Quality Health Indicators

1. Quality Health Indicators Brought to you by… Left click mouse or use down arrow to proceed through this presentation

2. Main Menu • About QHi • The PiHQ Portal • Defining your facility • Selecting Measures • Entering Data • Dashboards • Reports • How we use the data Select any menu item above to go directly to a topic or Click to continue through the presentation

3. Quality Health Indicators • The Quality Health Indicator (QHi) web site was developed through the Kansas Hospital Association (KHA) and the Kansas Rural Health Options Project (KRHOP) to facilitate a benchmarking project for rural Kansas hospitals. • The goal of QHi is to provide hospitals an economical instrument to evaluate internal processes of care and to seek ways to improve practices by comparing specific measures of quality with like hospitals. • Using QHi as a tool, regional networks of hospitals and individual facilities can select from a library of indicators to determine which measures meet their unique needs.

4. Quality Health Indicators • More than 900 users in over 250 Critical Access and other small rural hospitals in Alaska, Arizona, California, Colorado, Illinois, Kansas, Kentucky, Louisiana, Michigan, Minnesota, Missouri, Nebraska, New Mexico, Oklahoma, Oregon and Wyoming use QHi as a data collection and benchmarking tool. • As a user-driven multi-state project, QHi is well-positioned to serve as a significant repository of information on quality of care and performance in rural hospitals nationwide.

5. Quality Health Indicators Four Pillars Of Measurement Clinical Quality Financial Operational Employee Contribution Patient Satisfaction

6. QHi Core Measures Set All participating hospitals are asked to collect and report the 8 QHi Core Measures: • Clinical Quality • Healthcare Associated Infections per 100 inpatient days • Unassisted Patient Falls per 100 inpatient days • Pneumococcal Immunization (PPV23) – Age 65 and Older (CMS IMM-1b) • Discharge Instruction (CMS HF-1) • Employee Contribution • Benefits as a Percentage of Salary • Staff Turnover • Financial Operational • Days Cash on Hand • Gross Days in AR

7. Additionally, facilities can select from over 90 measures in the QHi library of indicators: • Clinical Quality Measures • Inpatients Screened for Pneumonia Vaccine Status (not a CMS measure) • Medication Omissions Resulting in Medication Errors • Medication Errors Resulting from Transcription Errors • ER Provider Response Times • Return ER Visits within 72 hours with same/similar diagnosis • Readmissions Within 30 Days with Same or Similar Diagnosis • Healthcare Associated Infections per 100 inpatient days* • Unassisted Patient Falls per 100 inpatient days* • Long Term Care Patient Falls per 100 Long Term Care patient days • CMS Pneumonia Measures • Inpatients Receiving O2 Assessment within 24 hours of admission - CMS PN-1 (retired) • Inpatients Receiving Pneumonia Immunization - CMS PN-2(retired) • Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital - CMS PN-3b • Adult Smoking Cessation Advice/Counseling - CMS PN-4 (retired) • Pneumonia Patients Receiving Initial Antibiotic Within 6 Hours of Hospital Arrival - CMS PN-5c(retired) • Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients - CMS-PN6 • Influenza Vaccination - CMS PN-7 (retired) • *Part of the 8 Core Measure Set

8. Clinical Quality Measures (continued) CMS OP Transfer Measures • Median Time to Fibrinolysis in the Emergency Department - CMS OP-1 • Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival in the Emergency Department - CMS OP-2 • Median Time to Transfer to Another Facility for Acute Coronary Intervention in the Emergency Department - CMS OP-3 • Aspirin at Arrival in the Emergency Department - CMS OP-4 • Median Time to ECG in the Emergency Department - CMS OP-5 • Timing of Antibiotic Prophylaxis in Hospital Outpatient Surgery - CMS OP-6 • Prophylactic Antibiotic Selection for Surgical Patients in Hospital Outpatient Surgery - CMS OP-7 CMS Immunization Measures • Pneumococcal Immunization (PPV23) – Overall Rate - CMS IMM-1a • Pneumococcal Immunization (PPV23) – Age 65 and Older* - CMS IMM-1b • Pneumococcal Immunization (PPV23) – High Risk Populations (Age 6 through 64 years) - CMS IMM-1c • Influenza Immunization - CMS IMM-2 *Part of the 8 Core Measure Set

9. Clinical Quality Measures (continued) CMS HF Measures • Discharge Instructions* – CMS HF-1 • Evaluation of LVS Function – CMS HF-2 • ACEI or ARB for LVSD – CMS HF-3 • Adult Smoking Cessation Advice/Counseling – CMS HF-4 (retired) CMS SCIP Measures • Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision – CMS SCIP-Inf-1a • Prophylactic Antibiotic Selection for Surgical Patients – CMS SCIP-Inf-2a • Prophylactic Antibiotics Discontinued Within 24 Hours after Surgery End Time – CMS SCIP-Inf-3a • Surgery Patients with Appropriate Hair Removal – CMS SCIP-Inf-6 • Urinary Catheter Removed on Postop Day 1 or Postop Day 2 with Day of Surgery being Day 0 – CMS SCIP-Inf-9 • Surgery Patients with Periop Temperature Management – CMS SCIP-Inf-10 • Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Periop Period – CMS SCIP-Card-2 • Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered – CMS SCIP-VTE-1 • Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery – CMS SCIP-VTE-2 *Part of the 8 Core Measure Set

10. Patient Satisfaction Measures • How well staff worked together to care for the patient (QHi1) • The extent to which the patient felt ready for discharge (QHi2) In addition to these two original QHi patient satisfaction measures, 22 HCAHPS measures are now in the library of indicators. • Employee Contribution Measures • Non-Nursing Staff Turnover • Average Time to Hire (All Staff) • Nursing Staff Turnover • Average Time to Hire (Nursing) • Average Time to Hire (Non-Nursing) • Salary to Operating Expenses Comparison • Benefits as a Percentage of Salary* • Staff Turnover* • Hospital Characteristics Measures • Average Inpatient Days • Monthly Inpatient Census • ALOS (in hours) Comparison *Part of the 8 Core Measure Set

11. Financial & Operational Measures • Operational • Physical Therapy Labor Hours per Unit of Service • Laboratory Labor Hours per Unit of Service • X-ray Labor Hours per Unit of Service • Mammogram Labor Hours per Unit of Service • Ultrasound Labor Hours per Unit of Service • CT Labor Hours per Unit of Service • MRI Labor Hours per Unit of Service • Pharmacy Labor Hours per Unit of Service • Nursing Hours per Patient Day • Rural Health Clinic Encounters per FTE • Long Term Care Hours per LTC Patient Day • Laboratory Hours per Billed Service • Financial • Bad Debt Expense • Charity Care • Cost per Patient Day • Labor Hours per Patient Day • Operating Profit Margin • Current Ratio • Net Patient Revenue per Patient Days • Payer Mix – Commercial • Payer Mix – Medicaid • Payer Mix – Medicare • Payer Mix – Other • Payer Mix – Other Government • Payer Mix – Self/Private Pay • Days Cash on Hand* • Gross Days in AR* *Part of the 8 Core Measure Set

12. Quality Health Indicators Web Site Access An email address and password are required to enter this secure web site. The level of access is determined by the User type: System Administrator – maintains the site – KHA/KHERF State Administrator –provides support to Hospital Contacts in their State Network Administrator – maintains Network profiles & provides support Hospital Contact– maintains Hospital profiles , adds users & enters data Hospital User – enters data and runs reports View Only – views data and runs reports Report Recipient – no access to QHi, only receives reports

13. Defining Your Hospital Return to Main Menu

14. Users navigate through the suite of resources in the PiHQ Portal by clicking on the blue-lettered links in the white menu bar

15. Hover text provides a brief description of each resource

16. All QHi, HSI and SQSS users have access to the PiHQ search engine.

17. …or on any page throughout the portal Users type in search topic here

18. Results are pulled from all Portal resources. Future enhancements will allow users to pull from resources outside of PiHQ as well.

19. The Resource Library holds all resource materials developed for PiHQ.

20. All users have access to the Resource Library

21. Results are pulled from all Portal resources. Icons identify the source of the information.

22. All users have access to the Calendar

23. The Calendar provides registration information for upcoming Quality Training Sessions

25. Users with access to this application are directed to the home page, without additional log in.

26. All HCAHPS measures can be automatically pulled from HSI and uploaded directly into QHi, eliminating duplicate entry. Future enhancements will allow any HSI measure to be uploaded into QHi.

27. Users with access to this application are directed to their customized home page, without additional log in.

28. Partners in Healthcare Quality are working with two notable Risk Management vendors to pull aggregate data directly into QHi, further reducing data entry, and enhancing comparative analysis and benchmarking opportunities.

29. Defining Your Hospital Return to Main Menu

30. Users navigate through QHi by selecting options from the red main-menu bar and the blue sub-menu bar Click Administration to view Hospital Profile page

31. Hospital Contacts are responsible for completing and maintaining the Hospital Profile page for their facility All fields with a red asterisk are required fields Hospital Characteristics define each facility for creation of peer groups when running reports

32. Question mark icons provide pop-up definitions throughout the QHi site Click drop-down to select Level of Measurement . This applies only to Financial/Operational measures

33. Selecting Measures Return to Main Menu

34. Click here to go to Measure Selection page

35. In Collected Measure Sets, users can select the default measures predetermined by their state or network Additional measure sets are available here The QHi Core Measure Set is pre-selected as it is required for all hospitals

36. Collected Measures lists the measures within the measure sets currently collected by the hospital Individual measures are displayed and can be selected under Additional Measures

37. Additional Measures lists: • individual measures currently collecting • other measures that are available to • collect Click the minus icon to remove measure from Currently Collecting Indicates the number of hospitals in QHi collecting the measure Click the plus icon to add measure to Currently Collecting

38. Click the question mark icon to display the calculation for each measure Click show elements to display the elements required to calculate the measure

39. Entering Data Return to Main Menu

40. Click Data Submissions to access the Data Submission page

41. Click Go to: drop-down arrow to select prior months’ data submissions To create a new data submissions page, select correct month and year from Month to add: drop-down arrows IMPORTANT: You must check Activate data for reporting box and then Save All and Stay in order for the data entered this month to be displayed on dashboards or in reports Click Save All and Stay to save data entered

42. If data for the month is entered and saved, but not activated, this message will appear to remind the user to activate the data for reporting

43. Data elements automatically populate this page based on the measures selected by the user in the Measure Selection page Click to automatically calculate measures and immediately display results Prior months’ data is displayed for easy reference

44. The Dashboard Return to Main Menu

45. The Core Measures Dashboard displays comparison data for the eight Core Measures The Dashboard can be displayed in graph, table, or graph/table views Roll mouse over any Dashboard graph to view the pop-up calculation for that measure

46. Table View

47. Graph and Table View

48. Dashboard data is calculated using a consecutive three-month summing average QHiAvg values reflect data from all hospitals in QHi reporting the same measure in the same time interval State Avg values reflect data from hospitals in the same state as My Hospital and reported in the same time interval

49. Financial measures on the Dashboard default to peer groups based on the hospital’s level of reporting (Hospital Only or Entire Enterprise) A hospital must have activated data for at least one of the three months in the Date Range in order for the measure to be displayed on the Dashboard My Hospital data for some clinical measures will not display on the Dashboard if the hospital had no occurrences during the Date Range period

50. The three months in the Date Range can be changed by clicking the drop-down to select the start month for the desired three-month period