copyright ©2011 georgia hospital association flex grant kathy mcgowan vice president, quality &...

Copyright ©2011 Georgia Hospital Association

FLEX GRANT

Kathy McGowanVice President, Quality & Safety

Samantha DulworthTechnical & Customer Specialist

November 13, 2013


Georgia’s QI Program

• Structured on requirements of Medicare Beneficiary Quality Improvement Project (MBQIP), Culture of Patient Safety, Technical Assistance, Education, and Training for Critical Access Hospitals.

• Georgia Hospital Association Research & Education Foundation serves as sub-grantee for the Georgia FLEX QI Program since 2002


QI Program Participation

• CMS Core Measures• CMS Partnership for Patients• Hospital Consumer Assessment of Healthcare

Providers and Systems (HCAHPS)• Data submission to Hospital Compare• Scheduled education• Scheduled training & technical assistance


QI Objectives

• Public quality reporting• Participation in MBQIP• Raising staff awareness regarding patient

safety• Examining trends in patient safety culture


QI Overall Program Requirements

• Education & training in the use of CART, Core Measures and MBQIP

• Public reporting to Hospital Compare on relevant processes of care quality measures:

Inpatient Outpatient HCAHPS

• Hospital Engagement Network initiative


QI Overall Program Requirements

• Actively work towards staff awareness about safety

• Examine trends in patient safety culture• Identify areas of strength and possible

improvement• Consistently improve the patient quality of

care outcomes in Georgia’s Critical Access Hospitals


Purpose & Goal

• Ensure patient safety• Deliver expected quality patient care

outcomes


Hospital Benefits

• Quarterly dashboards• Quarterly core measure composite scores• Minimum of two CART trainings annually• HCAHPS and MBQIP training• QI technical assistance• CART technical and customer assistance• Onsite coaching


Hospital Benefits

• Resources Data collection tools & definitions CART manuals Transfer / discharge checklists Stabilizing core measure data submissions to Hospital Compare


Education / Training

• Patient and Family Centered Care• Rounding• TeamSTEPPS• Reliable Process Design• Frontline Defects Analysis• Plan-Do-Check-Act (PDCA) Process

Improvement Principles


Education & Training

• Organizational Assessment Tool (OAT)• Culture of Patient Safety Survey• Continue focus on core measures

Pneumonia-6 Heart Failure-1



• Phase III of MBQIP (started 9/1/13) Pharmacist/Computerized Physician Order Entry

(CPEO)/Verification of Medication Orders within 24 hours

Outpatient Emergency Department Transfer Communication

• Needs assessment survey to all CAHs to establish baseline



• ST Elevated Myocardial Infection (STEMI) Program


Conflict of Interest

• State Office of Rural Health, Georgia Medical Care Foundation and GHA staff meet once a month

• Work together to avoid duplicating efforts


HeRMES

Samantha Dulworth


Products


Data Flow using Cart

HeRMES


GHA Deadline CMS Deadline

UB04 Deadlines &Initial Population counts

Joint Commission Both Inpatient & Outpatient

Warehouse/Quality Net Outpatient Only and Quality Net Inpatient Populations

CMS/Quality Net InpatientOPPS Clinical

Q1 2013June 1st 2013 June 15th 2013 August 1st 2013 August 15th 2013

Q2 2013September 1st 2013 September 15th 2013 November 1st 2013 November 15th 2013

Q3 2013December 1st 2013 December 15th 2013 February 1st 2014 February 15th 2014

Q4 2013March 1st 2014 March 15th 2014 May 1st 2014 May 15th 2014

Care Core Submission Deadlines


CART

Inpatient CART Version 4.14 for Discharges (7/1/2013 -12/31/2013)

Outpatient CART Version 1.10 for Encounters (7/1/2013 - 12/31/2013)

Looking at Upload Reports

Summary of Data


Running Population Report


Population Report

Measures will show in Red if there are not enough cases submitted for

Global and Ed throughput


Questions?


Care Core Reports


Creating Report in Care Core


Reports (TJC Core Measures)


Reports (Values)


Reports (Drill Down)


Reports (Run Report)


Patient Level Drill Down


Patient Detail


Reports (TJC Core Measures)


Reports (Run Report)


HeRMES


Data Flow using Cart


What CARE Service Line has the Highest Mortality Rate?


What CARE Service Line has the Highest Mortality Rate?

1. Pick your Quality Indicator2. Pick your Values3. Pick CARE Service Line in Drill Down4. Click Run Report5. Find your highest CARE Service Line


Report Outcome


HeRMES


How many patients left your Emergency Department against

medical advice?


Left Without Being Seen

1. Click on High Risk Patient Safety2. Click Quality Indicator “ER Patients Who

Leave against medical advice”3. Click “Run Report”


Running Report


Report Outcome


HeRMES


Which Physician has the highest Mortality Rate?


Which Physician has the highest Mortality Rate?

1. Click on MedEval2. Click on Mortality under Quality Indicators3. Click Physician Name and NPI number under

“Drill Down”4. Click on “Run Report”


Report Outcome


CoPS


CoPS Log in Screen


Report Selection


Executive Level Dashboard


Executive Level Dashboard – line graph


Hospital Compare


Question Level Drill Down


CoPS Links

CoPS Website addresshttps://cops.gha.org/Account/Login.aspx

CoPS Campaign Request: http://cops.gha.org/survey/n/CoPSCampaignRequest.aspx

https://cops.gha.org/Account/Login.aspx

https://cops.gha.org/Account/Login.aspx

http://cops.gha.org/survey/n/CoPSCampaignRequest.aspx


Questions?


GHA Contact Information

Kathy McGowen, Vice President of Quality & [email protected] 770-249-4519Joyce Reid, Vice President of Community Health [email protected] 770-249-4545Samantha Dulworth, Customer and Technical [email protected] 770-249-4550

mailto:[email protected]



copyright ©2011 georgia hospital association flex grant kathy mcgowan vice president, quality &...

Documents

georgia flex qi program

patient safetyexamining

core measures pneumonia

core measure data submissions

mbqipraising staff awareness

use of cart

gha staff

cart trainings annuallyhcahps