1. Organizational Assessment Tool (OAT) Faizah Muheb VP, Analytical Services June 2013

2. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 2 OAT Description  A comprehensive evidenced-based tool  Developed for the Hospital Engagement Networks (HENs) to:  Help identify areas for quality improvement  Support efforts to expand the use of models shown to improve care  Help achieve Partnership for Patients (PfP) goals  40% Reduction of HAC’s  20% Reduction of Readmissions

3. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 3  Safety culture  Leadership  Measurement  Medication  Purchasing practice  Procedural  Risk management  Nursing practice  Communication  Infection control  The OAT contains 139 questions organized by Areas of Focus  Markers for HACs and readmissions are included in the Areas of Focus OAT Description

4. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 4  Background Questions  Hospital type  Average daily census  Annual rate of hospital admissions  HEN the hospital is associated with  Electronic Health Record (EHR) system OAT Description

5. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 5 OAT Development  Reviewed evidence-based best practices  Developed markers to capture the highest standard of care known to mitigate patient harm  Conducted successive revisions of markers  CMS feedback  Clinical, patient safety, risk management, and quality improvement experts  Pilot tested the OAT with seven PfP hospitals

6. Learn. Act. Improve. Spread. Keep the Drum Beat Going. How will the OAT be used? – Assess Current Practices and Capabilities within GHA HEN – Prioritize efforts based on HEN results – Help identify hospitals with leading edge practices

7. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 7 OAT v2.0.0 replaces OAT v1.3.7, which hospitals completed in 2012 With the exception of some minor edits, the content of OAT v2.0.0 is the same – This is critical in providing hospitals with a way to compare their results from Year 1 to Year 2 – Ensures ease of use – items and organization of items already familiar to users Scoring has been revised to account for “Not applicable” responses – OAT v2.0.0 bases individual hospital scores on only those items that are applicable to them OAT Release 2.0

8. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 8 Completing the OAT  A single OAT is completed per hospital  Recommend responsibility be assigned to the VP-Quality, VP - Medical Affairs, PSO or equivalent  Individual responsible for OAT contacts appropriate staff to gather information, as necessary  Pilot test found the OAT required ½-6 hours to complete  Pilot test hospitals reported the act of completing the OAT was beneficial

9. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 9 OAT Scoring  Points assigned to markers vary depending on the type of response set:  Dichotomous responses (5= Yes, 0=No)  Check all that apply (1 point for each checked item)  Likert Scale: Number of points = scale response  Others  Counts  Yes/ Yes but/No 9

10. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 10 Access to OAT Data  The OAT is for the HENs and hospitals  Only the HENs will be able to identify its hospital partners  HENs will provide CMS and the NCD the de-identified OAT data  National trends  Norms

11. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 11 OAT Resources-Update  An online version of the OAT will be available via SNAP Survey WebHost (FISMA Compliant)  GHA will work with NCD to create an online account for each hospital to complete the OAT  SNAP software includes an array of powerful analytical tools and real-time reporting  An electronic offline solution (excel version OAT) will be available for hospitals that may not be able to complete the web-based OAT

12. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 12 Timeline GA HEN Hospitals have until July 31, 2013 to complete the OAT 12

13. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 13  OAT is a resource for the HENs to achieve the goals of the PfP  The OAT consists of 139 evidenced-based best practices  OAT useful for identifying their hospital’s strengths and weaknesses  The NCD will establish a SNAP WebHost account for each HEN to securely administer and collect OAT data Summary

14. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 14