Organizational Assessment Tool (OAT)

1. Organizational Assessment Tool (OAT) Faizah Muheb VP, Analytical Services June 2013

2. OAT Description • A comprehensive evidenced-based tool • Developed for the Hospital Engagement Networks (HENs) to: • Help identify areas for quality improvement • Support efforts to expand the use of models shown to improve care • Help achieve Partnership for Patients (PfP) goals • 40% Reduction of HAC’s • 20% Reduction of Readmissions

3. OAT Description • Safety culture • Leadership • Measurement • Medication • Purchasing practice • Procedural • Risk management • Nursing practice • Communication • Infection control • The OAT contains 139 questions organized by Areas of Focus • Markers for HACs and readmissions are included in the Areas of Focus

4. OAT Description • Background Questions • Hospital type • Average daily census • Annual rate of hospital admissions • HEN the hospital is associated with • Electronic Health Record (EHR) system

5. OATDevelopment • Reviewed evidence-based best practices • Developed markers to capture the highest standard of care known to mitigate patient harm • Conducted successive revisions of markers • CMS feedback • Clinical, patient safety, risk management, and quality improvement experts • Pilot tested the OAT with seven PfP hospitals

6. How will the OAT be used? • Assess Current Practices and Capabilities within GHA HEN • Prioritize efforts based on HEN results • Help identify hospitals with leading edge practices

7. OAT Release 2.0 • OAT v2.0.0 replaces OAT v1.3.7, which hospitals completed in 2012 • With the exception of some minor edits, the content of OAT v2.0.0 is the same • This is critical in providing hospitals with a way to compare their results from Year 1 to Year 2 • Ensures ease of use – items and organization of items already familiar to users • Scoring has been revised to account for “Not applicable” responses • OAT v2.0.0 bases individual hospital scores on only those items that are applicable to them

8. Completing the OAT • A single OAT is completed per hospital • Recommend responsibility be assigned to the VP-Quality, VP - Medical Affairs, PSO or equivalent • Individual responsible for OAT contacts appropriate staff to gather information, as necessary • Pilot test found the OAT required ½-6 hours to complete • Pilot test hospitals reported the act of completing the OAT was beneficial

9. OAT Scoring • Points assigned to markers vary depending on the type of response set: • Dichotomous responses (5= Yes, 0=No) • Check all that apply (1 point for each checked item) • Likert Scale: Number of points = scale response • Others • Counts • Yes/ Yes but/No

10. Access to OAT Data • The OAT is for the HENs and hospitals • Only the HENs will be able to identify its hospital partners • HENs will provide CMS and the NCD the de-identified OAT data • National trends • Norms

11. OAT Resources-update • An online version of the OAT will be available via SNAP Survey WebHost (FISMA Compliant) • GHA will work with NCD to create an online account for each hospital to complete the OAT • SNAP software includes an array of powerful analytical tools and real-time reporting • An electronic offline solution (excel version OAT) will be available for hospitals that may not be able to complete the web-based OAT

12. Timeline • GA HEN Hospitals have until July 31, 2013 to complete the OAT

13. Summary • OAT is a resource for the HENs to achieve the goals of the PfP • The OAT consists of 139 evidenced-based best practices • OAT useful for identifying their hospital’s strengths and weaknesses • The NCD will establish a SNAP WebHost account for each HEN to securely administer and collect OAT data

14. Thank you!