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8/15/20194Q18 Core Measures2Q19 MBQIP DataPromoting Interoperability Stage 3August 16, 2019Joshua Salander, MBA, PMPConsultantConflict of Interest / Disclaimer Conflict of Interest: I, Joshua Salander, am employed by ScheurerHospital. Any content or opinion in this presentation shall not beconstrued as an opinion or representation of Scheurer Hospital. Disclaimer: This presentation is informational only. You shouldreview requirements to determine specific impacts to your hospital.Persevion, LLC is not liable for the accuracy of this information orhow it pertains to your hospital. Disclaimer: Any information included in this presentation or theReports Appendix is intended for quality improvement andbenchmarking purposes only.2Reports delivery 4Q18 reports were sent via email on August 11, 2019 Quarterly Reports Quarterly Trend Charts31
8/15/2019MICAHQN Reports ScheduleQtrCMS Data Deadline*1st QtrAugust 15Data Provided By*August 312nd QtrNovember 15November 303rd QtrFebruary 15February 284th QtrMay 15May 314Summary of 4Q18 MICAHQN Core Measures PerformanceMeasure# 994.4%Top Performer(s)OP-111/401726OP-212/402356.5%See OP-2 SlideOP-3a23/4062117.5Spectrum Health Reed City HospitalOP-3b15/4042134.5Spectrum Health Reed City HospitalOP-3c14/402091.5Carson City 2/4032795.1%See IMM-2 SlideSchoolcraft Memorial HospitalSee OP-4a SlideOP-5a37/407367Helen Newberry Joy HospitalOP-5b37/403297Helen Newberry Joy HospitalOP-5c37/404076Borgess - Lee Memorial Hospital54Q18 – OP-2: Fibrinolytic Therapy Received Within 30 Minutes (100%)HospitalsAspirus Grand ViewHelen Newberry Joy HospitalMackinac Straits Health System, Inc.Munson Healthcare ManisteeSchoolcraft Memorial HospitalSt. Mary's of Michigan Standish Hospital62
8/15/20194Q18 – IMM-2: Influenza Immunization – Overall Rate (100%)HospitalsAspirus Iron River Hospital and ClinicsBaraga County Memorial HospitalBorgess - Lee Memorial HospitalCaro Community HospitalEaton Rapids Medical CenterKalkaska Memorial Health CenterMercy Health Lakeshore Campus74Q18 - OP-4a: Aspirin at Arrival (100%)HospitalsAllegan General HospitalHelen Newberry Joy HospitalAspirus Ontonagon HospitalHills & Dales General HospitalBorgess - Lee Memorial HospitalMackinac Straits Health System, Inc.Caro Community HospitalSchoolcraft Memorial HospitalDeckerville Community HospitalSheridan Community HospitalHarbor Beach Community Hospital, Inc.Spectrum Health Gerber MemorialHayes Green Beach Memorial Hospital8OP4a - Aspirin at Arrival - Overall ICAHQNOverallUCLLCL93
8/15/2019Summary of 4Q18 MICAHQN Core Measures PerformanceMeasure# 30121Mercy Health Lakeshore CampusTop Performer(s)OP-18b37/403521112Mercy Health Lakeshore CampusOP-18c36/40142191.5OP-18d37/40383204Bronson LakeView HospitalOP-2032/40318113Paul Oliver Memorial HospitalED-1a34/402609228St. Mary's of Michigan Standish HospitalED-1b34/402573227Harbor Beach Community Hospital, Inc.ED-1c17/4036252.5ED-2a33/40243662Deckerville Community HospitalED-2b33/40240262Deckerville Community HospitalED-2c13/403458Eaton Rapids Medical CenterMid Michigan Medical Center – ClareSchoolcraft Memorial Hospital10OP18a - Median Time from ED Arrival to ED Departure for Discharged ED Patients Overall135130125Median Time12011511010510095MICAHQNOverallUCLLCL11OP18b - Median Time from ED Arrival to ED Departure for Discharged ED Patients - ReportingMeasure125120Median Time11511010510095MICAHQNOverallUCLLCL124
8/15/2019OP18c - Median Time from ED Arrival to ED Departure forDischarged ED Patients - Psychiatric/Mental Health Patients250200Median Time150100500MICAHQNOverallUCLLCL13OP18d - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Transfer Patients250200Median Time150100500MICAHQNOverallUCLLCL14OP-18b -Median Time from ED Arrival to EDDeparture for Discharged ED Patients What benchmarks are you using for this measure?As a premier system of quality, the Michigan Critical Access Hospital Quality Network (MICAH QN) will be a model in developing processes thatdemonstrate the high quality service provided by CAHs. MICAH QN will identify opportunities for change that lead to continued improvement in thehealth status of the population we serve.5
8/15/2019As a premier system of quality, the Michigan Critical Access Hospital Quality Network (MICAH QN) will be a model in developing processes thatdemonstrate the high quality service provided by CAHs. MICAH QN will identify opportunities for change that lead to continued improvement in thehealth status of the population we serve.OP-18b -Median Time from ED Arrival to EDDeparture for Discharged ED Patients Factors contributing to higher times than desired Volume during peak hours Waiting for test results Waiting for Psychiatric/Behavioral Health evaluation Med/Surg nurses cover the ED when no patients on the floor,so when there is an admission it slows the process down Workforce cuts Changes in ED Providers (changed companies or hadproviders come and go) Variability in the productivity of ED Providers Use of Paper T-sheets (documentation not readily availableand needs to be scanned)As a premier system of quality, the Michigan Critical Access Hospital Quality Network (MICAH QN) will be a model in developing processes thatdemonstrate the high quality service provided by CAHs. MICAH QN will identify opportunities for change that lead to continued improvement in thehealth status of the population we serve.OP-18b -Median Time from ED Arrival to EDDeparture for Discharged ED Patients Steps being taken to reduce the time Hired more staff for peak hours Phasing out providers with lowproductivity Moving providers to EMR and usingDragon (medical record immediatelyavailable) ED Physicians covering as Hospitalists orat least able to admitAs a premier system of quality, the Michigan Critical Access Hospital Quality Network (MICAH QN) will be a model in developing processes thatdemonstrate the high quality service provided by CAHs. MICAH QN will identify opportunities for change that lead to continued improvement in thehealth status of the population we serve.6
8/15/2019ED-2a - Admit Decision Time to ED Departure Time for Admitted Patients - Overall Rate66.064.062.0Median ED-2b - Admit Decision Time to ED Departure Time for Admitted Patients - Reporting Measure66.064.0Median CLMedian TimeED-2c - Admit Decision Time to ED Departure Time for Admitted Patients - Psychiatric/Mental Health AHQNOverallUCL20LCLSummary of 2Q19 MBQIP PerformanceMeasure# HospitalsCurrentRate/ValueNotesEDTC-136/3696%22 @ 100%EDTC-236/3695%25 @ 100%EDTC-336/3697%22 @ 100%EDTC-436/3696%19 @ 100%EDTC-536/3696%19 @ 100%EDTC-636/3693%14 @ 100%EDTC-736/3697%26 @ 100%EDTC-Overall36/3687%7 @ 100%217
8/15/20192Q19 - EDTC-Overall (100%)HospitalsBronson LakeView HospitalEaton Rapids Medical CenterMackinac Straits Health System, Inc.McKenzie Health SystemMercy Health Lakeshore CampusSparrow Clinton HospitalSpectrum Health Gerber Memorial22All EDTC Measure100%90%80%70%Median oting InteroperabilityStage 3: Public Health and ClinicalData Exchange8
8/15/2019IT & Quality Collaboration25Promoting InteroperabilityStage 3: Public Health and Clinical Data ExchangeObjectivesDescriptionElectronic PrescribingGenerate and transmit permissible dischargeprescriptions electronicallyHealth Information ExchangeEncourage and leverage interoperability on abroader scale and promote health IT-based carecoordinationProvider to Patient ExchangeProvide patients electronic access to their healthinformationPublic Health & Clinical Data ExchangeMeasures that an eligible hospital or CAH attestsyes to being in active engagement with a publichealth agency (PHA) or clinical data registry (CDR)to submit electronic public health data in ameaningful way using certified electronic healthrecord technology (CEHRT) for two measureswithin the objective. Syndromic SurveillanceImmunization RegistryElectronic Case ReportingPublic Health RegistryClinical Data RegistryElectronic Reportable Laboratory Result bleofContents EH Medicare 2019.pdfPromoting InteroperabilityStage 3: Public Health and Clinical Data ExchangeMeasureElectronic PrescribingPoints10Query of Prescription Drug Monitoring Program (PDMP) (optional)5 bonusVerify Opioid Treatment Agreement (optional)5 bonusSupport Electronic Referral Loops by Sending Health Information20Support Electronic Referral Loops by Receiving and Incorporating Health Information20Provide Patients Electronic Access to their Health Information40Public Health & Clinical Data Exchange (attest to two edirect /ehrincentiveprograms/279
8/15/2019Promoting InteroperabilityStage 3: Public Health and Clinical Data areEH 2019 Obj2-.pdf28Promoting Interoperability Stage 3: PublicHealth and Clinical Data areEH 2019 Obj2-.pdf29Promoting Interoperability Stage 3: PublicHealth and Clinical Data Exchange Measures that an eligible hospital or CAH attests yes to being in active engagementwith a public health agency (PHA) or clinical data registry (CDR) to submit electronicpublic health data in a meaningful way using certified electronic health recordtechnology (CEHRT) for two measures within the objective. Make sure you’re familiar with the exclusions for each of the above careEH 2019 Obj2-.pdf3010
8/15/2019Promoting Interoperability Stage 3: Public Health and Clinical Data areEH 2019 Obj2-.pdf31Thank you!Joshua Salander, MBA, PMPConsultantjsalander@persevion.com(989) 666-703311
Dragon (medical record immediately available) ED Physicians covering as Hospitalists or at least able to admit . 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 e ED-2c - Admit Decision Time to ED Departure Time f
