3Q17 Core Measures and 1Q18 MBQIP Data
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1 3Q17 Core Measures and 1Q18 MBQIP Data May 18, 2018 Joshua Salander, MBA, PMP Consultant
2 Reports delivery Updated 3Q17 reports were sent via on May 15, 2018 Quarterly Reports Quarterly Trend Charts Please delete reports that were went on Sunday, May 13,
3 MICAHQN Reports Schedule Qtr CMS Data Deadline* Data Provided By* 1st Qtr August 15 August 31 2nd Qtr November 15 November 30 3rd Qtr February 15 February 28 4th Qtr May 15 May 31 3
4 Summary of 3Q17 MICAHQN Core Measures Performance OP1 (three quarters consecutively that has time decreased) OP2 (two quarters consecutively that rate has increased) OP3 (consistent performance) OP4 (consistent performance, AMI increased (all but one hospital at ) OP5 (overall measure decreased below lower control limit to five minutes) OP18 a and b five quarters above overall time c and d seven quarters above overall time; time to adjust overall time OP20 (two quarters consecutively that time has decreased) ED1 and ED2 (both showed increase in time) 4
5 Summary of 3Q17 MBQIP Performance EDTC-1 (nine quarters consecutively that rate has been above 95%) Best Quarter 4Q17 EDTC-2 (three quarters consecutively that rate has increased) Best Quarter 3Q16, 4Q16 EDTC-3 (nine quarters consecutively that rate has been above 95%) Best Quarter 2Q16, 3Q16, 1Q17 97% EDTC-4 (seven quarters consecutively that rate has been above 93%) Best Quarter 3Q15, 4Q16, 1Q17, 1Q18 95% EDTC-5 (six quarters consecutively that rate has been above 94%) Best Quarter 4Q16, 3Q17, 4Q17 95% EDTC-6 (six quarters consecutively that rate has been above 89%) Best Quarter 1Q18 95% EDTC-7 (nine quarters consecutively that rate has been above 95%) Best Quarter 4Q16 EDTC-Overall (six quarters consecutively that rate has been above 81%) Best Quarter 4Q17 88% 5
6 Project Management Processes Initiation Planning Executing Closure 6
7 Portfolio vs Program vs Project Project Management A project is a temporary endeavor undertaken to create a unique product, service, or result (PMBOK Guide 5 th Edition) Achieving objectives! Knowledge, Skills, Tools, Techniques Program Management Optimize utilization of resources Group of related projects Portfolio Management Larger scope and objectives Centralized management identify, prioritize, and authorize 7
8 Portfolio vs Program vs Project Portfolio Management Hospital Program Management Quality & Regulatory Nursing Ancillary Departments Project Management Core Measures MBQIP BCBSM P4P HIPAA Promoting Interoperability And so on 8
9 9
10 Project Initiation Phase Project Charter The WHY! Authorizes the project to begin Identify Stakeholders / Resource Allocation Who is affected (Employees, patients, community, volunteers) Resources allocated to support project 10
11 Project Charter Scope Objectives Goals or Measurement Project Name Milestones Executive Sponsor Assumptions Project Manager Revision Date Stakeholders Project Charter Attachments 11
12 12
13 MBQIP Graphs
14 Q MICAHQN 30 Q National Q MICAHQN Q MICAHQN 36 Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN 11 Q MICAHQN Q MICAHQN % 80% 84% 84% 84% 88% 89% 91% 91% 92% 93% 95% 95% 96% 96% 96% 96% 96% 97% 97% 97% 97% EDTC-1 Administrative Communication - 1Q18 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Hospital Q MICAHQN (96%) 14
15 Rate EDTC-1: Administrative Communication 95.0% 90.0% 85.0% 80.0% 75.0% MICAHQN Overall UCL LCL 15
16 22 36 Q MICAHQN Q National 24 Q MICAHQN Q MICAHQN Q MICAHQN 12 Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN % 80% 84% 87% 87% 88% 89% 90% 93% 94% 95% 95% 95% 96% 96% 96% 96% 97% 97% EDTC - 2 Patient Information - 1Q18 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Hospital Q MICAHQN (96%) 16
17 Median Time EDTC-2: Patient Information 95% 90% 85% 80% 75% MICAHQN Overall UCL LCL 17
18 22 37 Q MICAHQN Q National Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN % 82% 83% 87% 89% 90% 93% 93% 95% 95% 96% 96% 96% 96% 96% 96% 96% 97% 97% 97% 97% 97% 97% EDTC - 3 Vital Signs - 1Q18 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Hospital Q MICAHQN (97%) 18
19 Median Time EDTC-3: Vital Signs 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% MICAHQN Overall UCL LCL 19
20 Q MICAHQN 37 Q National Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN 12 Q MICAHQN Q MICAHQN % 78% 80% 81% 84% 88% 89% 89% 89% 91% 93% 93% 93% 93% 93% 93% 94% 94% 94% 95% 95% 95% 95% 95% 97% 97% 99% EDTC - 4 Medication Information - 1Q18 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Hospital Q MICAHQN (95%) 20
21 Median Time EDTC-4: Medication Information 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% MICAHQN Overall UCL LCL 21
22 25 22 Q MICAHQN Q National Q MICAHQN Q MICAHQN 18 Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN % 69% 77% 78% 84% 87% 87% 87% 87% 88% 89% 89% 90% 90% 94% 94% 94% 95% 95% 95% 95% 96% 96% 99% EDTC - 5 Physician or Practitioner Generated Information - 1Q18 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Hospital Q MICAHQN (94%) 22
23 Rate EDTC-5: Practitioner Information 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% MICAHQN Overall UCL LCL 23
24 22 Q MICAHQN 21 Q National Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN 39 Q MICAHQN 12 Q MICAHQN Q MICAHQN Q MICAHQN 24 Q MICAHQN % 76% 78% 82% 84% 84% 85% 87% 88% 88% 89% 89% 89% 90% 90% 91% 92% 93% 93% 93% 93% 93% 95% 96% 96% 97% 97% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% EDTC - 6 Nurse Generated Information - 1Q18 Hospital Q MICAHQN (95%) 24
25 Rate EDTC-6: Nurse Information 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% MICAHQN Overall UCL LCL 25
26 22 Q MICAHQN Q National 21 Q MICAHQN 5 Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN % 85% 87% 87% 89% 91% 92% 93% 95% 96% 96% 96% 97% 97% 97% 97% 97% 97% 96% 94% 92% 90% 88% 86% 84% 82% 80% 78% 76% 74% 72% 70% 68% 66% 64% 62% 60% 58% 56% 54% 52% 50% EDTC - 7 Procedures and Tests - 1Q18 Hospital Q MICAHQN (97%) 26
27 Rate EDTC-7: Procedures and Tests 95.0% 90.0% 85.0% 80.0% 75.0% MICAHQN Overall UCL LCL 27
28 25 22 Q MICAHQN 37 Q National Q MICAHQN Q MICAHQN 15 Q MICAHQN Q MICAHQN Q MICAHQN Q MICAHQN 30 Q MICAHQN Q MICAHQN 38 Q MICAHQN Q MICAHQN 5 Q MICAHQN % 45% 55% 64% 66% 66% 67% 70% 71% 73% 73% 76% 76% 76% 76% 77% 78% 78% 81% 82% 84% 84% 84% 85% 86% 87% 88% 89% 89% 89% 90% 91% 91% 95% 96% 96% 96% 96% All EDTC Measures - 1Q18 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Hospital Q MICAHQN (86%) 28
29 Median Time All EDTC Measure 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% MICAHQN Overall UCL LCL 29
30 Core Measure Graphs
31 Rate 90.0% OP AMI/CP Rate Based Measures - 3Q % 99.6% 97.6% 97.8% 96.9% 96.4% 96.7% 96.6% 97.2% 80.0% 70.0% 60.0% 61.9% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Fibrinolytic Therapy Received Within 30 Minutes Aspirin at Arrival - Overall Rate Aspirin at Arrival - AMI Aspirin at Arrival - Chest Pain MICAHQN Rate CAH Only Rate Rural Only Rate 31
32 Rate OP2 - Fibrinolytic Therapy Received Within 30 Minutes 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% MICAHQN Overall UCL LCL 32
33 Rate OP4a - Aspirin at Arrival - Overall Rate 99.0% 98.0% 97.0% 96.0% 95.0% 94.0% 93.0% MICAHQN Overall UCL LCL 33
34 Rate OP4b - Aspirin at Arrival - AMI 99.0% 98.0% 97.0% 96.0% 95.0% 94.0% 93.0% 92.0% 91.0% MICAHQN Overall UCL LCL 34
35 Rate OP4c - Aspirin at Arrival - Chest Pain 99.0% 98.0% 97.0% 96.0% 95.0% 94.0% MICAHQN Overall UCL LCL 35
36 0.0% 0.0% 0.0% 0.0% 60.0% 66.7% 95.0% 90.0% 85.0% 80.0% 75.0% 70.0% 65.0% 60.0% 55.0% 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% OP-2: Fibrinolytic Therapy Received Within 30 Minutes Hospital Q MICAHQN (61.9%) 36
37 90.0% 90.9% 91.7% 92.3% 93.0% 94.1% 94.4% 95.3% 95.5% 96.4% 96.7% OP-4a: Aspirin at Arrival - Overall Rate 98.0% 96.0% 94.0% 92.0% 90.0% 88.0% 86.0% 84.0% Hospital Q MICAHQN (97.6%) 37
38 92.3% 92.3% OP-4b: Aspirin at Arrival - AMI 98.0% 96.0% 94.0% 92.0% 90.0% 88.0% Hospital Q MICAHQN (99.1%) 38
39 83.3% 83.3% 87.5% 90.0% 90.0% 92.3% 92.6% 93.3% 93.5% 93.8% OP-4c: Aspirin at Arrival - Chest Pain 95.0% 90.0% 85.0% 80.0% 75.0% Hospital Q MICAHQN (96.7%) 39
40 OP AMI/CP Continuous Measures - 3Q17 Median Time to ECG - Chest Pain Median Time to ECG - AMI Median Time to ECG - Overall Rate Median Time to Transfer to Another Facility for Acute Coronary Intervention - QI Measure Median Time to Transfer to Another Facility for Acute Coronary Intervention - Reporting Measure Median Time to Transfer to Another Facility for Acute Coronary Intervention - Overall Median Time to Fibrinolysis Rural Only Values CAH Only Values MICAHQN Values Median Time 40
41 Median Time 45 OP1 - Median Time to Fibrinolysis MICAHQN Overall UCL LCL 41
42 Median Time 70 OP3a - Median Time to Transfer to Another Facility for Acute Coronary Intervention - Overall MICAHQN Overall UCL LCL 42
43 Median Time 70 OP3b - Median Time to Transfer to Another Facility for Acute Coronary Intervention - Reporting Measure MICAHQN Overall UCL LCL 43
44 Median Time 120 OP3c - Median Time to Transfer to Another Facility for Acute Coronary Intervention - QI Measure MICAHQN Overall UCL LCL 44
45 Median Time 9 OP5a - Median Time to ECG - Overall Rate MICAHQN Overall UCL LCL 45
46 Median Time 9 OP5b - Median Time to ECG - AMI MICAHQN Overall UCL LCL 46
47 Median Time 9 OP5c - Median Time to ECG - Chest Pain MICAHQN Overall UCL LCL 47
48 OP-1: Median Time to Fibrinolysis Hospital Q MICAHQN (26 minutes) 48
49 OP-3a: Median Time to Transfer to Another Facility for Acute Coronary Intervention - Overall Hospital Q MICAHQN (54.5 minutes) 49
50 OP-3b: Median Time to Transfer to Another Facility for Acute Coronary Intervention - Reporting Measure Hospital Q MICAHQN (53 minutes) 50
51 OP-3c: Median Time to Transfer to Another Facility for Acute Coronary Intervention - QI Measure Hospital Q MICAHQN (75 minutes) 51
52 OP-5a: Median Time to ECG - Overall Rate Hospital Q MICAHQN (5 minutes) 52
53 OP-5b: Median Time to ECG - AMI Hospital Q MICAHQN (6 minutes) 53
54 OP-5c: Median Time to ECG - Chest Pain Hospital Q MICAHQN (5 minutes) 54
55 OP Emergency Department Throughput - 3Q17 Door to Diagnostic Evaluation by a Qualified Medical Professional Median Time from ED Arrival to ED Departure for Discharged ED Patients - Transfer Patients Median Time from ED Arrival to ED Departure for Discharged ED Patients - Psychiatric/Mental Health Patients Median Time from ED Arrival to ED Departure for Discharged ED Patients - Reporting Measure Median Time from ED Arrival to ED Departure for Discharged ED Patients - Overall Rural Only Values CAH Only Values MICAHQN Values Median Time 55
56 Median Time 135 OP18a - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Overall MICAHQN Overall UCL LCL 56
57 Median Time 125 OP18b - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Reporting Measure MICAHQN Overall UCL LCL 57
58 Median Time 250 OP18c - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Psychiatric/Mental Health Patients MICAHQN Overall UCL LCL 58
59 Median Time 250 OP18d - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Transfer Patients MICAHQN Overall UCL LCL 59
60 Median Time 30 OP20 - Door to Diagnostic Evaluation by a Qualified Medical Professional MICAHQN Overall UCL LCL 60
61 OP-18a: Median Time from ED Arrival to ED Departure for Discharged ED Patients - Overall Hospital Q MICAHQN (124 minutes) 61
62 OP-18b: Median Time from ED Arrival to ED Departure for Discharged ED Patients - Reporting Measure Hospital Q MICAHQN (116 minutes) 62
63 OP-18c: Median Time from ED Arrival to ED Departure for Discharged ED Patients - Psychiatric/Mental Health Patients Hospital Q MICAHQN (212.5 minutes) 63
64 OP-18d: Median Time from ED Arrival to ED Departure for Discharged ED Patients - Transfer Patients Hospital Q MICAHQN (264.5 minutes) 64
65 OP-20: Door to Diagnostic Evaluation by a Qualified Medical Professional Hospital Q MICAHQN (14 minutes) 65
66 IP Emergency Department - 3Q17 Admit Decision Time to ED Departure Time for Admitted Patients - Psychiatric/Mental Health Patients Admit Decision Time to ED Departure Time for Admitted Patients - Reporting Measure Admit Decision Time to ED Departure Time for Admitted Patients - Overall Rate Median Time from ED Arrival to ED Departure for Admitted ED Patients - Psychiatric/Mental Health Patients Median Time from ED Arrival to ED Departure for Admitted ED Patients - Reporting Measure Median Time from ED Arrival to ED Departure for Admitted ED Patients - Overall Rate Rural Only Values CAH Only Values MICAHQN Values Median Time 66
67 Median Time 260 ED-1a - Median Time from ED Arrival to ED Departure for Admitted ED Patients - Overall Rate Q17 2Q17 3Q17 CAH Only Rural Only MICAHQN 67
68 Median Time 260 ED-1b - Median Time from ED Arrival to ED Departure for Admitted ED Patients - Reporting Measure Q17 2Q17 3Q17 CAH Only Rural Only MICAHQN 68
69 Median Time 300 ED-1c - Median Time from ED Arrival to ED Departure for Admitted ED Patients - Psychiatric/Mental Health Patients Q17 2Q17 3Q17 CAH Only Rural Only MICAHQN 69
70 Median Time 180 ED-2a - Admit Decision Time to ED Departure Time for Admitted Patients - Overall Rate Q17 2Q17 3Q17 CAH Only Rural Only MICAHQN 70
71 Median Time 180 ED-2b - Admit Decision Time to ED Departure Time for Admitted Patients - Reporting Measure Q17 2Q17 3Q17 CAH Only Rural Only MICAHQN 71
72 Median Time 250 ED-2c - Admit Decision Time to ED Departure Time for Admitted Patients - Psychiatric/Mental Health Patients Q17 2Q17 3Q17 CAH Only Rural Only MICAHQN 72
73 ED-1a: Median Time from ED Arrival to ED Departure for Admitted ED Patients - Overall Rate Hospital Q MICAHQN (236 minutes) 73
74 ED-1b: Median Time from ED Arrival to ED Departure for Admitted ED Patients - Reporting Measure Hospital Q MICAHQN (235 minutes) 74
75 ED-1c: Median Time from ED Arrival to ED Departure for Admitted ED Patients - Psychiatric/Mental Health Patients Hospital Q MICAHQN (275 minutes) 75
76 ED-2a: Admit Decision Time to ED Departure Time for Admitted Patients - Overall Rate Hospital Q MICAHQN (141 minutes) 76
77 ED-2b: Admit Decision Time to ED Departure Time for Admitted Patients - Reporting Measure Hospital Q MICAHQN (141 minutes) 77
78 ED-2c: Admit Decision Time to ED Departure Time for Admitted Patients - Psychiatric/Mental Health Patients Hospital Q MICAHQN (185 minutes) 78
79 Thank you! Joshua Salander, MBA, PMP Consultant (989)
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