Quality Health Indicators

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Quality Health Indicators

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• About QHi• The PiHQ Portal• Defining your facility• Selecting Measures• Entering Data• Dashboards• Reports• How we use the data

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

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

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

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More than 900 users in over 250 Critical Access and other small rural hospitals in Alaska, Arizona, California, Colorado, Illinois, Kansas, Kentucky, Louisiana, Michigan, Minnesota, Missouri, Nebraska, New Mexico, Oklahoma, Oregon and Wyoming use QHi as a data collection and benchmarking tool.

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

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Four Pillars Of Measurement


Clinical

Quality

Employee

Contribution

Patient

Satisfaction

Financial

Operational

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QHi Core Measures Set

Clinical Quality• Healthcare Associated Infections per 100 inpatient days• Unassisted Patient Falls per 100 inpatient days• Pneumococcal Immunization (PPV23) – Age 65 and Older (CMS IMM-1b)• Discharge Instruction (CMS HF-1)

Employee Contribution• Benefits as a Percentage of Salary• Staff Turnover

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

Financial Operational• Days Cash on Hand • Gross Days in AR

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

CMS Pneumonia Measures Inpatients Receiving O2 Assessment within 24 hours of admission - CMS PN-1 (retired) Inpatients Receiving Pneumonia Immunization - CMS PN-2 (retired) Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital - CMS PN-3b Adult Smoking Cessation Advice/Counseling - CMS PN-4 (retired) Pneumonia Patients Receiving Initial Antibiotic Within 6 Hours of Hospital Arrival - CMS PN-5c (retired) Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients - CMS-PN6 Influenza Vaccination - CMS PN-7 (retired)

*Part of the 8 Core Measure Set

Additionally, facilities can select from over 90 measures

in the QHi library of indicators:

Clinical Quality Measures (continued)

CMS OP Transfer Measures Median Time to Fibrinolysis in the Emergency Department - CMS OP-1 Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival in the Emergency Department - CMS OP-2 Median Time to Transfer to Another Facility for Acute Coronary Intervention in the Emergency Department - CMS

OP-3 Aspirin at Arrival in the Emergency Department - CMS OP-4 Median Time to ECG in the Emergency Department - CMS OP-5 Timing of Antibiotic Prophylaxis in Hospital Outpatient Surgery - CMS OP-6 Prophylactic Antibiotic Selection for Surgical Patients in Hospital Outpatient Surgery - CMS OP-7

CMS Immunization Measures Pneumococcal Immunization (PPV23) – Overall Rate - CMS IMM-1a Pneumococcal Immunization (PPV23) – Age 65 and Older* - CMS IMM-1b Pneumococcal Immunization (PPV23) – High Risk Populations (Age 6 through 64 years) - CMS IMM-1c Influenza Immunization - CMS IMM-2

*Part of the 8 Core Measure Set8

Clinical Quality Measures (continued) CMS HF Measures Discharge Instructions* – CMS HF-1 Evaluation of LVS Function – CMS HF-2 ACEI or ARB for LVSD – CMS HF-3 Adult Smoking Cessation Advice/Counseling – CMS HF-4 (retired)

CMS SCIP Measures Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision – CMS SCIP-Inf-1a Prophylactic Antibiotic Selection for Surgical Patients – CMS SCIP-Inf-2a Prophylactic Antibiotics Discontinued Within 24 Hours after Surgery End Time – CMS SCIP-Inf-3a Surgery Patients with Appropriate Hair Removal – CMS SCIP-Inf-6 Urinary Catheter Removed on Postop Day 1 or Postop Day 2 with Day of Surgery being Day 0 – CMS SCIP-Inf-9 Surgery Patients with Periop Temperature Management – CMS SCIP-Inf-10 Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Periop Period –

CMS SCIP-Card-2 Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered – CMS SCIP-VTE-1 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery

to 24 Hours After Surgery – CMS SCIP-VTE-2

*Part of the 8 Core Measure Set 9

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

Patient Satisfaction Measures

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

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


Hospital Characteristics Measures Average Inpatient Days

Monthly Inpatient Census

ALOS (in hours) Comparison

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Financial

Bad Debt Expense

Charity Care

Cost per Patient Day

Labor Hours per Patient Day

Operating Profit Margin

Current Ratio

Net Patient Revenue per Patient Days

Payer Mix – Commercial

Payer Mix – Medicaid

Payer Mix – Medicare

Payer Mix – Other

Payer Mix – Other Government

Payer Mix – Self/Private Pay

Days Cash on Hand*

Gross Days in AR*

Financial & Operational Measures

Operational

Physical Therapy Labor Hours per Unit of Service

Laboratory Labor Hours per Unit of Service

X-ray Labor Hours per Unit of Service

Mammogram Labor Hours per Unit of Service

Ultrasound Labor Hours per Unit of Service

CT Labor Hours per Unit of Service

MRI Labor Hours per Unit of Service

Pharmacy Labor Hours per Unit of Service

Nursing Hours per Patient Day

Rural Health Clinic Encounters per FTE

Long Term Care Hours per LTC Patient Day

Laboratory Hours per Billed Service


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

The level of access is determined by the User type:

System Administrator – maintains the site – KHA/KHERF

State Administrator –provides support to Hospital Contacts in their State

Network Administrator – maintains Network profiles & provides support

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

Hospital User – enters data and runs reports

View Only – views data and runs reports

Report Recipient – no access to QHi, only receives reports


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Defining

Your

HospitalReturn to Main Menu

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

on the blue-lettered links in the whitemenu bar

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Hover text provides a briefdescription of each resource

All QHi, HSI and SQSS users have access to the

PiHQ search engine.

Users type in search topic here

…or on any page throughout the portal

Results are pulled from all Portal resources.

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

The Resource Library holds all resource materials developed for PiHQ.

All users have access to the Resource Library

Results are pulled from all Portal resources.

Icons identify the source of the information.

All users have access to the Calendar

The Calendar provides registration information for upcoming Quality Training Sessions

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Users with access to this application are directed to the home page,

without additional log in.

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

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

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

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

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Defining

Your

HospitalReturn to Main Menu

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Users navigate through QHi by selecting options from

the red main-menu bar andthe blue sub-menu bar

Click Administration to viewHospital Profile page

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Hospital Contacts are responsible forcompleting and maintaining the

Hospital Profile page for their facility

All fields with a redasterisk are required

fields

Hospital Characteristicsdefine each facility for

creation of peer groupswhen running reports

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Click drop-down to select Level of

Measurement . This applies only to

Financial/Operational measures

Question mark icons provide pop-up

definitions throughout the QHi site

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Selecting

Measures

Return to Main Menu

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Click here to go toMeasure Selection

page

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In Collected Measure Sets, users can select the

default measures predetermined by their

state or network

The QHi Core Measure Set is pre-

selected as it is required for all

hospitals

Additional measure sets are available here

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Collected Measures lists the

measures within the measure sets

currently collected by the hospital

Individual measures are displayed and can be selected

under Additional Measures

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Additional Measures lists:(1) individual measures currently collecting (2) other measures that are available to collect

Indicates the numberof hospitals in QHi

collecting themeasureClick the plus icon to

add measure toCurrently Collecting

Click the minus icon to remove measure

fromCurrently Collecting

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Click the question mark icon todisplay the calculation for

each measure

Click show elements todisplay the elementsrequired to calculate

the measure

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Entering

Data

Return to Main Menu

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Click Data Submissions to accessthe Data Submission page

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Click Go to: drop-down arrow to selectprior months’

data submissions

To create a new data submissionspage, select correct month and

year from Month to add: drop-down arrows

IMPORTANT: You must check Activate datafor reporting box and then Save All and Stayin order for the data entered this month to be

displayed on dashboards or in reports

Click Save All and Stay tosave data entered

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

to remind the user to activate the datafor reporting

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Prior months’data is displayed

for easy reference

Click to automatically calculatemeasures and immediately

display results

Data elements automatically populate this pagebased on the measures selected by the user in

the Measure Selection page

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The

Dashboard

Return to Main Menu

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The Core Measures Dashboarddisplays comparison data for the

eight Core Measures

Roll mouse over anyDashboard graph to

view the pop-up calculationfor that measure

The Dashboard can bedisplayed in graph,table, or graph/table

views

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Table View

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Graph and Table View

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Dashboard data is calculated using aconsecutive three-month summing average

State Avg values reflect data fromhospitals in the same state asMy Hospital and reported in

the same time interval

QHi Avg values reflect data from allhospitals in QHi reporting the samemeasure in the same time interval

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Financial measures on the Dashboard default to peer groups

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

Enterprise)

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

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

displayed on the Dashboard

My Hospital data for some clinical measures will not

display on the Dashboard if the hospital had no

occurrences during the Date Range period

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

select the start month for the desiredthree-month period

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Click here to view theDashboard as a PDF

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PDF view

The PDF format allows the user to save, print

or email the Dashboard in graph, table or

graph/table views

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Users can email the Dashboard in PDF tothemselves by clicking To Myself

…or choose another recipient

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User selects from a list ofexisting registered users

…or choose to add a new recipient

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Enter the name and Emailaddress of the new recipient

…and click Add New

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Click Create Schedule to establish apre-determined schedule for mailing

Dashboard reports to selected recipients

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1. Select run date by clicking on calendar2. Select frequency (monthly, quarterly, annually)

3. Select recipients4. Click on Save Schedule

5. Report is sent through email as a PDF attachment

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Click View My Dashboard tocreate a customized Dashboard

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Only those measures being collected by the

hospital will be available in the list

Click drop-down to select a measure to display on

Dashboard

Selected measures are retained and are

user specific

Notes section available to add comments or

additional information

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Click At A Glance Dashboard toview a twelve-month trending

graph/table view of each of theeight Dashboard measures

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At A Glance twelve-monthtrending graphs for each

Core measure withtimeline and view options

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Reports

Return to Main Menu

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Reports is still available tousers to create peer reports.

However, its function hasbeen replaced by the

enhanced and upgradedNew Reports

Click New Reports to view measures andcreate peer reports

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Select report start and end dates

Select peer groups

Select data grouping

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Users can select up to five additional peer groups

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Available criteria selections for each peer group

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Users can only create a reporton measures that are being

collected by their hospital

Click on the blue measurescategory bar to display the

list of measures (beingcollected by that hospital)

in that category

Users can select more thanone measure from more

than one category

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Select output format

Select how wish to view report

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Webpage At A Glance view

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Webpage Line Graph view

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Webpage Bar Graph view

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Webpage Table view

The user’s facility isidentified as Hospital

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Webpage Table with detail view

Note that peer hospitals arenot identified by name but

have been assignedrandom numbers

Click on the envelope icon tocontact a peer hospital forbest practice information

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The Hospital Contact at theselected peer hospital will receive the email message

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Export format applies toTable and Table with detail

views

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From the Excel reportusers can create

customized graphs to meet their needs

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Gray Scale format displaysgraphs in black and white

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Click on Best Practice Reportto view and create reports that

list the top five performersfor any measure in QHi

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Hospitals can create a customized BestPractice report by selecting:

1. Comparison quarter2. Sorting and display option

3. Criteria4. Measures

5. Clicking on Run Report

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Reports the summed average of themost recent or selected quarter’s data

Top performers are defined by themost recent or selected quarter’s data

Previous two quarters are displayedfor reference purposes only

Click on the envelope icon tocontact a top performer hospital

for best practice information

If your hospital is not in the top 5 performers, it will be shown at the end of the list with

the ranking identified

If your hospital is in the top 5 performers of aCore measure, it will be identified on the

Dashboard with green stars and themessage: “Best Practice Top Performer”

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Training, educational materialsand QHi documents are availablefor download on the Help page

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How we use the data

Return to Main Menu

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

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

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

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

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

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


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

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Thank you for viewing this demonstration.

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

Sally Perkins, QHi System Administrator [email protected]

785-276-3118or

Stuart Moore, QHi [email protected]

785-276-3104


mailto:[email protected]

mailto:[email protected]

Documents

Quality Health Indicators