Michigan Critical Access
Hospital Quality Network
STRATEGY GROUP #3
FEBRUARY 21ST, 2020
AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
GOALImprove Care Transitions to 57% (↑ 2%)
by Q4 2019 (Known at June 2020)
AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
HCAHPS Data
AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
Previous State: Data pulled from Hospital Compare
Current State: Data provided directly
from the hospital/vendor
AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
HCAHPS Scores – Q1 and Q2 2019MICAH Q1
2019MICAH Q2 2019
MI Average National Average
Care Transitions Composite Score 58.22% 58.95% 54.0% 53.0%
AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
HCAHPS Scores – Q1 and Q2 2019Question Q1 2019 Q2 2019During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left
51.5% 54.38%
When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
59.5% 58.27%
When I left the hospital, I clearly understood the purpose for taking each of my medications.
64.31% 64.70%
Composite Score 58.22% 58.95%
AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
Readmissions Discussion Points: ◦ Very complex ◦ Data often old & difficult to obtain
outside of hospital level◦ Large SDoH impact◦ Out of scope of MICAH Quality
Managers? ◦ What data do we have to drive
change? ◦ CMS Priority
Conclusion: ◦ Working to prevent and reduce
readmissions is the right thing to do◦ Need to include patients and
families in this work◦ Timing is perfect to create an
intersection between inpatient and outpatient care
AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
Positive Impact on
Readmission Rates
Strengthen Person and
Family Engagement as
Partners in Their Care
Promote Effective
Prevention and Treatment of
Chronic Disease
FocusChronic Obstructive Pulmonary Disease
AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH
QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE
Example - Reducing Chronic Obstructive Pulmonary Disease Hospital Readmissions. An Official American Thoracic Society Workshop Report
Barriers to Optimal CareTransition to Home Finances Obstacles Tools / Resources NeededPoor Communication Inadequate reimbursement for time-intensive,
proper transitional careLimited empirical evidence
Ineffective discharge guidance Affordability of prescribed treatments and follow-up
Lack of compliance with existing guidelines
Limited efforts to engage patients and family Recognition of nonmedical barriers & availability of solutions
Diagnostic tool limitations/under and over diagnosis
Patient not being placed at center of care Policies that limit access to educators, respiratory therapists and others outside the hospital
Inadequate monitoring
Fragmentation of system/differences in where individual seeks care
Insufficient time for meaningful physician/patient engagement
Access and monitoring for issues related to oxygen
Access and referral to pulmonary rehabilitation limited
Use of ER as a treatment center
Insufficient physician and patient education
Lack of dissemination of existing tools
COPD Pocket Guide – www.copdfoundation.org
AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
Moving Forward
CURRENT STATE◦ Baseline Assessment
◦ What are the top reasons for MICAH readmissions?◦ Analysis of top diagnosis codes
◦ What readmission data do MICAH quality managers have access to?
◦ Additional thoughts?
Develop curriculum for MICAH QN meetings that focus on common chronic conditions affecting MICAH readmissions, with a lens of engaging patients and families. ◦ Ideas? ◦ Discussion?
AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
Book Club Facelift
AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
Current SG3 MembersJen Anderson
Crystal Barter
Michelle Deeter
Cindy Donajkowkski
Mariah Hesse
Jill Lackowski
Marc Marcotte
Sara Morin
Mary Kaye Ruegg
Heather Schragg
AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
Questions?THANK YOU!
AS A PREMIER SYSTEM OF QUALITY, THE MICHIGAN CRITICAL ACCESS HOSPITAL QUALITY NETWORK (MICAH QN) WILL BE A MODEL IN DEVELOPING PROCESSES THAT DEMONSTRATE THE HIGH QUALITY SERVICE PROVIDED BY CAHS. MICAH QN WILL IDENTIFY OPPORTUNITIES FOR CHANGE THAT LEAD TO CONTINUED IMPROVEMENT IN THE HEALTH STATUS OF THE POPULATION WE SERVE.
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