PowerHour September: MBQIPKathy McGowanLorna Martin

Outline• Video from Paul Moore, Senior Health Policy Advisor, HRSA• Goal for MBQIP• Timeline• Phases and Measures• Benefits of MBQIP• Where is Georgia??• How small is too small??

Brief Video• http://www.youtube.com/watch?v=hYbgvZUbTIg • Paul Moore, Senior Health Policy Advisor HRSA

Goals for MBQIP• MBQIP takes a proactive approach to ensure CAHs are well-

prepared to meet future quality requirements• Quality reporting and demonstrating value through providing

cost efficient quality care is where the health care environment is currently headed

Goals for MBQIP• The goal of MBQIP quarterly data is not to provide statistically

significant data but to provide an opportunity for each CAH to think about how they can improve care for each individual patient.

Goals

MBQIP data helps:• Hospitals engage in quality reporting and improvement

activities to get them to where they need to be in demonstrating value

• State Flex coordinators and partners determine where Flex dollars can be targeted to show impact of investments to address specific needs of CAHs

• ORHP show the impact of Flex dollars program wide in improving quality outcomes for CAHs

Timeline

Year 1: 2010-2011 Flex program education and planning

Year 2: 2011-2012 • By September 1, hospitals have begun reporting on

Phase 1 Measures• Pneumonia: Hospital Compare CMS Core Measure• Congestive Heart Failure: Hospital Compare CMS Core Measure

Year 3: 2012-2013 • By September 1, hospitals have begun reporting on

Phase 2 Measures• Outpatient 1-7: Hospital Compare CMS Measure• Hospital Consumer Assessment of Healthcare Providers and Systems

(HCAHPS)

Timeline

Year 4: 2013-2014 • By September 1, hospitals have begun reporting on

Phase 3 Measures• Pharmacist CPOE/Verification of Medication Orders Within 24 Hours• Outpatient Emergency Department Transfer Communication

Year 5: 2014-2015 • Hospitals continue reporting on All Phases

Phases of MBQIP• Pneumonia: • Hospital Compare CMS Core

Measure (Participate in all sub-measures); AND

• Congestive Heart Failure:• Hospital Compare CMS Core

Measure (Participate in all sub-measures)

Phase 1 Measures(Began September 2011)

Phases of MBQIP• Outpatient 1-7: • Hospital Compare CMS Measure (All

sub-measures that apply); AND• Hospital Consumer Assessment of

Healthcare Providers and Systems (HCAHPS)

Phase 2 Measures(Began September 2012)

Phase 2 Measures• OP-1: Median Time to Fibrinolysis in the Emergency Department• OP-2: Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival

in the Emergency Department • OP-3: Median Time to Transfer to another Facility for Acute

Coronary Intervention in the Emergency Department • OP-4: Aspirin at Arrival in the Emergency Department

Phase 2 Measures• OP-5: Median Time to ECG in the Emergency Department• OP-6: Timing of Antibiotic Prophylaxis (Prophylactic Antibiotic

Initiated Within One Hour Prior to Surgical Incision) in Surgery • OP-7: Prophylactic Antibiotic Selection for Surgical Patients in

Surgery

HCAHPS Survey Topics• Communication with doctors and nurses• Responsiveness of hospital staff• Cleanliness and quietness of hospital environment• Pain management• Communication about medications• Discharge information• Overall rating of the hospital• Rating of willingness to recommend hospital

Phases of MBQIP• Pharmacist CPOE/Verification of

Medication Orders within 24 hours (meets EHR “Meaningful Use” criteria); AND

• Outpatient Emergency Department Transfer Communication• Pre-transfer communication

information• Patient identification• Vital signs• Medication-related Information• Practitioner generated information• Nurse generated information• Procedures and tests

Phase 3 Measures(Begin September 2013)

Phase 3 Measures

• Pharmacist CPOE/Verification of Medication Orders within 24 hours:• Numerator: Number of electronically entered medication orders for

an inpatient admitted to a CAH (acute or swing-bed), verified by a pharmacist or directly entered by a pharmacist within 24 hours

• Denominator: Total number of electronically entered medication orders for an inpatient admitted to CAH (acute or swing-bed) during the reporting period

Phase 3 Measures

Critical Access Hospital Preparation:• To prepare for this measure, CAHs should:• Reach out to your vendor to check on the capability to have

report generated in your electronic order entry system.• Determine appropriate pharmacist coverage for your facility.• Do you already have onsite coverage 7 days a week? • If not, would it be possible to share pharmacist services with other

CAHs or hospitals in a system, or would remote pharmacy services be the best option for your needs?

Benefits of Participating in MBQIP

• Engage in quality improvement initiatives• Improves patient care across a broad population • Improves hospital services, administration and operations• Allows for clear benchmarking and the identification of best

practice CAHs

Benefits of Participating in MBQIP

• Receive technical assistance regarding cutting edge quality improvement tools and models

• Prepare CAHs for the future where CAHs will likely have to report measures

• Fulfills the Quality Improvement portion of the Flex Grant

Ties to PfP

Goals and Expectations• Increase CAH Hospital Compare participation for Phase 1 measures

(Pneumonia and Congestive Heart Failure) to 100% by FY2012 to improve publicly available data and motivate CAHs to implement related quality improvement initiatives.

• Achieve CAH Hospital Compare participation for Phase 2 measures (Outpatient and HCAHPS) and non-Hospital Compare Phase 3 measures (Pharmacy Review of Orders and Outpatient Emergency Department Transfer Communication) to 100% by FY2013 to motivate CAHs to implement quality improvement initiatives.

• Achieve a CAH participation rate of 75% by FY2013 and 100% by FY2014 in a quality improvement initiative to be reported to respective states.

Where is Georgia?

Where is Georgia?

How many Georgia CAH’s participate in MBQIP?94% of CAH’s!!

Where is Georgia?

How many Georgia CAH’s report to Hospital Compare?• As of 1st quarter 2013 – 100% of CAH’s have submitted

Inpatient Clinical Measures (Phase 1)• As of 1st quarter 2013 – 68% of CAH’s have submitted

Outpatient Clinical Measures (Phase 2)

Where is Georgia?

How many Georgia CAH’s report HCAHPS?87% of CAH’s have an HCAHPS vendor!!

Vendor # of Hosp

RCCN 8

Press Ganey 7

Healthstream 5

NCR Picker 3

Avatar 1

Conifor 1

J.L. Morgan 1

National Research Consultants 1

How Small is too Small?• Missed Opportunities:• Look at small numbers as missed opportunities rather than

percent of performance• Quality improvement isn’t about percentages as much as it is

misses• Example: 1 out of 5 is OK….now stand in a circle of 5 and decide who

in your group will not receive the care they need! Do you want it to be you?

• The Power of One:• Collecting data also has a human impact. Which case which

person is the one that missed quality care from your hospital?

How Small is too Small?• Directional vs. Definitive• Sampling data is directional• 100% data collection is definitive. Most CAH’s have to do 100%

data collection• Inference or Actual??• Sampling data infers performance whereas 100% data collection

define the actual performance

Questions??

Kathy McGowan – kmcgowan@gha.org 770-249-4519