Hospital QIPPublic Comment Webinar

March 8, 2017

HousekeepingHousekeepingTo avoid echoes and feedback, we request that you use the telephone instead of your computer microphone for listening/talking during the webinar.

If you are having technical difficulties, please let us know by using the “question” box.

This webinar is being recorded and will be emailed following the presentation

Following the Measurement Set review we will open the floor for Q&A.

ObjectivesObjectives

• Background and Summary of Proposed Measures 12:00‐12:05

• Proposed Changes to Existing Measures 2:05‐12:25

• Proposed New Measures  12:25‐12:45

• Provider Comment 12:45‐1:00

Hospital QIP TimelineHospital QIP Timeline

Current Measurement Year: 2016‐17

Measurement Set Development for: 2017‐18

July 1 2016 (start of 2016‐17 measurement year)

January‐March 2017(2017‐18 measure development)

June 2017(Publish 2017‐18 

Measures)

Guiding PrinciplesGuiding Principles1. Where possible, pay for outcomes instead of processes

2. Actionable measures

3. Feasible data collection

4. Collaboration with providers in measure development

5. Simplicity in the number of measures

6. Representation of different domains of care

7. Align measures that are meaningful

8. Stable measures

Summaries of Proposed Measures

2016‐17 Large Hospital Measures Proposed 2017‐18 Large Hospital Measures PointsHIE RequirementAdmissions, Discharge, and Transfer (ADT) interface

HIE RequirementFirst‐year QIP Participants:Admissions, Discharge, and Transfer (ADT) interface

Existing QIP Participants:Lab results and transcribed reports (ORU) or Medication list update (RDE)

N/A

1. All‐Cause Adult Readmission Rate*2. Advance Care Planning (Documentation of Inquiry or 

Obtained ACP Documentation)3. Elective Delivery before 39 weeks4. Exclusive Breast Milk Feeding 5. Vaginal Birth After Cesarean (VBAC)6. Timely Participation in California Perinatal Quality Care 

Collaborative Data Reporting7. Timely Participation in California Maternal Quality Care 

Collaborative Data Reporting8. VTE‐5 – VTE Warfarin Therapy Discharge Instructions9. VTE‐6 – Hospital‐Acquired Potentially‐Preventable VTE10. STK‐4 – Thrombolytic Therapy11. eTARs

*Back‐up measure: Follow‐up Post‐Discharge visit

1. All‐Cause Adult Readmission Rate* Advance Care Planning (Documentation of Inquiry or Obtained ACP Documentation)

2. Elective Delivery before 39 weeks 3. Exclusive Breast Milk Feeding

Vaginal Birth After Cesarean (VBAC)4. Timely Participation in California Perinatal Quality Care 

Collaborative Data Reporting5. Timely Participation in California Maternal Quality Care 

Collaborative Data ReportingVTE‐5 – VTE Warfarin Therapy Discharge Instructions

6. VTE‐6 – Hospital‐Acquired Potentially‐Preventable VTESTK‐4 – Thrombolytic TherapyeTARs

7. Palliative Care Capacity8. C‐Section Rate for First‐Time Mothers9. CHPSO Participation10. Infection Prevention Plan*Back‐up measure: Follow‐up Post‐Discharge visit

20

1010

5

5

5

10101010

2016‐17 Small Hospital Measures Proposed 2017‐18 Small Hospital Measures

Points

1. All‐Cause Adult Readmission Rate*

2. eTARs

*Back‐up measure: Follow‐up Post‐Dischargevisit

1. All‐Cause Adult Readmission Rate*

eTARs

2. Palliative Care Capacity

3. CHPSO Participation

4. QI Training Option

*Back‐up measure: Follow‐up Post‐Discharge visit

30

30

20

20

Existing Measures

HIE Participation RequirementHIE Participation Requirement

As the Hospital QIP is expanding with new participants added each year, we propose stratifying the HIE requirement by participation year:

• Existing Hospitals (2016‐17 and prior): hospitals to contribute to and retrieve ORU (lab results and transcribed reports) or RDE (medication list update) in addition to ADT interface with their established HIE partner. 

• New Hospitals (2017‐18): hospitals to implement ADT interface with their established HIE partner.

Readmissions (small and large hospitals) Readmissions (small and large hospitals) 

No change from 2016‐17.

DescriptionPercentage of acute hospital admissions that are within 30 days of a discharge. 

Numerator: The total number of adult acute inpatient stays that were followed by an unplanned acute readmission for any diagnosis within 30 days of discharge. 

Denominator: Total number of adult acute inpatient discharges from July 1‐May 31 during the measurement year.

Advance Care Planning (small and large hospitals)Advance Care Planning (small and large hospitals)

Proposed to Remove.

RationaleACP is a priority area for PHC, and we want to encourage more substantial ACP programs at our participating HQIP hospitals. 

For this reason, we would like to remove this outcome measure and replace with a more upstream Palliative Care Capacity measure (details on slide 22).

Rate of Elective Delivery before 39 weeks (large hospitals)Rate of Elective Delivery before 39 weeks (large hospitals)

No change from 2016‐17.

DescriptionPercent of patients with newborn deliveries at ≥ 37 to < 39 weeks gestation completed, where the delivery was elective.

Numerator: The number of patients in the denominator who had elective deliveries. 

Denominator: Patients delivering newborns with ≥ 37 and < 39 weeks of gestation completed during the measurement year.

eTARs (large and small hospitals)eTARs (large and small hospitals)

Proposed to remove.

RationaleAll hospitals met this measure in 2015‐16, with a plan‐wide 96.9% timely eTAR rate. 

We do not see need for improvement here and propose to remove this measure.

Exclusive Breast Milk Feeding Rate (large hospitals)Exclusive Breast Milk Feeding Rate (large hospitals)

No change from 2016‐17.

DescriptionExclusive breast milk feeding rate for all newborns during the newborn’s entire hospitalization. 

Numerator: The number of newborns in the denominator that were fed breast milk only since birth. 

Denominator: Single term newborns discharged alive from the hospital during the measurement year

Vaginal Birth after Cesarean (VBAC) (large hospitals)Vaginal Birth after Cesarean (VBAC) (large hospitals)

Proposed to Remove.

RationaleWe have heard from participating hospitals that it is expensive to set up a successful VBAC program and funds available through the QIP are not sufficient to establish a new program. 

We propose to remove this measure and to add a more upstream measure: C‐Section rate among first‐time mothers (see description on slide 19). 

California Perinatal Quality Care Collaborative (large hospitals)California Perinatal Quality Care Collaborative (large hospitals)

No change from 2016‐17.

DescriptionParticipation in the California Perinatal Quality Care Collaborative. 

Full Points: Six or more months participating in CPQCC and submitting data to CPQCC for at least 6 months of the measurement year 

Partial Points: Join CPQCC and submit data by June 30, 2017 (end of the measurement year) = 2.5 points 

California Maternal Quality Care Collaborative (large hospitals)California Maternal Quality Care Collaborative (large hospitals)

No change from 2016‐17.

DescriptionParticipation in the California Maternal Quality Care Collaborative. 

Full Points: • For hospitals new to the 2016‐17 Hospital QIP: six or more 

months of Active Track participation during the measurement year 

• For hospitals participating prior to 2016‐17: 12 months of Active Track participation during the measurement year = 5 points 

Partial Points: Establish Active Track participation in CMQCC

VTE Prophylaxis (large hospitals)VTE Prophylaxis (large hospitals)

Proposed to remove STK‐4 and VTE‐5 components.

RationaleSTK‐4 and VTE‐5 are set to be removed from JC’s 2017 (next version) specifications set. This change is to address the removal of these measures from CMS’ Hospital Inpatient Quality Reporting program beginning with 1/1/2017 discharges. 

We propose to also remove these measures to align with JC.

Proposed New Measures

Primary C-section rates for first time mothers (large hospitals)Primary C-section rates for first time mothers (large hospitals)

DescriptionPercentage of nulliparous women with a term, singleton baby in vertex position delivered by cesarean birth. 

RationaleThis is a national priority area: a Joint Commission Measure and a Healthy People 2020 goal.

Target:• Full Points: < 23.9% (HealthyPeople 2020 Goal)• Partial Points: <25.9%

This measure will apply to any large hospital (> 50 general acute beds) doing deliveries, with no minimum delivery.

Infection Prevention Plan (large hospitals)Infection Prevention Plan (large hospitals)

DescriptionWe propose the addition of a measure to monitor infection control and prevention efforts at our contracted hospitals.

RationaleInpatient infections are a national issue and safety concern supported by organizations such as The Joint Commission, CDC, and CMS. Literature suggests that in spite of improvements, hospital‐onset infections, particularly C. diff, are still a large problem area.

SpecificationsHospitals will report to PHC an infection prevention attestation form at the beginning of the measurement year. The form should include information on: • Roles of staff members participating in the infection prevention team• Measureable and actionable goals• What data will be gathered and used• How data will be reported

Infection Prevention Plan (large hospitals)Infection Prevention Plan (large hospitals)

Infection Prevention Plan Submission:

Infection Prevention Team Information• Name, title, responsibilities, and FTEs of Infection Prevention Team 

members• Description of how the team is selected, their reporting structure within the 

hospital, and how often the team meets

Improvement Plan• What activities/changes/interventions are planned to make improvements 

in this area? Please describe the changes, who will make the changes, and timelines for changes.

• How will you measure the effect of changes implemented? Describe the goal, the measurement strategy including the population impacted, measurement periods and timelines.

CHPSO Participation (large and small hospitals)CHPSO Participation (large and small hospitals)

DescriptionAdd a measure to encourage active participation in the California Hospital Patient Safety Organization.

RationalePatient safety is a key focus area of many hospitals and their QI staff. Like other QI activities, it is important to take a data‐drive approach and share best practices with peers. CHPSO provides both a confidential space and expertise to bring transparency to this area, and we would like to align with their efforts

SpecificationsUpon joining CHPSO and establishing patient safety evaluation system (PSES), requirements may include one or more of the following:• Attend at least one Safe Table Forum in‐person or via phone• Share patient safety data with CHPSO

Palliative Care Capacity (large and small hospitals)Palliative Care Capacity (large and small hospitals)

DescriptionWe propose to add a measure incentivizing development of palliative care teams. 

RationaleEstablishing dedicated, trained palliative care teams are key to providing more Advance Care Planning opportunities for our members.

SpecificationsHospitals with at least 20 general acute beds can meet the Advance Care Planning measure by one of the following options:

1. Dedicated inpatient palliative care team (option for large or small hospitals) 2. At least two nurses trained in ENLEC or EPEC, and an arrangement for availability of 

either video or in‐person consultation with a palliative care physician (option for small hospitals only)

Palliative Care Capacity (large and small hospitals)Palliative Care Capacity (large and small hospitals)

Name Title Responsibilities Palliative Care FTEs

Option 1: Palliative Care Team:

Please include name, title, and responsibilities of members below:

Option 2: At least two nurses trained in ELNEC or EPEC and an arrangement for availability of either video or in-person consultation with a palliative care physician (for hospitals with < 50 general acute beds)

Please complete the following information for trained nurses, and include ENLEC or EPEC training certificate or attendance record:

Name Title Date/ location of Training

Please complete the following information for palliative care physician, and include a report indicating total number ofpalliative care consultations between July 1, 2017 and June 30, 2018:

Name Title Responsibilities

Please include a brief description of how the team is selected, their reporting structure within the hospital, how often the team meets, number of patients served in 2017-18, and team goals/challenges addressed in 2017-18

QI Training Option (small hospitals)QI Training Option (small hospitals)DescriptionAttendance at a hospital QI training event facilitated by select healthcare QI organizations.

Rationale:There are many Hospital QI resources and trainings available, and we hope an incentive would allow hospitals to send/enroll more staff in QI trainings to drive performance in impactful areas of healthcare delivery.

SpecificationsParticipate in a PHC‐approved program or training aimed at improving one aspect of hospital quality. At least 2 staff members are involved in the training; training should total at least 4 hours per staff member/provider involved. If uncertain whether a training would qualify, you may HQIP@partnershiphp.org for approval prior to the training. Possible training areas:• Infection control or prevention• Outpatient care coordination• Telemedicine services• Perinatal Care

QI Training Option (small hospitals)QI Training Option (small hospitals)

6. Improvement Plan

a. Based on the training, what areas are you targeting for improvement?

b. What activities/changes/interventions are planned to make improvements in the areas targeted? Pleasedescribe the changes, who will make the changes, and timelines for changes.

c. How will you measure the effect of changes implemented? Describe the goal, the measurement strategyincluding the population impacted, measurement periods and timelines.

Training Option: Part I Submission (Improvement Plan) Template

(Due January 31, 2018)

1. Training attended and date of training:

2. Training organization:

3. Area of focus (please check one):

Infection Control or Prevention Perinatal Care Services

Outpatient Care Coordination Other: ___________________________

Telemedicine Services Capability

4. Objective(s) of the training:

5. Name and title of participating employees and length of training per attendee

QI Training Option (small hospitals)QI Training Option (small hospitals)Training Option: Part II Submission (Progress Report)

Template (Due July 31,

2018)

1. Based on your improvement plan, what activities/changes/interventions were completed? Please describe the activities (who did what and by when).

2. Comparing your re-measurement periods to baseline and other sources of data, did you observe improvements in the areas targeted? Did you meet your stated objectives in your improvement plan? Please describe changes in performance and which changes you believe contributed to improvements observed.

3. What challenges did you experience and how did you overcome these?

4. Attach patient feedback tool (e.g. comment cards, survey, etc)

Submitted by (Name & Title) on (Date)

2017‐18 Summary: Large Hospitals2017‐18 Summary: Large HospitalsProposed 2017‐18 Large Hospital Measures Points Reporting

HIE RequirementFirst‐year QIP Participants:Admissions, Discharge, and Transfer (ADT) interface

Existing QIP Participants:Lab results and transcribed reports (ORU) or Medication list update (RDE)

N/A Implementation Plan• Due October 31, 2017

Attestation• Due August 31, 2018

1. All‐Cause Adult Readmission Rate*2. Elective Delivery before 39 weeks 3.  Exclusive Breast Milk Feeding4. Timely Participation in California Perinatal Quality Care Collaborative Data Reporting 5. Timely Participation in California Maternal Quality Care Collaborative Data Reporting 6. VTE‐6 – Hospital‐Acquired Potentially‐Preventable VTE7. Palliative Care Capacity8. C‐Section Rate for First‐Time Mothers9. CHPSO Participation10. Infection Prevention Plan

*Back‐up measure: Follow‐up visit within 4 calendar days of discharge

20101055515101010

No Reporting by HospitalAugust 31, 2018August 31, 2018No Reporting by HospitalNo Reporting by HospitalAugust 31, 2018August 31, 2018August 31, 2018No Reporting by HospitalAugust 31, 2018

2017‐18 Summary: Small Hospitals2017‐18 Summary: Small Hospitals

Proposed 2017‐18 Small Hospital Measures Points Reporting1. All‐Cause Adult Readmission Rate*

2. Palliative Care Capacity

3. CHPSO Participation

4. QI Training Option

*Back‐up measure: Follow‐up visit within 4 calendar days of discharge

30

30

20

20

No Reporting by Hospital

August 31, 2018

No Reporting by Hospital

Part I: January 31, 2018Part II: August 31, 2018

Questions or Comments?Questions or Comments?

Please use the “hand raise” function to ask questions or the question box.

We will answer questions in the order in which they are received.

ResourcesResources

• PHC Hospital QIP web page: 

http://www.partnershiphp.org/Providers/Quality/Pages/HQIPLandingPage.aspx

• For HQIP questions: HQIP@partnershiphp.org

Hospital QIP Next StepsHospital QIP Next Steps

• Email HQIP@partnershiphp.org to be added to our email list