MICAHQN Quarterly Reports and Trend Charts12 95 100 105 110 115 120 125 e ... Dragon (medical record immediately available) •ED Physicians covering as Hospitalists or at least able

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4Q18 Core Measures 2Q19 MBQIP Data Promoting Interoperability Stage 3

August 16, 2019

Joshua Salander, MBA, PMP

Consultant

Conflict of Interest / Disclaimer

• Conflict of Interest: I, Joshua Salander, am employed by Scheurer Hospital. Any content or opinion in this presentation shall not be construed as an opinion or representation of Scheurer Hospital.

• Disclaimer: This presentation is informational only. You should review requirements to determine specific impacts to your hospital. Persevion, LLC is not liable for the accuracy of this information or how it pertains to your hospital.

• Disclaimer: Any information included in this presentation or the Reports Appendix is intended for quality improvement and benchmarking purposes only.

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Reports delivery

• 4Q18 reports were sent via email on August 11, 2019

• Quarterly Reports

• Quarterly Trend Charts

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MICAHQN Reports Schedule

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Qtr CMS Data Deadline* Data Provided By*

1st Qtr August 15 August 31

2nd Qtr November 15 November 30

3rd Qtr February 15 February 28

4th Qtr May 15 May 31

Summary of 4Q18 MICAHQN Core Measures Performance

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Measure # Hospitals Denominator Current Rate/Value

Top Performer(s)

IMM-2 34/40 2959 94.4% See IMM-2 Slide

OP-1 11/40 17 26 Schoolcraft Memorial Hospital

OP-2 12/40 23 56.5% See OP-2 Slide

OP-3a 23/40 62 117.5 Spectrum Health Reed City Hospital

OP-3b 15/40 42 134.5 Spectrum Health Reed City Hospital

OP-3c 14/40 20 91.5 Carson City Hospital

OP-4a 32/40 563 95.4% See OP-4a Slide

OP-4b 32/40 236 95.8%

OP-4c 32/40 327 95.1%

OP-5a 37/40 736 7 Helen Newberry Joy Hospital

OP-5b 37/40 329 7 Helen Newberry Joy Hospital

OP-5c 37/40 407 6 Borgess - Lee Memorial Hospital

4Q18 – OP-2: Fibrinolytic Therapy Received Within 30 Minutes (100%)

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Hospitals

Aspirus Grand View

Helen Newberry Joy Hospital

Mackinac Straits Health System, Inc.

Munson Healthcare Manistee

Schoolcraft Memorial Hospital

St. Mary's of Michigan Standish Hospital

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4Q18 – IMM-2: Influenza Immunization – Overall Rate (100%)

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Hospitals

Aspirus Iron River Hospital and Clinics

Baraga County Memorial Hospital

Borgess - Lee Memorial Hospital

Caro Community Hospital

Eaton Rapids Medical Center

Kalkaska Memorial Health Center

Mercy Health Lakeshore Campus

4Q18 - OP-4a: Aspirin at Arrival (100%)

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Hospitals

Allegan General Hospital Helen Newberry Joy Hospital

Aspirus Ontonagon Hospital Hills & Dales General Hospital

Borgess - Lee Memorial Hospital Mackinac Straits Health System, Inc.

Caro Community Hospital Schoolcraft Memorial Hospital

Deckerville Community Hospital Sheridan Community Hospital

Harbor Beach Community Hospital, Inc. Spectrum Health Gerber Memorial

Hayes Green Beach Memorial Hospital

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93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

Rat

e

OP4a - Aspirin at Arrival - Overall Rate

MICAHQN Overall UCL LCL

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Summary of 4Q18 MICAHQN Core Measures Performance

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Measure # Hospitals Denominator Current Rate/Value

Top Performer(s)

OP-18a 37/40 4030 121 Mercy Health Lakeshore Campus

OP-18b 37/40 3521 112 Mercy Health Lakeshore Campus

OP-18c 36/40 142 191.5 Mid Michigan Medical Center – Clare

OP-18d 37/40 383 204 Bronson LakeView Hospital

OP-20 32/40 3181 13 Paul Oliver Memorial Hospital

ED-1a 34/40 2609 228 St. Mary's of Michigan Standish Hospital

ED-1b 34/40 2573 227 Harbor Beach Community Hospital, Inc.

ED-1c 17/40 36 252.5 Schoolcraft Memorial Hospital

ED-2a 33/40 2436 62 Deckerville Community Hospital

ED-2b 33/40 2402 62 Deckerville Community Hospital

ED-2c 13/40 34 58 Eaton Rapids Medical Center

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95

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105

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135

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OP18a - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Overall


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125

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OP18b - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Reporting Measure


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13

0

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100

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OP18c - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Psychiatric/Mental Health Patients


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0

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OP18d - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Transfer Patients


OP-18b -Median Time from ED Arrival to ED Departure for Discharged ED Patients

• What benchmarks are you using for this measure?

As a premier system of quality, the Michigan Critical Access Hospital Quality Network (MICAH QN) will be a model in developing processes that demonstrate the high quality service provided by CAHs. MICAH QN will identify opportunities for change that lead to continued improvement in the health status of the population we serve.

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As a premier system of quality, the Michigan Critical Access Hospital Quality Network (MICAH QN) will be a model in developing processes that demonstrate the high quality service provided by CAHs. MICAH QN will identify opportunities for change that lead to continued improvement in the

health status of the population we serve.


• Factors contributing to higher times than desired • Volume during peak hours • Waiting for test results • Waiting for Psychiatric/Behavioral Health evaluation • Med/Surg nurses cover the ED when no patients on the floor,

so when there is an admission it slows the process down • Workforce cuts • Changes in ED Providers (changed companies or had

providers come and go) • Variability in the productivity of ED Providers • Use of Paper T-sheets (documentation not readily available

and needs to be scanned)



• Steps being taken to reduce the time

• Hired more staff for peak hours

• Phasing out providers with low productivity

• Moving providers to EMR and using Dragon (medical record immediately available)

• ED Physicians covering as Hospitalists or at least able to admit


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19

50.0

52.0

54.0

56.0

58.0

60.0

62.0

64.0

66.0

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ED-2a - Admit Decision Time to ED Departure Time for Admitted Patients - Overall Rate


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50.0

52.0

54.0

56.0

58.0

60.0

62.0

64.0

66.0

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ED-2b - Admit Decision Time to ED Departure Time for Admitted Patients - Reporting Measure


0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

Me

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ED-2c - Admit Decision Time to ED Departure Time for Admitted Patients - Psychiatric/Mental Health Patients


Summary of 2Q19 MBQIP Performance

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Measure # Hospitals Current Rate/Value

Notes

EDTC-1 36/36 96% 22 @ 100%

EDTC-2 36/36 95% 25 @ 100%

EDTC-3 36/36 97% 22 @ 100%

EDTC-4 36/36 96% 19 @ 100%

EDTC-5 36/36 96% 19 @ 100%

EDTC-6 36/36 93% 14 @ 100%

EDTC-7 36/36 97% 26 @ 100%

EDTC-Overall 36/36 87% 7 @ 100%

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2Q19 - EDTC-Overall (100%)

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Hospitals

Bronson LakeView Hospital

Eaton Rapids Medical Center

Mackinac Straits Health System, Inc.

McKenzie Health System

Mercy Health Lakeshore Campus

Sparrow Clinton Hospital

Spectrum Health Gerber Memorial

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

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All EDTC Measure


Promoting Interoperability Stage 3: Public Health and Clinical Data Exchange

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IT & Quality Collaboration

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Objectives Description

Electronic Prescribing Generate and transmit permissible discharge prescriptions electronically

Health Information Exchange Encourage and leverage interoperability on a broader scale and promote health IT-based care coordination

Provider to Patient Exchange Provide patients electronic access to their health information

Public Health & Clinical Data Exchange • Syndromic Surveillance • Immunization Registry • Electronic Case Reporting • Public Health Registry • Clinical Data Registry • Electronic Reportable Laboratory Result Reporting

Measures that an eligible hospital or CAH attests yes to being in active engagement with a public health agency (PHA) or clinical data registry (CDR) to submit electronic public health data in a meaningful way using certified electronic health record technology (CEHRT) for two measures within the objective.

26 https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/TableofContents_EH_Medicare_2019.pdf


Measure Points

Electronic Prescribing 10

Query of Prescription Drug Monitoring Program (PDMP) (optional) 5 bonus

Verify Opioid Treatment Agreement (optional) 5 bonus

Support Electronic Referral Loops by Sending Health Information 20

Support Electronic Referral Loops by Receiving and Incorporating Health Information 20

Provide Patients Electronic Access to their Health Information 40

Public Health & Clinical Data Exchange (attest to two measures) 10

27 https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/

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28 https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/MedicareEH_2019_Obj2-.pdf




• Measures that an eligible hospital or CAH attests yes to being in active engagement with a public health agency (PHA) or clinical data registry (CDR) to submit electronic public health data in a meaningful way using certified electronic health record

technology (CEHRT) for two measures within the objective.

• Make sure you’re familiar with the exclusions for each of the above measures!


https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/MedicareEH_2019_Obj2-.pdf
























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Thank you!

Joshua Salander, MBA, PMP

Consultant

[email protected]

(989) 666-7033









Documents

MICAHQN Quarterly Reports and Trend Charts12 95 100 105 110 115 120 125 e ... Dragon (medical record immediately available) •ED Physicians covering as Hospitalists or at least able