1. MHA Keystone Center Update
MICAH QN Meeting – August 18, 2017

2. BCBSM P4P – Keystone Lead
Kristy Swadley -

3. 2017-18 BCBSM P4P Pg5 Program – GLPP HIIN Quality Initiative
Updates & Reminders

4. MHA Keystone / GLPP HIIN Requirements
Critical Access Hospitals PG5
Updated Scoring Index 8/16/2017
Non-Critical Access Hospitals PG5

5. MHA Keystone / GLPP HIIN Requirements – Data Submission
Monthly data submission of ALL HIIN Measures will be reported from April 2017 – March 2018 (entire program year)
Hospitals will only be scored for the submission of outcome data they are eligible to collect. Please reference Appendix A (HIIN Encyclopedia of Measures) for a complete list of the required measures.
Data Submission
(Manual data entry ONLY)
Goal = Monthly (15th after each month submit previous months data)
Minimally = Quarterly

6. MHA Keystone / GLPP HIIN Requirements – Data Submission
EOM Cover Page – Administrative Claims Measures
Keystone Data System (KDS) Location
NOTE:
These measures are automatically uploaded for hospitals who submit to MIDB (Michigan Inpatient Data Base)
Confirm with your claims person or check KDS (6 month data lag)

7. MHA Keystone / GLPP HIIN Requirements – Data Submission
NOTE: NHSN Users
If you submit ALL HAI measures in NHSN, have conferred rights to Keystone, these measures will be automatically uploaded for your facility in KDS
Keystone Data System (KDS) Location
EOM Cover Page – NHSN Measures
NOTE:
If you DO NOT submit ALL HAI measures in NHSN, you will have to directly submit these measures in KDS!

8. MHA Keystone / GLPP HIIN Requirements – Data Submission
NHSN Users
Confer rights to MHA Keystone
If unit name changes, re- confer rights

9. MHA Keystone / GLPP HIIN Requirements – Data Submission
EOM Cover Page – Manual Entry Measures
Keystone Data System (KDS) Location
NOTE:
These are manual entry measures in KDS
(no other data sources available)

10. MHA Keystone / GLPP HIIN Requirements – Data Submission
GLPP HIIN EOM v. 2.1 – Updated 8/16/2017
To Do:
Review EOM Cover page for updates under v. 2.1
Review FAQ

11. MHA Keystone / GLPP HIIN Requirements – Performance
Critical Access Hospitals PG5
2 = FULL Points
Bonus points can ONLY be used towards Keystone HIIN Quality Initiative section
Non-Critical Access Hospitals PG5
2 = FULL Points

12. MHA Keystone / GLPP HIIN Requirements – Performance – CAH ONLY
Hospitals will be scored on their own performance over time, and whether they are demonstrating improvement in: CAUTI (Urinary Catheter Utilization Ratio OR CAUTI Rate), EDTC 1 (Element 1 OR Element 2), and EDTC 4 (Element 1 OR Element 2 OR Element 3) rates from the designated (hospital-specific) baseline to the listed performance period (Table 3)
Baseline will be select based on data submission during outlined timeframes
The highest performing metric/element under the designated measure will be selected at the end of the program year
Hospitals that maintain rates in the top quartile among all participating CAH hospitals will receive full points for improvement
Please see Appendix A & Appendix B for measure definition

13. MHA Keystone / GLPP HIIN Requirements - Performance - NON-CAH ONLY
Hospitals will be scored on their own performance over time, and whether they are demonstrating improvement in CAUTI (Urinary Catheter Utilization OR CAUTI SIR), Sepsis (Post-op Sepsis OR Sepsis Mortality) and Opioid ADE rates from the designated (hospital-specific) baseline to the listed performance period (Table 3).
The highest performing metric under the designated measure will be selected. This aligns with how the MHA Keystone Center will track performance of hospitals in the HIIN for all measures.
Hospitals that maintain rates in the top quartile among all participating hospitals will receive full points for improvement.
Please see Appendix A for measure definition
NON-CAH PG: Please watch for updated scoring index identifying baselines for performance measures!
Questions:

14. MHA Keystone / GLPP HIIN Requirements – Performance – Baseline Data
MHA Keystone is reviewing baseline data submission and will be reaching out to PG 5 participants to discuss:
missing data
baseline selection
Questions?

15. MHA Keystone / GLPP HIIN Requirements – PFE
The goal of this component is to implement a PFAC and/or include patient advisors on existing quality improvement team(s) by the end of the program year (if not currently implemented)
Hospitals would be asked to report on this component minimally twice during the program year, by simply indicating fully implemented, partially implemented, or not implemented in Keystone Data System
Please reference the MHA Community Website – Keystone Center Quality Initiatives – HIIN Foundational Concepts – Person & Family Engagement (PFE) folder for additional information on the launch of Patient & Family Advisory Councils and/or inclusion of patient advisors on existing quality improvement committees.

16. MHA Keystone / GLPP HIIN Requirements – AMS
Completion of the NHSN Patient Safety Annual Survey (which contains AMS questions) during 2017 will meet this requirement if the hospital has conferred rights to MHA Keystone Center
Hospitals who do not submit to NHSN must complete the MHA Keystone Center AMS assessment. Survey link sent back in late March to HIIN Infection & Primary Contacts!
Update: ALL PG5 hospitals have met this requirement!

17. PFE Mid-Year Data Update

18. PFE Mid-Year Data Update
Status update on the five PFE metrics by verifying the data in the H-2 survey in the Keystone Data System (KDS) by Aug. 25 [report updates for any measure(s) that is now “Partially” or “Fully-implemented”]
Reminder: PFE Metric 4 (BCBS P4P Requirement) needs to show “Fully Implemented” by the end of the program year

19. BCBSM P4P
Questions regarding BCBSM P4P GLPP HIIN requirements:

20. MHA Keystone GLPP HIIN
Updates & Reminders

21. GLPP HIIN Updates & Reminders
Upcoming Training Opportunities:
Sep. 19: MHA Keystone Fall Conference – HAIs (Dearborn)
Oct. 11 & 12: QuEST Training (Gaylord)
Reminders:
Submit your data!!

22. Health Equity Series – Save the Date
Webinar 1 – Setting the Stage for Success: PFE and Health Equity
Thursday, September 21, 10:00 am - 11:00 am ET / 9:00 am - 10:00 am CT
Webinar 2 - Collecting and Using REAL Data to Improve Quality and Safety
Thursday, October 19, 10:00 am - 11:00 am ET / 9:00 am - 10:00 am CT
Webinar 3 - Examples from the Field: How to Use REAL Data to Improve Quality and Safety

23. MHA Keystone PSO
Updates & Reminders

24. PSO – Updates & Reminders
Upcoming Training Opportunities:
Sep. 12: Safe Table: Behavioral Health (Livonia)
Sep. 20: RCA² Training (Livonia)
Oct. 23-Nov. 10: Culture Survey
Kickoff webinar #1: Aug. 28
Kickoff webinar #2: Sep. 6
Nov. 28: Safe Table: Rural Health (Petoskey)
Nov. 29: RCA² Training (Petoskey)
PSO Questions? Contact Adam Novak

25. Ewa K. Panetta