1. Copyright ©2011 Georgia Hospital Association FLEX GRANT Kathy McGowan Vice President, Quality & Safety Samantha Dulworth Technical & Customer Specialist November 13, 2013

2. Copyright ©2011 Georgia Hospital Association Georgia’s QI Program Structured on requirements of Medicare Beneficiary Quality Improvement Project (MBQIP), Culture of Patient Safety, Technical Assistance, Education, and Training for Critical Access Hospitals. Georgia Hospital Association Research & Education Foundation serves as sub-grantee for the Georgia FLEX QI Program since 2002

3. Copyright ©2011 Georgia Hospital Association QI Program Participation CMS Core Measures CMS Partnership for Patients Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Data submission to Hospital Compare Scheduled education Scheduled training & technical assistance

4. Copyright ©2011 Georgia Hospital Association QI Objectives Public quality reporting Participation in MBQIP Raising staff awareness regarding patient safety Examining trends in patient safety culture

5. Copyright ©2011 Georgia Hospital Association QI Overall Program Requirements Education & training in the use of CART, Core Measures and MBQIP Public reporting to Hospital Compare on relevant processes of care quality measures:  Inpatient  Outpatient  HCAHPS Hospital Engagement Network initiative

6. Copyright ©2011 Georgia Hospital Association QI Overall Program Requirements Actively work towards staff awareness about safety Examine trends in patient safety culture Identify areas of strength and possible improvement Consistently improve the patient quality of care outcomes in Georgia’s Critical Access Hospitals

7. Copyright ©2011 Georgia Hospital Association Purpose & Goal Ensure patient safety Deliver expected quality patient care outcomes

8. Copyright ©2011 Georgia Hospital Association Hospital Benefits Quarterly dashboards Quarterly core measure composite scores Minimum of two CART trainings annually HCAHPS and MBQIP training QI technical assistance CART technical and customer assistance Onsite coaching

9. Copyright ©2011 Georgia Hospital Association Hospital Benefits Resources  Data collection tools & definitions  CART manuals  Transfer / discharge checklists  Stabilizing core measure data submissions to Hospital Compare

10. Copyright ©2011 Georgia Hospital Association Education / Training Patient and Family Centered Care Rounding TeamSTEPPS Reliable Process Design Frontline Defects Analysis Plan-Do-Check-Act (PDCA) Process Improvement Principles

11. Copyright ©2011 Georgia Hospital Association Education & Training Organizational Assessment Tool (OAT) Culture of Patient Safety Survey Continue focus on core measures  Pneumonia-6  Heart Failure-1

12. Copyright ©2011 Georgia Hospital Association Education & Training Phase III of MBQIP (started 9/1/13)  Pharmacist/Computerized Physician Order Entry (CPEO)/Verification of Medication Orders within 24 hours  Outpatient Emergency Department Transfer Communication Needs assessment survey to all CAHs to establish baseline

13. Copyright ©2011 Georgia Hospital Association Education & Training ST Elevated Myocardial Infection (STEMI) Program

14. Copyright ©2011 Georgia Hospital Association Conflict of Interest State Office of Rural Health, Georgia Medical Care Foundation and GHA staff meet once a month Work together to avoid duplicating efforts

15. Copyright ©2011 Georgia Hospital Association HeRMES Samantha Dulworth

16. Copyright ©2011 Georgia Hospital Association Products

17. Copyright ©2011 Georgia Hospital Association Data Flow using Cart

18. HeRMES

19. Copyright ©2011 Georgia Hospital Association GHA DeadlineCMS Deadline UB04 Deadlines & Initial Population counts Joint Commission Both Inpatient & Outpatient Warehouse/Quality Net Outpatient Only and Quality Net Inpatient Populations CMS/Quality Net Inpatient OPPS Clinical Q1 2013June 1st 2013June 15th 2013August 1st 2013August 15th 2013 Q2 2013September 1st 2013September 15th 2013November 1st 2013November 15th 2013 Q3 2013December 1st 2013December 15th 2013February 1st 2014February 15th 2014 Q4 2013March 1st 2014March 15th 2014May 1st 2014May 15th 2014 Care Core Submission Deadlines

20. Copyright ©2011 Georgia Hospital Association CART  Inpatient CART Version 4.14 for Discharges (7/1/2013 -12/31/2013)  Outpatient CART Version 1.10 for Encounters (7/1/2013 - 12/31/2013)

21. Looking at Upload Reports

22. Summary of Data

24. Copyright ©2011 Georgia Hospital Association Running Population Report

25. Copyright ©2011 Georgia Hospital Association Population Report Measures will show in Red if there are not enough cases submitted for Global and Ed throughput

26. Copyright ©2011 Georgia Hospital Association Questions?

27. Copyright ©2011 Georgia Hospital Association Care Core Reports

28. Copyright ©2011 Georgia Hospital Association Creating Report in Care Core

29. Copyright ©2011 Georgia Hospital Association Reports (TJC Core Measures)

30. Copyright ©2011 Georgia Hospital Association Reports (TJC Core Measures)

31. Copyright ©2011 Georgia Hospital Association Reports (Values)

32. Copyright ©2011 Georgia Hospital Association Reports (Drill Down)

33. Copyright ©2011 Georgia Hospital Association Reports (Run Report)

34. Copyright ©2011 Georgia Hospital Association Patient Level Drill Down

35. Copyright ©2011 Georgia Hospital Association Patient Detail

36. Copyright ©2011 Georgia Hospital Association Reports (TJC Core Measures)

37. Copyright ©2011 Georgia Hospital Association Reports (Run Report)

38. Copyright ©2011 Georgia Hospital Association HeRMES

39. Copyright ©2011 Georgia Hospital Association Data Flow using Cart

40. Copyright ©2011 Georgia Hospital Association What CARE Service Line has the Highest Mortality Rate?

41. Copyright ©2011 Georgia Hospital Association What CARE Service Line has the Highest Mortality Rate? 1.Pick your Quality Indicator 2.Pick your Values 3.Pick CARE Service Line in Drill Down 4.Click Run Report 5.Find your highest CARE Service Line

42. Copyright ©2011 Georgia Hospital Association Report Outcome

43. Copyright ©2011 Georgia Hospital Association HeRMES

44. Copyright ©2011 Georgia Hospital Association How many patients left your Emergency Department against medical advice?

45. Copyright ©2011 Georgia Hospital Association Left Without Being Seen 1.Click on High Risk Patient Safety 2.Click Quality Indicator “ER Patients Who Leave against medical advice” 3.Click “Run Report”

46. Copyright ©2011 Georgia Hospital Association Running Report

47. Copyright ©2011 Georgia Hospital Association Report Outcome

48. Copyright ©2011 Georgia Hospital Association HeRMES

49. Copyright ©2011 Georgia Hospital Association Which Physician has the highest Mortality Rate?

50. Copyright ©2011 Georgia Hospital Association Which Physician has the highest Mortality Rate? 1.Click on MedEval 2.Click on Mortality under Quality Indicators 3.Click Physician Name and NPI number under “Drill Down” 4.Click on “Run Report”

51. Copyright ©2011 Georgia Hospital Association Report Outcome

52. Copyright ©2011 Georgia Hospital Association CoPS

53. Copyright ©2011 Georgia Hospital Association CoPS Log in Screen

54. Copyright ©2011 Georgia Hospital Association Report Selection

55. Copyright ©2011 Georgia Hospital Association Executive Level Dashboard

56. Copyright ©2011 Georgia Hospital Association Executive Level Dashboard – line graph

57. Copyright ©2011 Georgia Hospital Association Hospital Compare

58. Copyright ©2011 Georgia Hospital Association Question Level Drill Down

59. Copyright ©2011 Georgia Hospital Association Question Level Drill Down

60. Copyright ©2011 Georgia Hospital Association CoPS Links CoPS Website address https://cops.gha.org/Account/Login.aspx CoPS Campaign Request: http://cops.gha.org/survey/n/CoPSCampaignRequest.aspx http://cops.gha.org/survey/n/CoPSCampaignRequest.aspx

61. Copyright ©2011 Georgia Hospital Association Questions?

62. Copyright ©2011 Georgia Hospital Association GHA Contact Information Kathy McGowen, Vice President of Quality & Safety kmcgowen@gha.orgkmcgowen@gha.org 770-249-4519 Joyce Reid, Vice President of Community Health Connections jreid@gha.orgjreid@gha.org 770-249-4545 Samantha Dulworth, Customer and Technical Specialist sdulworth@gha.orgsdulworth@gha.org 770-249-4550