CQI Performance Index - bcbsm.com · PDF fileBlue Cross Blue Shield of Michigan. 2017 Hospital. Pay-for-Performance Program. Peer Groups 1 – 4. Hospital CQI Performance Index Scorecards

Blue Cross Blue Shield of Michigan

2017 Hospital Pay-for-Performance Program

Peer Groups 1 – 4

Hospital CQI Performance Index Scorecards and MHA Keystone Quality

Initiative Requirements

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CQIs and Pay-for-Performance

In 2017, the P4P program will offer hospitals the opportunity to earn a fixed 40% of the program’s incentive based upon its performance across MHA Keystone Initiatives or BCBSM-sponsored CQI initiatives. Unlike in program years past, the amount of incentive allocated to CQI performance will be equal for all participating hospitals regardless of the number of CQIs a hospital is eligible for.

The CQI program domain will remain capped at 40%, regardless of the number of participating initiatives. Hospitals eligible for and participating in more than ten CQIs will be scored using only the top 10 individual CQI performance scores, with preference given to BCBSM-sponsored CQIs.

With this program enhancement, hospitals participating in fewer CQIs will have a greater portion of the program’s incentive allocated to performance on an individual initiative.

In 2017, five (5) of the BCBSM-sponsored CQIs have been categorized as “Required” CQIs. In addition, individual MHA Keystone collaboratives have been replaced by the Great Lakes Partners for Patients Hospital Improvement Innovation Network (HIIN).

If your hospital is eligible for participation in a “required” CQI, and at the time of enrollment, voluntarily elects not to participate, your hospital will forfeit the ability to earn the associated program weight and P4P incentive attributed to that CQI. This will only count against your hospital after it has been provided the opportunity to participate through an enrollment application process. If your hospital has not been recruited or is ineligible to participate in a “required” CQI, then it will not be penalized for non-participation. There will be no negative impact on its P4P score if a hospital is deemed ineligible, has not been recruited for participation, or has been recruited for and voluntarily elects not to participate in a “non-required” CQI.

A hospital’s score on each CQI is determined by a CQI-specific performance index (described below) and hospitals are scored on a maximum of 10 CQIs. These 10 will include all required CQIs for which your hospital is eligible to participate, plus the highest scores of the non-required CQIs in which it participates. If your hospital is eligible to participate in less than 10 BCBSM-sponsored CQIs, both required and non-required, the HIIN will be considered as a CQI in your hospital’s score. Hospital participation in the HIIN is optional and will be weighted equivalent to two CQI programs- exact weights vary depending on total number of CQIs a hospital is participating in.

CQI Performance Index

Your hospital’s P4P score for each CQI is determined by its performance on specific measures related to that CQI. The measures and corresponding weights tied to each measure are referred to as the hospital’s CQI Performance Index scorecard. Some measures are related to program

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participation and engagement, such as meeting attendance and timely data submission. Other measures are performance-based and related to quality and clinical process improvement and outcomes, such as reductions in morbidity or surgical complications.

Each CQI’s performance index is developed by the corresponding CQI coordinating center and discussed with the participating hospital clinical champions before they are finalized. The measures in each CQI index scorecard are reviewed annually and updated if applicable, with increasing weight given to performance measures (versus participation measures) as programs become more established. The following pages provide the P4P Performance Index scorecard for each CQI.

Specific questions regarding Performance Index measures should be directed to the applicable CQI coordinating center Program Manager listed in the table below.

CQI Project Manager Contacts

CQI Clinical Focus Area Index Scorecard Link Project Manager

Phone Email

ASPIRE Anesthesiology ASPIRE Tory (Victoria) Lacca

734-936-8081 [email protected]

BMC2 Angioplasty and Vascular Surgery

BMC2 Andrea Jensen 734-998-6444 [email protected]

HMS Hospitalist Medicine HMS Elizabeth McLaughlin

734-936-0354 [email protected]

MAQI2 Anticoagulation MAQI2 Brian Haymart 734-998-5909 [email protected]

MARCQI Knee/Hip Arthroplasty MARCQI Rochelle Igrisan 734-998-0464 [email protected]

MBSC Bariatric Surgery MBSC Amanda Stricklen 734-998-7481 [email protected]

Rachel Ross 734-998-7502 [email protected]

MEDIC Emergency

Department MEDIC Greg Levine 734-763-5191 [email protected]

MROQC Radiation Oncology MROQC Melissa Meitze 734-936-1035 [email protected]

MSQC General Surgery MSQC Greta Krapohl 734-998-8200 [email protected]

MSSIC Spine Surgery MSSIC Lisa Pietrantoni 313-874-1892 [email protected]

MSTCVS Cardiac Surgery MSTCVS Patty Theurer 734-998-5918 [email protected]

MTQIP Trauma Surgery MTQIP Judy Mikhail 734-763-8227 [email protected]

MHA Keystone

Hospital Acquired Infections

Keystone Brittany Bogan 517-323-3443 [email protected]

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mailto:[email protected]








Measure # Weight Measure Description PointsQuarterly and Annual Meeting Participation ‐ Anesthesiology Quality

Champion or designated backup ‐ 3 Meetings Total

3/3 Meetings 10

2/3 Meetings 5

1 or less Meetings 0Quarterly and Annual Meeting Participation ‐ Anesthesiology Clinical

Quality Reviewer (ACQR) ‐ 3 Meetings Total

2 ‐ 3/3 Meetings 10

2/3 Meetings 5

1 or less Meetings 0Attend Monthly Webex ASPIRE Quality Committee Meetings

9 ‐ 10 meetings 10

7 ‐ 8 meetings 5

6 or less meetings 0ACQR/Anesthesiology Champion performing data validation, case

validation and submitting data on a monthly basis by the 17th of

each month

11/12 months 10

10 months 5

ACQR and Anesthesiology Quality Champion monthly meetings

12/12 months 10

11/12 months 5

10/12 months 0Site based quality meetings ‐ sites to hold an onsite meeting

following the ASPIRE Collaborative meetings to discuss the data and

plans for quality improvement

3/3 Meeting 20

2/3 Meeting 10

Performance Measure: NMB 01: cases receiving non‐depolarizing

neuromuscular blocker that have a Train of Four (TOF) monitor

documented

Performance is > 90% by month 12 15

Performance is < 90% but shows meaningful improvement from

month 1 to 12 (defined at >10% absolute increase)10

Any improvement (1 to 10% absolute increase) 5

No performance improvement or decline 0

Site directed measure, sites must choose a measure they are

performing below threshold by December 16, 2016


Performance is < 90% but shows meaningful improvement from

month 1 to 12 (defined at >10% absolute increase)10

Any improvement (1 to 10% absolute increase) 5

No performance improvement or decline 0

8 15%

2017 Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

Collaborative Quality Initiative Performance Index Scorecard

Cohort 1 ‐ Year 3 (2015 start)

2

1 10%

10%

10%3

4

9 or less months

1 or less Meetings

7 15%

0

10%

5 10%

6 20%

0

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2017 Performance Index Scorecard Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

Cohort 1 – Year 3 (2015 start)

Measure # 1: The ASPIRE Quality Champion (or a designated representative who must be an anesthesiologist) must attend 3 of the 3 ASPIRE Collaborative and Annual Meetings for 2017:

a. Friday, April 28, 2017 in conjunction with MSQC, Schoolcraft Community College, Livonia, MI b. Friday, July 21, 2017 ASPIRE Meeting, Lansing Community College, Lansing, Michigan c. Friday, October 20, 2017 – MPOG/ASPIRE Annual Retreat at ASA, Boston, MA

Measure # 2: The Anesthesiology Clinical Quality Reviewer (ACQR) will need to attend 2‐3 of the 3 ASPIRE Collaborative and Annual Meetings for 2017:


Measure # 3: ASPIRE Monthly Quality Committee meetings are held the fourth Monday of each month at 10:00am via Webex. One representative from each site will need to attend the meeting. There will be ten meetings in 2017 there will be no meeting in October due to ASA and December due to the holiday. Measure # 4: For detailed monthly upload schedule, please refer to the ASPIRE Maintenance Schedule on ASPIRE website: www.aspirecqi.org/resources. Measure # 5: ACQR and the ASPIRE Quality Champion need to meet on a monthly basis to discuss the data and plans for quality improvement. A log of the meeting dates/times need to be submitted to the ASPIRE Coordinating Center. The log is available on the ASPIRE website www.aspirecqi.org/p4p. Measure # 6: The site is expected to schedule a local meeting following each ASPIRE Collaborative meeting to discuss site based and collaborative quality outcomes with all clinical providers at their site. The physicians will participate in discussion of the data and plans for quality improvement. The site will provide the agendas, presentation and attendance list from the meeting to the ASPIRE Coordinating Center. The log is available on the ASPIRE website www.aspirecqi.org/p4p. Measure # 7: Sites will be awarded points for compliance with ASPIRE NMB 01 Quality Measure (see www.aspirecqi.org/aspire‐measures for more detail). To be awarded full points, compliance greater than threshold value by end of year is required. Measure # 8: Sites will choose a measure they are performing below threshold (see www.aspirecqi.org/aspire‐measures for list of measures). Sites must submit the measure to the ASPIRE Coordinating Center by Friday, December 16, 2016 for review and approval. To be awarded full points, compliance greater than threshold value by end of year is required.

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Measure # 1: The ASPIRE Quality Champion (or a designated representative who must be an anesthesiologist) must attend 3 of the 3 ASPIRE Quarterly and Annual Meetings for 2017:


Measure # 2: The Anesthesiology Clinical Quality Reviewer (ACQR) will need to attend 2-3 of the 3 ASPIRE Quarterly and Annual Meetings for 2017:


Measure # 3: ASPIRE Monthly Quality Committee meetings are held the fourth Monday of each month at 10:00am via Webex. One representative from each site will need to attend the meeting. Measure # 4: For detailed monthly uploads, please refer to monthly upload document on ASPIRE website. Measure # 5: ACQR and the ASPIRE Quality Champion need to meet on a monthly basis to discuss the data and plans for quality improvement. A log of the meeting dates/times need to be submitted to the ASPIRE Coordinating Center. The log is available on the ASPIRE website www.aspirecqi.org/p4p. Measure # 6: The site is expected to schedule local meetings following each ASPIRE Quarterly meetings to discuss site based and collaborative quality outcomes with all clinical providers at their site. The physicians will participate in discussion of the data and plans for quality improvement. The site will provide the agendas, presentation and attendance list from the meeting to the ASPIRE Coordinating Center. The log is available on the ASPIRE website www.aspirecqi.org/p4p. Measure # 7: Sites will be awarded points for compliance with ASPIRE NMB 01 Quality Measure (see www.aspirecqi.org/aspire-measures for more detail). To be awarded full points, compliance greater than threshold value by end of year is required. Measure # 8: Sites will choose a measure they are performing below threshold (see www.aspirecqi.org/aspire-measures for list of measures). Sites must submit the measure to the ASPIRE Coordinating Center by Friday, December 16, 2016 for review and approval. To be awarded full points, compliance greater than threshold value by end of year is required.

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http://www.aspirecqi.org/p4p


http://www.aspirecqi.org/aspire-measures


Measure # Weight Measure Description Points

Quarterly and Annual Meeting Participation ‐ Anesthesiology Quality

Champion or designated backup ‐ 3 Meetings Total

3/3 Meetings 10

2/3 Meetings 5

1 or less Meetings 0

Quarterly and Annual Meeting Participation ‐ Anesthesiology Clinical

Quality Reviewer (ACQR) ‐ 3 Meetings Total

2 ‐3/3 Meetings 10

1/3 Meetings 5

0 Meetings 0Attend Monthly Webex ASPIRE Quality Committee Meetings


7 ‐ 8 meetings 5

6 or less meetings 0

ACQR/Anesthesiology Champion performing data validation, case

validation and submitting data on a monthly basis by the 17th of

each month

11/12 months 20

10 months 10

9 months 5

8 or less 0

ACQR and Anesthesiology Quality Champion monthly meetings

12/12 months 10

11/12 months 5

10/12 months 0

Site based meetings ‐ sites to hold an onsite meeting following the

ASPIRE Collabortive meetings to discuss the data and plans for quality

improvement

3/3 Meeting 20

2/3 Meeting 10

Performance Measure: NMB 01: cases receiving non‐depolarizing

neuromuscular blocker that have a TOF monitor documented


Performance is < 90% but shows improvement month 1 to 12 5

Performance < 90% and shows no improvement month 1 to 12 0

Site directed measure, sites must choose a measure they are

performing below threshold by December 16, 2016

Performance > 90% by month 12 10

Performance < 90% but shows improvement month 1 to 12 5

Performance < 90% and shows no improvement month 1 to 12 0

0



Cohort 2 ‐ Year 2 (2016 start)

2

1 10%

6 20%

10%

10%3

4 20%

5 10%

10%8

10%7

1/3 Meetings

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Measure # 1: The ASPIRE Quality Champion (or a designated representative who must be an anesthesiologist) must attend 3 out of 3 ASPIRE Quarterly and Annual Meetings for 2017:




Measure # 3: ASPIRE Monthly Quality Committee meetings are held the fourth Monday of each month at 10:00am via Webex. One representative from each site will need to attend the meeting. No meetings will be held in October due to ASA and December due to the holiday. Measure # 4: For detailed monthly uploads, please refer to monthly upload document on ASPIRE website. Measure # 5: ACQR and the ASPIRE Quality Champion need to meet on a monthly basis to discuss the data and plans for quality improvement. A log of the meeting dates/times need to be submitted to the ASPIRE Coordinating Center. The log is available on the ASPIRE website www.aspirecqi.org/p4p. Measure # 6: The site is expected to schedule a local meeting following each ASPIRE Collaborative meeting to discuss site based and collaborative quality outcomes with all clinical providers at their site. The physicians will participate in discussion of the data and plans for quality improvement. The site will provide the agendas, presentation and attendance list from the meeting to the ASPIRE Coordinating Center. The log is available on the ASPIRE website: www.aspirecqi.org/p4p. Measure # 7: Sites will be awarded points for compliance with ASPIRE NMB 01 Quality Measure (see www.aspirecqi.org/aspire-measures for more detail). To be awarded full points, compliance greater than threshold value by end of year is required. Measure # 8: Sites will choose a measure they are performing below threshold (see www.aspirecqi.org/aspire-measures for list of measures). Sites must submit the measure to the ASPIRE Coordinating Center by Friday, December 16, 2016 for review and approval. To be awarded full points, compliance greater than threshold value by end of year is required.

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Measure # 3: ASPIRE Monthly Quality Committee meetings are held the fourth Monday of each month at 10:00am via Webex. One representative from each site will need to attend the meeting. Measure # 4: For detailed monthly uploads, please refer to monthly upload document on ASPIRE website. Measure # 5: ACQR and the ASPIRE Quality Champion need to meet on a monthly basis to discuss the data and plans for quality improvement. A log of the meeting dates/times need to be submitted to the ASPIRE Coordinating Center. The log is available on the ASPIRE website www.aspirecqi.org/p4p. Measure # 6: The site is expected to schedule local meetings following each ASPIRE Quarterly meetings to discuss site based and collaborative quality outcomes with all clinical providers at their site. The physicians will participate in discussion of the data and plans for quality improvement. The site will provide the agendas, presentation and attendance list from the meeting to the ASPIRE Coordinating Center. The log is available on the ASPIRE website: www.aspirecqi.org/p4p. Measure # 7: Sites will be awarded points for compliance with ASPIRE NMB 01 Quality Measure (see www.aspirecqi.org/aspire-measures for more detail). To be awarded full points, compliance greater than threshold value by end of year is required. Measure # 8: Sites will choose a measure they are performing below threshold (see www.aspirecqi.org/aspire-measures for list of measures). Sites must submit the measure to the ASPIRE Coordinating Center by Friday, December 16, 2016 for review and approval. To be awarded full points, compliance greater than threshold value by end of year is required.

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Collaborative and Annual Meeting Participation ‐ Anesthesiology

Quality Champion or their designated backup

3/3 Meetings 10

2/3 Meetings 5

1 or less Meetings 0

Collaborative and Annual Meeting Participation ‐ Anesthesiology

Clinical Quality Reviewer (ACQR)

2 ‐ 3/5 Meetings 10

2/3 Meetings 5

0 Meetings 0

Attend Monthly Webex ASPIRE Quality Committee Meetings


7 ‐ 8 meetings 5

6 or less meetings 0

Timeliness of Regulatory/Legal documentation

Data Use Agreement (DUA), MPOG Bylaws and IRB

Submitted by April 1, 2017 10

Submitted by July 1, 2017 5

Submitted after July 2, 2017 0

Hiring an Anesthesiology Clinical Quality Reviewer (ACQR)

ACQR Start by February 1, 2017 10

ACQR Start by April 1, 2017 5

ACQR Start after April 1, 2017 0

Timeliness of data submission (with Case by Case Validation and Data

Diagnostics)

Data submitted by July 1, 2017 20

Data submitted by September 1, 2017 10

Data submitted after September 2, 2017 0

Performance Metric: Accuracy of data of "High" and "Required"

priority data diagnostics marked as "Data Accurately Represented" in

Data Diagnostics Tool

≥ 90% diagnostics marked as "Data Accurately Represented" 20

≥ 75 ‐ 90% marked as "Data Accurately Represented" 10

< 75% marked as "Data Accurately Represented" 0

Timeliness of Responses to Coordinating Center Inquiry Requests

Within 2 business days 10

Within 5 business days 5

Greater than 5 business days 0

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Cohort 3 ‐ Year 1 (start 2017)

2

1 10%

10%8

7 20%

10%

10%4

5 10%

6 20%

10%

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Measure # 1: The ASPIRE Quality Champion (or a designated representative who must be an anesthesiologist) must attend 3 out of 3 ASPIRE Collaborative and Annual Meetings for 2017:


Measure # 2: The Anesthesiology Clinical Quality Reviewer (ACQR) will need to attend 2 out of 3 of the 3 ASPIRE Collaborative and Annual Meetings for 2017:


Measure # 3: ASPIRE Monthly Quality Committee meetings are held the fourth Monday of each month at 10:00am via Webex. One representative from each site will need to attend the meeting. There will be ten meetings in 2017. There will be no meeting held in October due to ASA and December due to the holiday. Measure # 4: All regulatory/legal documentation must be finalized by April 1, 2017. This includes the following documents:

1. Data Use Agreement (DUA) 2. IRB 3. MPOG Bylaws

Measure # 5: Must hire Anesthesiology Clinical Quality Reviewer (ACQR) by February 1, 2017. The success of the program is greater when the ACQR is hired early in the process. Measure # 6: The minimum data requirements must be uploaded into the Multicenter Perioperative Outcomes Group (MPOG) Central Repository by July 1, 2017 Measure # 7: Data must be of high quality before January 1, 2017 upload. The ASPIRE QI Coordinator and ASPIRE technical team will assist in ensuring data accuracy.

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Measure # 2: The Anesthesiology Clinical Quality Reviewer (ACQR) will need to attend 2 out of 3 of the 3 ASPIRE Quarterly and Annual Meetings for 2017:


Measure # 3: ASPIRE Monthly Quality Committee meetings are held the fourth Monday of each month at 10:00am via Webex. One representative from each site will need to attend the meeting. Measure # 4: For detailed monthly uploads, please refer to monthly upload document on ASPIRE website. Measure # 5: Must hire Anesthesiology Clinical Quality Reviewer (ACQR) by February 1, 2017. The earlier you can start the ACQR the better for the program’s success. Measure # 6: The minimum data requirements must be uploaded into the Multicenter Perioperative Outcomes Group (MPOG) Central Repository by July 1, 2017 Measure # 7: Data must be of high quality before January 1, 2017 upload. The ASPIRE QI Coordinator and ASPIRE technical team will assist in ensuring data accuracy.

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Measure Weight Measure Description2017 Meeting participation – Clinician Lead PCI Vascular Surgery2 meetings 5 51 meeting 2.5 2.5Did not participate 0 0

2017 Data Coordinator Expectations1 PCI Vascular SurgeryMeets All Expectations 5 5Meets Most Expectations 2.5 2.5Does Not Meet Most Expectations 0 0

NEW Vascular Surgery Performance Goal - Case Reviews (Based on 2016 cases)2 PCI Vascular SurgerySubmitted Reviews for ≥75% of Cases 10Submitted Reviews for <75% of Cases 0* Case review form filled out in REDCapNEW Vascular Surgery Performance Goal Reduce SSI - Chlorhexadine & Alcohol Skin Prep ≥90% (Based on Q1-Q3 2017 data)

PCI Vascular Surgery

Goal Met – ≥ 90% 10Goal Not Met - rate higher than last year 5Goal Not Met - rate equal to/lower than last year 0NEW Vascular Surgery Performance Goal Reduce SSI - Antibiotic Redosing ≥75%(Based on Q1-Q3 2017 data)


Goal Met – ≥ 75% 10Goal Not Met - rate higher than last year 5Goal Not Met - rate equal to/lower than last year 0PCI Performance Goal - Ratio of Contrast Volume to Glomerular Filtration Rate (GFR) Over 3 -Goal ≤ 30% (based on 2017 data)


Contrast Volume/GFR Ratio Over 3 – ≤ 30% of all patients 10Contrast Volume/GFR Ratio Over 3 – 31-35% of all patients 5Contrast Volume/GFR Ratio Over 3 – >35% of all patients 0

PCI Performance Goal - Cardiac Rehab Referral– Goal ≥ 75% (based on 2017 data) PCI Vascular Surgery

Referred – ≥75% 10Referred – 50-74% 5Referred – <50% 0

NEW PCI Performance Goal - PCI Internal Case Reviews (based on 2015 cases)3 PCI Vascular SurgerySubmit Reviews for ≥75% of Cases 10Submit Reviews for <75% of Cases 0* Case review form filled out in REDCapNEW PCI Performance Goal - Physician Review of Assigned Cases for Web-based Peer

Review (based on 2015 cases)3 PCI Vascular Surgery

Submit Reviews for 100% of Cases (20 cases max/year) 10Submit Reviews for <100% of Cases 0* Case review form filled out in REDCapNEW PCI Goal - Data Coordinator Upload of Case Documentation for Web-based Peer

Review (based on 2015 cases)3 PCI Vascular Surgery

Upload documenation for 100% of Reviews (12 cases max/year) 10Upload documenation for <100% of Reviews 0* Case documentation uploaded to BMC2 Repository for Case Documents

* Measures 6 & 7 will be based on the data available at the time P4P scores are due, either Q1-Q2 2017 or Q1-Q3 2017 data.

6 10

7 10

8 10

3Measures 8, 9, & 10 - Sites that do not have cases that meet the selection criteria for review will receive full credit.

9 10

10 10

1Measure 2 - Data Coordinator Expectations include entering all required data on time, cooperating with audit requests, attendance of most meetings/calls, distribution of reports, proof of data use/QI plans, and meeting expectations for data accuracy.

2 Measure 3 - Sites that do not have cases that meet the selection criteria for review will receive full credit.

4 10

5 10

3 10

2017 Blue Cross and Blue Shield of Michigan Cardiovascular Consortium (BMC2) Collaborative Quality Initiative Performance Index Scorecard

Points Possible

1 10

2 10

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Measure Weight Measure Description Points Possible2017 Meeting participation – Clinician Lead PCI2 meetings 101 meeting 5Did not participate 0

2017 Data Coordinator Expectations1 PCIMeets All Expectations 10Meets Most Expectations 5Does Not Meet Most Expectations 0PCI Performance Goal - Ratio of Contrast Volume to Glomerular Filtration Rate (GFR) Over 3 - Goal ≤ 30% (based on 2017 data)

PCI

Contrast Volume/GFR Ratio Over 3 – ≤ 30% of all patients 10Contrast Volume/GFR Ratio Over 3 – 31-35% of all patients 5Contrast Volume/GFR Ratio Over 3 – >35% of all patients 0

PCI Performance Goal - Cardiac Rehab Referral– Goal ≥ 75% (based on 2017 data) PCI

Referred – ≥75% 10Referred – 50-74% 5Referred – <50% 0

NEW PCI Performance Goal - PCI Internal Case Reviews (based on 2015 cases)2 PCISubmit Reviews for ≥75% of Cases 10Submit Reviews for <75% of Cases 0* Case review form filled out in REDCapNEW PCI Performance Goal - Physician Review of Assigned Cases for Web-based

Peer Review (based on 2015 cases)3 PCI

Submit Reviews for 100% of Cases (20 cases max/year) 10Submit Reviews for <100% of Cases 0* Case review form filled out in REDCapNEW PCI Goal - Data Coordinator Upload of Case Documentation for Web-based

Peer Review (based on 2015 cases)3 PCI

Upload documenation for 100% of Reviews (12 cases max/year) 10Upload documenation for <100% of Reviews 0* Case documentation uploaded to BMC2 Repository for Case Documents


1 10

2 10

3 10

4 10

5 10

2Measures 5, 6, & 7 - Sites that do not have cases that meet the selection criteria for review will receive full credit.* Measures 3 & 4 will be based on the data available at the time P4P scores are due, either Q1-Q2 2017 or Q1-Q3 2017 data.

6 10

7 10


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Measure Weight Measure Description

2017 Meeting participation – Clinician Lead Vascular Surgery

2 meetings 101 meeting 5Did not participate 0

2017 Data Coordinator Expectations1 Vascular Surgery

Meets All Expectations 10Meets Most Expectations 5Does Not Meet Most Expectations 0NEW Vascular Surgery Performance Goal - Case Reviews (Based on 2016

cases)2Vascular Surgery

Submitted Reviews for ≥75% of Cases 10Submitted Reviews for <75% of Cases 0* Case review form filled out in REDCapNEW Vascular Surgery Performance Goal Reduce SSI - Chlorhexadine & Alcohol Skin Prep ≥90% (Based on Q1-Q3 2017 data)

Vascular Surgery

Goal Met – ≥ 90% 10Goal Not Met - rate higher than last year 5Goal Not Met - rate equal to/lower than last year 0

NEW Vascular Surgery Performance Goal Reduce SSI - Antibiotic Redosing ≥75%(Based on Q1-Q3 2017 data)

Vascular Surgery

Goal Met – ≥ 75% 10Goal Not Met - rate higher than last year 5Goal Not Met - rate equal to/lower than last year 0

3 10


1 10

2 10


2 Measure 53- Sites that do not have cases that meet the selection criteria for review will receive full credit.

4 10

5 10

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Measure 1: 2017 Meeting participation – Clinician Lead – The PCI physician champion and Vascular Surgery physician champion must each attend 2 of the BMC2 meeting opportunities, corresponding to their registry involvement, in 2017 for full P4P points. If the physician champion is unable to attend, the site may send a participating PCI or Vascular Surgery physician in their place to receive credit. Meeting opportunities include: PCI

1. 2/23/17 – PCI Physician Dinner Meeting (Baronette Renaissance, Novi, 6-9pm) 2. 4/29/17 – PCI Collaborative Meeting (Baronette Renaissance, Novi, 8am-4pm) 3. TBD

Vascular Surgery

1. 5/18/17 – VIC & Michigan Vascular Physician Meeting (Boyne Mountain Resort, Boyne, Time TBD) 2. 10/14/17 – VIC Collaborative Meeting (Baronette Renaissance, Novi, 8am-4pm)

Measure 2: 2017 Data Coordinator Expectations – Data coordinators are required to meet expectations in the following areas, corresponding to their registry participation. Some sites participate in both PCI and Vascular Surgery and some participate in only one:

1. All consecutive cases entered/on time (based on Q1-Q2 2017 data entry) 2. Attendance at most/all meetings and calls. If a coordinator is unable to attend, they may send someone in

their place to receive credit. 3. Demonstration of data use/quality improvement – submission of documentation demonstrating use of

registry data for at least 2 registry, goal-related, quality improvement projects. This can be in an existing site format (i.e. PDCA, Sigma Six, Lean) or the BMC2 provided template. *Coordinators no longer need to submit physician attestation forms as part of the index, as it is assumed physicians and other staff will be involved in quality improvement.

4. Meeting opportunities include:

PCI

• 4/29/17 – PCI Combined Physician & Coordinator Meeting at Baronette Renaissance, Novi, MI (8am-3pm)

• 9/14/17 – PCI Coordinator Meeting at BCBSM Lyon Meadows, New Hudson, MI (8am-3pm)

Vascular Surgery

• 6/8/17 – Vascular Surgery Coordinator Meeting at BCBSM Lyon Meadows, New Hudson, MI (8am-3pm)

• 10/14/17 – Vascular Surgery Combined Physician & Coordinator Meeting at Baronette Renaissance, Novi, MI (8am-3pm)

Measure 3: New Indicator – Vascular Surgery ONLY – Internal Case Reviews (based on 2016 cases) – Case lists will be provided by the BMC2 coordinating center. These will be (internal to the site) case reviews of abdominal aortic aneurysms (AAA) and carotid procedures. The cases on the list must be internally reviewed and review information entered into the REDCap review form. Reviews must be submitted through REDCap for ≥ 75% to receive full points. No points will be awarded for <75% submitted reviews.

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Measure 4*: New Indicator – Vascular Surgery Only – Reduce SSI (based on Q1-Q3 2017 data): Chlorhexadine & Alcohol Skin Prep ≥90% - Calculation Definition:

Numerator: Number of open AAA, EVAR, or OBP procedures with procedure marked status “Elective” and “Chlorhexadine & Alcohol” as skin prep

Denominator: Number of open AAA, EVAR, or OBP procedures marked status “Elective”

Measure 5*: New Indicator – Vascular Surgery Only – Reduce SSI (based on Q1-Q3 2017 data): Antibiotic Redosing ≥75% - Calculation Definition:

Numerator: Number of open AAA, EVAR, or OBP procedures in which one of the following is true: the patient was given Cefazolin (or “Other” antibiotic) pre-procedure, procedure was >4.5 hrs in length, and “yes” is marked for “Redosed (Q4 hours)” OR the patient was given Clindamycin pre-procedure, procedure was >6.5 hrs in length, and “yes” is marked for “Redosed (Q6 hours)

Denominator: Number of elective open AAA, EVAR, or OBP procedures in which one of the following is true: the patient was given Cefazolin (or “Other” antibiotic) pre-procedure and the procedure was >4.5 hrs in length OR the patient was given Clindamycin pre-procedure and the procedure was >6.5 hrs in length.

Measure 6*: PCI Only – Ratio of Contrast Volume to Glomerular Filtration Rate (GFR) Over 3 – Goal ≤ 30% (based on 2017 data) – 30% or fewer, of all patients should have a contrast volume to glomerular filtration rate over 3.

Numerator: Number of procedures noted to have ratio of contrast dose (Contrast Volume/GFR) with results over 3. (NCDR Sequence #'s: 2050, 2060, 2070-76, 4060, 7315-16, 5325).

Denominator: Total procedures with exclusion of procedures lacking information in data fields used to calculate this field, as well as patients currently on dialysis (#4065). Including DOB, race, sex, weight, serum creatinine, and contrast volume.

Measure 7*: PCI Only – Cardiac Rehab Referral – Goal ≥ 75% (based on 2017 data) – Calculation Definition:

Numerator: Number of discharges with cardiac rehabilitation referral documented “yes.” (NCDR #9050)

Denominator: Discharges with status “Alive.” - Please note the following exclusions apply: (NCDR #9050) "ineligible," (NCDR #9045) patients transferred to another acute care facility, hospice, or who left against medical advice (AMA)

Measure 8: New Indicator – PCI Only – Internal Data Reviews (based on 2016 cases) – Case lists will be provided by the BMC2 coordinating center. The cases on the list must be internally reviewed and review information entered into the REDCap review form. Reviews must be submitted through REDCap for ≥ 75% to receive full points. No points will be awarded for <75% submitted reviews.

17

Measure 9: New Indicator – PCI Only – Physician Review of Assigned Cases for Web-based Peer Review – PCI sites must designate a physician to review cases sent through REDCap from across the collaborative. Case information sent through REDCap by the BMC2 coordinating center must be reviewed by the designated physician case reviewers at each site. The review form must be filled out and submitted to the coordinating center through the REDCap system. Physicians must review 100% of cases sent to them, a maximum of 20/year, to receive P4P credit.

Measure 10: New Indicator – PCI Only – Data Coordinator Upload of Case Documentation for Web-based Peer Review Coordinators must upload clinical documentation to the designated documentation upload repository for the cases provided by the BMC2 coordinating center. This documentation must include: Angiograms, H&P, Stress Test, and Physician Dictations. All documentation must be completely redacted of PHI and Hospital/site identification. Coordinators must upload documentation for 100% of the provided cases, a maximum of 12/year, to receive credit. Coordinators must notify the coordinating center of any issues they encounter that may prevent them from providing documentation.

*In cases where the site did not meet the timeliness or consecutive case measure (#2), points will be deducted for measures where complete data is needed to report accurate information.

18

Measure Weight Measure Description Points

Timeliness of HMS Data 1

On time ≥ 95% 5 On time < 95% 0

Completeness 1 and Accuracy 2 of HMS Data ≥ 95% 5 < 95% 0

Consortium-wide Meeting Participation3 – clinician lead or designee 3 meetings 10 2 meetings 7 1 meeting 5 No meetings 0

Consortium-wide Meeting Participation 3 – data abstractor, QI staff, or other 3 meetings 10 2 meetings 7 1 meeting 5 No meetings 0

VTE Risk Assessment Completed (on admission) 4 ↑ 90-100% of patients assessed for risk on admission 5 < 90% of patients assessed for risk on admission 0

Appropriate Prophylaxis Given (on admission) 4, 5, 6 ↑ 85-100% of patients at high risk for VTE 10 75-84% of patients at high risk for VTE 5 < 75% of patients at high risk for VTE 0

VTE Pharmacologic Prophylaxis Given in Low Risk (on admission) 4, 6 ↓ 0-35% (Caprini 0-2) or 0-65% (Padua < 4) of patients at low risk for VTE 5 > 35% (Caprini 0-2) or > 65% (Padua < 4) of patients at low risk for VTE 0

PICCs in for ≤ 5 Days 6 (excluding deaths) ↓≤ 20% of cases with PICC in for ≤ 5 Days 15

> 20% of cases with PICC in for ≤ 5 Days 0

PICCs in Patients with eGFR < 45 (without Nephrology approval) 6 ↓≤ 10% of cases with PICC have eGFR < 45 1511-15% of cases with PICC have eGFR < 45 8> 15% of cases with PICC have eGFR < 45 0

Use of Single Lumen PICCs 6 ↑ ≥ 25% of cases with PICC have a single lumen 15< 25% of cases with PICC have a single lumen 0

QI Activity 7

Have a hospital committee that reviews data related to vascular access devices including PICCs which meets at least quarterly AND develop a plan for how the HMS data from the Antimicrobial Use Initiative will be reviewed & used for quality improvement work

5

No vascular access review committee AND/OR plan submitted for use of the Antimicrobial Use Initiative data

0

2017 Michigan Hospital Medicine Safety (HMS) Consortium Collaborative Quality Initiative Performance Index Scorecard

11 5

4

7 5

5

10

5

6 10

10 15

8 15

9

3

1 5

2 5

10

15

19

1Assessed at year end based on data submitted during calendar year 2017. All required cases must be completed by year end. Final due date will be announced by Coordinating Center.

2 Assessed at site audit

3 Based on all meetings scheduled during calendar year 2017. Clinician lead or designee must be a physician as outlined in Hospital Expectations.

4 Assessed at year end based on final quarter of data submitted during calendar year 2017.

5 This measure includes pharmacologic prophylaxis given on admission for at risk patients with no contraindications and mechanical prophylaxis ordered on admission for at risk patients with contraindications.

6 Assessed at year end based on final quarter of data submitted during the calendar year 2017. If the final quarter of data does not include at least 30 cases that can be reviewed for this measure (as the denominator), cases from prior quarters during calendar year 2017 will be used as well to have at least 30 total cases to review for this measure. If a hospital does not have 30 cases that can be reviewed for this measure, the measure will not apply to the hospital given too low a volume of relevant cases.

7 Both parts must be completed to get the points for this measure. Based on semi-annual survey responses. Minutes from the committee that reviews data related to vascular access devices will need to be sent with the semi-annual survey & the minutes will need to outline the quality improvement work being done at the hospital related to the PICC Initiative. The plan for using the Antimicrobial Use Initiative will need to be submitted in the semi-annual survey submitted in the fall of 2017.

20

Measure # WeightMeasure Description

Points

Extended INR testing interval project ≥75% of eligible patients received extended intervals 40 55-74% of eligible patients received extended intervals 30 35-54% of eligible patients received extended intervals 20 15-34% of eligible patients received extended intervals 10 <15% of eligible patients received extended intervals 0Rate of ED visits for minor bleeds or high INRs

<4 per 100 pt-yr (2017 total) or >25% decrease (Q3-Q4 2017 vs. Q3-Q4 2016)

30

4.1-7 per 100 pt-yr (2017 total) or 15-24% decrease (Q3-Q4 2017 vs. Q3-Q4 2016)

20

7.1-10 per 100 pt-yr (2017 total) or 5-14% decrease (Q3-Q4 2017 vs. Q3-Q4 2016)

10

>10 per 100 pt-yr ((2017 total) or < 5% decrease (Q3-Q4 2017 vs. Q3-Q4 2016)

0

Quarterly Meetings participation -Clinical Champion (CC)attended all 4 meetings 10attended 3 out of 4 meetings 8attended 2 out of 4 meetings 6attended 1 out of 4 meetings 4did not attend any meetings 0

Quarterly Meeting participation – Coordinator/Lead Abstractorattended all 4 meetings 10attended 3 out of 4 meetings 8attended 2 out of 4 meetings 6attended 1 out of 4 meetings 4did not attend any meetings 0

Completeness and Accuracy of dataCritical data elements are complete/accurate in >90% of cases 10Critical data elements are complete/accurate in 70-89% of cases 5Critical data elements are complete/accurate in <70% of cases 0

2017 Michigan Anticoagulation Quality Improvement (MAQI) Collaborative Quality Initiative Performance Index Scorecard

5

30

10

10

10

4

1 40

2

3

21

2017 Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) Performance Index Scorecard

COHORTS 1 - 4

Measure Weight Measure Description Points possible

#1 10% Collaborative Meeting Participation Clinical Champion (1/1/17-12/31/17)

3 out of 3 meetings attended 10


< 2 meetings attended 0

#2 10% Collaborative Meeting Participation Clinical Data Abstractor (CDA) or Hospital Representative (1/1/17-12/31/17)



2 or less meetings attended 0

#3

70% QI Based Performance Based Measure* Site and overall consortium performance on identified measures Points computed using method described in Appendix A (maximum of 70 points) This measurement year for this metric will be 7/1/16-6/30/17.

#4 10% Timeliness, Accuracy and Completeness of Data Submission

On time/complete >95-100% of the time 10

On time/complete 80-94% of the time 5

On time/complete < 79% of the time 0

22

2017 Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) Performance Index Scorecard

COHORTS 5 Year 2

Measure Weight Measure Description Points possible

#1 20% Collaborative Meeting Participation Clinical Champion (1/1/17-12/31/17)



< 2 meetings attended 0

#2 20% Collaborative Meeting Participation Clinical Data Abstractor (CDA) or Hospital Representative (1/1/17-12/31/17)



2 or less meetings attended 0

#3

20% Performance Based Measure* Site and overall consortium performance on identified measures Points computed using method described in Appendix A (maximum of 20 points) The measurement year for this metric is 7/1/16-6/30/17

#4 10% Timeliness and Completeness of Data Submission

On time/complete >90-100% of the time 10

On time/complete 80-89% of the time 5

On time/complete < 79% of the time 0

#5 20% Accuracy of Data (based on audit)

On accuracy >90-100% of the data 20

On accuracy < 80-89% of the data 10

On accuracy < 79% of the data 0

#6 10% Access to Surgeon’s Office Records ( 90 day events)

90%+ of patient data captured 10

75%-89% of patient data captured 5

Less than 75% captured 0

23

2017 Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI)Performance Index Supporting Documentation Cohort 1-4 Cohort 5

1. Infection rate at the end of the scoring period (scorecard received November 2017).Found on the Infection Theme report

The site is awarded points if its risk is in the green on the forest plots at the close of FY '17. The goal and current collaborative average is 0.4%[1]

15

5

The site is awarded points if its risk is in the tan on the report at the close of FY'17. 10

2.5

The site is not awarded points if its risk is in the orange on the report at the close of FY'17. 0

0

2. Emergency Department visit rate at the end of the scoring period ( scorecard date11/17) Found in the Overview report; 90 day events

The site is awarded points if its risk is in the green on the forest plots at the close of FY'17. The current collaborative rate is 9.4%. Goal is 8%. 10

5

The site is awarded points if its risk is in the tan on the report at the close of FY'17. 5

2.5

The site is not awarded points if its risk is in the orange on the report at the close of FY'17. 0

0

3. Decrease in discharges to ECF/SNF/IPR by the end of the scoring period (Scorecard date11/17) Found on the Readmission and ECF report

The site is awarded points if the discharge rate is in the green on the forest plots at the close of FY'17. Current collaborative average is 19.2%. Goal is 15%

15

5

The site is awarded points if its risk is in the tan on report at the close of FY'17.10

2.5

The site is not awarded points if they are in the orange on report at the close of FY'17. 0

0

4. Site based Quality MeetingsThe site is awarded points for holding a minimum of 3 meetings a year (following the MARCQI Collaborative meetings) to discuss site based and collaborative quality outcomes with the orthopedic surgeons. The physicians and CDA will participate in discussion of the data and plans for quality improvement. The site will complete the 'Site Based QI Meeting ' form and send to the Coordinating Center by Dec 15, 2017. These meetings should be ones where in-person attendance and participation are expected. If the site has videoconferencing that allows attendees to be on camera and participate, then this is acceptable. This metric is based on meetings held generally following the February 2017, May 2017 and September 2017 Quarterly Meetings 15

5

5. Implementation of one new site specific quality initiative (linked to a MARCQI qualityinitiative). If orange on scorecard of May, 2016, must choose this as the project. If no orange, you can choose a 'tan'. Progress Reports are due in March & December 2017. Final results are based on quarterly reports of November, 2017. This should be a stretch goal; ideally getting from orange to tan or tan to green.QI plan is developed and Implemented and target, as identified by site, is met. 15 NAQI plan is developed and implemented but target not met. 7.5 0QI plan is not developed or implemented or if Mid-term progress and final reports are not submitted on time. 0

0

Potential Total Performance Points 70 20

24

Measure

#

Weight

%Measure Description Points

Grade 1 Complication Rate: (October 1, 2016-September 30, 2017) *Adjusted; Rounded to

nearest whole number*

0% to ≤4% rate 15>4% to ≤6% rate 10>6% rate 0

Serious Complication Rate: (October 1, 2016 to September 30, 2017) *Adjusted; Rounded to

2 decimal places*

0% to ≤1.75% rate 15>1.75% to ≤1.84% rate 10>1.84% rate 0

Improvement/Excellence In Grade 1 Complication Rate: (Data trended

over a 3-yr period from October 1, 2014 to September 30, 2017) *Z-Score rounded to nearest

whole number*

Major improvement (z-score less than -1 or Grade 1 complication rate ≤5%) 10

Moderate improvement/maintained complication rate (z-score between 0 and -1) 5

No improvement/rates of grade 1 complications increased (z-score ≥0) 0Improvement/Excellence in Serious Complication Rate: (Data

trended over a 3-yr period from October 1, 2014 to September 30, 2017) *Z-Score rounded to


Major improvement (z-score less than -1 or serious complication rate ≤2.0%) 10

Moderate improvement/maintained complication rate (z-score between 0 and -1) 5

No improvement/rates of serious complications increased (z-score ≥0) 0Patient Satisfaction (Very Satisfied, %): (Based off the 1-

year annual follow-up survey question "Overall how satisfied are you with your bariatric

surgery") (For OR dates of October 1, 2015 to September 30, 2016) *Adjusted; Rounded to nearest whole number*

≥85% very satisfied 1083-85% very satisfied 5≤82% very satisfied 0

Compliance with VTE prophylaxis - Pre-operatively: (Calendar Year 2017) *Unadjusted;

Rounded to nearest whole number*

≥99% compliance with guidelines 5>95% to 99% compliance with guidelines 30 to 94% compliance with guidelines 0

Compliance with VTE prophylaxis - Post-operatively: (Calendar Year 2017) *Unadjusted;

Rounded to nearest whole number*

≥98% compliance with guidelines 5

>94% to 98% compliance with guidelines 3

0 to 93% compliance with guidelines 0

Meeting Attendance - Surgeon: (Calendar Year 2017)Attended 3 out of 3 meetings 5

Attended 2 out of 3 meetings 3

Attended fewer than 2 meetings 0

Meeting Attendance - Abstractor/Coordinator: (Calendar Year 2017)Attended 3 out of 3 meetings 5


Attended fewer than 2 meetings 0

70%

30%

2017 Michigan Bariatric Surgery Collaborative (MBSC) Quality Initiative Performance Index Scorecard

6

7

8

9

1

2

3

4

5

25

Timely Monthly Data Submissions (30-day information & registry paperwork):

(Submitted to coordinating center by the last business day of each month (Please refer to

2017 Data Entry Deadlines Spreadsheet) (Calendar Year 2017)On time 11-12 months 5

On time 10 months 3

On time 9 months or less 0

Consent Rate: (October 1, 2016 to September 30, 2017) *Unadjusted; Rounded to


≥90% consented patients 5

80-89% consented patients 3

<80% consented patients 0

Physician Engagement: (October 1, 2016 to December 31, 2017)** Note: For each site, a surgeon or surgeons must participate in at least 2 of the engagement

activities listed below in order to receive the 10 points available for this measure.** 10Rate 10 videos (counts as 10 points)

Rate 5 videos

Committee participation

Presentation at the MBSC meeting

Presentation at a national meeting using MBSC data

Coauthor a paper

Be a coach

Be a coachee

Participate in a quality site visit as the visited hospital or visiting surgeon

No participation 0

Total 100

12

30%

10

11

26

Measure # Weight Measure Description PointsCompletion of Electronic Data Transfer for All Data Elements:Electronic Transfer of Data completed per MEDic Data Dictionary. 1. Patient 2. Visit 3. Diagnosis 4. Vital signs5. Procedure 6. Admission 7. ProviderAll required data elements transferred 1575-99% of required data elements provided 1051%-74% of required data elements provided 050% or less data of required data elements provided 0Timeliness of Electronic Data Transfer:Electronic Transfer for all ED visits data in a timely mannerAll required data transfers on time 1575-99% data transfers on time 1051%-74% data transfers on time 050% or less data transfers on time 0Manual Data AbstractionAll clincical cases accurately abstracted within 30 days of loading 2075-99% data abstraction on time 1551%-74% data abstraction on time 550% or less data abstraction on time 0

Identify and develop plan for one intervention to increase appropriate CT scans for head injuries (decrease inappropriate scans)*Complete by July 31, 2017 20Completed by September 30, 2017 10No plan by September 30, 2017 0

Collaborative-wide Meeting Participation – Clinical Champion All Meetings 15Miss 1 Meeting 10Miss >1 Meeting 0Collaborative-Wide Meeting Participation – Data AbstractorAll Meetings 15Miss 1 Meeting 10Miss >1 Meeting 0

2017 Michigan Emergency Department Improvement Collaborative (MEDIC) Collaborative Quality Initiative Performance Index Scorecard

Year 2

20

1 15

2 15

4

3 20

5 15

6 15

* In the first quarter of 2017, the MEDIC Coordinating Center (CC) will share data with each hospitalregarding use of Head CT scans to set a baseline from those data. At that time, each hospital will be asked to submit a plan to decrease inappropriate scans based on a template provided by the MEDIC CC. Components of this plan will likely include a description of the specific intervention planned with a timeline to implement, providing some rationale for the implementation and any evidence demonstrating why it would be effective. It should also describe feasibility and any limitations or risks associated with the actions.

27


All Data Sharing Agreements (including but not limited to Particiation Agreement,

Business Associates Agreement, and Data Use Agreement, and including IRB if

necessary) required to begin flow of data

All Data Sharing Agreements signed and returned to MEDIC within 90 days of

receipt5

Data Sharing Agreements signed and returned to MEDIC after 90 days of receipt 3

Data Sharing Agreements not signed 0

Staffing / Data Abstractor

Data Abstractor in place within 90 days of signed agreements 20

Data Abstractor in place 91-120 days of signed agreements 10

No Data Abstractor in place within 120 days of signed agreements 0

Completion of Electronic Data Transfer for All Data Elements:

Electronic Transfer of Data completed per MEDic Data Dictionary.

1. Patient 2. Visit 3. Diagnosis 4. Vital signs

5. Procedure 6. Admission 7. Provider

0-3 Month lag in transferring data required by MEDIC data dictionary 25



No data transfers 0

Electronic Transfer of Medical Records - Sustaining data transfers in a timely

manner

All required data transfers on time 20

75-99% data transfers on time 10

51%-74% data transfers on time 5

50% or less data transfers on time 0

Collaborative-wide Meeting Participation – Clinical Champion

All Meetings 15

Miss 1 Meeting 10

Miss >1 Meeting 0

Collaborative-Wide Meeting Participation – Data Abstractor )

All Meetings 15

Miss 1 Meeting 10

Miss >1 Meeting 0

20

4 15

5

3 25

3 20

2017 Michigan Emergency Department Improvement Collaborative (MEDIC) Collaborative Quality Initiative Performance

Index Scorecard

Year 1

1

2

5

15

28


On-Site Audit of Clinical and Physics Data

>95% score on audit 5

85% - 95% 4

70%- 84% 2

<70% 0

Submission/Completion of Clinical Surveys (Internal Audit)

>95% clinical surveys submitted 5

85% - 95% 4

70%- 84% 2

<70% 0

Submission of Technical Data (Dose Volume Histogram, DICOM-RT Plan

File(s), andPhysics Radiotherapy Technical Details Survey)

>85% of technical data submitted within six weeks of treatment 6

>85% of technical data submitted within eight weeks 5

>85% of technical data submitted within twelve weeks 4

>85% of technical data submitted after twelve weeks 3

<85% of technical data submitted after twelve weeks 0

Mean heart dose for 90% of node negative breast patients

≤ 2 Gy 12

2.01– 3 Gy 8

3.01 – 4 Gy 4

> 4 Gy 0

Use of Accelerated Whole Breast Irradiation on appropriate patients

85% or more appropriate patients receive AWBI 12

66-84% 8

50-65% 4

<50% 0

PTV expansion has been drawn around lumpectomy cavity for

treatment planning

50% or more breast cancer patients have PTV expansion 12

40-49% 8

30-39% 4

<30% 0

2017 Michigan Radiation Oncology (MROQC) Collaborative Quality Initiative Performance Index Scorecard

5

6

5

6

12

12

12

4

1 5

2

3

29


2017 Michigan Radiation Oncology (MROQC) Collaborative Quality Initiative Performance Index Scorecard

Respiratory motion assessed at the time of simulation for lung patients

>90% underwent motion assessment at time of simulation 12

50-90% 8

25-49% 4

<25% 0

GTV is defined in accordance with MROQC Practice Patterns Lung Target

Delineation guidelines

A GTV is defined with the aid of motion assessment or motion

management.

>80% of patients have an appropriately defined GTV 12

70-80% 8

60-69% 4

<60% 0

PTV is defined in accordance with MROQC Practice Patterns Lung Target

Delineation guidelines

A separate PTV is defined using ≥5 mm expansion with daily imaging or

>5 mm expansion for less frequent imaging.

>80% of patients have an appropriately defined PTV 12

70-80% 8

60-69% 4

<60% 0

Meeting Participation – Clinical Champion

All meetings 4

Two meetings 3

One meeting 2

None 0

Meeting Participation – Physics Lead

All meetings 4

Two meetings 3

One meeting 2

None 0

Meeting Participation – Data Coordinator

All meetings 4

Two meetings 3

One meeting 2

None 0

7 12

8 12

12 4

Five (5) points will be deducted from total points earned for each

occurrence of submission of protected health information (PHI)

9 12

410

11 4

30


2 meetings 8

1 meeting 4

0 meetings 0

2 meetings 8

1 meeting 4

0 meetings 0

3 or More calls 4

2 calls 2

1 call 1

0 calls 0

3 or More calls 4

2 calls 2

1 call 1

0 calls 0

Passes SCQR Certification Exam with score ≥ 90% 2

• 4 Quarters - each with 30-day follow up rate ≥ 80% 4



• 1 Quarter with 30-day follow up rate ≥ 80% 1

• 0 Quarter with 30-day follow up rate ≥ 80% 0

Adjusted Rate < 4.3% 10

Adjusted Rate 4.3% - 8.2% 5

Adjusted Rate > 8.2% 0

2017 Michigan Surgical Quality Collaborative (MSQC)


1 8

Collaborative Meeting (2) - SCQR

2 8

Collaborative Meeting (2)- Surgeon Champion

3 4

Conference Calls (4) - SCQR

4 4

Conference Calls (4) - Surgeon Champion

5 6

Accuracy and Completeness of Data

Certification Exam

Thirty Day Follow Up

6 10

Performance Measure - Morbidity (Elective, Core Cases)

31


Perform one of the following:

(1) Conduct Readmission, Sepsis, or Surgical Site Infection case analysis to

identify future performance improvement interventions

(2) Actively participate in a MSQC workgroup to identify and share successful

implementation strategies related to Site Specific Quality Improvement

Initiative

(3) Demonstrate statistically and clinically significant improvement on one or

more high priority QI target measures - Enhanced Recovery Program

(Morbidity, Length of Stay, Return to Emergency Department, Readmissions),

Sepsis, or Surgical Site Infection - as a result of specific process change

20

None of the above performed 0

Developed and implemented and meets ≥ 95% of target goal 40

Developed and implemented and meets 75-94% of target goal 36



Developed and implemented with no improvement of target goal 20

Not developed or implemented 0

2017 Michigan Surgical Quality Collaborative (MSQC)


Site Specific Quality Improvement Initiative

8 40

Collaborative Quality Improvement Initiatives

7 20

32

2017 Michigan Surgical Quality Collaborative (MSQC) Supporting Documentation for Performance Index Scorecard Measures 6, 7 and 8

Measure #6 Performance Measure - Morbidity Elective, Core Cases

Measure Description

Corresponding points will be achieved based on the following:

Adjusted Rate < 4.3% **to be validated by statistician** 10 points

Achievement of Morbidity rate (for elective, core cases) less than 4.3% for the time period 9/1/16-8/31/17.

Adjusted Rate 4.3% - 8.2% **to be validated by statistician** 5 points

Achievement of Morbidity rate (for elective, core cases) between 4.3% and 8.2% for the time period 9/1/16-8/31/17.

Adjusted Rate > 8.2% **to be validated by statistician** 0 points

Achievement of Morbidity rate (for elective, core cases) greater than 8.2% for the time period 9/1/16-8/31/17.

The following complications contribute to the Morbidity rate:

Acute Kidney Injury Anastomotic Leak Cardiac Arrest Deep Vein Thrombosis Myocardial Infarction Pneumonia

Pulmonary Embolism Sepsis, Severe Sepsis, Septic Shock Stroke/CVA Surgical Site Infection (Superficial, Deep, Organ/Space) Unplanned Intubation Urinary Tract Infection

Measure #7 Collaborative Quality Improvement Initiatives

Measure Description

The site will be expected to perform one of the following to achieve 20 points for this measure:

Conduct Readmission, Sepsis, or Surgical Site Infection case analysis to identify future performance improvement interventions

Perform drilldown and submit an annual summary of all patients identified as having either a readmission, sepsis or surgical site infection occurrence.

Actively participate in a MSQC workgroup to identify and share successful implementation strategies related to Site Specific Quality Improvement Initiative

Provide quality improvement project updates during regularly scheduled group conference calls. Share successes, strategies for overcoming barriers, and provide a variety of resources (i.e. policies, procedures, tracking forms, educational materials) to the group.

Demonstrate statistically and clinically significant improvement on one or more high priority QI target measures – Enhanced Recovery Program (Morbidity, Length of Stay, Return to Emergency Department, Readmissions), Sepsis, or Surgical Site Infection – as a result of specific process change

Submit baseline and performance data (from the MSQC reporting application) evidencing improvement in QI outcome measure(s) for Enhanced Recovery Program, Sepsis, or Surgical Site Infection related to processes identified in the quality improvement project.

If none of the above are performed, the site will receive zero points for this measure

33

Measure #8 Site Specific Quality Improvement Initiative

Measure Description Corresponding points will be achieved based on submission of annual summary report including the following:

Developed and implemented and meets ≥ 95% of target goal 40 points

Documentation of successful implementation of defined QI objectives, and process measurement data demonstrating improvement greater than or equal to 95% of target goal

Developed and implemented and meets 75-94% of target goal 36 points

Documentation of successful implementation of defined QI objectives, and process measurement data demonstrating improvement of 75-94% of target goal





Developed and implemented with no improvement of target goal 20 points

Documentation of successful implementation of defined QI objectives, but process measurement data does not demonstrate improvement of target goal

Not developed or implemented 0 points

No defined QI objectives and process measurement tracking

34


Meeting participation - Surgeon Champion1

Attended all 3 meetings 10


Attended 1out of 3 meetings 2

No Attendance 0

Meeting participating – Clinical Data Abstractor or designee

abstractor (If site has multiple abstractors only 1 abstractor need

attend meeting)




No Attendance 0

Conference Calls Surgeon Champion (3 calls/year)1

Attended 3 calls 10

Attended 2 calls 5

Attended 1 call 2

No Calls 0

Conference Calls - Clinical Data Abstractor (12 calls/year)

Participate on 12 calls 5




Participate on less than 9 calls 0

Completeness of Data Including Access to Surgeon's Office Clinic

Records

>90% of patient data captured 10

>81-89% of patient data captured 5

80% or less of patient data captured 0

Annual Audit Review – Data Review: Accuracy of data

Complete and accurate >90-100% of the time 10

Complete and accurate > 80-89%of the time 5

Complete and accurate < 80% of the time 0

Combined collection rate of completed Patient Report Outcome

(PRO) questionnaires

> 65% 5

40-64% 2

< 39% 0

57

2017 Michigan Spine Surgery Improvement Collaborative (MSSIC) Quality Initiative Performance Index

Scorecard Cohort 1, Year 4

2

3

5

10

54

1 10

6 10

105

35



1 10Implementation of one Collaborative Wide Quality Improvement

Initiative. The initiative is chosen from one of the high-priority

target measures: Surgical Site Infection, Readmissions or Urinary

Retention . The goals of improvement are stated in the

Performance Index Supporting Document.

The QI Plan was developed, implemented and there was

improvement in the target goal. In addition, both progress reports

were submitted on time. The breakdown is as follows:

Site met 100% or greater of the target goal 25

Site met 75-99% of the target goal 23



The QI Plan was developed and implemented, but there was no

improvement to the target goal. In addition, both progress reports

were submitted on time.

10

The QI Plan was developed and implemented, but one of the

progress reports was not submitted on time.5

The QI Plan was not developed or implemented; or both progress

reports were not submitted on time.0

Implementation of a second Quality Improvement Initiative

utilizing MSSIC data. The second QI Initiative can be either one of

the high-priority target measures (Surgical Site Infection,

Readmissions or Urinary Retention) or a a site-specific initiative

approved by the Coordinating Center.








The QI Plan was developed and implemented, but there was no 10





258

9 20

36






No Attendance 0



attend meeting)




No Attendance 0


Attended 3 calls 10

Attended 2 calls 5

Attended 1 call 2

No Calls 0








Records










> 65% 10

40-64% 5

< 39% 0

Implementation of one Collaborative Wide Quality Improvement





107

8 30



2

3

10

10

54

1 15

6 10

105

37














15





8 30

38






No Attendance 0



attend meeting)




No Attendance 0


Attended 3 calls 10

Attended 2 calls 5

Attended 1 call 2

No Calls 0








Records










> 65% 10

40-64% 5

< 39% 0

Implementation of one Collaborative Wide Quality Improvement





104

1 20

6 10

105



2

3

10

10

107

8 20

39














10





8 20

40

The MSSIC Performance Index is separated into two areas of focus, participation and performance. Each focus area is then divided into measures, with each measure being assigned a point value for a total of 100 points possible. Participation points total 55 and performance points total 45. Participation: At least one Surgeon Champion, and Data Abstractor is expected to attend each meeting. One Surgeon Champion is expected to be on each of the three Surgeon calls and an Abstractor is expected to be on each Abstractor conference call. See exceptions for meeting attendance for surgeons below. 1Meeting attendance for Surgeon Champions: We would like the MSSIC collaborative to be as equally balanced and interactive between orthopedic surgeons and neurosurgeons as it can possibly be, and strongly encourage both specialties to attend all meetings. However, we understand the difficulty of scheduling time off for two surgeons to attend the same meeting. Currently it is not a requirement for both Surgeon Champions to attend each meeting – a rotating schedule between specialties is acceptable, but each designated Surgeon Champion must attend at least one meeting and one conference call. If a hospital currently has only one specialty we would ask that the Surgeon Champion or a designee surgeon attempt to attend all meetings. A Nurse Practitioner or Physician Assistant is no longer considered an acceptable substitute for the Surgeon Champion – no points will be awarded if a surgeon is not in attendance. A surgeon cannot represent two hospitals at a meeting or on a conference call. Points earned for participation will only go to one hospital. Access to Surgeon’s Office Clinic Records: The MSSIC data abstraction requires information about the patient prior to having surgery, and up to 90 days after. It is crucial that a patient’s medical record is made available to data abstractors for accurate data collection, including records from the surgeon’s clinic. Cohort 1, Year 4 Performance: For Cohort 1, two separately scored Quality Improvement Initiatives are required. The first QI initiative is a Collaborative Wide Quality Improvement Initiative. The initiative is chosen from one of the high-priority target measures: Surgical Site Infection, Readmissions or Urinary Retention. The sites will email the MSSIC QI Nurse Leader and the Program Manager no later than January 31, 2017 notifying them of their choice. Utilizing the MSSIC QI Report template, sites are to submit progress reports twice a year to communicate the project’s development and movement. Lines 1-9 are due May 15, 2017 and the complete MSSIC QI Report, including the outcome of the project, is due December 15, 2017. The goals of improvement for the three high-priority target measures are:

• Surgical Site Infection: A reduction in the baseline rate by 20%

• Readmissions: A reduction in the baseline rate by 10%

• Urinary Retention: A reduction in the baseline rate by 20%

There are 25 points available for the Collaborative Wide QI Initiative:

• The QI Plan was developed, implemented and there was improvement in the target goal. In addition, both progress reports were submitted on time.

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o Site met 100% or greater of the target goal – 25 points o Site met 75-99% of the target goal – 23 points o Site met 50-74% of the target goal – 20 points o Site met 1-49% of the target goal – 15 points

• The QI Plan was developed and implemented, but there was no improvement to the target goal. In addition, both progress reports were submitted on time – 10 points

• The QI Plan was developed and implemented, but one of the progress reports was not submitted on time – 5 points

• The QI Plan was not developed or implemented; or both progress reports were not submitted on time – 0 points

The second QI Initiative can be either one of the high-priority target measures (Surgical Site Infection, Readmissions or Urinary Retention) or a site-specific initiative approved by the Coordinating Center. If a facility chooses a site-specific initiative, they will email their proposed QI Initiative to the MSSIC QI Nurse Leader and the Program Manager no later than January 31, 2017. The Coordinating Center will review the proposal and make a determination. Once an initiative is approved, the Coordinating Center will work with site to determine the target goal for the project. If the site chooses from one of the high-priority target measures, they will email the MSSIC QI Nurse Leader and the Program Manager no later than January 31, 2017 notifying them of their choice. Utilizing the MSSIC QI Report template, sites are to submit progress reports twice a year to communicate the project’s development and movement. Lines 1-9 are due May 15, 2017 and the complete MSSIC QI Report, including the outcome of the project, is due December 15, 2017. There are 20 points available for the second QI Initiative:






Patient-reported questionnaires: Patients in the MSSIC registry are asked to complete a validated health status questionnaire prior to surgery and then at 3, 12, and 24 months after surgery. The questionnaires can be completed on paper, on the MSSIC website, or by phone. Each participating site is responsible to reach out to their patients to collect this information. Using the top 10% of facilities as a benchmark, the combined collection rate of completed Patient Report Outcome questionnaires is scored as follows:

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• > 65% of completed Patient Reported Outcome questionnaires collected: 5 points

• 40-64% of completed Patient Reported Outcome questionnaires collected: 2 points

• < 39% of completed Patient Reported Outcome questionnaires collected: 0 points

Cohort 2, Year 3 Performance: For Cohort 2, a Collaborative Wide Quality Improvement Initiative is required. The initiative is chosen from one of the high-priority target measures: Surgical Site Infection, Readmissions or Urinary Retention. The sites will email the MSSIC QI Nurse Leader and the Program Manager no later than January 31, 2017 notifying them of their choice. Utilizing the MSSIC QI Report template, sites are to submit progress reports twice a year to communicate the project’s development and movement. Lines 1-9 are due May 15, 2017 and the complete MSSIC QI Report, including the outcome of the project, is due December 15, 2017. The goals of improvement for the three high-priority target measures are:













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Cohort 3, Year 2 Performance: For Cohort 3, a Collaborative Wide Quality Improvement Initiative is required. The initiative is chosen from one of the high-priority target measures: Surgical Site Infection, Readmissions or Urinary Retention. The sites will email the MSSIC QI Nurse Leader and the Program Manager no later than January 31, 2017 notifying them of their choice. Utilizing the MSSIC QI Report template, sites are to submit progress reports twice a year to communicate the project’s development and movement. Lines 1-9 are due May 15, 2017 and the complete MSSIC QI Report, including the outcome of the project, is due December 15, 2017. The goals of improvement for the three high-priority target measures are:














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Expectations of the MSSIC Collaborative: MSSIC is unique in that there are two specialties involved in the framework of the Collaborative. While it is our hope that participating sites have both Neuro and Ortho surgeons working actively together, we recognize the necessity to be flexible, as the makeup of sites may vary, or may unexpectedly change.

• Both specialties at a site: Participating sites that have both neurosurgeons and orthopedic surgeons performing spine surgery will provide a letter of commitment, assuring the willingness of the two specialties to work together in the collaborative.

• Both specialties at site, one stops performing spine surgeries: If a site joins MSSIC with both specialties active and one discontinues performing spine surgery MSSIC would not drop the site. The site stays in as long as case volume stays above 150/year. The Coordinating Center would work with the site and BCBSM to agree on appropriate FTE adjustments. If case volume falls below 150, participation would continue only with special agreement between the site, Coordinating Center, and BCBSM.

• One specialty at site, case volume is acceptable: A site with only one specialty may participate

in MSSIC if their case volume is acceptable (200 cases/year).

• One specialty at a site, the other specialty joins: If a participating site joins MSSIC with only one specialty performing spine surgery and then there is a change to both specialties performing surgeries, MSSIC will require the site to agree to recruit a new Surgeon Champion for the second specialty. MSSIC will also require a letter that the two specialties are willing to work together in the collaborative.

• Surgeon Champion leaves:

o Both specialties at site: If one of the two Surgeon Champions leaves, it would be an expectation that the participating site would reassign the Surgeon Champion role, and still have the second specialty participating in QI initiatives. MSSIC would not drop a site if a Surgeon Champion leaves.

o One specialty at site: If the Surgeon Champions leaves, it would be an expectation that the participating site would reassign the Surgeon Champion role, and still have the specialty participating in QI initiatives. MSSIC would not drop a site if a Surgeon Champion leaves.

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MSSIC QI Report Template: (Lines 1-8 due May 15, 2017. Complete report due December 15, 2017)

1. Prepared by: Date:

2. MSSIC Site:

3. QI Metric: (i.e. Surgical Site Infection rate, 90 day Readmission rate) 4. Team Members/Departments:

5. Baseline Data: (Where do things stand today? Use facts and data. Be visual. Use charts or process maps to help make the problem clear. Go to where the work is being done and talk to the people who do the work.)

6. Goal/Target: (State a measurable, specific target. Where do you want to be? Remember the acronym SMART. Goals should be Specific, Measurable, Achievable, Realistic and Time-based.)

7. Analysis/Root Cause: (Use the simplest tool that will find the root cause of the problem. Why is the problem occurring? What are any barriers to reaching the goal? Possible tools: Five Whys, fishbone diagram).

8. Proposed Countermeasures: (What do you recommend and why? Brief explanation of how what you are recommending will specifically address the root cause in the Analysis box.)

9. Plan: (Timeline with who is responsible for what, when, where and how.) What Who When Status

(What task, how and where) (date implemented) (met, not met) 10. Evaluation Summary: (How did it work? What does your data look like after implementing your plan? Did you reach your goal? Any remaining issues? What were the lessons learned? How will you ensure ongoing P-D-C-A?

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2017 Michigan Society of Thoracic and Cardiovascular Surgeons (MSTCVS) Quality Collaborative Performance Index Scorecard

Measure # Weight Measure Points Earned

#1 10

Accuracy of data

5-star audit score 4-star audit score 3-star audit score ≤ 2-star audit score

10 8 6 0

#2 10

Quarterly collaborative meeting participation - surgeon lead (Jan 1, 2017–Dec 31, 2017)

Attended 4 quarterly meetings Attended 3 quarterly meetings Attended < 3 quarterly meetings

10 5 0

#3 5

Quarterly collaborative meeting participation - data manager/representative (Jan 1, 2017–Dec 31, 2017)

Attended 4 quarterly meetings Attended 3 quarterly meetings Attended < 3 quarterly meetings

5 3 0

#4 5

Quarterly data manager educational meeting - data manager (Jan 1, 2017–Dec 31, 2017)

Attended 4 data manager meetings Attended 3 manager meetings Attended < 3 quarterly meetings

5 3 0

#5 15

Collaborative-wide quality initiative 2017: CAB Readmissions (Jan 1, 2017–Dec 31, 2017)

Collaborative mean readmission rate ≤9.0% Collaborative mean readmission rate > 9.0%

15 0

#6 15

Site specific quality initiative (Jan 1, 2017–Dec 31, 2017)

Met improvement goal Improved but did not meet goal Implemented plan but did not improve Unable to implement plan

15 10 5 0

#7 20

Isolated CABG: O/E mortality for 12 months (Jan 1, 2017–Dec 31, 2017)

O/E ≤ 1.0 O/E ≤ 1.5 O/E > 1.5

20 10 0

#8 20

Isolated AVR: O/E mortality for rolling 36 months (Jan 1, 2015–Dec 31, 2017)

O/E ≤ 1.0 O/E ≤ 1.5 O/E > 1.5

20 10 0

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Michigan Trauma Quality Improvement Program (MTQIP) 2017 Performance Index January 1, 2017 to December 31, 2017

Measure Weight Measure Description Points

#1 10 Data Submission (Partial/Incomplete Submissions No Points) On time and complete 3 of 3 times On time and complete 2 of 3 times On time and complete 1 of 3 times

10 5 0

PA

RTI

CIP

ATI

ON

(3

0%) #2 10 Meeting Participation All Disciplines *Surgeon represents 1 hospital only

Surgeon, and (TPM or MCR) Participate in 3 of 3 Collaborative meetings (9 pts) Surgeon, and (TPM or MCR) Participate in 2 of 3 Collaborative meetings (6 pts) Surgeon, and (TPM or MCR) Participate in 1 of 3 Collaborative meetings (3 pts) Surgeon, and (TPM or MCR) Participate in 0 of 3 Collaborative meetings (0 pts) Registrar, and/or MCR Participate in the Data Abstractor Meeting (1 pt)

0-10

#3 10 Data Accuracy 1st Validation Visit-Error Rate >2 Validation Visits-Error Rate 10 8 5 3 0

5 Star Validation 4 Star Validation 3 Star Validation 2 Star Validation 1 Star Validation

0-4.5% 4.6-5.5% 5.6-8.0% 8.1-9.0%

>9.0%

0-4.0% 4.1-5.0% 5.1-6.0% 6.1-7.0%

>7.0%

#4 10 Venous Thromboembolism (VTE) Prophylaxis Initiated Within 48 Hours of Arrival in Trauma Service Admits with ≥ 2 Day Length of Stay (18 Mo’s: 1/1/16-6/30/17) ≥ 50% ≥ 40% < 40%

10 5 0

PER

FOR

MA

NC

E (7

0%

)

#5 10 Low Molecular Weight Heparin (LMWH) Venous Thromboembolism (VTE) Prophylaxis Use in Trauma Service Admits (18 Mo’s: 1/1/16-6/30/17) ≥ 50% 21-49% 5-20% < 5%

10 7 5 0

#6 10 Red Blood Cell to Plasma Ratio (Weighted Mean Points) of Patients Transfused >5 Units in 1st 4 Hours (18 Mo’s: 1/1/16-6/30/17) 10 pts: Tier 1: < 1.5 10 pts: Tier 2: 1.6-2.0 5 pts: Tier 3: 2.1-2.5 0 pts: Tier 4: >2.5

0-10

#7 10 Serious Complication Rate-Trauma Service Admits (3 years: 7/1/14-6/30/17) Z-score: < -1 (major improvement) Z-score: -1 to 1 or serious complications low-outlier (average or better rate) Z-score: > 1 (rates of serious complications increased)

10 7 5

#8 10 Mortality Rate-Trauma Service Admits (3 years: 7/1/14-6/30/17) Z-score: < -1 (major improvement) Z-score: -1 to 1 or mortality low-outlier (average or better rate) Z-score: > 1 (rates of mortality increased)

10 7 5

#9 10 Inferior Vena Cava Filter Use (All Admits) (Collaborative Wide) (7/1/16-6/30/17) ≤ 1.2 > 1.2

10 0

#10 10 Site Specific Quality Improvement Project (Jan-Dec 2017) Implemented, and met or exceeded target Implemented, showed improvement, but did not meet target Implemented, but showed no improvement

10 7 0

Total (Max Points) = 100

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2017 Michigan Trauma Quality Improvement Program (MTQIP) Performance Index – Supporting Documentation

2017 MTQIP Performance Index Supporting Documentation

Measure 6: Red Blood Cell to Plasma Ratio

Average of tier points assigned to patients transfused >5 units PRBC’s in 1st 4 Hours.

Ratio PRBC to Plasma for each patient

Tier Points

≤ 1.5 1 10

1.6 – 2.0 2 10

2.1 – 2.5 3 5

> 2.5 4 0

Example:

Measure 7: Serious Complication Rate Serious complications are any complication with a severity grade of 2 or 3 as defined below:

Complication severity grade 2 a. Definition: Potentially life-threatening complications b. Complications: abdominal compartment syndrome, decubitus ulcer, DVT, enterocutaneous fistula, extremity compartment syndrome, pneumonia, pulmonary embolism, unplanned intubation, unplanned return to OR

Complication severity grade 3 a. Definition: Life-threatening complications with residual or lasting disability or mortality b. Complications: acute lung injury/ARDS, acute kidney injury, cardiac arrest with CPR, myocardial infarction, severe sepsis, stroke/CVA

Z-Score Explanation

The z-score is a measure a hospital’s trend in [serious complications, mortality] over the three-year time period. For each hospital, we fit a linear regression model with [serious complications, mortality] as the outcome, and time period and patient characteristics as the explanatory variables. The z-score is an estimate of the slope of a hospital’s own linear trend line over time, standardized by the error estimate. This z-score is used to test whether the hospital’s trend is flat or trending upwards/downwards. If the z-score is one standard deviation away (either >1 or <-1), there is more evidence that the hospital’s performance has a linear trend in one of these directions (as opposed to being flat).

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2017 Michigan Trauma Quality Improvement Program (MTQIP) Performance Index – Supporting Documentation

2017 MTQIP Performance Index Supporting Documentation

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MHA Keystone Center / Great Lakes Partners for Patients Hospital Improvement Innovation Network (HIIN)

Peer Group 1-4 BCBSM Pay for Performance Program Requirements

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 January – December 2017

Performance: Improvement on pain management, sepsis, and CAUTI measures (individual improvement from HIIN baselines)

25% Once Varies by measure

(see Table 3)

Person & Family Engagement: Patient & Family Advisory Councils (PFAC)

20% Twice 1: January – June 2017

2: July – December 2017

Antimicrobial Stewardship: Current practices assessment

15% Once

Due by Feb. 28, 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

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2017 BCBSM P4P Scoring Index – MHA Keystone Center Updated 11/11/2016

Launch of Patient & Family Advisory Council (PFAC) and/or Inclusion of Patient Advisor on Existing Quality Improvement Team***

- PFAC / inclusion of patient advisors - Fully implemented - PFAC / inclusion of patient advisors - Partially implemented - PFAC / inclusion of patient advisors - Not implemented

20 points 10 points 5 points

Antimicrobial Stewardship (AMS)**** - Completion of AMS assessment / gap analysis by Feb. 28, 2017 - No completion of AMS assessment / gap analysis by Feb. 28, 2017

15 points

0 points

Total Possible Points 100 points

Table 3: MHA Keystone / Great Lakes Partners for Patients HIIN Outcomes Performance

Measure HIIN 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

Oct. 2016 – March 2017

Jan. – Sept. 2017

Sepsis: Post-op Sepsis (KDS-HIIN-SEP-1) Or Sepsis Mortality (KDS-HIIN-SEP-2)

Q4 2015 July –

December 2016 Jan. – June 2017

Opioid Adverse Drug Events: Use of naloxone among inpatients receiving opioids (KDS-HIIN-ADE-4)

Q4 2016 Jan. – March

2017 Jan. – Sept.

2017

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)

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2017 BCBSM P4P Scoring Index – MHA Keystone Center Updated 11/11/2016

* 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

** Hospitals will be scored on their own performance over time, and whether they are demonstrating

improvement in CAUTI, Sepsis and Opioid ADE rates from the designated (hospital-specific) baseline to the listed

performance period (Table 3). 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.

*** Please reference the MHA Keystone Roadmap to Person & Family Engagement for additional information

on the launch of Patient & Family Advisory Councils and/or inclusion of patient advisors on existing quality

improvement committees.

**** MHA Keystone Center will provide HIIN infection prevention contacts the link to complete the AMS

assessment. Hospitals will designate these contacts upon enrollment in the HIIN.

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