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 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