1 FLEX-MBQIP Regional MeetingOctober, 2016

2 Welcome and IntroductionsStephen Njenga, MPH, MHA, CPHQ, CPPS Director of Performance Measurement Compliance Missouri Hospital Association 573/ , ext. 1325

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4 Housekeeping Mileage reimbursementThis only applies to you if you travelled over 50 miles one way. Expense sheet in your handouts The timeframe to submit them for reimbursement Handouts

5 I am very happy to share with a win todayI am very happy to share with a win today! In July, the Missouri FLEX program received an award from the Federal Office of Rural Health Policy to recognize our outstanding performance in the Emergency Department Transfer Communication Measures. W were recognized for the improvement in our performance from 2014 to I want to deeply thank each of you who have submitted data and contributed to this effort. This was a new measure to the program, so you have worked very hard over the past year to learn the specifications, learn new processes and submit data. I encourage you to celebrate this win within their organization and teams, so staff know that their efforts are paying off. In addition to the award, two weeks ago data stipend checks were mailed to hospitals that had submitted EDTC data through 2nd Quarter Again, this was just a token of our appreciate for the hard work.

6 Financial and OperationalFLEX Grant Activities Quality Patient safety, patient engagement, care transitions, outpatient care Financial and Operational Financial and operational assessments and actions, revenue cycle management, operational improvement Population Health Identify specific health needs of CAH communities and implement activities These are the categories included in the FLEX grant for The sections include quality, financial and operational and population health. In the Quality section, we collect data on patient safety, patient engagement, care transitions and outpatient care in order to find our gaps and work to improve processes. Quality of care in our small communities is very important to the reputation and financial viability of the hospital. In the financial and operational section, our technical support and resources are aimed at financial and operational assessments and actions, revenue cycle management and operational improvement. MHA strives to provide generalized support, to all participating hospitals, as well as individualized support to six hospitals identified as financially-distressed. In population health, we are focused on assisting our hospitals in identifying specific health needs of their communities and how to implement activities.

7 Medicare Rural Hospital Flexibility GrantNational program with resources and benchmarking Create or sustain improvement in quality, patient safety, financial and operational outcomes, and population health management Critical Access Hospitals only! 32 out of 36 Missouri hospitals participating Before Stephen begins his in-depth overview of MBQIP, I want to briefly frame the grant and make you aware of the other activities that are occurring in other areas of the grant formal name of the FLEX is the Medicare Rural Hospital Flexibility Grant. The goal of this program is to…. A large part of the value of participation in the program is access to national programs and resources. Not only does MHA have access to these things to provide to you, in many cases, you have access to them directly. Another benefit of the program is that it includes CAHs only, so the reports, benchmarks and activities are aimed at those hospitals. In Missouri, we have 32 out of 36 hospitals participating in the program. We have three that have opted out of the participation and one that was released from the program because they had not submitted data.

8 Goals of MBQIP CAHs report common set of rural-relevant measuresMeasure and demonstrate improvement Help CAHs prepare for value-based reimbursement

9 MBQIP and Hospital CompareNationwide effort Critical Access Hospitals Improve quality Public reporting Unique benchmarking Rural Appropriate Measures & Processes Sample size is a non issue Hospital Compare Nationwide effort All Hospitals Improve quality Public reporting Overall benchmarking Minimal case volume required for public reporting Why is MBQIP Important? What’s the difference with hospital compare?

10 Finance and Operations

11 Current Activities and ProjectsStrategic planning and data analysis led to: Generalized support to all FLEX participants Individualized support extended to six financially stressed hospitals In-depth financial analysis with scope of work identified Support from BKD CPAs and advisors In late 2015 and 2016, the FLEX grant was focused on identifying baselines and developing a strategic plan that includes data analysis at the statewide and hospital level. This analysis will provide further insight into how our state and members are performing, so we can offer focused resources. To support our hospitals, MHA is offering two levels of support – generalized and individualized. The generalized support will include education sessions, resources and tools to all of our FLEX participating hospitals. The individualized support for the hospitals will include an in-depth financial analysis with identified scope of work. Upon acceptance of the scope of work, BKD CPAs and Advisors will then work individually, on-site, with these hospitals. These six hospitals were identified using national FLEX reports, which include several financial indicators. We have been working with the CEOs and CFOs of those hospitals to obtain additional documentation, to contribute to the analysis.

12 Future Activities and ProjectsContinue generalized and individualized support Create a financial dashboard In-person CAH financial/operational education session focused on revenue cycle management, coding, service line analysis and chargemaster review For the remainder of 2016 and into 2017, future financial and operational activities include continued support – both generalized and individualized. We are also looking at options for a financial dashboard, to provide a snapshot of performance and allow for more robust benchmarking. Lastly, we are discussing the possibility of holding an in-person education session, focused on the various aspects of CAH finances and operations. We understand that these characteristics are different than those that acute care hospitals face, so the goal is to provided topics applicable to CAHS. Stay tuned for more information.

13 Population Health The last topic I will discuss is population health.

14 Current Activities and ProjectsDistribution of MHA’s Community Health Needs Assessment guidance document Reimbursement for data collection and analysis related to the assessment Access to national population health portal and resources In the winter, we distributed MHA’s Community Health Needs Assessment Guidance Document. Stephen is actually reviewing the document now, as it is now ready for updates with the new regulations. Through the FLEX grant, we also provided reimbursement for data collection and analysis to hospitals that provided and invoice and expense report for those services. In February, access to a national population health portal was distributed. This portal was developed by our national FLEX sponsors and is offered to CAHs nation-wide, free of charge. The portal offers an assessment, along with focused resources. If you need any of that information sent to you again via , please let me know and I will be happy to get that to you.

15 Future Activities and ProjectsStatewide CAH CHNA analysis with focused support Update Community Health Needs Assessment guidance document Creation of Community Health Needs Assessment Strategy Implementation Guide Creation of Community Health Needs Assessment Legal Guide Webinar — How to Identify and Implement Strategies using Community Health Needs Assessment To finish out 2016, and move into 2017, we are working on a collaborated statewide analysis with the Department of Health and Senior Services. This analysis will be a summary of all FLEX participating hospitals’ CHNAs. (Those that are required to do them). We will then identify 3- 5 topics in the state that we will provide focused support for. In that analysis, we’ll begin to look at trends by region, hospital type, and etc. Also, we will release and distribute the updated Community Health Needs Assessment Guidance document that I mentioned Stephen is reviewing. To further support that document, the MHA team will create and disseminate a Community Health Needs Assessment Strategy Implementation Guide and CHNA Legal Guide. After those resources have been disseminated, we will host a webinar on how to identify and implement strategies using your hospital’s community health needs assessment.

16 MBQIP Requirements

17 You will be receiving three different reports moving forward: EDTC, HCAHPS and OP/Patient Safety

18 Data Submission DeadlinesRemember OP-4 and OP-18 are not on the timetable but are due at the same time with the other chart abstracted measures.

19 Emergency Department Transfer CommunicationEDTC

20 Emergency Department Transfer CommunicationEDTC reporting has increased from five hospitals reporting to 26, which equates to a 400 percent increase. The number of individual records reviewed and reported has increased from 225, to per the Q12016 data report, which is a 360 percent increase. Increased reporting. When we look at the baseline data which is an aggregate for CY2015, we have seen a 27.1% Improvement

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22 Performance Trending

23 Statewide EDTC Measures SnapshotBaseline CY15 2Q16 Percent Change EDTC - 1 93% 94% 1.1% EDTC - 2 97% 4.3% EDTC - 3 3.2% EDTC - 4 91% 92% EDTC - 5 6.5% EDTC - 6 84% 8.3% EDTC - 7 98% ALL EDTC 71% 77% 8.4% Overall improvement (EDTC 1-7, ALL EDTC) 37.2%

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26 Identify Gaps and develop PI strategy.

27 Performance Improvement StrategyEDTC-4: Medication Information Home Medications Medications administered in ED Allergies/Reactions Select Y (Yes) if there is documentation that medications administered were sent to the receiving facility. Select Y (Yes) if there is documentation the patient’s allergy information was sent to the receiving facility. Select Y (Yes) if there is documentation medication history was sent to the receiving facility.

28 Performance Improvement StrategyEDTC-6 Nurse Generated Information Nursing Notes Sensory Status Catheters/IV Immobilizations Respiratory Support Oral Restrictions Yes or No for the first 2 and N/A for the last four.

29 EDTC Statistical MethodologyCMS uses the “All or Nothing” approach for EDTC calculation Cases abstracted MUST meet all the 27 different data elements to get credit This methodology does not use the “average” concept

30 Participation, Performance and Reporting processOutpatient Reporting Participation, Performance and Reporting process

31 Outpatient Measures OP-1: Median Time to FibrinolysisOP-2: Fibrinolytic Therapy Received Within 30 Minutes OP-3: Median Time to Transfer to Another Facility for Acute Coronary Intervention OP-4: Aspirin at Arrival OP-5: Median Time to ECG (electrocardiogram) OP-18: Median Time from ED Arrival to ED Departure for Discharged ED Patients

32 Continued… OP-20: Door to Diagnostic Evaluation by a Qualified Medical Professional OP-21: Median Time to Pain Management for Long Bone Fracture OP-22: Left Without Being Seen (Emergency Department Patient Safety Measures: OP-27 Influenza Vaccination Coverage among Healthcare Personnel IMM-2 Influenza Immunization (Only IP Measure)

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35 Since OP-27 is a new measure, it will not appear on the MBQIP reports until 1Q16.

36 Missouri Aggregate OP/Patient Safety Report

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38 Outpatient Reporting Gap

39 Outpatient Reporting Nationwide

40 OP Reporting and Performance

41 OP Reporting and Performance

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43 Reminder: IMM-2 MeasureAbstraction and reporting required throughout the year Data reported from April to September is excluded because it is not during the flu season. Hospitals are to answer questions on patients meeting IP guidelines Only required for October-March IMM-2 measure is one of the CMS Inpatient Global Measures with an initial patient population that includes all patients discharged from acute inpatient care with a length of stay less than or equal to 120 days. Other measures pulled from this patient population include the optional MBQIP measures of ED-1 (Median time from arrival to departure for admitted patients) and ED-2 (Admit decision time to ED departure for admitted patients). Following the CMS Global Measures instructions, IMM-2 should be abstracted each quarter as there are no timeframe exclusions in the population definition. During Q2 and Q3, the hospitals should still be identifying their global population, seeing if the sampling requirement can be met if they chose to sample, and abstract those cases. Since the discharge date falls outside of the flu vaccine timeframe, all the abstracted cases will end up being excluded from the IMM-2 measure but not the global population.  On the MBQIP reports, hospitals that submit their population will show a D/E on the MBQIP reports for this measure for these two quarters. In continuing efforts to align MBQIP with the CMS Reporting Programs, FORHP expects hospitals to follow the data collection instructions for the IMM-2 measure found in the Inpatient Specifications Manual, which indicate data is to be collected each quarter.

44 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

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48 Completed Surveys and Response Rates for CAHs Q2 2014 – Q1 2015

49 CAH’s Reporting HCAHPS

50 Response rates and your HCAHPS vendorYour HCAHPS survey vendor can have a big influence on your HCAHPS response rates. When choosing a vendor, ask them: What are your typical response rates? Is the response rate around the national average of 29 percent?1 If it’s lower or higher, why might that be? How long do you wait to administer the surveys after you’ve received the list of patients from us?

51 Response rates and your HCAHPS vendorHow often, and how many times, do you try to reach patients to get their completed response? Consider how it fit your expectations. What mode do you use to administer the survey? Phone, paper, or mixed mode (i.e. both)? One CMS study found that mixed mode may produce the best response rates, followed by mail, but consider what might be best given your patient population.

52 Important InformationYou may also consider connecting with your vendor regularly. For example, having quarterly calls to talk about HCAHPS and any suggestions they may have for you.

53 Response rates and your hospitalThe vendor isn’t all that matters. Here are some ways that might increase response rates that your hospital can control: Administer surveys quickly after patient discharge. Send your list of eligible patients to the survey vendor on a weekly basis, not monthly. Confirm with your patients before they leave the hospital that you have their correct phone numbers and/or mailing addresses.

54 Response rates and your hospitalLet your patients know the survey will be coming. Even though you can’t try to influence their responses, give some advance notice that they may be contacted. Make sure they know if this contact will be by mail or by phone, as well. Tell patients why their input matters. One hospital gives patients a “calling card” notifying them that they may receive two calls: “One so that we can check on you, and one so that you can help us improve.”

55 Remember Hospitals with higher HCAHPS scores also tend to have better response rates. Perhaps the key to higher response rates, as well as better scores, is providing a positive overall patient experience.

56 SHIP Grant

57 Small Rural Hospital Improvement Grant Program (SHIP)Department of Health and Senior Services Office of Primary Care and Rural Health State Office of Rural Health Department of Health and Senior Services Office of Primary Care and Rural Health State Office of Rural Health

58 SHIP Hospital EligibilityForty-nine (49) staffed beds or less as reported on the hospital’s most recently filed Medicare Cost Report, line 14. Hospital must be located in a rural area outside a Metropolitan Statistical Area (urban area). Check the Rural Health Information Hub ‘s “Am I Rural”? website to find out if you are Rural. Critical Access Hospitals (CAHs) are all eligible.

59 Funding Availability Fiscal Year (FY) 2015 Grant Period:September 1, 2015 – May 31, $9,596.00 FY 2016 Grant Period : June 1, May 31, (not awarded yet) Approximate amount for each hospital: $9,000.00

60 SHIP Program - Use of FundsThe SHIP funds should be prioritized by Critical Access Hospitals (CAHs) in the following manner: Priority 1: HCAHPS or ICD-10 Activities Both of these must be fully implemented and HCAHPS must be publicly reported to Hospital Compare, before your hospital can select any other investment options. Priority is not given to one over the other so your hospital may choose both.

61 SHIP Program - Use of FundsPriority 2: If your hospital is already participating fully in HCAHPS and ICD-10, you may select a different investment listed on the SHIP purchasing menu Priority 3: If your hospital has already completed ALL investments your hospital may identify an alternative piece of equipment and/or service ONLY IF: See next page

62 SHIP Program - Use of FundsThe purchase will optimally affect your hospital's transformation into an accountable care organization, increase value-based purchasing objectives and/or aid in the adoption of ICD-10; Your hospital receives pre-approval from both your state SHIP Director - Lisa Branson and the appropriate FORHP Project Coordinator. Click here to watch the SHIP Webinar Link

63 Contact Information Lisa Branson SHIP Director State Office of Rural Health (573)

64 Overall Star Rating CAHS

65 What it Encompasses The Overall Hospital Quality Star Rating combines 64 measures that are already public on Hospital Compare into one star rating. The measures fall into seven groups: Mortality, Safety of care, Readmission, Patient experience, Effectiveness of care, Timeliness of care Efficient use of medical imaging.

66 Measure Groups & Percent WeightTo meet the minimum threshold to have a star rating calculated hospitals must have at least three measures, in at least three groups, with at least one outcome group. CMS organizes measures into groups by measure type (see table); outcomes measures comprise 66% of the measure weighting while process measures comprise 44% weight.. CMS assigns weights to the group scores (mortality, safety, readmission and patient experience are each weighted 22 percent, and effectiveness of care, timeliness of care and efficient use of medical imaging each get 4 percent) and then assigns a summary score. If a hospital is missing data in a group, the agency redistributes the weights among the other categories. Then, CMS calculates an overall rating using the summary score.

67 Overall Star Rating Because the quality measures used for the overall rating reflect routine care and hospital- acquired infections, specialized care provided by certain hospitals is not reflected in the ratings A hospital's rating is only calculated using as many measures for which data is available. That means hospitals' star ratings could be based on as few as nine measures or as many as 64; the average is roughly 40.

68 Analysis Methodology If a hospital doesn't have data for three measures within at least three of the seven measure groups, including one outcome group (meaning mortality, safety or readmission), the hospital doesn't get a score. Currently, 937 hospitals do not have an overall star rating. Star ratings will be updated each quarter.

69 Concerns on CMS MethodologyCMS delayed launching the program for three months because of pushback it received from stakeholders and members of congress. They argued that because the methodology is not risk-adjusted and doesn't account for socioeconomic factors, it puts certain hospitals, like academic medical centers and safety-net hospitals, at a disadvantage.

70 Star Rating Release – July 2016

71 Overall Star Rating DesignationOverall Star Rating Results based on Critical Access Hospital (CAH) Status CMS found a higher average Star Rating among CAHs (mean = 3.31) in comparison to the average Star Rating among non-CAHs (mean = 2.99). The range of among CAHs was more narrowly distributed, from 2 to 4 stars, while the range of Star Ratings among non-CAHs was more broadly distributed, from 1 to 5 stars

72 Spotlight Hospital

73 OP Reporting Process CART Tool

74 Quality Reporting ChannelsOP-22 Left Without Being Seen

75 Quality Reporting Channels

76 Quality Reporting Process

77 Reporting using CART tool?Access using the QualityNet Specifications Manuals CART (Centers for Medicare and Medicaid Services Abstraction and Reporting Tool)/data collection tool Secure Log-in

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89 Enter Cases and Submit Enter cases into the CART tool and submit by the designated deadline per the CMS guidelines. Make sure to do the necessary checks to make sure your submission is successiful If you get errors on the detailed report, resolve them per instructions and resubmit per the guidelines. If you are using a vender, they should be able to guide you through this process to resolve any errors.

90 Watch: Cart Tool 101 Video MBQIP Webinar: Cart Tool PowerPoint Recording

91 Notice of ParticipationPledging Process

92 Notice of ParticipationAlthough it is not necessary for Critical Access Hospitals (CAHs) to complete the inpatient or outpatient notice of participation (NOP) in order to participate in the Medicare Beneficiary Quality Improvement Project (MBQIP), the NOPs must be completed in order for data submitted to QualityNet to appear on Hospital Compare.

93 Notice of Participation ProcessComplete the registration process to gain access to the QualityNet secure web portal Designated security administrator is the only individual who may complete the “Notice of Participation” so that hospital-specific data may appear on the Hospital Compare website NOP MUST be completed for Inpatients and Outpatients. NOTE: Same process should be completed for HCAHPS reporting.

94 Steps to Complete the NOPLog into the QualityNet secure portal. Under “Quality Programs,” select “Hospital Quality Reporting.” You now will see the “My Tasks” page. In the box titled “Manage Notice of Participation,” click “View/Edit Notice of Participation, Contacts and Campuses.” Follow the instructions to see your hospital’s status. Once your hospital’s NOP is accepted, it remains active unless your hospital changes its pledge status.

95 MBQIP Dashboard ReportsHIDI Analytic Advantage® Sample Reports

96 EDTC Dashboard Report

97 EDTC Dashboard Report

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99 FLEX Webpage & ResourcesMBQIP

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103 References MHA http://web.mhanet.com/mbqip.aspxQualityNet https://www.qualitynet.org Hospital Compare https://www.medicare.gov/hospitalcompare/sear ch.html National Rural Health Resource Center https://www.ruralcenter.org/tasc/mbqip Quality Improvement Implementation Guide and Toolkit for Critical Access Hospitals.

104 Guide and toolkit for CAHSThis guide and toolkit offers strategies and resources to help critical access hospital (CAH) staff organize and support efforts to implement best practices for quality improvement. Quality Improvement Implementation Guide and Toolkit for Critical Access Hospitals [PDF 1 MB] Brainstorming Tool [Word 33KB] Internal Quality Monitoring Tool [Excel 558 KB] Internal Quality Montiroing Tool video tutorial [WMF 23min ] Project Action Plan Template [Word 23 KB] Quality and Patient Safety Meeting Agenda/Minute Template [Word 35 KB] Rapid Tests of Change Tool [Word 25 KB] Rapid Tests of Change Tool - Example [PDF 168 KB] Ten Step Quality Improvement Project Documentation Template [Word 30 KB]  CAH Quality Prioritization Tool [Excel 296 KB] A quality improvement implementation model for small, rural hospital settings A 10-step guide to leading quality improvement efforts Summaries of key national quality initiatives that align with the priorities of the Medicare Beneficiary Quality Improvement Project (MBQIP) Best practices for improvement for current MBQIP measures A simple, Excel-based tool to assist CAHs with tracking and displaying real time data for MBQIP and other quality and patient safety measures to support internal improvement efforts An Excel-based tool to help CAH quality and patient safety leaders prioritize and make decisions related to patient safety and quality planning

105 Video Links QualityNet Secure Portal: New User Enrollment TrainingHospital Quality Reporting Notice of Participation

106 Resources Measures of Variation Quality Resource BriefUsing Data to Drive Improvement

107 Upcoming Events Fall Regional Meetings October 6 — CarrolltonOctober 11 — Springfield October 25 — Festus Remainder of 2016 MCE events Please refer to memo dated August 3. Register using the FLEX payment option. Registrations are released approximately eight to 12 weeks out, depending on speaker. Please visit our website for registration links.

108 Questions

109 Primary Contact Stephen Njenga, MPH, MHA, CPHQ, CPPS Director of Performance Measurement Compliance Missouri Hospital Association 573/ , ext. 1325 Stephen