Presentation on theme: "Quality Health Indicators"— Presentation transcript:
1 Quality Health Indicators Brought to you by…Quality Health IndicatorsLeft Click mouse or use down arrow to proceed through this presentation.
2 Menu About QHi Defining your facility Selecting Measures Entering Data DashboardsReportsHow we use the dataClick on any menu item above to go directly to a topic or left mouse click (down arrow) to continue through the presentation.
3 Quality Health Indicators The Quality Health Indicator (QHi) web site was developed through KHA and KRHOP to facilitate a benchmarking project for rural Kansas hospitals.The goal of QHi is to provide hospitals an economical instrument to evaluate internal processes of care and to seek ways to improve those practices by comparing specific measures of quality with like hospitals.Using QHi as a tool, regional networks of hospitals and individual facilities can select from a library of quality indicators to determine which measures meet their unique needs.
4 Quality Health Indicators Critical Access Hospitals in Kansas, Michigan, Nebraska, Oklahoma, South Dakota, Alaska, Wyoming and Missouri use QHi as a data collection tool.Through this multi-state project, QHi is well positioned to serve as a significant repository of information on quality of care and performance in Critical Access Hospitals nationwide.
5 Quality Health Indicators Four Pillars Of MeasurementClinicalQualityFinancialOperationalEmployeeContributionPatientSatisfaction
6 QHi Core Measure Set Clinical Quality All participating hospitals are asked to collect and report the 8 QHi Core MeasuresClinical QualityHealthcare Acquired Infections per Patient DayPneumonia Patients Given Antibiotics within 6 hours of admission (CMS PN-5c)Pneumonia Patients Receiving Pneumonia Immunization (CMS PN-2 )Unassisted Patient FallsEmployee ContributionBenefits as a Percentage of SalaryStaff TurnoverFinancial OperationalGross Days in ARDays Cash on Hand
7 Clinical Quality Measures Additionally, facilities select from over 50 measuresin the QHi library of indicatorsClinical Quality MeasuresHealthcare Acquired Infections per Patient DayUnassisted Patient FallsInpatients Screened for PneumoniaMedication Omissions Resulting in Medication ErrorMedication Errors Resulting from Transcription ErrorsER Provider Response TimesReturn ER Visits within 72 hours with same diagnosisReadmits Within 30 Days with Same or Similar DiagnosisCMS Pneumonia MeasuresInpatients Receiving O2 Assessment within 24 hours of admission - CMS Pn-1Inpatients Receiving Pneumonia Immunization - CMS Pn-2Pneumonia Given Antibiotics within 4 hours of admission - CMS Pn-5bPneumonia Given Antibiotics within 6 hours of admission - CMS Pn-5cCMS OP Transfer MeasuresPercentage of eligible patients who received thrombolytic therapy - CMS OP-1 and OP-2Median Time from Emergency Dept Arrival to Time of Transfer to another Facility for Acute Coronary Intervention -compare to CMS OP-3Number of AMI patients without aspirin contraindications who received aspirin within 24 hrs -CMS OP-4Percentage of AMI or Chest Pain pts receiving ECG within 10 min. of arrival (prior to transfer) CMS OP-5
8 The following measures exist for each pillar: Financial/OperationalBad Debt ExpenseCharity CareCost per Patient DayCurrent RatioDays Cash on Hand *Gross Days in AR *Labor Hours per Patient DayNet Patient Revenue per Patient DaysNewest Financial/Operational MeasuresPhysical Therapy Labor Hours per Unit of ServiceLaboratory Labor Hours per Unit of ServiceX-Ray Labor Hours per Unit of ServiceMammogram Labor Hours per Unit of ServiceUltrasound Labor Hours per Unit of ServiceCT Labor Hours per Unit of ServiceMRI Labor Hours per Unit of ServicePharmacy Labor Hours per Unit of ServiceNursing Hours per Patient DayRural Health Clinic Encounters per FTELong Term Care Hours per LTC Patient DayLaboratory Hours per Billed ServiceOperating Profit Margin (percent)Payer Mix - CommercialPayer Mix - MedicaidPayer Mix - MedicarePayer Mix - OtherPayer Mix - Other GovernmentPayer Mix - Self/Private Pay*QHi Core Measure Set
9 The following measures exist for each pillar: EmployeesAverage Time to Hire (All Staff)Average Time to Hire (Non-Nursing)Average Time to Hire (Nursing)Benefits as a Percentage of Salary*Non-Nursing Staff TurnoverNursing Staff TurnoverSalary to Operating Expenses ComparisonStaff Turnover *Patient SatisfactionHow well staff worked together to care for the patientHow well the patients pain was controlledLikelihood of recommending this hospital to othersOverall rating of care given to hospitalThe extent to which the patient felt ready for discharge*QHi Core Measure Set
10 QHi users log directly in to the site at www. qualityhealthindicators QHi users log directly in to the site at
11 Quality Health Indicators A user name ( address) and password is required to enter this secure web site. The password must be 8 characters that include upper and lower case letters and at least one number. For example: myQhi789The level of access is determined by the user type.System Administrator – maintains the site (KHA)State Administrator –provides support to Hospital Contacts in their StateNetwork Administrator – maintains Network profiles & provides supportHospital Contact – maintains Hospital profiles , adds users & enters dataHospital User – enters data and runs reportsView Only – views data and runs reports
12 Select Announcements & Calendar to view the portal home page. The HQRA (Healthcare Quality in Rural America) portal, introduced in 2008, provides access to multiple resources with just one log in.Users navigate from resource to resource by selecting the appropriate tab.
13 Click QHi tab to return to QHi The Event Calendar provides a monthly view of upcoming QHi training sessions and advisory committee meetings… as well as Webinars related to the overall Quality Project.
15 Click Administration to view Hospital Profile Page
16 Hospital Characteristics define each facility for the creation of peer groups when running reports. Question marks provide pop-up definitions throughout the QHI site.16
17 17 Entire Enterprise or CAH only. Select Entire Enterprise, if other entities are included in your financial reporting, i.e. Long Term Care Unit or Rural Health Clinics.Select Hospital only for CAH or 25 beds or less or Hospital only for non-CAH, greater than 25 beds, if you will report financial information for your Hospital only.Note: This applies only to Financial/Operational measures. Clinical Quality measures should be reported only for your acute care hospital.17
19 In Part E of the Hospital Profile, users can select the default measures predetermined by their State or Network.19
20 Part G lists the measures within the measure sets currently collected by the hospital. 20
21 The show elements link displays the elements required to calculate the measure. Question marks provide further definition of the elements.21
22 The number of hospitals collecting the measure. Additional measures can be selected in Part H.The number of hospitals collecting the measure.Individual hospitals can select any/all measures that meet their needs.22
24 The prior months entry displays for guidance. Data elements populate the data entry screen based on measures selected in the Hospital Profile.The prior months entry displays for guidance.Calculate Measures provides instant feedback by automatically calculating measures and immediately displaying results.24
25 Users Save data by clicking “Save All and Stay” In addition, new enhancements provide instant validation for most elements, displaying error messages if potential ‘outliers’ are entered.Entered information is not pulled into the database for display on the dashboard or in reports until the Activate Data for Reporting box is checked.
27 The Core Measures Dashboard provides comparison data for the 8 QHi Core measures. All data is calculated using a consecutive three month summing average.State Avg values pertain to data from hospitals that reside in the same state as hospital being viewed and are reporting in the same time interval.QHi Avg values pertain to all hospitals in QHi that are reporting same measure and are reporting in the same time interval.
28 Financial measures on the dashboard default to peer groups based on the hospitals level of reporting, either CAH Only or Entire Enterprise.Hospitals must have activated data for at least one of the three months displayed to view the dashboard measure.Hospital specific data for pneumonia measures will not display for hospitals with no occurrences during the reporting period.
42 Reports are available for all measures in QHi. Hospitals view reports only for those measures and data elements they collect.There are 6 categories of reportsClinical QualityEmployeesFinancial OperationalHospital CharacteristicsPatient SatisfactionSystem42
43 43 Step 2: Select a date range and grouping interval Step 1: Select from these 4 default peer groups.StateAll QHiMy NetworkMy Medicare Region43
44 In Step 3, hospitals define a customized peer group based on a list of hospital characteristics. Multiple values can be selected to better define the peer group.44
45 Step 4 lists available values for the criteria in Step 3. 45
46 Step 5 holds the selected criteria. The results can be displayed in 4 formats by clicking:View Line GraphView Bar GraphView Table orView Text Detail MeasureStep 5 holds the selected criteria.46
50 50 Click Export to export report data to Excel. The users facility is identified by ‘Hospital’The Text Detail ViewPlease note: Hospitals are not identified by name.50
51 From Excel users can create customized graphical displays to meet their needs.
52 Hospitals can be contacted for benchmarking by clicking the envelope icon. The Text Detail View52
53 The hospital contact at the selected facility receives an email message. Hello,Hospital 2 is interested in discussing some benchmarking opportunities with your facility.You may contact me atThank you, Sally53
54 Educational materials and worksheets to facilitate data collection are available for download on the Help page.54
56 Quality Health Indicators What do we do with the data?A few comments from our hospitals…I print a copy of the graphs and take it to the board for discussion. They appreciate seeing in color how we compare to other CAHs in KS as well as others in the USA.On a quarterly basis I am giving a copy of the bar graphs to our Board Members at their meeting.I give the Quality Committee a copy of the quality reports on a quarterly basis.We track and present our indicators monthly and are usually above the norm. On the occasions when we fall below, it prompts us to review processes to seek improvements.If we fall below expectations, we look for ways to improve and then report back to the board in the next quarter.We like the Days in AR report. This is our only source for comparative information on this measure.
57 Thank you for viewing this demonstration. If you have any questions or would like additional information on the QHi project, please contactSally Perkins, QHi System AdministratorDirector of Data Servicesat the Kansas Hospital Association