs reports Report Recipient – no access to QHi, only receives reports Quality Health Indicators

12 The PiHQ Portal Return to Main Menu

Users navigate through the suite of resources in the PiHQ Portal by using blue links across the top.

Hover text provides a brief description of each resource.

All QHi, HSI and SQSS users have access to the PiHQ search engine.

Users type in search topic here Or on any page throughout the portal here

Results are pulled from all Portal resources. Future enhancements will allow users to pull from resources outside of PiHQ as well.

The Resource Library holds all resource materials developed for PiHQ.

All users have access to the Resource Library

Results are pulled from all Portal resources. Icons identify the source of the information.

All users have access to the Calendar

The Calendar provides registration information for upcoming Quality Training Sessions

Users with access to the application are directed to the home pate, without additional log in.

All HCAHPS measures can be automatically pulled from HSI and uploaded directly into QHi, eliminating duplicate entry. Future enhancements will allow any HSI measure to be uploaded into QHi.

This Calendar system, developed by Darlene Bainbridge, is now in live beta-testing. Users with access to the application are directed to their customized home page, without additional log in.

Partners in Healthcare Quality are working with 2 notable Risk Management vendors to pull aggregate data directly into QHi, further reducing data entry, and enhancing comparative analysis and benchmarking opportunities.

28 Defining Your Hospital Return to Main Menu

29 Click Administration to view Hospital Profile page Users navigate through QHi by clicking the main menu and sub-menu options

30 All fields with a red asterisk * are required fields Hospital Characteristics define each facility for creation of peer groups when running reports Hospital Contacts are responsible for completing and maintaining the Hospital Profile page for their facility.

31 Click drop-down to select Level of Measurement. This applies only to Financial/Operational measures Question marks ? provide pop-up definitions throughout the QHi site

32 Selecting Measures Return to Main Menu

33 Click here to go to Measures Selection page

34 In Collected Measure Sets, users can select the default measures predetermined by their state or network The QHi Core Measure Set is pre- selected as it is required for all hospitals Additional Measure sets are available here

35 Collected Measures lists the measures within the measure sets currently collected by the hospital Individual measures are selected and displayed under Additional Measures.

36 Additional Measures lists (1)Individual measures currently collected and (2) other measures that are available to collect Indicates the number of hospitals in QHi collecting the measure Click the plus + icon to measure to Currently Collecting Click the negative - icon to remove measure from Currently Collecting

37 Click question mark icon ? to display the calculation for each measure Click show elements to display the elements required to calculate the measure

38 Entering Data Return to Main Menu

39 Click Data Submissions to open the Data Submission page

40 Select correct month and year from Month to add drop-down Click Save to save data entered IMPORTANT: User must check Activate data for reporting box in order for the data entered this month to be displayed on dashboards or in reports Data elements populate the data entry screen based on measures selected in the Hospital Profile. Click Go to: drop-down to select prior months’ data submissions

41 If data for the month is entered and saved but not activated, this message will appear to remind the user to activate data for reporting

42 Data elements automatically populate this screen based on the measures selected by the user in the Measures Selection page Click to automatically calculate measures and immediately display results The prior month’s data is displayed for easy reference

43 The Dashboard Return to Main Menu

44 The Core Measures Dashboard provides comparison data for the eight QHi Core Measures Roll mouse over any dashboard graph to view the calculation The Dashboard can be viewed as a table

45 table View The Dashboard can also be viewed as combined graph and table

46 Graph and table View

47 Dashboard data is calculated using a consecutive three month summing average Dashboard data is calculated using a consecutive three-month summing average State Avg values reflect data from hospitals in the same state as My Hospital and reported in the same time interval QHi Avg values reflect data from all hospitals in QHi reporting the same measure in the same time interval

48 Financial measures on the Dashboard default to peer groups based on the hospital’s level of reporting (Hospital Only or Entire Enterprise) A hospital must have activated data for at least one of the three months in the Date Range in order for the measure to be displayed on the Dashboard My Hospital data for some clinical measures will not display on the Dashboard if the hospital had no occurrences during the Date Range period

49 The three months in the Date Range can be changed by clicking the drop-down to select the start month for the desired three-month period

50 Click here to view the Dashboard as a PDF

51 PDF view The PDF format allows the user to save, print or the Dashboard in graph, table or graph/table views

52 Users can the Dashboard in PDF to themselves by clicking To Myself …or choose another recipient

53 User selects from a list of existing registered users …or choose to add a new recipient

54 Enter the name and address of the new recipient …and click Add New

55 …Enter the Name and address of the new recipient …and click Add New

56 Click Create Schedule to establish a pre-determined schedule for ing Dashboard reports to selected recipients

57 1.Select run date (Click on calendar icon) 2.Select frequency (click drop-down) 3.Select recipients 4.Click Save Schedule Dashboard is sent through (as scheduled) as a PDF attachment 57 1.Select a run date 2.Select the frequency 3.Select Recipients 4.Save Schedule 5.Report is sent through as a PDF attachment.

58 Click View My Dashboard to create a customized Dashboard

59 Only those measures being collected by the hospital will be available in the list Click drop-down to select a measure to display on Dashboard Selected measures are retained and are user specific Notes section available to add comments or additional information

60 Reports Return to Main Menu

61 Click Reports to view measures and create reports

62 There are 6 categories of reports: 1.Clinical Quality 2.Employees 3.Financial Operational 4.Hospital Characteristics 5.Patient Satisfaction 6.System A hospital can view reports only for the measures and data elements it is collecting The measures being collected by the hospital are listed in each category Click on a measure to create a report

63 Pick peer groups Select date criteria

64 Pick optional hospital characteristics Multiple criteria selected will more narrowly define the peer group

65 Available values are listed for the criteria chosen in Step 3

66 Displays and holds the criteria selected The report can be displayed in four formats

67 Line Graph View

68 Bar Graph View

69 table View The user’s facility is identified as Hospital Click to export report data to Excel

70 Text Detail Measure View Note that peer hospitals are not identified by name Click to export report data to Excel

71 From the Excel report users can create customized graphs to meet their needs

72 Text Detail Measure View Click on the envelope icon to contact a peer hospital for benchmarking information

73 The Hospital Contact at the selected peer hospital will receive the message

74 Training and educational materials are available for download on the Help page

75 How we use the data Return to Main Menu

76  I print a copy of the graphs and take it to the board for discussion. They appreciate seeing in color how we compare to other CAHs in KS as well as others in the USA.  On a quarterly basis I am giving a copy of the bar graphs to our Board Members at their meeting.  I give the Quality Committee a copy of the quality reports on a quarterly basis.  We track and present our indicators monthly and are usually above the norm. On the occasions when we fall below, it prompts us to review processes to seek improvements.  If we fall below expectations, we look for ways to improve and then report back to the board in the next quarter.  We like the Days in AR report. This is our only source for comparative information on this measure. Quality Health Indicators What do we do with the data? A few comments from our hospitals…

77 Thank you for viewing this demonstration. If you have any questions or would like additional information on the QHi project, please contact: Sally Perkins, QHi System Administrator or Stuart Moore, QHi Coordinator Quality Health Indicators