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Hospital Quality Improvement Program
(Hospital QIP)
2015‐16 Measurement Set Release Webinar
June 22, 2015
Presenters:
Robert Moore, MD, MPH, CMO
Anne Gulley, MPH, Project Coordinator
HousekeepingHousekeepingTo avoid echoes and feedback, we request that you use the telephone instead of your computer microphone for listening/talking during the webinar.
If you are having technical difficulties, please let us know by using the “question” box.
This webinar is being recorded and will be emailed following the presentation
Following the Measurement Set review we will open the floor for Q&A.
ObjectivesObjectives
• Review Hospital QIP Measurement Set 12:20‐12:55
• Submission Process 12:55‐1:00
• Q&A 1:00‐1:25
• Available Resources 1:25‐1:30
SummarySummary15‐16 Hospital QIP Measures Full Points
All‐cause 30‐day Adult Readmission Rate 20
Follow‐up Post Discharge Visits (back‐up measure) ‐
Advance Directive Status 15
Rate of Elective Delivery before 39 Weeks 10
Exclusive Breast Milk Feeding Rate 10
VBAC Rate 10
Participation in Cal Perinatal Quality Care Collaborative (CPQCC) 5
Participation in Cal Maternal Quality Care Collaborative (CMQCC) 5
Venous Thromboembolism (VTE) Prophylaxis 15
Electronic Treatment Authorization Requests (eTAR) 10
Health Information Exchange (HIE) Participation ‐
Total 100
ReadmissionsReadmissionsAll‐Cause (30‐day) Readmission Rate
Numerator: Number of all 30‐day readmissions of those in the denominator
Denominator: Number of all continuous stays for members continuously enrolled with PHC 120 days prior to the index discharge date through 30 days after index discharge date
Target: Full Points: ≤12.0% Readmission Rate = 20 pointsPartial Points: 12.1% ‐ ˂15.0% Readmission Rate = 10 points
Reporting: PHC‐extracted data reported bi‐annually to hospitals
ReadmissionsReadmissionsFollow‐up Post Discharge Visits
• If all‐cause readmission target is not met, points can be earned for this measure
Numerator: Number of discharges with a qualifying follow‐up visit within 4 days of discharge
Denominator: Number of discharges during the measurement year
Target: ≥ 30% of PHC members who have a physician office visit within 4 calendar days of discharge = 20 points (No partial points option)
Reporting: PHC‐extracted data, reported bi‐annually to hospitals
Advance Care PlanningAdvance Care PlanningAdvance Directive for Patients 65 Years of Age or Older
Option 1: Documentation of Inquiry
Numerator: Number of patients in the denominator who have an indication of an Advance Directive status entered using structured data
Denominator: Number of unique patients age 65 or older admitted during the measurement year
Target: Full Points: ≥90.0% = 15 pointsPartial Points: Between 80.0% and ˂90.0% = 7.5 points
Reporting: Hospitals report to PHC by August 31, 2016
Advance Care PlanningAdvance Care Planning
Advance Directive for Patients 65 Years of Age or OlderOption 2: Obtained Advance Care Planning Documentation
Numerator: Number of patients in denominator who have Advance Care Planning documentation in the medical record (i.e. POLST/Advance Directive)
Denominator: The number of unique patients age 65 or older admitted during the measurement year
Target: Full Points: ≥50.0%= 15 pointsPartial Points: Between 40.0% and <50.0%= 7.5 points
Reporting: Hospitals report to Partnership HealthPlan by August 31, 2016
Clinical Quality: OB/Newborn/PedClinical Quality: OB/Newborn/Ped
Elective Delivery before 39 Weeks
Numerator: Number of patients in the denominator who had elective deliveries
Denominator: Patients delivering newborns with ≥ 37 and < 39 weeks of gestation completed during the measurement year
Target: Full Points: ≤3.0% = 10 pointsPartial Points: 3.1% ‐ 5.0% = 5 points
Reporting: Hospitals report to PHC by August 31, 2016
Clinical Quality: OB/Newborn/PedClinical Quality: OB/Newborn/PedExclusive Breast Milk Feeding Rate
Numerator: Number of newborns in the denominator that were fed breast milk only since birth
Denominator: Single term newborns discharged alive from the hospital during the measurement year
Target: Full Points: Within 3% of PHC participating Hospital QIP average = 10 pointsPartial Points: within 5% of PHC participating Hospital QIP average = 5 points
Reporting: Hospitals report to Partnership HealthPlan by August 31, 2016
Clinical Quality: OB/Newborn/PedClinical Quality: OB/Newborn/PedVaginal Birth after Cesarean (VBAC) Rate, Uncomplicated
Numerator: Number of vaginal deliveries among cases meeting inclusion criteria for the denominator
Denominator: All deliveries with any listed ICD‐9 diagnosisCode for previous Cesarean delivery
Target: Full points for reporting data on the measure for calendar year 2015 and the first six months of 2016 = 10 points
Reporting: Hospitals report 2015 calendar year data to PHC by March 1, 2016 and full‐year data by August 31, 2016
Clinical Quality: OB/Newborn/PedClinical Quality: OB/Newborn/Ped
Timely Participation in CPQCC/CMQCC Data Reporting
CPQCC = California Perinatal Quality Care CollaborativeCMQCC = California Maternal Quality Care Collaborative
Target: Full Points: Six or more months participating in collaborative (data submission) = 5 pointsPartial Points: Join collaborative and submit data by June 30, 2016 = 2.5 points
Reporting: Collaborative will send report to PHC by July 31, 2016 noting all hospitals participating and start date for participation
Patient SafetyPatient SafetyVTE Prophylaxis
Numerator: Patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given
VTE‐1‐ (Non ICU patients)• the day of or the day after hospital admission • the day of or the day after surgery end date for surgeries that start the
day of or the day after hospital admission
VTE‐2 (ICU Patients)• the day of or the day after ICU admission (or transfer) • the day of or the day after surgery end date for surgeries that start the
day of or the day after ICU admission (or transfer)
STK‐1 (Stroke Patients) • the day of or the day after hospital admission
Patient SafetyPatient SafetyVTE Prophylaxis
Denominator:
1. VTE‐1‐ (Non ICU patients): All‐hospital patient population
2. VTE‐2 (ICU Patients): Patients directly admitted or transferred to ICU
3. STK‐1 (Stroke Patients): Ischemic or hemorrhagic stroke patients
Target: Full Points: ≥ 85.0% = 15 points (5 points per measure)Partial Points Target: 75.0% to <85.0% = 7.5 points (2.5 points per measure)
Reporting: Hospitals report to Partnership HealthPlan by August 31, 2016
Operations and EfficiencyOperations and Efficiency
Inpatient Treatment Authorization Requests ‐ Electronic Submission (eTARs)
Numerator: Total number of Inpatient TARs submitted electronically by Hospital by 11:59 pm of the next business day following admission
Denominator: All Inpatient TARs received from Hospital by Partnership HealthPlan Of California
Target: Full Points: ≥ 85.0% = 10 pointsPartial Points: 80.0% ‐ < 85.0% = 5 points
Reporting: PHC will provide monthly reports to Hospitals
Operations and EfficiencyOperations and EfficiencyHealth Information Exchange (HIE) Participation
• New requirement for participation in the Hospital QIP
Target: 3 options for meeting participation criteria:
1. Attestation of completion of ADT interface, including a list of the total number of ADT files, received by the community HIE by June 30, 2016
2. Attestation, indicating the number of laboratory results and reports transmitted from the hospital to at least two different local PCP providers, each using a different non‐native Electronic Health Record (not the same EHR as the hospital’s system)
3. Attestation of membership of community HIE in good standing, with a detailed ADT interface implementation plan, including date of implementation before December 31, 2016.
Operations and EfficiencyOperations and Efficiency
Health Information Exchange
Reporting: Part I: By October 31, 2015, hospital will submit HIE participation pathway to PHC via a submission form.
• Following review, PHC may return this plan for clarification/modification
Part II: By August 31, 2016, hospital will submit anattestation from their community HIE on state of information exchange with hospital or a hospital/health system HIE with the hospital’s data
SubmissionsSubmissions
• Measurement Period
• Data Reporting
• Sample Submission Template
• Important Dates
Hospital QIP Measurement YearHospital QIP Measurement Year
• Readmissions• Exclusive Breast Milk• VBAC
• CPQCC/CMQCC• eTAR• Health Information Exchange
Fiscal Year 2015-16: July 1, 2015 – June 30, 2016
Calendar Year 2015: January 1, 2015 – December 31, 2015
• Advance Care Planning• Rate of Elective Delivery• VTE
• *VBAC (baseline data report – March 2016)
Sample Submission TemplateSample Submission Template
• Hospital‐reported data due by August 31, 2016• Email all material to [email protected]
1) Elective delivery before 39 weeks Complete the following table and attach a hospital report to this submission form.
Target population data is reported on
Denominator
Numerator
Percentage (Num/Den)
All-hospital deliveries
Definitions:
Denominator: Patients delivering newborns with ≥ 37 and < 39 weeks of gestation completed between 1/1/2015 and 12/31/2015. Numerator: Patients in the denominator with elective deliveries.
Data ReportingData ReportingPHC‐Reported Data:
eTAR – Monthly (5th of each month) Readmissions – (Oct 31st – Final)
CPQCC/CMQCC reported to PHC (July 31, 2016)
Hospital‐Reported Data:
All measures except eTAR and Readmissions will be reported to PHC via Submission Template by August 31, 2016.
• Health Information Exchange1. Pathway Selection due to PHC by October 31, 2015
OR2. Attestation of participation from local HIE due to PHC by
August 31, 2016
Questions?Questions?
Please use the “hand raise” function to ask questions and not the question box
We will answer questions in the order in which they are received.
ResourcesResources
• Anne Gulley – Program Coordinator (707) 863‐4582
• Email [email protected]
• PHC Hospital QIP web page – Coming Soon!