Data Management5.18.2018

BCBSM Attestation Due June 1st

KDS & NHSN - monthlyQuarter 2 Data

MBQIP due to Crystal by July 24th

Outpatient due to QNet/Quantros by August 1st

Inpatient due to QNet/Quantros by August 15th

ED-1 and ED-2 Initial population is the same as IMM-2

▪ Inpatient hospitalization for acute medical/surgical care

▪ Does not include Observation patients

▪ Does not include Swing Bed patients

▪ Does not include Inpatient Hospice patients

▪ No, it’s not specifically defined In the Specs Manual

Tip from Josh: If you are sampling your total population for the ED measures, make sure to remove cases before you sample.

Questions

EDTC Composite Measure Report only for the current BCBSM P4P PG5

Program year (Q2 2018 through Q1 2019)

http://www.mcrh.msu.edu/programs/CAH/Quality%20Improvement%20NEW.html

MICAH QN Measures – Excel Sheet

BLHED-1b Median Time from ED Arrival to ED Department for Admitted

Patients VARIANCE REPORT

299

268

290

285

280

247

256254

240

232

230

259

243242

255257

250

260

270

300

310

January February March April May June July August September October November December

Axi

sTi

tle

BLH meets target 247 min

BLH - Rapid Triage and Pull

until FullGoal-door to room < 6min

BLH - Collaboration and goal

sharing with IP and HouseSupervisors orders received to

depart < 15min

BLH - New charge nurse

role posted and hired to

facilitate throughputBLH - Phlebotomistin ED

BLH - Standard work for pt.

room prep

BLH - Triage Lean standardwork developed and trained

BLH - Registration standard

work and improvement in

communication

From our last meeting

Sherri’s use of a Run Chart that includes:• Target line• Initiatives/Action taken

Current

Reporting

Period

Average TargetMeasure

1.4%1.9%since

Q2 14

Average

<=3%

Bad Debt/Charity Care

Write-off Percentage

Trend - When 6 or more data points are all going up or down. A trend suggests the process needs to be reviewed because something has changed which is causing a significant effect. This usually indicates a process in transition.

Shift – When 8 or more consecutive data points are all either above or below the center line. Values on the line can be ignored. A shift can be positive or negative, but likely comes as a result of a significant change.

Redlines are set at 3 Standard Deviation - 99.7% of the data points will fall within 3 standard deviations. We are perfectly designed to score between the red lines.

Q4 2017BC P4P Year

Q2 17 - Q1 18Target

Hospital Compare and Blue Cross Blue Shield of Michigan (BCBSM)

Pay for Performance MeasuresMeasure

Emergency

Department

Throughput

Times

Time from Door to

Physician Evaluation

14Minutes

15

< 33

BC P4P full

payment

Trend

Davis BalestracciHarmony Consulting, LLCPortland, ME(207)-899-0962www.davisdatasanity.com

For an interesting approach to data…

Mini-lessons can be found on YouTube (posted by QIO/CMS)- Bite-Size Learning: Run Charts (Davis Balestracci)- Bite-Size Learning: Red-Yellow-Green (Davis Balestracci)- Bite-Size Learning: Commons Cause (Davis Balestracci)

The EDTC Technical Expert Panel in conjunction with the University of Minnesota Rural Health Research Center are recommending the NQF make modifications to the EDTC measures.

If the recommendations are endorsed by the NQF, we will see the changes take effect in the Spring of 2019.

Keep

Medications administered in the ED

Allergies

Home Medications

Provider note

Mental status/orientation

Reason for transfer and/or plan of care

Tests and procedures done

Tests and procedures sent

Administrative communication - remove nurse to nurse and physician to physician communication

Patient information - remove name, address, age, gender, significant other contact info, and insurance

Vital Signs – remove P, RR, BP, Temp, O2 Sat and modify neuro status

Nurse generated info – remove immobilizations, cath’s, respiratory support, oral limitations, and modify sensory status

EDTC Next Steps

U of MN “measure owner and steward”

submits revisions to National Quality

Forum to update endorsement.

With NQF endorsement…

• EDTC and MBQIP

• Data collection and submission

• CMS Outpatient Prospective Payment

System (OPPS) measures

21

RQITA Overview: Tools andResources

RQITA Overview: Tools and ResourcesNew or recently updated

– Patient and Family Engagement in Critical Access Hospitals: A Flex ProgramStory (new)

– Quality Improvement Implementation Guide and Toolkit for CAHs (updated)

– Flex Program Resources: Inpatient and Outpatient Measure ComparisonTemplate (updated)

– Interpreting MBQIP Hospital Data Reports for Quality Improvement (updated)

Ongoing:

– MBQIP Monthly

– MBQIP Data Reporting Reminders

https://www.ruralcenter.org/ to get to these resources - use the search feature