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MONTANA RURAL HOSPITAL FLEXIBILITY GRANT (FLEX)

TUESDAY JANUARY 17 @ 2:00 – 3:00 PMAUDIO: 1-877-594-8353

ID: 70979270

Quarterly Quality Webinar

AGENDA

IMPORTANT DATES

UPCOMING PROJECTS

DATA ENTRY AND VALIDITY

PEER SHARING

Q & A

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FEBRUARY 1, 2017 Zero population submitted to QualityNet Q3-16 Outpatient cases submitted to CART/QualityNet

OP AMI: 1-5, OP Pain Management: 21, OP ED Throughput: 18, 20

Q4-16 ED Transfer Communications to MT Flex

FEBRUARY 15, 2017 Q3-16 IMM-2 cases submitted to CART/QualityNet

In continuing efforts with aligning MBQIP with the CMS reporting programs, FORHP expects hospitals to follow the data collection instructions for the IMM-2 measure found in the Inpatient Specifications Manual, which indicates data is to be collected each quarter, even if out of flu season.

IMM-2 is a CMS Inpatient Global Measure with an initial patient population that includes all patients discharged from acute inpatient care with a length of stay less than or equal to 120 days. Other measures are pulled from this population.

As long as CAHs meet the minimum threshold of submission they will be considered participation in MBQIP even if they do not submit cases for IMM-2 in Q2 and Q3.

March 22-24, 2017 MHA Health Summit, Helena, MT

IMPORTANT DATES

UPCOMING PROJECTS

Outpatient M2O Sign Up Now!

Register by January 20 February 15: Pre-project data collection due. Include the following for all 2016 ED cases in excel or

csv format: patient number (for your reference), admit date/time, discharge date/time Four 2 hr webinars: March 1, April 5 & 19, and report out on May 10 Face to face workshop at the MHA Summit March 21- 22 (Flex Program will provide participant support for

workshop attendance: mileage, lodging) Poster presentation at MHA Convention in September (do not need to be present at the convention)

Meets Quality Award Criteria #3: Engagement with MT CAHs

EDTC Quality Improvement Study Coming Soon!

Targeted improvement based on each facility’s specific needs using EDTC data already submitted.

Requirement: Complete a survey/analysis to identify specific causes of missed communication measures and/or tricks and tools used for documenting EDTC data elements consistently. Share proven resources among members to raise overall performance

Quality Award Criteria #1: Performance Improvement

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UPCOMING PROJECTS

F&O 2017 Project Update on Days in AR Project Sign up date TBD

Replicate Days in AR Project with new cohort Quality Award Criteria #3: Engagement with MT CAHs

Healthcare Worker Immunization Quality Improvement Study Update!

30 facilities are participating in the study. 26/30 are in Flex/HEN User Group Final step is to report HCW Immunization data to NHSN for 2016- 2017 flu

season (Oct 2016-March 2017) by May 15, 2017 Montana PIN HCW Immunization Toolkit Quality Award Criteria #1: Performance Improvement

PARTICIPATION

Reminder: Minimum threshold requirementsThe minimum requirements to participate in Flex-funded activities in FY 2017 (September 1, 2017 - August 31, 2018) include:

1. A CAH must have a signed MBQIP Memorandum of Understanding (All MT CAHs have completed this requirement)

2. A CAH must have reported data on at least one measure for at least one quarterwithin the reporting period listed below in at least two of the four MBQIP CoreQuality Domains.

Patient Safety: IMM-2: 3Q15 – 2Q16 ExpiredOP-27: Enrolled in NHSN (Or reporting)

Patient Engagement (HCAHPS): 3Q15 - 2Q16 Expired Care Transitions (EDTC): 1Q16 – 4Q16 Outpatient (OP-1-5, OP-18, 20-22): 3Q15 – 2Q16 Expired

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PARTICIPATION

MEASURE STATUS

Reported 83% 40 79% 38 86% 41 86% 

( )

41 79% 38

Zero Cases 0% 0 2% 1 0% 0 0 0

Did Not Report 21% 10 12% 6 14% 7 21% 10

Reported 75% 36 71%  34 79% 38

Zero Cases 0% 0 0% 0

Did Not Report 29% 

( )

14 21% 10

Reported 40% 19 38% 18

Zero Cases

Did Not Report 62% 30

Reported 56% 27 52% 

( )

25 48% 23

Zero Cases 2% 1 12% 6

Did Not Report 46%  22 40% 19

Q3 201616‐17 GOAL

MONTANA MBQIP REPORTING RATES

Q4 2015 Q1 2016 Q2 2016

CARE TRANSITIONS

PATIENT ENGAGEMENT

EDTC

HCAHPS

OP‐27

IMM‐2

not flu seasonnot flu season

reported yearly

included with 

quarter 1 data

reported yearly

included with 

quarter 1 data

reported

Feb 2017

reported

Nov 2016

NAreported yearly

included with 

quarter 1 data

PATIENT SAFETY

PARTICIPATION

MEASURE STATUS

Reported 56% 27 17% 8 14% 7 13% 6

Zero Cases 38% 18 42% 20 37% 18

Did Not Report 45% 22 44% 21 50% 24

Reported 65% 31 50% 24 20% 10 50% 24

Zero Cases 10% 5 40% 19 8% 4

Did Not Report 40% 19 40% 19 42% 20

Reported 55% 26 52% 25 54% 26 58% 28

Zero Cases

Did Not Report 48% 23 46% 22 42% 20

Reported 67% 32 52% 25 52% 25 50% 24

Zero Cases 10% 5 6% 3 6% 3

Did Not Report 38% 18 42% 20 44% 21

Reported 46% 22 44% 21

Zero Cases

Did Not Report 56% 27

reported yearly

included with 

quarter 4 data

reported yearly

included with 

quarter 4 data

reported

Feb 2017

reported

Feb 2017

reported yearly

included with 

quarter 4 dataNA

NANA

reported

Feb 2017

OP 1‐3(AMI)

OP 22(Left w/o being 

seen)

OUTPATIENT 

reported

Feb 2017

OP‐21 (Long bone fracture 

pain management)

OP 4‐5(AMI)

OP 18, 20(ED Throughput)

MONTANA MBQIP REPORTING RATES

16‐17 GOAL Q4 2015 Q1 2016 Q2 2016 Q3 2016

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CART UpdatesCMS recently released CART Inpatient (ver 4.19) and Outpatient (ver 1.15) modules for Q1-Q4 2017 cases. Updates are ready for download from the QualityNet website. You may download the updates now, but you will have to ensure you select the correct time frame for case entry when cases are entered into CART.

ED Transfer Data InconsistenciesWe have found inconsistencies between the number of ED transfers reported for MBQIP ED Transfer Communication (EDTC) measures and the number of ED transfers reported to PIN Benchmarking (measure#27). ED transfers less than 45 in one quarter should match what is reported to both projects. For ED Transfers more than 45 in one quarter, a sample of 45 should be reported to MBQIP EDTC measures and the entire number of transfers reported to PIN Benchmarking. For PIN Benchmarking we use this data to calculate the percentage of ED visits that are transferred.

Inconsistency example: # Transfers Benchmarking \ # Transfers MBQIP EDTC30 | 16

Both count of ED Transfers should be 30 and 30 cases should be submitted to MBQIP ETDC.

MBQIP OutliersErrors in data submitted directly to CART/QNet cannot be changed by us. This last quarter several hospitals had huge outliers that we can contribute to an error in dates entered.

DATA ENTRY & VALIDATION

Zero Cases/Zero Population

There is an official process for indicating outpatient measures with zero cases or zero patient population. This process will take place of the survey monkey tool provided by MT Flex. You should not have zero cases for OP ED Throughput measures 18 & 20 unless you had zero ED Visits in the quarter.If you have zero cases and you do not accurately complete this process it will result in non-participation.

***DISCLAIMER! QualityNet has made a change and not everyone is able to enter zero cases on QualityNet right now. If you are not able to, please screen shot your error and send to me the measures you have 0 cases in. Our technical assistance (RQITA) is working on this issue.***

DATA ENTRY & VALIDATION

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DATA ENTRY & VALIDATION

DATA ENTRY & VALIDATION

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DATA ENTRY & VALIDATION

DATA ENTRY & VALIDATION

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DATA ENTRY & VALIDATION

DATA ENTRY & VALIDATION

Review the summary screen and click Continue.  Choose to Save, or if there are errors Edit.  When it is complete there will be a pop up that says “Update Successful”.  Click Okay.  Repeat for ED Throughput and Pain Management measures. 

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Peer Sharing

IMM-2 Performance Barrett Hospital and Healthcare

Reporting Successes! Mountainview Medical Center Northern Rockies Medical Center Sheridan Memorial Hospital

Meets Quality Award Criteria #4 Project Circulation

Q&A

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Flex Grant Staff

Flex DirectorGina Bruner 457-8016 gina.bruner@mtha.org

Rural Hospital Improvement CoordinatorJamie Schultz 457-8002 jamie.schultz@mtha.org

Flex Program SpecialistJennifer Wagner 457-8000 jennifer.wagner@mtha.org

CART Updates

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CART Updates

Determine your current CART version.

Log into CART under OP or IP.

Click on Help; the “About Quality Management System

CART Updates

CART Updates can be downloaded at www.qualitynet.org

• Right side, third box down named Downloads. Do the inpatient download or upgrade first, then outpatient.

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CART Updates

Choose the most recent version. If there are more versions between the current and this, upload each separately to avoid issues.

Click “Go” and follow download instructions

CART Updates

Choose the correct version in CART Click on Administration, then Provider

Choose the correct version in CART Click on Administration, then Provider Time Period

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CART Updates

Under Provider Preferences on the right, choose the time period and measures you are entering cases for.

This may not be the same as the most recent update.