1. Medicare Beneficiary Quality Improvement Project (MBQIP) March 17, 2016 1

2. Welcome and Introductions Melissa VanDyne Rural Health Manager Missouri Department of Health and Senior Services Office of Primary Care and Rural Health Stephen Njenga, MPH, MHA, CPHQ Director of Performance Measurement Compliance Missouri Hospital Association Dana Downing, B.S., MBA-H, CPHQ Vice President of Quality Program Development Missouri Hospital Association 2

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4. Collaborations Melissa VanDyne 4

5. Secretary Deputy Secretary Chief of Staff Office of the Secretary Operating Divisions HHS Organizational Chart Centers for Disease Control and Prevention (CDC)* Administration for Children and Families (ACF) Administration for Community Living (ACL) Agency for Toxic Substances and Disease Registry (ATSDR)* Agency for Healthcare Research and Quality (AHRQ) Office of the Assistant Secretary for Administration (ASA) Office of the Assistant Secretary for Financial Resources (ASFR) Office of the Assistant Secretary for Health (OASH) Office of the Assistant Secretary for Legislation (ASL) Office of the Assistant Secretary for Planning and Evaluation (ASPE) Office of the Assistant Secretary for Preparedness and Response (ASPR)* Office of the General Counsel (OGC) Office of Global Affairs (OGA)* Office of the Assistant Secretary for Public Affairs (ASPA) Office of Inspector General (OIG) Office of Medicare Hearings and Appeals (OMHA) Office of the National Coordinator for Health Information Technology (ONC) Centers for Medicare & Medicaid Services (CMS) Food and Drug Administration (FDA)* Health Resources and Services Administration (HRSA)* Indian Health Service (IHS)* National Institutes of Health (NIH)* Substance Abuse and Mental Health Services Administration (SAMHSA)* Office of the Civil Rights (OCR) Departmental Appeals Board (DAB) Office of Health Reform (OHR) The Executive Secretariat (ES)Office of Intergovenmental and External Affairs (IEA)

6. OFFICE OF THE ADMINISTRATOR Administrator Deputy Administrator Senior Health Advisor Chief Public Health Officer Offices Bureaus HRSA Organizational Chart HIV/AIDS Bureau Associate Administrator Bureau of Health Workforce Associate Administrator Bureau of Primary Health Care Associates Administrator Healthcare Systems Bureau Associate Administrator Federal Office of Rural Health Policy Associate Administrator Office of Communications Director Office of Equal Opportunity, Civil Rights, and Diversity Management Director Office of Federal Assistance Management Associate Administrator Office of Global Health Director Office of Health Equity Director Office of Legislation Director Office of Women’s Health Director Office of Operations Chief Operating Officer Maternal and Child Health Bureau Associate Administrator Office of Planning Analysis and Evaluation Director Office of Regional Operations Associate Administrator

7. FORHP Organizational Chart Office of the Associate Administrator Associate Administrator Deputy Associate Administrator Hospital State Division Administrative Operations Division Policy Research Division Community-Based Division Office for the Advancement of Telehealth

8. Hospital State Division Organizational Chart Hospital State Division State Offices of Rural Health Program (SORH) Rural Quality Improvement Technical Assistance Small Rural Hospital Improvement Program (SHIP) Medicare Rural Hospital Flexibility Program (FLEX) Evaluation Medicare Rural Hospital Flexibility Program (FLEX) Small Rural Hospital Transitions Project (SRHT)

9.  Three (3) year project period with priority on quality and financial improvement 1. Quality Improvement (required) 2. Financial and Operational Improvement (required) 3. Population Health Management and EMS Integration (optional) 4. Designation of CAHs in the State (required as requested) 5. Integration of Innovative Health Care Models (optional)

10.  Four (4) Quality Domains: 1. Patient Safety 2. Patient Engagement 3. Care Transitions 4. Outpatient Care Back

11. Small Rural Hospital Improvement Grant Program (SHIP) Department of Health and Senior Services Office of Primary Care and Rural Health State Office of Rural Health

12. SHIP Hospital Eligibility Forty-nine (49) staffed beds or less as reported on the hospital’s most recently filed Medicare Cost Report, line 14. Hospital must be located in a rural area outside a Metropolitan Statistical Area (urban area). Check the Rural Health Information Hub ‘s “Am I Rural”? website (http://www.ruralhealthinfo.org/am-i-rural/tool) to find out if you are Rural.http://www.ruralhealthinfo.org/am-i-rural/tool Critical Access Hospitals (CAHs) are all eligible.

13. Funding Availability Fiscal Year (FY) 2015 Grant Period: September 1, 2015 – May 31, 2016 - $9,596.00 FY 2016 Grant Period : June 1, 2016 - May 31, 2017 - (not awarded yet) Approximate amount for each hospital: $9,000.00

14. SHIP Program - Use of Funds The SHIP funds should be prioritized by Critical Access Hospitals (CAHs) in the following manner: Priority 1: HCAHPS or ICD-10 Activities Both of these must be fully implemented and HCAHPS must be publicly reported to Hospital Compare, before your hospital can select any other investment options. Priority is not given to one over the other so your hospital may choose both. For information on Hospital Compare, see the Centers for Medicare & Medicaid Services at: www.hospitalcompare.hhs.gov. www.hospitalcompare.hhs.gov Priority 2: If your hospital is already participating fully in HCAHPS and ICD-10, you may select a different investment listed on the SHIP purchasing menu;

15. The SHIP funds should be prioritized by Critical Access Hospitals (CAHs) in the following manner: Priority 3: If your hospital has already completed ALL investments your hospital may identify an alternative piece of equipment and/or service ONLY IF: 1. The purchase will optimally affect your hospital's transformation into an accountable care organization, increase value-based purchasing objectives and/or aid in the adoption of ICD-10; 2. Your hospital receives pre-approval from both your state SHIP Director - Lisa Branson and the appropriate FORHP Project Coordinator. SHIP Program - Use of Funds

16. The SHIP funds should be prioritized by Non- Critical Access Hospitals in the following manner: Priority 1: Implementation of ICD-10 Priority 2: After implementation then selection among the activities listed on the SHIP Purchasing Menu. Priority 3: If a Non-CAH has completed all Purchasing Menu activities, it may engage in a different purchase, provided that:  The purchase will optimally affect a hospital’s transformation into an accountable care organization, increase value based purchasing objectives, aid in the adoption of ICD-10; and,  The hospital must receive permission from their state SHIP Director.

17. Contact Information Lisa Branson SHIP Director State Office of Rural Health (573) 526-2825 Lisa.Branson@health.m o.gov SHIP Webinar Link: http://health.mo.gov/living/families/ruralhealth/webinars.php

18. MHA Quality Improvement Initiatives Dana Downing 18

19. Critical Access Hospital Quality Reporting Quality Reporting Program Reporting Requirements Data Steward Data Collection System Reporting Frequency MHA Primary Contact MBQIP Strongly EncouragedHRSACART tool and/or core measure vendor and HCAHPS vendor and NHSN and Excel QuarterlyStephen Njenga Missouri Quality Transparency Strongly EncouragedMissouri Hospital Association Hospital Industry Data Institute QuarterlyDana Downing HEN 2.0 VoluntaryCMS/AHA/HRETHIDI Quality CollectionsMonthlyJessica Rowden Immersion Projects Voluntary; Mandatory for HEN 2.0 participants. MHA, CMS/AHA/HRETHIDI and HIDI Quality Collections and Qualaris Monthly or Quarterly Alison Williams/Jessica Rowden PQRS Billing method II may participate in PQRS. If you do not participate, you will receive penalty. CMSRegistry, EHR, Qualified Clinical Data Registry, Group Practice Reporting, CMS- Certified Vendor AnnuallyPrimaris – Sandy Pogones Q-HIP Mandatory if participating in the BCBS program Anthem BlueCross BlueShield Q-HIP web toolAnnuallyLocal BCBS contact PSO Voluntary. CMS proposed rule beginning Jan. 1, 2017 CMS/AHRQDependent on vendorVariesCenter for Patient Safety *Required, voluntary, or strongly encouraged, based on facility’s services and licensures. Please research your hospital’s eligibility for each listed quality reporting program. 19

20. MBQIP  Quality improvement activity under Medicare Rural Hospital Flexibility grant program of the Health Resources Service Administration’s Federal Office of Rural Health Policy  Goal — Improve quality of care in critical access hospitals nationwide.  Focus on quality reporting and improvement activities based on analyzed data.  Measure categories include patient safety, patient engagement, care transitions and outpatient care.  November 2015 – August 2016, with two possible additional years. 20

21. MHA Quality Transparency Initiative  Goals  Reduce variation  Coordinate care across the continuum of care  Increase transparency through non-competitive methods  Implement population-based health management and improvement strategies 21

22. MHA Quality Transparency Measures 22

23. Data Specifics  Data source — HIDI discharge claims data  Reduces the burden of collecting measures, therefore, providing more time and resources for analysis and implementation.  Ensures consistent data from facility to facility.  Frequency — quarterly  Ongoing project 23

24. HEN 2.0  CMS national project facilitated by American Hospital Association/Health Research Education and Trust  Aim  Reduce all-cause preventable harm by 40 percent  Reduce readmissions by 20 percent  Project slated until September 23, 2016 24

25. Data Specifics  11 topic areas of focus  Data source – HIDI Quality Collections, NHSN, HIDI claims, Hospital Data Entry 25

26. Immersion Projects  Goals  Provide a structured framework between evidence- based practice and sustained implementation  Provide cohort-based shared learning and networking  Increase organizational capacity, frontline engagement, leadership support  Encourage rapid-cycle improvement, use of QI tools and data to drive sustainable results  Team-based approach  October 2015 – November 2016 26

27. Data Specifics  All Immersion Pilot Projects have an outcome goal and a list of suggested process measures  Most outcome goals are claims/NHSN/AHRQ-based and already are reported through HIDI  Process measures are encouraged as “bundles”  Not required to report — internal use only  Should truly measure the care linked to improved outcomes 27

28. Individual Immersion Projects  Falls — Jessica Rowden  Sepsis — Jessica Rowden  CAUTI — Alison Williams  Readmissions — Alison Williams  OB Harm — Alison Williams 28

29. PQRS 29

30. Reporting Options — Individual EPs 30

31. Reporting Options — Group 31

32. PQRS Contact Sandy Pogones, Program Manager Primaris 200 N. Keene Street, #101 Columbia, MO 65201 800/735-6776 sandy.pogones@area-b.hcqis.org 32

33. Quality In-Sights: Hospital Incentive Program  Anthem BCBS program aimed at recognizing facilities for evidence-based medicine and implementing national best practices in patient safety, health outcomes and member satisfaction  Annual report  Regional  Ongoing project 33

34. Data Specifics  Anthem pulls HCAHPS and readmission data from Hospital Compare  Q-HIP web tool to be used for data entry  Benchmarks are calculated on data from Joint Commission, Hospital Compare, ACC-NCDR and STS 34

35. Patient Safety Organization  Reporting adverse events and patient harm, while focusing on protection, learning and prevention  PSOs create a legally secure environment where hospitals can voluntarily report events  CMS Final Rule — Beginning January 1, 2017, hospitals greater than 50 beds utilize a PSO or implement an evidence-based initiative to improve health care quality  Ongoing project 35

36. Resources 36

37. Quality Reporting Guides 37

38. MHA Website 38

39. Medicare Beneficiary Quality Improvement Program Stephen Njenga 39

40. Quality Requirements for MBQIP 40

41. MBQIP Reporting Processes  QualityNet via CMS Abstraction and Reporting Tool (CART) or vendor  QualityNet via online tool  QualityNet via approved HCAHPS surveyor  National Healthcare Safety Network (NHSN)  EDTC template to state Flex Program via ceads@mhanet.com ceads@mhanet.com 41

42. Data Submission Deadlines 42

43. Quality Improvement “Quality Improvement (QI) is an integrative process that links knowledge, structures, processes and outcomes to enhance quality throughout an organization.” - National Committee for Quality Assurance 43

44. Why QI?  In a time of changing landscapes in health care, QI can help answer key questions for CAHs:  Are we using our resources (staff, money, time) in the best way? – We often hear, “work smarter, not harder.”  Are we getting the intended outcomes?  Are we using data to drive our strategy?  Do we have all the tools and support that we need to be successful? 44

45. Quality Improvement  Proactive — works on processes before problems occur  Self-determined  Led by staff  Continuous  Exceeds expectations QA and QI — They are not the same!!! Quality Assurance  Reactive; works on problems after they occur  Regulatory  Led by management  One point at a time 45

46. Patient Engagement Domain Measures HCAHPS 46

47. HCAHPS Measures Composite Topics Nurse Communication Question 1, Q2,Q3 Doctor Communication (Q5,Q6,Q7) Responsiveness of Hospital Staff (Q4,Q11) Pain Management (Q13,Q14) Communication About Medicines (Q16,Q17) Discharge Information (Q19,Q20) Individual Items Cleanliness of Hospital Environment(Q8) Quietness of Hospital Environment(Q9) Global Items Overall Rating of Hospital(Q21) Willingness to Recommend(Q22) 47

48. Importance of HCAHPS  Growing evidence of positive associations between patient experience and  Health outcomes  Adherence to recommended medication and treatment  Preventative care  Health care resource use  Quality and safety of care  Provides objective and meaningful comparisons of domains of hospital care that are important to patients  Creates incentives for hospitals to improve  Enhances public accountability 48

49. Benchmarking Participation in HCAHPS 49

50. Missouri Participation in HCAHPS 50

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52. HCAHPS Performance Over Time 52

53. Inpatient Domain Measures 53

54. 54 IP - IMM-2 Patient Safety Measure Required (New)

55. Patient Safety Measures 55

56. IMM-2: Immunization for Influenza MBQIP Domain Patient Safety DescriptionPercentage of inpatients assessed and given influenza vaccination Reporting ProcessQualityNet via Inpatient CART or vendor ImportanceOne in five people in the U.S. get influenza each season. Combined with pneumonia, influenza is the 8th leading cause of death, with two-thirds of those attributable to patients hospitalized during the flu season. Hospitalization is an under-utilized opportunity to vaccinate. 56

57. OP-27: Influenza Vaccination for Health Care Personnel MBQIP Domain Patient Safety DescriptionPercentage of health care workers given influenza vaccination. Reporting ProcessNational Healthcare Safety Network (NHSN) Website ImportanceOne in five people in the U.S. get influenza each season. Combined with pneumonia, influenza is the 8th leading cause of death, with two-thirds of those attributable to patients hospitalized during the flu season. 57

58. Outpatient Domain Measures 58

59. Required Outpatient Measures Outpatient Measures OP-1: Median Time to Fibrinolysis OP-2: Fibrinolytic Therapy Received Within 30 Minutes OP-3: Median Time to Transfer to Another Facility for Acute Coronary Intervention OP-5: Median Time to ECG (electrocardiogram) OP-20: Door to Diagnostic Evaluation by a Qualified Medical Professional OP-21: Median Time to Pain Management for Long Bone Fracture OP-22: Left Without Being Seen (Emergency Department) 59

60. Benchmarking MBQIP Reporting 60

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62. Things to Remember Abstract all the required outpatient measures Use data transparently to drive change Focus on the process Engage process drivers Use evidence-based tools for your improvement efforts Increased sample size ensures validity and reliability Share successes Use barriers create an opportunity for improvement 62

63. Care Transitions Domain Measures 63

64. EDTC Quality Measures 64 MBQIP Domain Care Transitions DescriptionSeven Sub Measures (Percent) 1. Administrative Communication (2 elements) 2. Patient Information (6 elements) 3. Vital Signs (6 elements) 4. Medication Information (3 elements) 5. Physician/Practitioner Generated Information (2 elements) 6. Nurse-Generated Information (6 elements) 7. Procedures and Tests (2 elements) EDTC All or None Composite (27 elements) ImportanceTimely, accurate and direct communication facilitates a patient handoff to the receiving facility, provides continuity of care and avoids medical errors and redundant tests.

65. National Reporting for EDTC 65

66. State Reporting for EDTC 66 307% Reporting Increase

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68. EDTC Reporting Q12015 - Q32015 68

69. Are You Publicly Reporting Your Data? Are your results displayed on the Hospital Compare website? Who is your security administrator for QualityNet? Have they completed the required process to allow for publicly reporting your data? CAHs must complete this process since they are not part of the Inpatient Quality Reporting (IQR) and Outpatient Quality Reporting (OQR) programs. Process takes time, but we recommend hospitals check with QualityNet after completing the process for verification. QualityNet’s help desk may be able to give you an idea on when your data will display on the Hospital Compare website. 69

70. EDTC Data Collection Tool Demonstration Stratis Data Collection Tool 70

71. Questions? 71

72. MBQIP Quality Measures and Reporting Process 72

73. Outpatient Quality Domain Measures 73

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81. Patient Safety Quality Domain 81

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84. Care Transitions Domain Measures EDTC 84

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93. References  HCAHPS http://www.hcahpsonline.org/home.aspxhttp://www.hcahpsonline.org/home.aspx  MBQIP Measures Fact Sheets http://web.mhanet.com/SQI/mbqip/MBQIP-Measures- Fact-Sheets-Final_2015-11-10.pdf http://web.mhanet.com/SQI/mbqip/MBQIP-Measures- Fact-Sheets-Final_2015-11-10.pdf  Federal Office of Rural Health Policy http://www.hrsa.gov/ruralhealth/ http://www.hrsa.gov/ruralhealth/  FLEX Monitoring Team http://www.flexmonitoring.org/http://www.flexmonitoring.org/  QualityNet https://www.qualitynet.org/https://www.qualitynet.org/ 93

94. Questions? 94