1. Free Powerpoint Templates Page 1 Using Data to Guide Improvement Presented by: Brooke Thomas, Program Advisor February 28, 2013

2. Free Powerpoint Templates Page 2 NQF Denominator Numerator Utilization Measure Quality Measure Data

3. Free Powerpoint Templates Page 3 Data assists us in understanding what is happening in the delivery of our health services, what factors affect delivery and how we can influence them to achieve improvement. Data helps us to improve our service by giving us the tools to describe what’s going on and to compare our performance, either against known standards or against previous performance. What does Data do?

4. Free Powerpoint Templates Page 4 Measurement Components

5. Free Powerpoint Templates Page 5 Denominator  A figure representing the total population. Total amount of diabetic patients within your practice.

6. Free Powerpoint Templates Page 6 Numerator Diabetic patients with an HgA1c above 9

7. Free Powerpoint Templates Page 7 Quality Measure  A measurement of a disease state. Example: Hypertension blood pressure measurement indicates how well a disease is managed.

8. Free Powerpoint Templates Page 8 National Quality Forum (NQF) www.qualityforum.org

9. Free Powerpoint Templates Page 9

10. Free Powerpoint Templates Page 10 NQF 0101 Falls: Screening, Risk Assessment, and Plan of Care to Prevent Future Falls Measure Description: This is a clinical process measure that assesses fall prevention in older adults. The measure has three rates: A) Screening for Future Fall Risk: Percentage of patients aged 65 years and older who were screened for fall risk (2 or more falls in the past year or any fall with injury in the past year) at least once within 12 months. B) Multifactorial Risk Assessment for Falls: Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months. C) Plan of Care to Prevent Future Falls: Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months. Numerator Population: This measure has three rates. The numerators for the three rates are as follows: A) Screening for Future Fall Risk: Patients who were screened for future fall* risk** at last once within 12 months. B) Multifactorial Falls Risk Assessment: Patients at risk* of future fall** who had a multifactorial risk assessment*** for falls completed within 12 months. C) Plan of Care to Prevent Future Falls: Patients at risk* of future fall** with a plan of care**** for falls prevention documented within 12 months.

11. Free Powerpoint Templates Page 11 NQF 0101 Continued - Definitions *A fall is defined as a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of a sudden onset of paralysis, epileptic seizure, or overwhelming external force. **Risk of future falls is defined as having had had 2 or more falls in the past year or any fall with injury in the past year. ***Risk assessment is defined as at a minimum comprised of balance/gait AND one or more of the following: postural blood pressure, vision, home fall hazards, and documentation on whether medications are a contributing factor or not to falls within the past 12 months. ***Plan of care is defined as at a minimum consideration of appropriate assistance device AND balance, strength and gait training.

12. Free Powerpoint Templates Page 12 NQF 0101 Continued Denominator Population: A)Screening for Future Fall Risk: All patients aged 65 years and older seen by an eligible provider in the past year. B & C) Multifactorial Falls Risk Assessment & Plan of Care to Prevent Future Falls: All patients aged 65 years and older with a history of falls (history of falls is defined as 2 or more falls in the past year or any fall with injury in the past year) seen by an eligible provider in the past year. Exclusions: Patients who have documentation of medical reason(s) for not screening for future fall risk, undergoing a risk- assessment or having a plan of care (e.g., patient is not ambulatory) are considered exclusion to this measure.

13. Free Powerpoint Templates Page 13 Measure Description: Percentage of patients aged 6 months and older seen for a visit during the reporting period who received an influenza immunization OR patient reported previous influenza immunization during reporting period. Numerator Population: Patients who received an influenza immunization OR who reported previous receipt* of influenza immunization. Denominator Population: All patients aged 6 months and older seen for a visit during the reporting period. EXCLUSIONS: Documentation of medical reason(s) for not receiving influenza immunization. (eg, patient allergy, other medical reason) Documentation of patient reason(s) for not receiving influenza immunization. (eg, patient declined, other patient reason) Documentation of system reason(s) for not receiving influenza immunization. (eg, vaccine not available, other system reason) NQF0041 Influenza Immunization

14. Free Powerpoint Templates Page 14 NQF0028 Tobacco Use: Screening & Cessation Measure Description: Percentage of patients aged 18 years and older who were screened for tobacco use at least once during the two-year measurement period AND who received tobacco cessation counseling intervention if identified as a tobacco user. Numerator Population: Patients who were screened for tobacco use* at least once during the two-year measurement period AND who received tobacco cessation counseling intervention** if identified as a tobacco user. Denominator Population: All patients aged 18 years and older who were seen twice for any visits or who had at least one preventive care visit during the two-year measurement period. EXCLUSIONS: Documentation of medical reason(s) for not screening for tobacco use. (eg, limited life expectancy)

15. Free Powerpoint Templates Page 15 NQF 0418 Screening for Clinical Depression Measure Description: Percentage of patients aged 18 years and older screened for clinical depression using a standardized tool and follow up plan documented. Numerator Population: Patient's screening for clinical depression is documented and follow up plan is documented. Denominator Population: Patient 18 years of age and older. Exclusions: A patient is not eligible if one or more of the following conditions exist: Patient refuses to participate. Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status. Situations where the patient’s motivation to improve may impact the accuracy of results of nationally recognized standardized depression assessment tools. For example: certain court appointed cases Patient was referred with a diagnosis of depression. Patient has been participating in ongoing treatment with screening of clinical depression in a preceding reporting period. Severe mental and/or physical incapacity where the person is unable to express himself/herself in a manner understood by others. For example: cases such as delirium or severe cognitive impairment, where depression cannot be accurately assessed through use of nationally recognized standardized depression assessment tools.

16. Free Powerpoint Templates Page 16 Personal Health Questionnaire (PHQ) 2 & 9 PHQ 2 Questions: “In the past 2 weeks… 1. Have you had little interest or pleasure in doing things? 2. Have you felt down, depressed or hopeless?” If “yes” on either question, complete full PHQ-9*. http://www.healthteamworks.org/guidelines/depression.html

17. Free Powerpoint Templates Page 17 NQF0034 Colorectal Cancer Screening Measure Description: The percentage of members 50–75 years of age who had a screening for colorectal cancer. Numerator Population: Patients who have had one or more of the following screenings: fecal occult blood test (FOBT) during the measurement year. flexible sigmoidoscopy during or up to four years prior to the reporting period. double contrast barium enema (DCBE) during or up to four years prior to the reporting period. Colonoscopy during or up to nine years prior to the measurement year. Denominator Population: Patients 51–75 years of age as of December 31 of the measurement year. EXCLUSIONS: Patients with a diagnosis of colorectal cancer or total colectomy. Look for evidence of colorectal cancer or total colectomy as far back as possible in the patient’s history, through either administrative data or medical record review. Exclusionary evidence in the medical record must include a note indicating a diagnosis of colorectal cancer or total colectomy, which must have occurred by December 31 of the measurement year.

18. Free Powerpoint Templates Page 18 NQF0031 Breast Cancer Screening Measure Description: Percentage of eligible women 40-69 who receive a mammogram during the reporting period. Numerator Population: Patients who have had one or more mammograms during or up to one year prior to the reporting period. Denominator Population: Women 42–69 years of age. Exclusions: Women who had a bilateral mastectomy or for whom there is evidence of two unilateral mastectomies.

19. Free Powerpoint Templates Page 19 NQF0064 LDL-C Control <100 mg/dL Measure Description: The percentage of members 18-75 years of age with diabetes (type 1 and type 2) whose most recent LDL-C test is <100 mg/dL during the measurement year. Numerator Population: Members whose most recent LDL-C test is <100 mg/dL during the measurement year. Denominator Population: Members 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year. EXCLUSIONS: Patients with a diagnosis of polycystic ovaries who did not have a face-to-face encounter, in any setting, with a diagnosis of diabetes during or up to one year prior to the reporting period. Patients with gestational or steroid-induced diabetes who did not have a face-to-face encounter, in any setting, with a diagnosis of diabetes during or up to one year prior to the measurement year.

20. Free Powerpoint Templates Page 20 NQF0061 Blood Pressure Control (<140/90 mm Hg) Measure Description: The percentage of members 18-75 years of age with diabetes (type 1 and type 2) whose most recent blood pressure (BP) reading is <140/90 mm Hg during the reporting period. Numerator Population: Members whose most recent BP reading is <140/90 mm Hg during the reporting period. Denominator Statement: Members 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year. EXCLUSIONS: Patients with a diagnosis of polycystic ovaries who did not have a face-to-face encounter, in any setting, with a diagnosis of diabetes during or up to one year prior to the reporting period. Patients with gestational or steroid-induced diabetes who did not have a face-to-face encounter, in any setting, with a diagnosis of diabetes during or up to one year prior to the measurement year.

21. Free Powerpoint Templates Page 21 NQF0059 Hemoglobin A1c Poor Control Measure Description: The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent HgA1c level during the reporting period was greater than 9.0%, or an HgA1c test was not done during the reporting period. Numerator Population: Members whose most recent HgA1c level is greater than 9.0% or an HbA1c test was not done during the reporting period. Denominator Population: Members 18-75 years of age who had a diagnosis of diabetes (type 1 or type 2) during or up to one year prior to the reporting period. EXCLUSIONS: Patients with a diagnosis of polycystic ovaries who did not have a face-to-face encounter, in any setting, with a diagnosis of diabetes during or up to one year prior to the reporting period. Patients with gestational or steroid-induced diabetes who did not have a face-to-face encounter, in any setting, with a diagnosis of diabetes during or up to one year prior to the reporting period.

22. Free Powerpoint Templates Page 22 NQF0018 Controlling High Blood Pressure Measure Description: The percentage of patients 18–85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the reporting period. Numerator Population: The number of patients in the denominator whose most recent, representative BP is adequately controlled during the reporting period. For a member’s BP to be controlled, both the systolic and diastolic BP must be <140/90mm Hg. Denominator Population: Patients 18-85 with hypertension. A patient is considered hypertensive if there is at least one outpatient encounter with a diagnosis of HTN during the first six months of the reporting period. EXCLUSIONS: Patients with evidence of end-stage renal disease (ESRD) (including dialysis or renal transplant), all patients who are pregnant, and all patients who had an admission to a non-acute inpatient setting on or prior to December 31 of the reporting period.

23. Free Powerpoint Templates Page 23 NQF0075 Complete Lipid Profile and LDL Control <100 Measure Description: The percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) from January 1–November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during or up to one year prior to measurement year, who had each of the following during the measurement year. Numerator Population: Patients with a complete lipid profile performed during the measurement year. A LDL-C control result of <100mg/dL using the most recent LDL-C screening test during the measurement year. Denominator Population: Patients 18 years of age an older as of December 31st of the measurement year who were discharged alive for AMI, CABG or PCI on or between January 1 and November 1 of the year prior to the measurement year or who had a diagnosis of IVD during both the measurement year and the year prior to the measurement year. EXCLUSIONS: None.

24. Free Powerpoint Templates Page 24 NQF0083 Beta-blocker therapy for Left Ventricular Systolic Dysfunction Measure Description: Percentage of patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting or at hospital discharge. Numerator Population: Patients who were prescribed* beta-blocker therapy** either within a 12 month period when seen in the outpatient setting or at hospital discharge. Denominator Population: All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40%. LVEF < 40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction. EXCLUSIONS: Documentation of medical reason(s) for not prescribing beta-blocker therapy. Documentation of patient reason(s) for not prescribing beta-blocker therapy. Documentation of system reason(s) for not prescribing beta-blocker therapy.

25. Free Powerpoint Templates Page 25 NQF0036 Use of appropriate medications for people with asthma Measure Description: The measure assesses the percentage of patients 5-64 years of age during the measurement year who were identified as having moderate to severe persistent asthma and who were appropriately prescribed medication during the measurement year. Numerator Population: The number of patients who were dispensed at least one prescription for a preferred therapy during the measurement year. Denominator Statement: All health plan patients 5–64 years of age during the measurement year who were identified as having moderate to severe persistent asthma. EXCLUSIONS: Exclude any patients who had at least one encounter, in any setting, with any code to identify a diagnosis of emphysema, COPD, cystic fibrosis, or acute respiratory failure (Table ASM-E) any time on or prior to December 31 of the measurement year.

26. Free Powerpoint Templates Page 26 NQF 0024 Weight Assessment and Counseling for children and Adolescents Measure Description: =Percentage of children 3-17 years of age who had an outpatient visit with a primary care physician (PCP) or an OB/GYN and who had evidence of body mass index (BMI) percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year. Numerator Population: Body mass index (BMI) percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year. Denominator Population: Children 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or OB-GYN. EXCLUSIONS: Optional Exclusion: Children who have a diagnosis of pregnancy during the measurement year.

27. Free Powerpoint Templates Page 27 Questions?

28. Free Powerpoint Templates Page 28 Utilization Measures  Provides an indication of a patient or patient population’s amount of usage of health care services or health care facilities. Example: Number of emergency room visits. Number of hospital admissions.

29. Free Powerpoint Templates Page 29 Why Measure?

30. Free Powerpoint Templates Page 30 What does it mean?

31. Free Powerpoint Templates Page 31 What do I do now? Analyze data Identify affected workflows and process  Process Maps  Utilize PDSAs Implement Monitor Evaluate progress Cycle Back

32. Free Powerpoint Templates Page 32 PDSA Cycle

33. Free Powerpoint Templates Page 33 Tips to making data useful. Data Sources Data Elements  Specific - Discrete data fields Data Presentation  Data walls

34. Free Powerpoint Templates Page 34 Data Wall Examples

35. Free Powerpoint Templates Page 35 Tools and resources National Quality Forum (NQF) - www.qualityforum.orgwww.qualityforum.org PDSA Cycle - www.ihi.org/knowledge/Pages/HowtoImprovewww.ihi.org/knowledge/Pages/HowtoImprove Centers for Medicare & Medicaid Services (CMS) - www.cms.govwww.cms.gov

36. Free Powerpoint Templates Page 36 Questions?

37. Free Powerpoint Templates Page 37 Thank you for joining us on this webinar. Brooke Thomas, Program Advisor brooke.thomas@rmhp.org brooke.thomas@rmhp.org