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1 Quality Health Indicators Brought to you by… Left click mouse or use down arrow to proceed through this presentation
2 About QHi The PiHQ Portal Defining your facility Selecting Measures Entering Data Dashboards Reports How we use the data Select any menu item above to go directly to a topic or Click to continue through the presentation Main Menu
3 Quality Health Indicators The Quality Health Indicator (QHi) web site was developed through the Kansas Hospital Association (KHA) and the Kansas Rural Health Options Project (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 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 indicators to determine which measures meet their unique needs.
4 Quality Health Indicators More than 900 users in over 250 Critical Access and other small rural hospitals in Alaska, Arizona, California, Colorado, Illinois, Kansas, Kentucky, Louisiana, Michigan, Minnesota, Missouri, Nebraska, New Mexico, Oklahoma, Oregon and Wyoming use QHi as a data collection and benchmarking tool. As a user-driven multi-state project, QHi is well-positioned to serve as a significant repository of information on quality of care and performance in rural hospitals nationwide.
5 Four Pillars Of Measurement Quality Health Indicators Clinical Quality Employee Contribution Patient Satisfaction Financial Operational
6 QHi Core Measures Set Clinical Quality Healthcare Associated Infections per 100 inpatient days Unassisted Patient Falls per 100 inpatient days Pneumococcal Immunization (PPV23) – Age 65 and Older (CMS IMM-1b) Discharge Instruction (CMS HF-1) Employee Contribution Benefits as a Percentage of Salary Staff Turnover All participating hospitals are asked to collect and report the 8 QHi Core Measures: Financial Operational Days Cash on Hand Gross Days in AR
7 Clinical Quality Measures Inpatients Screened for Pneumonia Vaccine Status (not a CMS measure) Medication Omissions Resulting in Medication Errors Medication Errors Resulting from Transcription Errors ER Provider Response Times Return ER Visits within 72 hours with same/similar diagnosis Readmissions Within 30 Days with Same or Similar Diagnosis Healthcare Associated Infections per 100 inpatient days* Unassisted Patient Falls per 100 inpatient days* Long Term Care Patient Falls per 100 Long Term Care patient days CMS Pneumonia Measures Inpatients Receiving O2 Assessment within 24 hours of admission - CMS PN-1 (retired) Inpatients Receiving Pneumonia Immunization - CMS PN-2 (retired) Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital - CMS PN-3b Adult Smoking Cessation Advice/Counseling - CMS PN-4 (retired) Pneumonia Patients Receiving Initial Antibiotic Within 6 Hours of Hospital Arrival - CMS PN-5c (retired) Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients - CMS-PN6 Influenza Vaccination - CMS PN-7 (retired) *Part of the 8 Core Measure Set Additionally, facilities can select from over 90 measures in the QHi library of indicators:
Clinical Quality Measures (continued) CMS OP Transfer Measures Median Time to Fibrinolysis in the Emergency Department - CMS OP-1 Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival in the Emergency Department - CMS OP-2 Median Time to Transfer to Another Facility for Acute Coronary Intervention in the Emergency Department - CMS OP-3 Aspirin at Arrival in the Emergency Department - CMS OP-4 Median Time to ECG in the Emergency Department - CMS OP-5 Timing of Antibiotic Prophylaxis in Hospital Outpatient Surgery - CMS OP-6 Prophylactic Antibiotic Selection for Surgical Patients in Hospital Outpatient Surgery - CMS OP-7 CMS Immunization Measures Pneumococcal Immunization (PPV23) – Overall Rate - CMS IMM-1a Pneumococcal Immunization (PPV23) – Age 65 and Older* - CMS IMM-1b Pneumococcal Immunization (PPV23) – High Risk Populations (Age 6 through 64 years) - CMS IMM-1c Influenza Immunization - CMS IMM-2 *Part of the 8 Core Measure Set 8
Clinical Quality Measures (continued ) CMS HF Measures Discharge Instructions* – CMS HF-1 Evaluation of LVS Function – CMS HF-2 ACEI or ARB for LVSD – CMS HF-3 Adult Smoking Cessation Advice/Counseling – CMS HF-4 (retired) CMS SCIP Measures Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision – CMS SCIP-Inf-1a Prophylactic Antibiotic Selection for Surgical Patients – CMS SCIP-Inf-2a Prophylactic Antibiotics Discontinued Within 24 Hours after Surgery End Time – CMS SCIP-Inf-3a Surgery Patients with Appropriate Hair Removal – CMS SCIP-Inf-6 Urinary Catheter Removed on Postop Day 1 or Postop Day 2 with Day of Surgery being Day 0 – CMS SCIP-Inf-9 Surgery Patients with Periop Temperature Management – CMS SCIP-Inf-10 Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Periop Period – CMS SCIP-Card-2 Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered – CMS SCIP-VTE-1 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery – CMS SCIP-VTE-2 *Part of the 8 Core Measure Set 9
10 Employee Contribution Measures Non-Nursing Staff Turnover Average Time to Hire (All Staff) Nursing Staff Turnover Average Time to Hire (Nursing) Average Time to Hire (Non-Nursing) Salary to Operating Expenses Comparison Benefits as a Percentage of Salary* Staff Turnover* Patient Satisfaction Measures How well staff worked together to care for the patient (QHi1) The extent to which the patient felt ready for discharge (QHi2) In addition to these two original QHi patient satisfaction measures, 22 HCAHPS measures are now in the library of indicators. *Part of the 8 Core Measure Set Hospital Characteristics Measures Average Inpatient Days Monthly Inpatient Census ALOS (in hours) Comparison
11 Financial Bad Debt Expense Charity Care Cost per Patient Day Labor Hours per Patient Day Operating Profit Margin Current Ratio Net Patient Revenue per Patient Days Payer Mix – Commercial Payer Mix – Medicaid Payer Mix – Medicare Payer Mix – Other Payer Mix – Other Government Payer Mix – Self/Private Pay Days Cash on Hand* Gross Days in AR* Financial & Operational Measures Operational Physical Therapy Labor Hours per Unit of Service Laboratory Labor Hours per Unit of Service X-ray Labor Hours per Unit of Service Mammogram Labor Hours per Unit of Service Ultrasound Labor Hours per Unit of Service CT Labor Hours per Unit of Service MRI Labor Hours per Unit of Service Pharmacy Labor Hours per Unit of Service Nursing Hours per Patient Day Rural Health Clinic Encounters per FTE Long Term Care Hours per LTC Patient Day Laboratory Hours per Billed Service *Part of the 8 Core Measure Set
12 Web Site Access An email address and password are required to enter this secure web site. The level of access is determined by the User type : System Administrator – maintains the site – KHA/KHERF State Administrator –provides support to Hospital Contacts in their State Network Administrator – maintains Network profiles & provides support Hospital Contact – maintains Hospital profiles, adds users & enters data Hospital User – enters data and runs reports View Only – views data and runs reports Report Recipient – no access to QHi, only receives reports Quality Health Indicators
Users with access to this application are directed to the home page, without additional log in.
All HCAHPS measures can be automatically pulled from HSI and uploaded directly into QHi, eliminating duplicate entry. Future enhancements will allow any HSI measure to be uploaded into QHi.
Users with access to this application are directed to their customized home page, without additional log in.
Partners in Healthcare Quality are working with two notable Risk Management vendors to pull aggregate data directly into QHi, further reducing data entry, and enhancing comparative analysis and benchmarking opportunities.
30 Users navigate through QHi by selecting options from the red main-menu bar and the blue sub-menu bar Click Administration to view Hospital Profile page
31 Hospital Contacts are responsible for completing and maintaining the Hospital Profile page for their facility All fields with a red asterisk are required fields Hospital Characteristics define each facility for creation of peer groups when running reports
32 Click drop-down to select Level of Measurement. This applies only to Financial/Operational measures Question mark icons provide pop-up definitions throughout the QHi site
35 In Collected Measure Sets, users can select the default measures predetermined by their state or network The QHi Core Measure Set is pre- selected as it is required for all hospitals Additional measure sets are available here
36 Collected Measures lists the measures within the measure sets currently collected by the hospital Individual measures are displayed and can be selected under Additional Measures
37 Additional Measures lists: (1) individual measures currently collecting (2) other measures that are available to collect Indicates the number of hospitals in QHi collecting the measure Click the plus icon to add measure to Currently Collecting Click the minus icon to remove measure from Currently Collecting
38 Click the question mark icon to display the calculation for each measure Click show elements to display the elements required to calculate the measure
40 Click Data Submissions to access the Data Submission page
41 Click Go to: drop-down arrow to select prior months’ data submissions To create a new data submissions page, select correct month and year from Month to add: drop-down arrows IMPORTANT: You must check Activate data for reporting box and then Save All and Stay in order for the data entered this month to be displayed on dashboards or in reports Click Save All and Stay to save data entered
42 If data for the month is entered and saved, but not activated, this message will appear to remind the user to activate the data for reporting
43 Prior months’ data is displayed for easy reference Click to automatically calculate measures and immediately display results Data elements automatically populate this page based on the measures selected by the user in the Measure Selection page
45 The Core Measures Dashboard displays comparison data for the eight Core Measures Roll mouse over any Dashboard graph to view the pop-up calculation for that measure The Dashboard can be displayed in graph, table, or graph/table views
48 Dashboard data is calculated using a consecutive three-month summing average State Avg values reflect data from hospitals in the same state as My Hospital and reported in the same time interval QHi Avg values reflect data from all hospitals in QHi reporting the same measure in the same time interval
49 Financial measures on the Dashboard default to peer groups based on the hospital’s level of reporting (Hospital Only or Entire Enterprise) A hospital must have activated data for at least one of the three months in the Date Range in order for the measure to be displayed on the Dashboard My Hospital data for some clinical measures will not display on the Dashboard if the hospital had no occurrences during the Date Range period
50 The three months in the Date Range can be changed by clicking the drop-down to select the start month for the desired three-month period
57 Click Create Schedule to establish a pre-determined schedule for mailing Dashboard reports to selected recipients
58 1. Select run date by clicking on calendar 2. Select frequency (monthly, quarterly, annually) 3. Select recipients 4. Click on Save Schedule 5. Report is sent through email as a PDF attachment
59 Click View My Dashboard to create a customized Dashboard
60 Only those measures being collected by the hospital will be available in the list Click drop-down to select a measure to display on Dashboard Selected measures are retained and are user specific Notes section available to add comments or additional information
61 Click At A Glance Dashboard to view a twelve-month trending graph/table view of each of the eight Dashboard measures
62 At A Glance twelve-month trending graphs for each Core measure with timeline and view options
64 Reports is still available to users to create peer reports. However, its function has been replaced by the enhanced and upgraded New Reports Click New Reports to view measures and create peer reports
65 Select report start and end dates Select peer groups Select data grouping
66 Users can select up to five additional peer groups
67 Available criteria selections for each peer group
68 Users can only create a report on measures that are being collected by their hospital Click on the blue measures category bar to display the list of measures (being collected by that hospital) in that category Users can select more than one measure from more than one category
69 Select output format Select how wish to view report
73 Webpage Table view The user’s facility is identified as Hospital
74 Webpage Table with detail view Note that peer hospitals are not identified by name but have been assigned random numbers Click on the envelope icon to contact a peer hospital for best practice information
75 The Hospital Contact at the selected peer hospital will receive the email message
76 Export format applies to Table and Table with detail views
77 From the Excel report users can create customized graphs to meet their needs
78 Gray Scale format displays graphs in black and white
79 Click on Best Practice Report to view and create reports that list the top five performers for any measure in QHi
80 Hospitals can create a customized Best Practice report by selecting: 1.Comparison quarter 2.Sorting and display option 3.Criteria 4.Measures 5. Clicking on Run Report
81 Reports the summed average of the most recent or selected quarter’s data Top performers are defined by the most recent or selected quarter’s data Previous two quarters are displayed for reference purposes only Click on the envelope icon to contact a top performer hospital for best practice information If your hospital is not in the top 5 performers, it will be shown at the end of the list with the ranking identified If your hospital is in the top 5 performers of a Core measure, it will be identified on the Dashboard with green stars and the message: “Best Practice Top Performer”
82 Training, educational materials and QHi documents are available for download on the Help page
84 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. Quality Health Indicators What do we do with the data? A few comments from our hospitals…
85 Thank you for viewing this demonstration. If you have any questions or would like additional information on the QHi project, please contact: Sally Perkins, QHi System Administrator firstname.lastname@example.org 785-276-3118 or Stuart Moore, QHi Coordinator email@example.com 785-276-3104 Quality Health Indicators
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