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AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE. Michigan Critical Access Hospital Quality Network Strategy Group #2 Data Management and Analysis February 15, 2019
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Michigan Critical Access Hospital Quality Network

Oct 05, 2021

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Page 1: Michigan Critical Access Hospital Quality Network

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Michigan Critical Access

Hospital Quality Network

Strategy Group #2 Data Management and Analysis

February 15, 2019

Page 2: Michigan Critical Access Hospital Quality Network

Strategy Group #2 Data Management and Analysis Goal: Michigan CAHs consistently submit timely and accurate data and are knowledgeable about how to utilize the data to identify gaps. No CAH left behind!

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Page 3: Michigan Critical Access Hospital Quality Network

Reminders Monthly – Submit to KDS & NHSN Quarterly – Q1 2019 data ◦April 23rd - Email MBQIP EDTC results to Crystal

◦May 1st - Outpatient results are due to QNet (Most use Quantros) ◦May 15th - Inpatient results are due to QNet

Annually ◦May 15th - Submit OP-22 (ED Left Without Being Seen) to QNet

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Page 4: Michigan Critical Access Hospital Quality Network

Random Sampling for EDTC • If you have more than 15 cases a month, consider sampling. • If you do sample, please use a randomizing tool.

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Page 5: Michigan Critical Access Hospital Quality Network

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

This will be added to the MPQIP worksheet in the MICAH QN Measure – Excel Sheet

Page 6: Michigan Critical Access Hospital Quality Network

Measure Spreadsheet Update

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

MICAH QN Measures – Excel Sheet

http://www.mcrh.msu.edu/programs/CAH/Quality%20Improvement%20NEW.html

Page 7: Michigan Critical Access Hospital Quality Network

OP-22 ED Left Without Being Seen • OP 22 is being reported as part of our commitment to MBQIP • Results have to be manually entered on QNet by May 15th

• Results will also be posted on Hospital Compare

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

There are instructions at the end of this presentation and they will also be

added to the MPQIP worksheet in the MICAH QN Measure – Excel Sheet

Page 8: Michigan Critical Access Hospital Quality Network

Abstracting for Accuracy Working Together to Ensure Data Quality

• What is it? • Resource offered by Stratis Health • Provides one-on-one education and assistance on how to abstract the core measures in MBQIP. • Ensures data is consistently abstracted using the appropriate criteria and abstraction definitions.

• What is the process? • The review will consist of comparing abstraction results between two abstractors to assess the

comparability of findings. • A sample of abstracted medical records is abstracted a second time by an independent abstractor to

ensure data quality, and an element-to-element comparison is performed.

• What is the outcome? • Identification of problem areas in the abstraction process, as well as areas that may need further

explanation or clarification. It also provides an opportunity for hospital abstractors to comment on variables that may be confusing and need more explanation.

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Page 9: Michigan Critical Access Hospital Quality Network

Helen Newberry Joy’s Experience Process: • Initial phone conversation with Robyn •Business Associate Agreement (BAA) •Hand selected 2 charts from each Core Measure and 2 from

EDTC = 10 charts total •Mailed paper copy of each episode and completed

abstraction tool for Robyn to review •Compared findings via phone •Lessons Learned • Implemented changes

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Page 10: Michigan Critical Access Hospital Quality Network

Interested? • Hand-out on registration table • Web-page - https://www.ruralcenter.org/resource-library/abstracting-for-accuracy-project

• Useful Resource: MBQIP Monthly- https://www.ruralcenter.org/tasc/mbqip/mbqip-monthly

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Page 11: Michigan Critical Access Hospital Quality Network

Organizational Scorecard Showcase

Borgess Lee Memorial

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Page 12: Michigan Critical Access Hospital Quality Network

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Page 13: Michigan Critical Access Hospital Quality Network

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Page 14: Michigan Critical Access Hospital Quality Network

OP-22 ED Left Without Being Seen • OP 22 is being reported as part of our commitment to MBQIP • Results will also be posted on Hospital Compare

• Results have to be manually entered on QNet by May 15th • You will be entering your results for all of 2018

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

After logging in QNet, Go to the Quality Programs tab and select

Hospital Quality Reporting: IQR, …

Page 15: Michigan Critical Access Hospital Quality Network

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Select Manage Measures

Select Outpatient Web-Based

Measures

Page 16: Michigan Critical Access Hospital Quality Network

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Select

2020

You are entering your 2018 results for Payment Year 2020.

For CAH’s this will not affect payment. This is reporting only for MBQIP and Hospital Compare.

Page 17: Michigan Critical Access Hospital Quality Network

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Click on OP-22

The Submission Period is open through May 15th

Enter your hospital’s results for 2018

Scroll down below and you’ll see these options. Select

Calculate

Page 18: Michigan Critical Access Hospital Quality Network

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

It will display your 2018 result. They round off the %

so in this case it rounded down to 0%.

If it appears correct, select

Submit and then back to return to

the previous screen

Make sure it has “Completed” below OP-22

Page 19: Michigan Critical Access Hospital Quality Network

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Results on OP-22 end up on

Hospital Compare

Page 20: Michigan Critical Access Hospital Quality Network

The other measures are optional

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Page 21: Michigan Critical Access Hospital Quality Network

You can report on two Inpatient Structure Measures

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.

Submission Period doesn’t open until April 1 and closes May 15th

Quick win on Hospital Compare

Page 22: Michigan Critical Access Hospital Quality Network

Strategy Group #2 Data Management and Analysis

Goal: Michigan CAHs consistently submit timely and accurate data and are knowledgeable about how to utilize the data to identify gaps. No CAH left behind!

•Update members on current clinical quality measures and track on new and retired measures (including eCQMs, Star Ratings, and potential new areas of focus).

•Provide education regarding when and how to report on measures.

•Drive sharing of ideas on how to share results and scorecard examples while encouraging transparency, promoting professional development, offering opportunities for networking and inspiring change.

•Work with consultants to present the data in a meaningful way, including benchmarking and comparison data.

•Provide best practices on specific measures related to data collection and reporting.

•Be proactive – identify measures that we want to be held accountable for and recommend they be used by agencies like MHA, FORH and payors like BCBSM for VBP. Go toward them, not wait for them.

AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.