1. MHA Keystone Center
MICAH QN Meeting - May 19, 2017

2. Introduction
Kristy Swadley

3. 2017-18 BCBSM P4P Pg5 Program – GLPP HIIN Quality Initiative
Updates & Reminders

4. 2016-17 BCBSM P4P PG5 program ended March 31, 2017
Reminder:
BCBSM P4P PG5 program ended March 31, 2017
MHA Keystone Center Final Score Performance Reports ( program)
Delivery Date: by June 16
To: BCBS P4P Primary Contacts
From:
Questions/Concerns: respond by June 30

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

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

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

8. 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

9. 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)

10. 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!

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

12. 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)

13. 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

14. 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

15. 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

16. 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

17. 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 Mar. 2018) = 𝑆𝑈𝑀 𝑜𝑓 Numerator (𝐴𝑝𝑟. 17−𝑀𝑎𝑟.18) 𝑆𝑈𝑀 𝑜𝑓 Denominator(𝐴𝑝𝑟. 17−𝑀𝑎𝑟.18)

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

19. 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!

20. Submission of PFE Metrics in KDS
PFE Data Submission
Submission of PFE Metrics in KDS

21. Submission of PFE Metrics in KDS
PFE Data Submission
Submission of PFE Metrics in KDS

22. PFE Data Submission H2-2017 – PFE Status Update
H data locks at the end of June
H data will be automatically uploaded for ALL hospitals who submitted the data to H 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!

23. BCBSM P4P
Questions regarding BCBSM P4P GLPP HIIN requirements:

24. MHA Keystone GLPP HIIN
Updates & Reminders

25. 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 Q (manual entry)
Resources:
MHA Community - Keystone Center Quality Initiatives
CMS PfP Webinars – available to all HIIN participants (national participation)

26. MHA Keystone PSO
Updates & Reminders

27. 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)

28. 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

29. Ewa K. Panetta