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Intermountain HEN Measurement

Intermountain HEN Measurement. April 12, 2013. Introduction . Lucy Savitz , PhD, MBA Overview of: Changes in CMS requirement for reporting Criteria for measure selection . HEN Data Collection Process. Amy Wuthrich . Data Collection Process: behind the scenes.

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Intermountain HEN Measurement

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  1. Intermountain HEN Measurement April 12, 2013

  2. Introduction • Lucy Savitz, PhD, MBA • Overview of: • Changes in CMS requirement for reporting • Criteria for measure selection

  3. HEN Data Collection Process Amy Wuthrich

  4. Data Collection Process:behind the scenes • The data template is generated using the COGNOS system and the data tables in the electronic data warehouse (EDW) • This allows for a extremely large amount of data to be condensed into a coherent document, for the entire HEN, rather than having to do it manually for each site

  5. Data Collection Process: generating contact • The body of the email is entered into the COGNOS system • SQL query connects the appropriate hospital/system ID to the appropriate contact email • It takes several hours for the program to run • Emails are sent from the system to the data contact at the HEN hospitals approximately three weeks prior to data submission deadline

  6. Data Collection Process: once we have data • Completed data requests are emailed back to Jesse Gygi • Data is entered into the data tables which are stored on the EDW • Internal validity is established • 2 person accuracy checks • If possible, run charts are sent back to hospital data contact to double check

  7. Data Collection Process: once we have data • Preliminary run charts are created • HEN team meets to review the run charts • Looks for questions/concerns in the data reported • Correct any inconsistencies • Charts are prepared for CMS reports/feedback reports

  8. Remaining 2013 Data Collection Milestones • May 20th – January through March data • August 20th – April through June data • November 20th – July through September data

  9. HEN Data Process and Feedback Reports Tom Belnap

  10. Monthly Progress Reports • Progress reports are submitted to CMS monthly • These include: • Narrative highlighting progress and successes • Data contribution and reporting from members • Data showing current rates on metrics • Barriers to continued improvement

  11. Data Reporting Process

  12. Feedback Reports • Feedback reports will be sent out to each site quarterly • Sent to data contacts first and then other contacts • Hospital data will be compared to the HEN average rate

  13. Feedback Reports • Purpose of feedback reports: • Benchmark performance against HEN • Track hospital progress over time • Ensure data completeness and accuracy • Encourage dialog within hospitals and greater involvement/communication across the HEN • We welcome feedback on the feedback and any suggestions

  14. Reporting to CMS Jason Scott

  15. What we report to CMS • HEN level run charts • Run charts stratified by hospital bed size large – 331+ beds medium – 140 to 330 beds small – 1 to 139 beds • Hospital specific success stories with your approval

  16. HEN level run charts

  17. Stratified run charts

  18. Hospital success stories • http://www.henlearner.org/additional-resources/success-stories/

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