Quality Health Indicators

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Quality Health Indicators

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• About QHi

• The PiHQ Portal

• Defining your facility

• Selecting Measures

• Entering Data

• Dashboards

• Reports

• How we use the data

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click to continue through the presentation.

Main Menu

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The Quality Health Indicator (QHi) web site was developed through the Kansas Hospital Association, KHA, and KRHOP the Kansas Rural Health Options Project to facilitate a benchmarking project for rural Kansas hospitals.

The goal of QHi is to provide hospitals an economical instrument to evaluate internal processes of care and to seek ways to improve practices by comparing specific measures of quality with like hospitals.

Using QHi as a tool, regional networks of hospitals and individual facilities can select from a library of indicators to determine which measures meet their unique needs.

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More than 700 users in over 200 Critical Access and other small rural hospitals in Alaska, Arizona, California, Colorado, Kansas, Louisiana, Michigan, Minnesota, Missouri, Nebraska, New Mexico, Oklahoma and Wyoming use QHi as a data collection and benchmarking tool.

As a user-driven multi-state project, QHi is well-positioned to serve as a significant repository of information on quality of care and performance in rural hospitals nationwide.

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Four Pillars Of Measurement


Clinical

Quality

Employee

Contribution

Patient

Satisfaction

Financial

Operational

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QHi Core Measures Set

Clinical Quality• Hospital Associated Infections per 100 inpatient days

• Unassisted Patient Falls per 1000 inpatient days

• Inpatients Receiving Pneumonia Immunization (CMS PN-2)

• Pneumonia Patients Given Antibiotics within 6 hours of admission (CMS PN-5c)

Employee Contribution

• Benefits as a Percentage of Salary

• Staff Turnover

All participating hospitals are asked to collect and report the 8 QHi Core Measures:

Financial Operational

• Days Cash on Hand

• Gross Days in AR

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Clinical Quality Measures Inpatients Screened for Pneumonia (not a CMS measure) Medication Omissions Resulting in Medication Error Medication Errors Resulting from Transcription Errors ER Provider Response Times Return ER Visits within 72 hours with same/similar diagnosis Readmits Within 30 Days with Same or Similar Diagnosis Hospital Associated Infections per 100 inpatient days* Unassisted Patient Falls per 1000 inpatient days*

CMS Pneumonia Measures Inpatients Receiving O2 Assessment within 24 hours of admission - CMS Pn-1 (retired)

Inpatients Receiving Pneumonia Immunization - CMS PN-2*

Pneumonia Patients Given Antibiotics within 6 hours of admission - CMS PN-5c *

CMS OP Transfer Measures Percentage of eligible patients who received thrombolytic therapy - CMS OP-1 and OP-2 Median Time from Emergency Dept Arrival to Time of Transfer to another Facility for Acute Coronary Intervention -

CMS OP-3 Number of AMI patients without aspirin contraindications who received aspirin within 24 hours - CMS OP-4 Percentage of AMI or Chest Pain patients receiving ECG within 10 minutes of arrival (prior to transfer) - CMS OP-5

*Part of the 8 Core Measure Set

Additionally, facilities can select from over 90 measures

in the QHi library of indicators:

Clinical Quality Measures (continued) HF Measures Discharge Instructions provided to HF patients – CMS HF-1

Evaluation of LVS Function – CMS HF-2

ACEI or ARB for LVSD – CMS HF-3

Adult Smoking Cessation Advice/Counseling – CMS HF-4

SCIP Measures Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision – CMS SCIP-Inf-1a

Prophylactic Antibiotic Selection for Surgical Patients – CMS SCIP-Inf-2a

Prophylactic Antibiotics Discontinued Within 24 Hours after Surgery End Time – CMS SCIP-Inf-3a

Surgery Patients with Appropriate Hair Removal – CMS SCIP-Inf-6

Urinary Catheter Removed on Postop Day 1 or Postop Day 2 with Day of Surgery being Day 0 – CMS SCIP-Inf-9

Surgery Patients with Periop Temperature Management – CMS SCIP-Inf-10

Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Periop Period – CMS SCIP-Card-2

Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered – CMS SCIP-VTE-1

Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery – CMS SCIP-VTE-2 8

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Employee Contribution Measures Non-Nursing Staff Turnover Average Time to Hire (All Staff) Nursing Staff Turnover Average Time to Hire (Nursing) Average Time to Hire (Non-Nursing) Salary to Operating Expenses Comparison Benefits as a Percentage of Salary* Staff Turnover*

Patient Satisfaction Measures

How well staff worked together to care for the patient (QHi1) The extent to which the patient felt ready for discharge (QHi2)

In addition to these original QHi patient satisfaction measures, 22 HCAHPS measures are now in the library of indicators.


Hospital Characteristic Measures Average Inpatient Days

Monthly Inpatient Census

Multi-State ALOS (in hours) Comparison

ALOS (in hours) Comparison

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Financial

Bad Debt Expense

Charity Care

Cost per Patient Day

Labor Hours per Patient Day

Operating Profit Margin

Current Ratio

Net Patient Revenue per Patient Days

Payer Mix – Commercial

Payer Mix – Medicaid

Payer Mix – Medicare

Payer Mix – Other

Payer Mix – Other Government

Payer Mix – Self/Private Pay

Days Cash on Hand *

Gross Days in AR *

Financial & Operational Measures

Operational

Physical Therapy Labor Hours per Unit of Service

Laboratory Labor Hours per Unit of Service

X-ray Labor Hours per Unit of Service

Mammogram Labor Hours per Unit of Service

Ultrasound Labor Hours per Unit of Service

CT Labor Hours per Unit of Service

MRI Labor Hours per Unit of Service

Pharmacy Labor Hours per Unit of Service

Nursing Hours per Patient Day

Rural Health Clinic Encounters per FTE

Long Term Care Hours per LTC Patient Day

Laboratory Hours per Billed Service


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Web Site AccessAn email address and password are required to enter this secure web site.

The level of access is determined by the User type:

System Administrator – maintains the site – KHA/KHERF

State Administrator –provides support to Hospital Contacts in their State

Network Administrator – maintains Network profiles & provides support

Hospital Contact – maintains Hospital profiles , adds users & enters data

Hospital User – enters data and runs reports

View Only – views data and runs reports

Report Recipient – no access to QHi, only receives reports


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The PiHQ Portal

Return to Main Menu

Users navigate through the suite of resources in the PiHQ Portal by using

blue links across the top.

Hover text provides a brief description of each

resource.

All QHi, HSI and SQSS users have access to the

PiHQ search engine.

Users type in search topic here

Or on any page throughout the portal here

Results are pulled from all Portal resources.

Future enhancements will allow users to pull from resources outside of PiHQ as well.

The Resource Library holds all resource materials developed for PiHQ.

All users have access to the Resource Library

Results are pulled from all Portal resources.

Icons identify the source of the information.

All users have access to the Calendar

The Calendar provides registration information for upcoming Quality Training Sessions

Users with access to the application are directed to the home pate, without additional log in.

All HCAHPS measures can be automatically pulled from HSI and uploaded directly into QHi, eliminating duplicate entry.

Future enhancements will allow any HSI measure to be uploaded into QHi.

This Calendar system, developed by Darlene Bainbridge, is now in live beta-testing.

Users with access to the application are directed to their customized home page, without additional log in.

Partners in Healthcare Quality are working with 2 notable Risk Management vendors to pull aggregate data directly into QHi, further reducing data entry, and enhancing comparative analysis and benchmarking opportunities.

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Defining

Your

HospitalReturn to

Main Menu

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Click Administration to viewHospital Profile page

Users navigate through QHi by clicking the main

menu and sub-menu options

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All fields with a red asterisk *

are required fields

Hospital Characteristics

define each facility for creation of peer groupswhen running reports

Hospital Contacts are responsible for completing and maintaining the

Hospital Profile page for their facility.

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Click drop-down to select Level of

Measurement . This applies only to

Financial/Operational measures

Question marks ? provide pop-up

definitions throughout the QHi site

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Selecting

Measures

Return to Main Menu

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Click here to go to Measures Selection

page

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In Collected Measure Sets, users can select the

default measures predetermined by their

state or network

The QHi Core Measure Set is pre-

selected as it is required for all

hospitals

Additional Measure sets are available here

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Collected Measures lists the

measures within the measure sets

currently collected by the hospital

Individual measures are selected and displayed under

Additional Measures .

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Additional Measures lists(1)Individual measures currently collected and(2) other measures that are available to collect

Indicates the numberof hospitals in QHi

collecting themeasure

Click the plus + icon to measure to

Currently Collecting

Click the negative -icon to remove measure from

Currently Collecting

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Click question mark icon ? to display the calculation for

each measure

Click show elementsto display the elementsrequired to calculate

the measure

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Entering

Data

Return to Main Menu

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Click Data Submissions to open the Data Submission page

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Select correct month and year from Month to add

drop-down

Click Save to save data entered IMPORTANT: User must check Activate data for reporting box in order for the data entered this

month to be displayed on dashboards or in reports

Data elements populate the data entry screen based on measures selected in the Hospital Profile.

Click Go to: drop-down to select prior months’ data

submissions

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If data for the month is entered and saved but not activated, this message will appear to

remind the user to activate data for reporting

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Data elements automatically populate this screen based

on the measures selected by the user in the Measures

Selection page

Click to automatically calculatemeasures and immediately

display results

The prior month’s data is displayed for

easy reference

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The

Dashboard

Return to Main Menu

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The Core Measures Dashboard provides comparison data for the

eight QHi Core Measures

Roll mouse over any dashboard graph to view the calculation

The Dashboard can be viewed as a table

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table View

The Dashboard can also be viewed as

combined graph and table

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Graph and table View

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Dashboard data is calculated using a consecutive three month summing average

Dashboard data is calculated using a

consecutive three-month summing average

State Avg values reflect data from hospitals in the same state as My Hospital and

reported in the same time interval

QHi Avg values reflect data from all hospitals in QHi reporting the same

measure in the same time interval

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Financial measures on the Dashboard default to peer groups

based on the hospital’s level of reporting (Hospital Only or Entire

Enterprise)

A hospital must have activated data for at least one of the three

months in the Date Range in order for the measure to be

displayed on the Dashboard

My Hospital data for some clinical measures will not

display on the Dashboard if the hospital had no

occurrences during the Date Range period

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The three months in the Date Range can be changed by clicking the drop-down to

select the start month for the desired three-month period

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Click here to view theDashboard as a PDF

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PDF view

The PDF format allows the user to save, print

or email the Dashboard in graph, table or

graph/table views

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Users can email the Dashboard in PDF to

themselves by clicking To Myself

…or choose another recipient

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User selects from a list of existing registered users

…or choose to add a new recipient

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Enter the name and Email address of the

new recipient

…and click Add New

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…Enter the Name and Email address of the new recipient

…and click Add New

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Click Create Schedule to establish a pre-determined

schedule for emailing Dashboard reports to selected recipients

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1. Select run date (Click on calendar icon)2. Select frequency (click drop-down)

3. Select recipients4. Click Save Schedule

Dashboard is sent throughEmail (as scheduled) as a

PDF attachment

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1. Select a run date2. Select the frequency3. Select Recipients4. Save Schedule5. Report is sent through email as a

PDF attachment.

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Click View My Dashboardto create a customized

Dashboard

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Only those measures being collected by the

hospital will be available in the list

Click drop-down to select a measure to display on

Dashboard

Selected measures are retained and are

user specific

Notes section available to add comments or

additional information

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Reports

Return to Main Menu

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Click Reports to view measures and create reports

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There are 6 categories of reports:1.Clinical Quality2.Employees3.Financial Operational4.Hospital Characteristics5.Patient Satisfaction6.System

A hospital can view reports only for the measures and data elements it is collecting

The measures being collected by the

hospital are listed ineach category

Click on a measureto create a report

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Pick peer groups

Select date criteria

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Pick optional hospitalcharacteristics

Multiple criteria selected will more narrowly define

the peer group

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Available values are listed for the criteria chosen in

Step 3

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Displays and holdsthe criteria selected

The report can be displayed in four formats

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Line Graph View

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Bar Graph View

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table View

The user’s facilityis identified as

Hospital

Click to export report data to

Excel

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Text Detail Measure View

Note that peer hospitalsare not identified by

name

Click to exportreport data

to Excel

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From the Excel reportusers can create

customized graphsto meet their needs

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Text Detail Measure View

Click on the envelope icon to contact a peer hospital

for benchmarking information

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The Hospital Contact at theselected peer hospital will

receive the Email message

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Training and educationalmaterials are available

for download on theHelp page

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How we use the data

Return to Main Menu

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I print a copy of the graphs and take it to the board for discussion. They appreciate seeing in color how we compare to other CAHs in KS as well as others in the USA.

On a quarterly basis I am giving a copy of the bar graphs to our Board Members at their meeting.

I give the Quality Committee a copy of the quality reports on a quarterly basis.

We track and present our indicators monthly and are usually above the norm. On the occasions when we fall below, it prompts us to review processes to seek improvements.

If we fall below expectations, we look for ways to improve and then report back to the board in the next quarter.

We like the Days in AR report. This is our only source for comparative information on this measure.


What do we do with the data? A few comments from our hospitals…

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Thank you for viewing this demonstration.

If you have any questions or would like additional information on the QHi project, please contact:

Sally Perkins, QHi System Administrator [email protected]

785-276-3118or

Stuart Moore, QHi [email protected]

785-276-3104


Quality Health Indicators

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