 Intermountain HEN Measurement April 12, 2013

Introduction  Lucy Savitz, PhD, MBA  Overview of:  Changes in CMS requirement for reporting  Criteria for measure selection

 HEN Data Collection Process Amy Wuthrich

Data Collection Process: behind the scenes  The data template is generated using the COGNOS system and the data tables in the electronic data warehouse (EDW)  This allows for a extremely large amount of data to be condensed into a coherent document, for the entire HEN, rather than having to do it manually for each site

Data Collection Process: generating contact  The body of the is entered into the COGNOS system  SQL query connects the appropriate hospital/system ID to the appropriate contact  It takes several hours for the program to run  s are sent from the system to the data contact at the HEN hospitals approximately three weeks prior to data submission deadline

Data Collection Process: once we have data  Completed data requests are ed back to Jesse Gygi  Data is entered into the data tables which are stored on the EDW  Internal validity is established  2 person accuracy checks  If possible, run charts are sent back to hospital data contact to double check

Data Collection Process: once we have data  Preliminary run charts are created  HEN team meets to review the run charts  Looks for questions/concerns in the data reported  Correct any inconsistencies  Charts are prepared for CMS reports/feedback reports

Remaining 2013 Data Collection Milestones  May 20 th – January through March data  August 20 th – April through June data  November 20 th – July through September data

 HEN Data Process and Feedback Reports Tom Belnap

Monthly Progress Reports  Progress reports are submitted to CMS monthly  These include:  Narrative highlighting progress and successes  Data contribution and reporting from members  Data showing current rates on metrics  Barriers to continued improvement

Data Reporting Process

Feedback Reports  Feedback reports will be sent out to each site quarterly  Sent to data contacts first and then other contacts  Hospital data will be compared to the HEN average rate

Feedback Reports  Purpose of feedback reports:  Benchmark performance against HEN  Track hospital progress over time  Ensure data completeness and accuracy  Encourage dialog within hospitals and greater involvement/communication across the HEN  We welcome feedback on the feedback and any suggestions

 Reporting to CMS Jason Scott

What we report to CMS  HEN level run charts  Run charts stratified by hospital bed size large – 331+ beds medium – 140 to 330 beds small – 1 to 139 beds  Hospital specific success stories with your approval

HEN level run charts

Stratified run charts

Hospital success stories 