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 KRHOP the Kansas Rural Health Options Project 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 700 users in over 200 Critical Access and other small rural hospitals in Alaska, Arizona, California, Colorado, Kansas, Louisiana, Michigan, Minnesota, Missouri, Nebraska, New Mexico, Oklahoma 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 • Hospital Associated Infections per 100 inpatient days • Unassisted Patient Falls per 1000 inpatient days • Inpatients Receiving Pneumonia Immunization (CMS PN-2) • Pneumonia Patients Given Antibiotics within 6 hours of admission (CMS PN-5c) • 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 (not a CMS measure) • Medication Omissions Resulting in Medication Error • Medication Errors Resulting from Transcription Errors • ER Provider Response Times • Return ER Visits within 72 hours with same/similar diagnosis • Readmits Within 30 Days with Same or Similar Diagnosis • Hospital Associated Infections per 100 inpatient days* • Unassisted Patient Falls per 1000 inpatient days* • CMS Pneumonia Measures • Inpatients Receiving O2 Assessment within 24 hours of admission - CMS Pn-1 (retired) • Inpatients Receiving Pneumonia Immunization - CMS PN-2* • Pneumonia Patients Given Antibiotics within 6 hours of admission - CMS PN-5c * • CMS OP Transfer Measures • Percentage of eligible patients who received thrombolytic therapy - CMS OP-1 and OP-2 • Median Time from Emergency Dept Arrival to Time of Transfer to another Facility for Acute Coronary Intervention - CMS OP-3 • Number of AMI patients without aspirin contraindications who received aspirin within 24 hours - CMS OP-4 • Percentage of AMI or Chest Pain patients receiving ECG within 10 minutes of arrival (prior to transfer) - CMS OP-5 *Part of the 8 Core Measure Set

8. Clinical Quality Measures (continued) HF Measures • Discharge Instructions provided to HF patients – 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 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

9. 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 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 Characteristic Measures • Average Inpatient Days • Monthly Inpatient Census • Multi-State ALOS (in hours) Comparison • ALOS (in hours) Comparison *Part of the 8 Core Measure Set

10. Financial & Operational Measures • 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 * • 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 *Part of the 8 Core Measure Set

11. 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

12. The PiHQ Portal Return to Main Menu

13. Users navigate through the suite of resources in the PiHQ Portal by using blue links across the top.

14. Hover text provides a brief description of each resource.

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

16. Or on any page throughout the portal here Users type in search topic here

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

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

19. All users have access to the Resource Library

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

21. All users have access to the Calendar

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

24. Users with access to the application are directed to the home pate, without additional log in.

25. 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.

26. This Calendar system, developed by Darlene Bainbridge, is now in live beta-testing. Users with access to the application are directed to their customized home page, without additional log in.

27. Partners in Healthcare Quality are working with 2 notable Risk Management vendors to pull aggregate data directly into QHi, further reducing data entry, and enhancing comparative analysis and benchmarking opportunities.

28. Defining Your Hospital Return to Main Menu

29. Users navigate through QHi by clicking the main menu and sub-menu options Click Administration to view Hospital Profile page

30. Hospital Contacts are responsible for completing and maintaining the Hospital Profile page for their facility. Allfields with a redasterisk* arerequiredfields Hospital Characteristics define each facility for creation of peer groups when running reports

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

32. Selecting Measures Return to Main Menu

33. Click here to go to Measures Selection page

34. 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

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

36. Additional Measures lists • Individual measures currently collected and • (2) other measures that are available to collect Click the negative -icon to remove measure from Currently Collecting Indicates the number of hospitals in QHi collecting the measure Click the plus + icon to measure to Currently Collecting

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

38. Entering Data Return to Main Menu

39. Click Data Submissions to open the Data Submission page

40. Data elements populate the data entry screen based on measures selected in the Hospital Profile. Click Go to: drop-down to select prior months’ data submissions Select correct month and year from Month to add drop-down IMPORTANT: User must check Activate data for reporting box in order for the data entered this month to be displayed on dashboards or in reports Click Save to save data entered

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

42. The prior month’s data is displayed for easy reference Data elements automatically populate this screen based on the measures selected by the user in the Measures Selection page Click to automatically calculate measures and immediately display results

43. The Dashboard Return to Main Menu

44. The Core Measures Dashboard provides comparison data for the eight QHi Core Measures The Dashboard can be viewed as a table Roll mouse over any dashboard graph to view the calculation

45. The Dashboard can also be viewed as combined graph and table table View

46. Graph and table View

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

48. 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

49. 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

50. Click here to view the Dashboard as a PDF