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April 2017‐March 2018 BCBSM Peer Group 5 Hospital Pay‐for‐Performance Program Contact: [email protected] 1
Blue Cross Blue Shield of Michigan (BCBSM) designates small, rural acute care facilities that provide
access to care in areas where no other care is available as peer group 5 facilities (PG 5). Additionally,
many of these hospitals are also classified as Critical Access Hospitals (CAH) by Medicare. The BCBSM
PG5 Hospital Pay‐for‐Performance (P4P) program provides these hospitals with an opportunity to
demonstrate value to their communities and customers by meeting expectations for access,
effectiveness and quality of care.
The PG 5 Hospital P4P program described in this document is effective April 1st, 2017 through March
31st, 2018. Performance in the program determines up to six percentage points of a rural hospital’s
payment rate, effective October 1st, 2018.
The PG5 hospital community can provide valuable feedback about the P4P program through the PG5
P4P Advisory Group. This group is dedicated to collaboratively discuss each year’s P4P program and
evaluate program measures to ensure each positively challenges rural hospitals to deliver the most
value to the communities they serve. The PG5 P4P Advisory group includes representatives from
BCBSM, the Michigan Health & Hospital Association (MHA), and members of the PG5 hospital
community – membership and contact information can be found in Appendix A. PG5 hospitals may
contact these representatives to provide comments related to the P4P program, and any comments
received will be presented at future Advisory Group meetings for consideration.
Program Enhancements in 2017‐2018
Although the overall structure of the PG5 P4P program remains largely unchanged, notable
enhancements in the 2017‐2018 PG5 P4P program year include:
Retirement of individual MHA Keystone Initiatives and introduction of MHA‐sponsored Great
Lakes Partners for Patients Hospital Improvement Innovation Network (HIIN)
Different program weights for non‐CAH
Program Overview
2017‐2018 Peer Group 5 Hospital Pay‐for‐Performance Program
April 2017 through March 2018
April 2017‐March 2018 BCBSM Peer Group 5 Hospital Pay‐for‐Performance Program Contact: [email protected] 2
2017‐2018 P4P Program Structure
Pre‐Qualifying Condition & CEO Attestation Form
In order for hospitals to participate in the PG5 P4P program, each much first meet the culture of patient
safety survey pre‐qualifying condition. PG5 hospitals must conduct a hospital‐wide patient safety
assessment survey at least once every two years, in either 2016 or 2017. There are three eligible surveys:
Hospital Survey on Patient Safety Culture (HSOPSC)
Safety Assessment Questionnaire (SAQ)
MHA SCORE Survey
The survey can be assessed by a vendor, online assessment tool or a hospital self‐assessment process, but
the assessment process must provide guidance on how to make improvements in patient safety culture.
A hospital wishing to use an alternative survey may contact BCBSM for review and consideration.
April 2017‐March 2018 BCBSM Peer Group 5 Hospital Pay‐for‐Performance Program Contact: [email protected] 3
CEO Attestation Form
The P4P also requires hospitals to submit a yearly CEO attestation to BCBSM, certifying that the
information being sent to BCBSM for the PG5 P4P program is true and to the best of the knowledge of
each hospital. This form also provides documentation for each of the individual program components,
outlines information on the results of the patient safety assessment, and describes any activities the
hospital plans to implement to address findings from the assessment. Completed CEO attestation forms
should be submitted to BCBSM by fax or email at [email protected] by June 1, 2018.
Health of the Community (CAH 30%; Non‐CAH 40%)
The Health of the Community component maintains the same program structure from the 2016‐2017
program year. In order to support Michigan’s rural providers in being national leaders in collecting and
reporting patient experience information1, HCAHPS survey submission will remain a mandatory
requirement for all participating‐sites. Hospitals will have the option to select two additional activities to
earn the remaining incentive.
2017‐2018 Health of the Community requirements include:
Measure Name Program Weight
CAH Program Weight
Non‐CAH
HCAHPS Survey Submission 10% 15%
Choose two of the following:
Community Service Plan (CSP)
10% each (Choose Two)
12.5% each (Choose Two)
Population Health Management Champion Attestation
Admission, Discharge and Transfer (ADT) notification service
HCAHPS Survey
Hospitals will also be required to collect HCAHPS survey information, at a minimum, for the following four
questions:
Question 3 – During this hospital stay, how often did nurses explain things in a way you could
understand?
Question 7 – How often did doctors explain things in a way you could understand?
Question 19 – Did hospital staff talk with you about whether you would have the help you
needed when you left the hospital?
Question 20 – Did you get the information in writing about what symptoms or health problems
to look out for after you left the hospital?
1 http://www.flexmonitoring.org/wp‐content/uploads/2015/04/Michigan.pdf
April 2017‐March 2018 BCBSM Peer Group 5 Hospital Pay‐for‐Performance Program Contact: [email protected] 4
Hospitals can either submit HCAHPS data directly to BCBSM or attest that HCAHPS data has been
submitted to the CMS Hospital Compare website via CEO attestation form.
Please note: beginning with the 2014‐2015 program year, HCAHPS survey submission is no longer
accepted as an alternative to participation in one or more MHA Keystone quality initiatives.
Population Health Management Activities
PG5 hospitals are required to select two of the following measures:
1. Community Service Plan
In order to offer hospitals credit for the investments that each is already making to improve the health
of their communities, BCBSM has included the Community Service Plan (CSP) dimension to the P4P.
The goal of the CSP is for each hospital to provide a high‐level narrative of their community service
initiatives. As with years past, hospitals will receive full credit for submitting at least one CSP proposal
(Appendix C). With the approval of individual P4P‐participating hospitals, BCBSM will compile CSP
responses into a single Community Benefit Information Booklet with the intent to share best practices
for improving population health within rural hospital communities.
2. Population Health Management Champion Attestation
In an effort to continue to increase awareness of population‐health management within Michigan
rural hospital communities, the 2017‐2018 program year will continue to offer PG5 hospitals the
opportunity to designate a “Population Health Champion”. These champions are intended to be the
point of contact for all population‐health management activities and collaboration efforts with other
healthcare providers in the community and across care settings.
For the 2017‐2018 program year, BCBSM will continue to encourage champions to review BCBSM’s
Population Insights Reporting and share insights with appropriate representatives within their
hospitals and other care providers. Additionally, champions will be required to fill out an attestation
form (Appendix D) analyzing Population Insights Reporting and explaining current population health
management activities taking place within their organization.
3. Admission, Discharge and Transfer (ADT) notification service
In the 2017‐2018 program year, hospitals will have the opportunity to engage in Health Information
Exchange (HIE) activities, including the statewide Admission, Discharge and Transfer (ADT) notification
service. This program measure is an option to PG5 hospitals to assist rural providers in joining the
existing HIE efforts that PG1‐4 acute care hospitals and Skilled Nursing Facility post‐acute providers
have been required to make in their own incentive programs. With the unique care that PG5 hospitals
provide, those sites who are successful in engaging in these new HIE activities may find themselves
better able to improve care transitions and reduce readmissions for the patients they serve. Early
adopters may also find themselves better positioned to take advantage of HIE activities in future P4P
program years.
April 2017‐March 2018 BCBSM Peer Group 5 Hospital Pay‐for‐Performance Program Contact: [email protected] 5
This measure will require hospitals to electronically transmit all patient, all payer admission,
discharge and transfer data, on a daily basis, into the statewide notification service established
through the Michigan Health Information Network Shared Services (MiHIN) for distribution to
practitioners who have a care relationship with each patient (Appendix E).
Clinical Quality Indicators (CAH 30%; Non‐CAH 40%)
The Clinical Quality Indicator program component of the 2017‐2018 program year will maintain all five
measures from the prior program year. Each quality indicator will be worth 6% for CAH and 8% for Non‐
CAH and program weights for measures with less than 20 cases will be equally redistributed across
remaining eligible measures.
CMS Indicator Program Weight
CAH Program Weight
Non‐CAH
OP ‐ 4a Aspirin at arrival ‐ overall (AMI & chest pain) 6% 8%
OP ‐ 5a Median time to ECG ‐ overall (AMI & chest pain) 6% 8%
OP ‐ 20 Door to Diagnostic Evaluation by a Qualified Medical Personnel 6% 8%
OP ‐ 27 Influenza Vaccination Coverage among Healthcare Personnel 6% 8%
IMM ‐ 2 Immunization for Influenza 6% 8%
Scoring Thresholds
Hospitals will be scored on the above clinical quality indicator measures by comparing actual performance
against scoring thresholds. BCBSM encourages that thresholds increase each year or that measures be
retired when nearly all hospitals meet > 95% compliance. Each June, representatives from BCBSM, MHA
and the hospital community meet to review the prior year’s hospital performance on these measures and
establish new scoring thresholds. Because the quality data from the previous program year is not
available until June 1st, thresholds are established during the first quarter of current program year and
communicated to hospitals no later than June 30, 2017.
For scoring thresholds that include a range, such as the thresholds for OP‐4a and IMM‐2, hospitals earn
full points for scoring above the range, zero points for scoring below the range, or points equal to
performance falling within the range. For example, for a scoring threshold of 93‐95%, a score greater than
95% will earn a hospital 100%, a score less than 93% will earn the hospital 0%, and hospitals performing
within the range will earn points equal to the performance rate.
April 2017‐March 2018 BCBSM Peer Group 5 Hospital Pay‐for‐Performance Program Contact: [email protected] 6
Quality Initiatives (CAH 40%; Non‐CAH 20%)
The Quality Indicator program component requires hospitals to participate in the following initiatives:
Michigan Critical Access Hospital Quality Network (MICAHQN) Participation
MHA Great Lakes Partners for Patients Hospital Improvement Innovation Network (HIIN)
Participation in the MICAHQN and attendance at quarterly meetings is mandatory for all CAH facilities.
Great Lakes Partners for Patients Hospital Improvement Innovation Network (HIIN)
For the 2017‐2018 program year, the MHA, in partnership with the Illinois Health and Hospital Association
and Wisconsin Hospital Association, has combined Keystone collaborative efforts into a single, two‐year
long Hospital Improvement Innovation Network (HIIN) initiative, named Great Lakes Partners for Patients
HIIN. In 2017‐2018, all targeted improvement work will occur under the Great Lakes Partners for Patients
HIIN and as such, the MHA Keystone center will not be enrolling hospitals in individual collaboratives.
In 2017‐2018, Hospital participation in the HIIN is required and will be weighted at 40% of the overall
program for CAH and 20% for non‐CAH.
The HIIN will focus on implementing person and family engagement practices, enhancing antimicrobial
stewardship, building cultures of high reliability, reducing readmissions and addressing 11 types of
inpatient harm. A HIIN Performance Index scorecard outlining measure requirements can be found in at
the end of this program guide.
Although enrollment in the HIIN closed on November 10th, 2016, hospitals that desire to join for BCBSM
purposes may still do so. In addition, hospitals planning to participate in a HIIN other than the Great Lakes
Partners for Patients may still be eligible for points and should contact the MHA Keystone Center for more
information at [email protected].
Quality Initiative Performance Index
A hospital’s quality initiative score is determined by its performance on specific measures related to
MICAHQN and MHA HIIN initiative and will each be worth up to 20%. Performance Index scores will be
shared with hospitals prior to their submission to BCBSM. Hospitals should contact either the MHA
Keystone or MICAHQN representative if interested in obtaining performance status at any time during the
program period.
P4P Incentive Payments
BCBSM will communicate P4P payment rates to hospitals by July 31st, 2018 with rates becoming effective
October 1st, 2018. The BCBSM Peer Group 5 P4P program, established by the BCBSM Participating
Hospital Agreement for Peer Group 5 facilities, determines up to six percentage points of a participating
hospital’s inpatient and outpatient payment rate. Regardless of a hospital’s fiscal year end, the P4P
payment rate is effective for a twelve month period beginning on October 1st.
April 2017‐March 2018 BCBSM Peer Group 5 Hospital Pay‐for‐Performance Program Contact: [email protected] 7
Pay‐for‐Performance payment rates are calculated by multiplying a facility’s final P4P score by the 6
percent maximum payment rate that each peer group 5 hospital is eligible to receive. For those hospitals
earning a P4P score less than 100%, the difference between the corresponding P4P payment rate and six
percent maximum is subtracted from your overall reimbursement rate. If applicable, any rate adjustments
made for the 2016‐2017 P4P program year will be added back at this time. In October, hospital’s earning
less than the full six percentage points attributed to P4P performance can expect to receive a revised rate
sheet from BCBSM’s Facility Reimbursement department.
Appendix A PG5 Advisory Group Representatives
April 2017‐March 2018 BCBSM Peer Group 5 Hospital Pay‐for‐Performance Program Contact: [email protected] 8
PG5 Hospital Representatives
Chris Wilhelm Barb Cote Lee Gascho
COO Director, Total Quality Management
Quality Improvement System Leader
Charlevoix Area Hospital Spectrum Health Reed City Scheurer Hospital
14700 Lake Shore Dr 300 North Patterson Rd 170 N Caseville Rd
Charlevoix, MI 48720 Reed City, MI 49677 Pigeon, MI 48755
(231) 547‐4024 (231) 832‐7159 (989) 453‐4475
[email protected] barb.cote@spectrum‐health.org [email protected]
Brenda Bolsby Rodney Nelson Tiffany Friar
QA/Risk Management CEO Director of Clinical Integration
Marlette Regional Hospital Mackinac Straits Health System Hayes Green Beach Memorial Hospital
2270 Main Street 1140 North State Street 321 East Harris Street
Marlette, MI 48452 St. Ignace, MI 49781 Charlotte, MI 48813
(989) 635‐4009 (906) 643‐0456 (517) 543‐1050 Ext. 1208
[email protected] [email protected] [email protected] [email protected]
William Roeser Joanne Schroeder Debbie Smith
CEO President & CEO Senior Director of Quality Risk Management
Sparrow Ionia Hospital South Haven Community Hospital South Haven Community Hospital
479 Lafayette St 955 South Bailey Ave 955 South Bailey Ave
Ionia, MI 48846 South Haven, MI 49090 South Haven, MI 49090
(616) 527‐4200 (269) 639‐2806 (269) 639‐2806
[email protected] jschroeder@sh‐hs.org dsmith@sh‐hs.org
Carolyn Vanwert
Case Management & Quality Analyst
MidMichigan ‐ Gladwin
515 Quarter St
Gladwin, MI 48624
(989) 246‐9426
Appendix A PG5 Advisory Group Representatives
April 2017‐March 2018 BCBSM Peer Group 5 Hospital Pay‐for‐Performance Program Contact: [email protected] 9
MHA Representatives
Bill Jackson Sam Watson Jason Jorkasky
Senior Vice President Senior Vice President Senior Director, Policy
MHA MHA Keystone Center MHA
2112 University Park Drive 2112 University Park Drive 2112 University Park Drive
Okemos, MI 48864 Okemos, MI 48864 Okemos, MI 48864
(517) 323‐3443 (517) 886‐8362 (517) 703‐8649
[email protected] [email protected] [email protected] [email protected]
Marilyn Litka‐Klein Brittany Bogan Ewa Panetta
Vice President, Health Finance Vice President, Patient Safety and Quality Project Coordinator
MHA MHA Keystone Center MHA Keystone Center
2112 University Park Drive 2112 University Park Drive 2112 University Park Drive
Okemos, MI 48864 Okemos, MI 48864 Okemos, MI 48864
(517) 703‐8603 (517) 886‐8313 (517) 886‐8364
[email protected] [email protected] [email protected]
BCBSM Representatives
Kristen Frey Lauren Rossi Michael Andreshak
Hospital Incentive Programs Hospital Incentive Programs Hospital Contracting and Policy
BCBSM BCBSM BCBSM
600 E. Lafayette 600 E. Lafayette 600 E. Lafayette
Detroit, MI 48226 Detroit, MI 48226 Detroit, MI 48226
(313) 448‐4746 (313) 448‐6090 (313) 448‐3905
[email protected] [email protected] [email protected] [email protected]
Appendix B Quality Initiative Scoring Index
April 2017‐March 2018 BCBSM Peer Group 5 Hospital Pay‐for‐Performance Program Contact: [email protected] 10
Michigan Critical Access Hospital Quality Network (MICAHQN)
Measure Name Weight Measure Performance Points Earned
Participation in Meetings
100
All four meetings (in‐person or teleconference)
100
Two or three meetings 75
One meeting 25
Did not attend any meeting 0
Hospitals with questions regarding MICAH Quality Network measure performance may contact Crystal Barter, Email: [email protected]; Phone: (517) 432‐0006
Appendix C Community Benefit Information – Community Service Program
April 2017‐March 2018 BCBSM Peer Group 5 Hospital Pay‐for‐Performance Program Contact: [email protected] 11
Peer Group 5 Hospital Pay‐for‐Performance Program Community Service Program April 2017 through March 2018
Hospital Name: _____________________________________________________________
Completed Community Service Program(s) must be returned to BCBSM with a signed, PG5 P4P CEO
Attestation form by June 1, 2018.
Identify Program
Counties Served
Health Status of Population
Monitoring/Measurements of
population (baseline and re‐
measurement)
Communication of
program/interventions
Participation/Partnerships
Rate of success
Appendix D Population Health Champion Attestation
April 2017‐March 2018 BCBSM Peer Group 5 Hospital Pay‐for‐Performance Program Contact: [email protected] 12
BCBSM Peer Group 5 Pay‐for‐Performance Program (P4P) Population Health Champion Attestation
4/1/2017 – 3/31/2018 P4P (Due June 1, 2018)
I certify that I have reviewed the Population Insights Report and Population Profiling Tool for Peer Group 5 Pay‐for‐Performance Program, and it is true to the best of my knowledge.
_________________________________________ Printed Name – Population Health Champion _________________________________________ Signature _________________________________________ Facility
_________________________________________ Title _________________________________________ Email _________________________________________ Facility Code
PGIP Physician Organizations (PO) with whom Hospital has a shared patient population:
Physician Organization (PO) Sub‐Physician Organization (SubPO)
Using BCBSM’s Population Insights Report, identify partnering PGIP PO utilization measures showing opportunity for improvement, if applicable:
Utilization Metrics
For the above, identify any interventions currently in place to improve utilization rates (if none, explain how your hospital intends on working on the issue):
Appendix D Population Health Champion Attestation
April 2017‐March 2018 BCBSM Peer Group 5 Hospital Pay‐for‐Performance Program Contact: [email protected] 13
Fill out the table below according to current population health management activities your hospital is participating in:
Population Health Activities
Does your hospital currently participate in an Accountable Care Organization (ACO)? If yes, which one?
ACO Participants
What population health activities does your hospital participate in as part of an ACO?
What are your long term goals of ACO participation?
Are there any programs or population health management activities your hospital participates in outside of ACO‐related activities?
Non‐ACO Participants
What are your barriers to entry in participating in an ACO?
Are you participating in any population health management activities? (i.e. actively engaging with physician partners to better coordinate care)
Appendix E Health Information Exchange – ADT Measure
April 2017‐March 2018 BCBSM Peer Group 5 Hospital Pay‐for‐Performance Program Contact: [email protected] 14
PG5 P4P Program – Health Information Exchange (HIE) Activity:
Admission, Discharge and Transfer (ADT) notification service
Overview
The BCBSM Hospital Pay‐for‐Performance Health Information Exchange (HIE) Daily Hospital Census
Reporting Admit, Discharge, Transfer (ADT) and ED Visit measure will reward hospitals who participate in
the statewide notification service established by the Michigan Health Information Network (MiHIN).
Participation in the notification service is expected to improve care transitions and reduce readmissions.
In 2017‐2018, the P4P weight for the HIE ADT measure is 10 points and will be based on the successful
implementation of the admission, discharge, transfer and emergency room visit use case.
Background
The population‐based model of health promotes a team‐based approach and a commitment to caring for
the patient across time and settings of care. Despite the need for this longitudinal approach, there are
many obstacles that prevent consistent communication across the care continuum. A primary issue is the
number of individuals and organizations involved in managing a patient’s health. This includes hospitals,
primary care physicians, specialists, mental health providers, skilled nursing facilities, pharmacists, care
coordinators, other care givers and public and private insurers. Caregivers need to receive timely
notification of their patients’ ADT and ER visits so they can improve the care coordination process and
reduce the likelihood of an unplanned readmission.
Many health systems have a process in place, but the communications are generally limited to a narrow
set of affiliated providers. For most hospitals, a large proportion of their patients have primary caregivers
who are not affiliated with the hospital. In these situations, the patient’s primary care physician and other
caregivers are often unaware of the ADT or ER event until the patient calls for a follow‐up appointment.
For some patients this delayed notification can result in a sub‐optimal transition from the acute care
setting and insufficient follow‐up during the critical first days following discharge.
The Michigan Health Information Network – Statewide Notification Service
To address the need for more timely information, MiHIN established a statewide notification service to
give practitioners daily all‐payer ADT and ER census reports for their patients. The goal is to help
practitioners better prepare for and support their patients when they are discharged from an acute care
hospital or ER into the home or another care setting. This should improve the transition process, result in
a better health outcome for the patient and reduce the likelihood of an unplanned readmission.
The MiHIN notification service routes ADT and ER visit information from hospitals to a patient’s caregivers,
regardless of where the patient has been admitted or whether his or her primary caregivers have an
affiliation with the hospital. The MiHIN service uses existing HIE infrastructure to receive hospital ADT and
ER visit data, identify the physicians who have a care relationship with each patient, and transmit a
Appendix E Health Information Exchange – ADT Measure
April 2017‐March 2018 BCBSM Peer Group 5 Hospital Pay‐for‐Performance Program Contact: [email protected] 15
notification to the relevant physician organization. Each PO determines for itself how it wants to receive
these notifications and how it will distribute the information to its practice units or care coordinators.
In addition to its technical role in Michigan’s HIE infrastructure, an important function provided by MiHIN
is to ensure all parties participating in the service adhere to the necessary HIPAA and legal requirements
that govern the sharing of data. Each party transmitting or receiving data through the notification service
must sign an ADT Use Case Agreement. The agreement establishes a “chain of trust” across all users by
clearly specifying who has access to the data, how it will be routed across participants, and how it can be
used by recipients. The Use Case Agreement also requires MiHIN to discard data for which there is no
identified recipient with an applicable care relationship. MiHIN does not function as a data repository and
discards all data after 30 days.
Principles of the statewide notification service
To ensure maximum effectiveness and ease of use, the MiHIN statewide notification service is designed
around the following four principles:
Hospitals should only need to communicate ADT and ER visit information once, regardless of the
number of recipients.
Hospitals should be able to send the information through the electronic channel of their choice,
as long as it connects to the appropriate clinical process for managing transitions.
Practitioners should be able to receive the information in the manner they choose to support their
clinical processes.
Report information should meet standard expectations related to common data definitions, fields
etc.
In addition to improved transitions, timely ADT notification can help improve the care provided to patients
while they are still in the hospital. For example, physicians may have information about a patient that will
improve the care provided during a hospitalization. A daily ADT report will alert physicians of these
hospitalized patients and help ensure relevant information is shared with the hospital on a timely basis.
The statewide notification service is an all‐payer, all‐patient solution. A statewide group of stakeholders,
including MiHIN, sub‐state HIEs, BCBSM, hospitals and physicians provided input and guidance on the
design and implementation of the service.
Other Benefits of the MiHIN Statewide Notification System
The architecture of the statewide notification service is also designed to allow expansion into other
services. For example, the same technical platform is used to send discharge medication information to
providers, which significantly impacts their ability to perform care transitions. The transmission of
additional types of data, such as laboratory and imaging results, is currently in development.
Appendix E Health Information Exchange – ADT Measure
April 2017‐March 2018 BCBSM Peer Group 5 Hospital Pay‐for‐Performance Program Contact: [email protected] 16
Criteria for Participation in the MiHIN Notification Service
In order to be considered as successfully participating in the MiHIN statewide notification service for the
purpose of BCBSM’s P4P program, a hospital must meet the following criteria:
Agree to all respective data use case agreements associated with the notification service
Agree to meet timelines associated with the project
Electronically transmit the MiHIN required minimum ADT data elements on a daily basis (data
conformance will be required prior to hospital onboarding)
A hospital will be considered fully participating when it is transmitting all‐payer, all‐patient, validated ADT
data into the MiHIN service. A hospital will NOT be considered fully participating if only a limited subset
of its ADT data (e.g., BCBSM member data only) is transmitted into the service.
MiHIN will notify BCBSM of the status of the on‐boarding process for each hospital and whether there are
issues related to a hospital being able to meet the P4P Health Information Exchange ADT measure
expectations. If there are implementation issues that are beyond a hospital’s ability to resolve, BCBSM
will take this into account when scoring the measure.
Contact Information
For questions regarding data specifications and to schedule an implementation kick‐off meeting, please
contact Marty Woodruff at MiHIN, [email protected].
For questions regarding the BCBSM Pay‐for‐Performance Health Information Exchange ADT measure,
please contact Jen Cerre at [email protected].
2017-18 BCBSM Peer Group 5 P4P Scoring Index – MHA Keystone Center HIIN – CAH ONLY Updated 2/6/2017
MHA Keystone Center Great Lakes Partners for Patients Hospital Improvement Innovation Network (HIIN) Scoring Index
2017-18 BCBSM Peer Group 5 Pay-for-Performance Program Critical Access Hospitals (CAH) ONLY
Table 1: MHA Keystone / Great Lakes Partners for Patients HIIN Requirements
Component Weight Scoring Frequency Reporting Timeframe Data submission: Outcome Measures (Appendix A)
40% Monthly April 2017 – March 2018
Performance: Improvement on CAUTI, EDTC-1, and EDTC-4 measures (individual improvement from designated baselines)
25% Once Varies by measure
(see Table 3)
Person & Family Engagement: Patient & Family Advisory Councils
(PFAC)/ inclusion of patient advisors
20% Twice 1: April 2017 - September 2017 2: October 2017 – March 2018
Antimicrobial Stewardship: Current practices assessment
15% Once
Due by April 30, 2017
Pay for Performance Program Peer Group 5 Critical Access Hospital (CAH) ONL
2017-18 BCBSM Peer Group 5 P4P Scoring Index – MHA Keystone Center HIIN – CAH ONLY Updated 2/6/2017
Table 3: MHA Keystone / Outcomes Performance
Measure Baseline Performance
Period for Mid-year Score
Performance Period –
Final Score
CAUTI (Hospital wide): Urinary Catheter Utilization (KDS-HIIN-CAUTI-3a and KDS-HIIN-CAUTI-3b) OR
CAUTI Rate (KDS-HIIN-CAUTI-2a (all units))
Q1 2014
Apr. 2017 – Sept. 2017
Apr. 2017 – Mar. 2018
EDTC-1: Administrative Communication Element 1: Healthcare facility to healthcare facility (MBQIP) OR Element 2: Physician to physician communication (MBQIP)
Q1 2016 Apr. 2017 – Sept. 2017
Apr. 2017 – Mar. 2018
Table 2: MHA Keystone / Great Lakes Partners for Patients HIIN Scoring Index
Component Description Available Points
Data Submission*
o At least 90% of outcome data submitted across 12-month period o 70 – 89% of all outcome data submitted across 12-month period o Less than 70% of all outcome data submitted across 12-month period
40 points
25 points
15 points
Performance on outcomes for CAUTI, EDTC-1, and EDTC-4** (see table 3 for additional detail)
o Improvement from baseline on 3 of 3 measures o Improvement from HIIN baseline on 2 of 3 measures o Improvement from HIIN baseline on 1 of 3 measures
30 points (5 bonus) 25 points 10 points
Launch of Patient & Family Advisory Council (PFAC) and/or Inclusion of Patient Advisor on Existing Quality Improvement Team***
o PFAC / inclusion of patient advisors - Fully implemented o PFAC / inclusion of patient advisors - Partially implemented o PFAC / inclusion of patient advisors - Not implemented
20 points 10 points 5 points
Antimicrobial Stewardship (AMS)**** o Completion of AMS assessment by April 30, 2017 o No completion of AMS assessment by April 30, 2017
15 points
0 points
Total Possible Points
100 points
2017-18 BCBSM Peer Group 5 P4P Scoring Index – MHA Keystone Center HIIN – CAH ONLY Updated 2/6/2017
EDTC-4: Medication Information Element 1: Medications administered in ED (MBQIP) OR Element 2: Allergies (MBQIP) OR Element 3: Home medications (MBQIP)
Q1 2016 Apr. 2017 – Sept. 2017
Apr. 2017 – Mar. 2018
* Hospitals will only be scored for the submission of outcome data they are eligible to collect. Please reference
Appendix A (HIIN Encyclopedia of Measures) for a complete list of the required measures.
General HIIN Participation Requirements
Completion of an enrollment assessment to identify primary contacts including quality and risk leaders, executive, physician and nursing champions, data lead, PFE contact, pharmacy contact and infection prevention lead.
Participate in HIIN-wide quality improvement activities and/or site-specific activities related to the achieving the aims of the HIIN (20% reduction in all-cause harm and 12% reduction in preventable readmissions over a two-year period).
In addition to the required components above, hospitals may also be invited to:
Participate in Improvement Action Networks (IANs), Safe Tables, or Site Visits (Maximum requests = 4 per year)
** Hospitals will be scored on their own performance over time, and whether they are demonstrating
improvement in CAUTI (Urinary Catheter Utilization Ratio OR CAUTI Rate), EDTC 1 (Element 1 OR Element 2), and
EDTC 4 (Element 1 OR Element 2 OR Element 3) rates from the designated (hospital-specific) baseline to the
listed performance period (Table 3). The highest performing metric/element under the designated measure will
be selected. Hospitals that maintain rates in the top quartile among all participating CAH hospitals will receive
full points for improvement (please see Appendix A & Appendix B for measure definition).
*** The goal of this component is to implement a PFAC and/or include patient advisors on existing quality
improvement teams by the end of the program year (if not currently implemented). Hospitals would be asked to
report on this component minimally twice during the program year, by simply indicating fully implemented,
partially implemented, or not implemented in KDS. Please reference the MHA Community Website – Keystone
Center Quality Initiatives – HIIN Foundational Concepts – Person & Family Engagement (PFE) folder for
additional information on the launch of Patient & Family Advisory Councils and/or inclusion of patient advisors
on existing quality improvement committees.
**** Completion of the NHSN Patient Safety Annual Survey (which contains AMS questions) during 2017 will
meet this requirement if the hospital has conferred rights to MHA Keystone Center. Hospitals who do not submit
to NHSN, MHA Keystone Center will provide HIIN infection prevention contacts a link to complete the AMS
assessment. Hospitals have designated these contacts upon enrollment in the HIIN.
2017-18 BCBSM Peer Group 5 P4P Scoring Index – MHA Keystone Center HIIN – Non-CAH ONLY Updated 2/6/2017
MHA Keystone Center Great Lakes Partners for Patients Hospital Improvement Innovation Network (HIIN) Scoring Index
2017-18 BCBSM Peer Group 5 Pay-for-Performance Program
Non-Critical Access Hospitals ONLY
Table 1: MHA Keystone / Great Lakes Partners for Patients HIIN Requirements
Component Weight Scoring Frequency Reporting Timeframe Data submission: Outcome Measures (Appendix A)
40% Monthly April 2017 – March 2018
Performance: Improvement on CAUTI, sepsis, and pain management measures (individual improvement from HIIN baselines)
25% Once Varies by measure
(see Table 3)
Person & Family Engagement: Patient & Family Advisory Councils
(PFAC)/ inclusion of patient advisors
20% Twice 1: April 2017 - September 2017 2: October 2017 – March 2018
Antimicrobial Stewardship: Current practices assessment
15% Once
Due by April 30, 2017
Pay for Performance Program Peer Group 5 Critical Access Hospital (CAH) ONL
2017-18 BCBSM Peer Group 5 P4P Scoring Index – MHA Keystone Center HIIN – Non-CAH ONLY Updated 2/6/2017
Table 2: MHA Keystone / Great Lakes Partners for Patients HIIN Scoring Index
Component Description Available Points
Data Submission*
o At least 90% of outcome data submitted across 12-month period o 70 – 89% of all outcome data submitted across 12-month period o Less than 70% of all outcome data submitted across 12-month period
40 points
25 points
15 points
Performance on outcomes for CAUTI, Sepsis and Opioid Adverse Events** (see Table 3 for additional detail)
o Improvement from HIIN baseline on 3 of 3 measures o Improvement from HIIN baseline on 2 of 3 measures o Improvement from HIIN baseline on 1 of 3 measures
30 points (5 bonus) 25 points 10 points
Launch of Patient & Family Advisory Council (PFAC) and/or Inclusion of Patient Advisor on Existing Quality Improvement Team***
o PFAC / inclusion of patient advisors - Fully implemented o PFAC / inclusion of patient advisors - Partially implemented o PFAC / inclusion of patient advisors - Not implemented
20 points 10 points 5 points
Antimicrobial Stewardship (AMS)**** o Completion of AMS assessment by April 30, 2017 o No completion of AMS assessment by April 30, 2017
15 points
0 points
Total Possible Points 100 points
Table 3: MHA Keystone / Great Lakes Partners for Patients HIIN Outcomes Performance
Measure Baseline Performance
Period for Mid-year Score
Performance Period –
Final Score
CAUTI (ICUs): Urinary Catheter Utilization (KDS-HIIN-CAUTI-3b) OR CAUTI SIR (KDS-HIIN-CAUTI-1b)
Q1 2014
Q1 2015
Apr. 2017 – Sept. 2017
Apr. 2017 – Mar. 2018
Sepsis: Post-op Sepsis (KDS-HIIN-SEP-1) OR Sepsis Mortality (KDS-HIIN-SEP-2)
Q4 2015 Apr. 2017 – Sept. 2017
Apr. 2017 – Mar. 2018
Opioid Adverse Drug Events: Use of naloxone among inpatients receiving opioids (KDS-HIIN-ADE-4)
Q4 2016 Apr. 2017 – Sept. 2017
Apr. 2017 – Mar. 2018
2017-18 BCBSM Peer Group 5 P4P Scoring Index – MHA Keystone Center HIIN – Non-CAH ONLY Updated 2/6/2017
* Hospitals will only be scored for the submission of outcome data they are eligible to collect. Please reference
Appendix A (HIIN Encyclopedia of Measures) for a complete list of the required measures
General HIIN Participation Requirements
Completion of an enrollment assessment to identify primary contacts including quality and risk leaders, executive, physician and nursing champions, data lead, PFE contact, pharmacy contact and infection prevention lead.
Participate in HIIN-wide quality improvement activities and/or site-specific activities related to the achieving the aims of the HIIN (20% reduction in all-cause harm and 12% reduction in preventable readmissions over a two-year period).
In addition to the required components above, hospitals may also be invited to:
Participate in Improvement Action Networks (IANs), Safe Tables, or Site Visits (Maximum requests = 4 per year)
** Hospitals will be scored on their own performance over time, and whether they are demonstrating improvement in CAUTI (Urinary Catheter Utilization OR CAUTI SIR), Sepsis (Post-op Sepsis OR Sepsis Mortality) and Opioid ADE rates from the designated (hospital-specific) baseline to the listed performance period (Table 3). The highest performing metric under the designated measure will be selected. This aligns with how the MHA Keystone Center will track performance of hospitals in the HIIN for all measures. Hospitals that maintain rates in the top quartile among all participating hospitals will receive full points for improvement. *** The goal of this component is to implement a PFAC and/or include patient advisors on existing quality improvement teams by the end of the program year (if not currently implemented). Hospitals would be asked to report on this component minimally twice during the program year, by simply indicating fully implemented, partially implemented, or not implemented in KDS. Please reference the MHA Community Website – Keystone Center Quality Initiatives – HIIN Foundational Concepts – Person & Family Engagement (PFE) folder for additional information on the launch of Patient & Family Advisory Councils and/or inclusion of patient advisors on existing quality improvement committees. **** Completion of the NHSN Patient Safety Annual Survey (which contains AMS questions) during 2017 will meet this requirement if the hospital has conferred rights to MHA Keystone Center. Hospitals who do not submit to NHSN, MHA Keystone Center will provide HIIN infection prevention contacts a link to complete the AMS assessment. Hospitals have designated these contacts upon enrollment in the HIIN.