2012 User Group

22 | 10/11/2014 | © eHealth Data Solutions 2012 User Group Convert Your Data into Action June 20, :30-2:45 Melinda Cotton Julie Standerfer Joyce Rutherford-Donner

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44 | 10/11/2014 | © eHealth Data Solutions 2012 User Group Quality Improvement and eHealth Data Solutions eHealth Data Solutions believes in using data for decisions, so we have designed our products to help you convert data to action and support quality improvement. CareWatch uses the hundreds of data points found on the Minimum Data Set to populate Watch pages for quality and provides Statistical Process Control charts to help you interpret changes over time.

55 | 10/11/2014 | © eHealth Data Solutions 2012 User Group 5 Elements of Quality Assessment/Process Improvement Element 1: Design and Scope Element 2: Governance and Leadership Element 3: Feedback, Data Systems and Monitoring Element 4: Performance Improvement Projects (PIPs) Element 5: Systematic Analysis and Systemic Action

66 | 10/11/2014 | © eHealth Data Solutions 2012 User Group Interdisciplinary Team Administration Medical Director Nursing leadership Pharmacy Activities Social Services MDS Coordinator Nursing Assistant Dietary Environmental Services

77 | 10/11/2014 | © eHealth Data Solutions 2012 User Group Plan – Do – Study – Act Three Fundamental Questions What are we trying to accomplish What changes can we make that will result in an improvement How will we know that a change is an improvement

88 | 10/11/2014 | © eHealth Data Solutions 2012 User Group FOCUS PDSA Find a process that needs improvement Organize a TEAM that knows the process Clarify current knowledge of the process Understand causes of process variation Select the process improvement

99 | 10/11/2014 | © eHealth Data Solutions 2012 User Group FOCUS PDSA Plan the improvement process Do the new process and collect data Study the results of the new process Act to hold gains and improve further

10 | 10/11/2014 | © eHealth Data Solutions 2012 User Group Quality Measures Enhancing the Quality Measure Benchmarks Surveyor Quality Measures

11 | 10/11/2014 | © eHealth Data Solutions 2012 User Group Using Benchmark Data Successfully Check related QM indicators to avoid working in silos › ADL Decline with weight loss and depression › In-dwelling Catheter with UTI and high risk PU › High Risk PU with weight loss and depression › Pain Management and Pressure Ulcers (short stay) Drill down into the Watch pages

12 | 10/11/2014 | © eHealth Data Solutions 2012 User Group Surveyor QMs ONLY in Casper Reports Were used prior to the 3.0 Are all long stay measures Surveyors thought they were too good to leave out

13 | 10/11/2014 | © eHealth Data Solutions 2012 User Group Percentage of Residents Who Have Had a Fall During Their Episode of Care Numerator › One or more look-back assessments where J1800=1 Denominator › All long stay nursing home residents with one or more look-back assessments Exclusions › Look-back assessments where J1800= -

14 | 10/11/2014 | © eHealth Data Solutions 2012 User Group Psychoactive Drugs Percentage of Residents Who Are Receiving Psychoactive Drugs But Do Not Have Evidence of Psychotic or Related Conditions Numerator › Prior to 4/1/2012 N0400A=1 › 4/1/2012 or later N0410A=1,2,3,4,5,6,7 Denominator › All long stay residents with a selected target assessment

15 | 10/11/2014 | © eHealth Data Solutions 2012 User Group Psychoactive Drugs Exclusions: › Resident did not qualify for the numerator and any of the following is true:  Assessment with target dates on or before3/31/2012: N0400A= -  Assessment with target dates on or after 4/1/2012: N0410= - › Any of the following related conditions are present on the target assessment  Schizophrenia  Psychotic disorder  Manic depression (bipolar disease)  Tourette’s Syndrome on the prior assessment if this item is not active on the target assessment and if a prior assessment is available

16 | 10/11/2014 | © eHealth Data Solutions 2012 User Group Psychoactive Drugs More Exceptions › Tourette’s Syndrome › Huntington’s Disease › Hallucinations › Delusions

17 | 10/11/2014 | © eHealth Data Solutions 2012 User Group Prevalence of Antianxiety/Hypnotic Use Numerator › Assessments with target date on or before 3/31  N0400B=1 or N0400D=1 › Assessments with target date on or after 4/1  N0410B=1,2,3,4,5,6,7 or No410D= 1,2,3,4,5,6,7 Denominator › All long stay residents with a selected target assessment

18 | 10/11/2014 | © eHealth Data Solutions 2012 User Group Prevalence of Antianxiety/Hypnotic Use Exceptions › Pre 4/1 N0400B, N0400D equal – › 4/1 and post N0410B, N0400D equal – › Any of the following conditions are present on the target assessment  Schizophrenia,  Psychotic disorder  Manic depression  Tourette’s Syndrome  Tourette’s on the prior assessment if this item is not active on the target assessment and if a prior assessment is available

19 | 10/11/2014 | © eHealth Data Solutions 2012 User Group Prevalence of Antianxiety/Hypnotic Use More exceptions › Huntington’s disease › Hallucinations › Delusions › Anxiety disorder › Post traumatic stress disorder › Post traumatic stress disorder on the prior assessment if this item is not active on the target assessment and if a prior assessment is available.

20 | 10/11/2014 | © eHealth Data Solutions 2012 User Group Prevalence of Behavior Symptoms Affecting Others Numerator › Presence of physical behavioral symptoms directed towards others: E0200A=1,2,3 or › Presence of verbal behavioral symptoms directed towards others: E0200B=1,2,3 or › Presence of other behavioral symptoms directed towards others: E0200C=1,2,3 or › Rejection of care:E0800=1,2,3 or › Wandering: E0900=1,2,3

21 | 10/11/2014 | © eHealth Data Solutions 2012 User Group Prevalence of Behavior Symptoms Affecting Others Denominator › All residents with a selected target assessment except those with exclusions Exceptions › Target assessment is a discharge: A0310F=10,11 › E0200A,B,C is equal to - ^ › E0800 is equal to - ^ › E0900 is equal to - ^

22 | 10/11/2014 | © eHealth Data Solutions 2012 User Group How to Find This Information in CareWatch Prevalence of Falls › Reports/MDS 3.0 Details  Set date range back for a year  Go to Section J: Falls  Sort for J1800 Other three QMs › Tasks/MDS 3.0 Details Definition  Write out how you want the report to look first  Follow the Help to create

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24 | 10/11/2014 | © eHealth Data Solutions 2012 User Group Statistical Process Control Charts (SPC) SPC Charts tell a story about performance that should not be ignored. Selection of a QM to “correct” from a single point in time QM report could cause a facility to spend time on something that may not be a problem and could actually cause more problems for the facility. It is desired that the minimum points of data (months or quarters) is used. Trend is 5 or more points in a row in which the measure increases, decreases, or is above or below a benchmark.

25 | 10/11/2014 | © eHealth Data Solutions 2012 User Group Questions and Discussion