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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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Michigan Critical Access Hospital Quality NetworkAS 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
February 15, 2019
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.
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.
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.
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
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
• 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
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.
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.
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.
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.
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.
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.
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, …
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
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.
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
Enter your hospital’s results for 2018
Scroll down below and you’ll see these options. Select
Calculate
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
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
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.
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
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.
Slide Number 1
Reminders
Abstracting for Accuracy Working Together to Ensure Data Quality
Helen Newberry Joy’s Experience
Interested?
Slide Number 15
Slide Number 16
Slide Number 17
Slide Number 18
Slide Number 19
You can report on two Inpatient Structure Measures
Strategy Group #2 Data Management and Analysis