NRI Behavioral Healthcare Performance Measurement System

1. NRI Behavioral Healthcare Performance Measurement System Lucille Schacht, Ph.D. – Director Kathleen Monihan – Analyst Michelle Custodio – Data Architect Marie Huddle – Contracts Specialist NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

2. Overview • BHPMS Background • Responses to Survey of Interests • Accessing reports on the website • Coming Attractions • Collaborations & Core Measures NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

3. BHPMS Background • Started in 1997 in response to JCAHO requirement known as ORYX • Hospitals submit monthly case-level data • Hospitals select 9 or more measures to include in quality improvement activity • BHPMS provides standard definitions for data elements and performance measures • BHPMS computes measure rates for each hospital and comparison groups • BHPMS offices in Alexandria and Lexington NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

4. BHPMS Background (cont.) • Alexandria Office Activities • Administration • Contracts & Business Associate Agreements • Topical & Public Reports • Kentucky Office Activities • Data Processing and Monthly Reports • Data Integrity Reviews • Website • Staff: Trish, Diane, Peggy, Huyi, Graham, Harry, Kristi, Donna, & Brian NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

5. Survey of Interests • Conducted in September 2004 • Hard copy surveys mailed to Commissioners and Hospital Directors • Non-respondents followed-up with a postcard reminder of survey NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

6. Summary of Respondents NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

7. Report Breakdowns What types of reports would you find helpful? Directors Commissioners NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

8. Report Focus Areas What focus areas are you interested in? NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

9. Attending Conferences Would you send staff to a 2-day or 3-hour web conference? Directors Commissioners • Issues identified: cost of travel, location of meeting NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

10. Who uses the Website Do you access and/or delegate access to the website? Directors Commissioners NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

11. ReceivingReports How do you receive and how do you prefer to receive reports? Directors 99% receive reports Commissioners 72% receive reports Current Preferred NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

12. Web Reports Interface NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

13. Public vs. Restricted Access • Public area provides access to Background, Inpatient Survey, Public Reports, Workgroup descriptions • Members only area provides access to the Implementation Guide, Presentations, Description of Reports, Web Reports, Data Upload and Download NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

14. Public Reports • National Public Rates: includes national means and standard deviations for every measure for every month • Final Report of Inpatient Consumer Survey: includes results of pilot test and description of domains extracted from responses • Instrument is available without a fee. • Race/ethnicity of Clients Served: presents the diagnostic profile and legal status of clients in each of the race/ethnicity categories NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

15. Public Reports (cont.) • Persons with Developmental Disabilities Served in State Psychiatric Hospitals: description of clients with developmental disabilities and comparison with other hospital clients • Depot Antipsychotic Use: shows percentage of clients receiving antipsychotic medications who receive depot antipsychotics • Diagnostic Profile of Clients Served: provides the percentage of census with several specific diagnoses and clusters, suggests possible groups of hospitals NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

16. User YourName Logged in User: YourName Member Options NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

17. Performance Measurement Reports • Comparison Charts: monthly comparison of hospital’s rates to the national mean • Control Charts: allows hospitals to evaluate the stability of their rates for each measure • HCO Rank by Measure Report: allows hospitals to see how they rank in comparison to other hospitals on any measure NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

18. Performance Measurement Reports (cont.) • Risk Adjusted Reports: provides a comparison group for facilities based on characteristics of clients and treatment units • Forensic Stratification Report: allows for comparison based on forensic status of clients • Age Stratification Report: displays separate rates for 6 age groups from child to geriatric NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

19. Topical Reports • Shift Reports: provides information on the occurrence of restrictive interventions by shift • Supplemental Reports: shows additional information related to the measures for the hospital along with national data • Diagnostic Profile of Clients Served: provides the diagnostic profile of clients served (similar to public report) NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

20. White Paper Reports • Reports Overview: summaries of reports available on the NRI BHPMS website • Elopement Indicators & Actions: provides examples of data and program changes used by fellow hospitals as part of the QI process • Seclusion and Restraint by Shift: explains the content and use of the monthly report on restrictive interventions • Readmission Rate Risk Adjustment Summary: explains the model, the variables/factors, and how to interpret the rate • Measure Information: list of measures, ID and type NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

21. Notifications • Friday Facts • Data Processing • Targeted E-mail NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

22. Coming Attractions • Directory of participating facilities for networking • New reports to address emerging needs • New measures developed for staff injury and clients with co-occurring substance abuse disorders • User Group Meeting – August 25-26, 2005 NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

23. Collaborations and Core Measures • NRI, NASMHPD, and NAPHS - Private-Public Collaborative continues to focus on standardizing measures and developing core measure sets • Provide benchmarking information to the field and help shape the development of uniformly used definitions and measures • Pilot Study of public and private facilities to use common data elements and measures, recommend areas for further development • Collaborative activity with JCAHO to develop Core Measure Sets for inpatient psychiatric care NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System

24. How to contact NRI … Lucille Schacht, Ph.D. – Director of the BHPMS NASMHPD Research Institute, Inc. 66 Canal Center Plaza, Suite 302 Alexandria, Virginia 22314 Phone: 703-739-9333 ext. 125 E-mail: lucille.schacht@nri-inc.org Website: http://www.nri-inc.org NASMHPD Research Institute, Inc. – Behavioral Healthcare Performance Measurement System