2020 cqi performance index - bcbsm

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.

Blue Cross Blue Shield of Michigan

2020 Hospital Pay-for-Performance Program (for peer groups 1 through 4)

Hospital CQI Performance Index Scorecards

BCBSM/BCN 2020 Performance Index

CQIs and Pay-for-Performance Program

In 2020, the Pay-for-Performance Program will offer hospitals the opportunity to earn a fixed 40 percent of the program’s incentive based upon its performance across MHA Keystone/Great Lakes partners for patients’ programs or Blue Cross Blue Shield of Michigan-sponsored CQI initiatives. As in the previous program year, the amount of incentive allocated to CQI performance will be equal for all participating hospitals. The number of CQIs a hospital is eligible for doesn’t apply.

The CQI program domain will remain capped at 40 percent, regardless of the number of participating initiatives. Hospitals eligible for and participating in more than 10 CQIs will be scored using only the top 10 individual CQI performance scores, with preference given to Blue Cross-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 2020, seven of the Blue Cross-sponsored CQIs have been categorized as “required” CQIs. In addition, individual MHA Keystone collaboratives include the Great Lakes Partners for Patients Hospital Improvement Innovation Network.

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’s been provided the opportunity to participate through an enrollment application process. If your hospital hasn’t been recruited or is ineligible to participate in a “required” CQI, then it won’t be penalized for nonparticipation. There will be no negative impact on its P4P score if a hospital is deemed ineligible, hasn’t 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 Blue Cross-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. The total number of CQIs a hospital can participate in will determine exact weights. New in 2020, hospitals who participate in all CQIs for which they have been recruited will be eligible for a fixed-dollar bonus paid from the unearned incentive dollars within the CQI component. Please see the full 2020 program guide for additional details.

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 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’re 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

Page Project Manager Phone Email

ASPIRE Anesthesiology 10 Tory (Victoria) Lacca 734-936-8081 [email protected]

BMC2 Angioplasty and Vascular Surgery 14 Andrea Jensen 734-998-6444 [email protected]

HMS Hospitalist Medicine 19 Elizabeth McLaughlin 734-936-0354 [email protected]

I-MPACT Care Transitions 22 Pam Jones 734-615-9752 [email protected]

MAQI2 Anticoagulation 30 Brian Haymart 734-998-5631 [email protected]

MARCQI Knee/Hip Arthroplasty 33 Tae Kim 734-998-0464 [email protected]

MBSC Bariatric Surgery 35 Amanda Stricklen 734-998-7481 [email protected]

Rachel Ross 734-998-7502 [email protected]

MEDIC Emergency Department 37 Andy Scott 734-763-5191 [email protected]

MROQC Radiation Oncology 41 Melissa Mietzel 734-936-1035 [email protected]

MSQC General Surgery 44 Kathy Bishop 734-763-3717 [email protected]

MSSIC Spine Surgery 47 Jamie Myers 313-874-1892 [email protected]

MSTCVS Cardiac Surgery 50 Patty Theurer 734-998-5918 [email protected]

MTQIP Trauma Surgery 51 Judy Mikhail 734-763-8227 [email protected]

OBI Obstetrics 53 Nina Bobowski 734-232-2175 [email protected]

mailto:[email protected]



















Michigan Trauma Quality Improvement Program (MTQIP) 2020 Performance Index 1/1/2020 – 12/31/2020

Measure Weight Measure Description Points

1 10

Data Submission 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

PART

ICIP

ATIO

N (3

0%)

2 10

Meeting Participation Surgeon and (TPM or MCR) participate in 3 of 3 Collaborative meetings (9 pt) Surgeon and (TPM or MCR) participate in 2 of 3 Collaborative meetings (6 pt) Surgeon and (TPM or MCR) participate in 0-1 of 3 Collaborative meetings (0 pt) Registrar or MCR participate in the Annual June Data Abstractor meeting (1 pt)

0-10

3 10

Data Validation Error Rate 0-4.0% 4.1-5.0% 5.1-6.0% 6.1-7.0% > 7.0%

10 8 5 3 0

4 10

Timely LMWH VTE Prophylaxis in Trauma Service Admits (18 mo: 1/1/19-6/30/20) ≥ 50% of patients (≤ 48 hr) ≥ 45% of patients (≤ 48 hr) ≥ 40% of patients (≤ 48 hr) < 40% of patients (≤ 48 hr)

10 8 5 0

PERF

ORM

ANCE

(70%

)

5 10

Timely Surgical Repair in Geriatric (Age ≥ 65) Isolated Hip Fxs (12 mo: 7/1/19-6/30/20) ≥ 90% of patients (≤ 48 hr) ≥ 85% of patients (≤ 48 hr) ≥ 80% of patients (≤ 48 hr) < 80% of patients (≤ 48 hr)

10 8 5 0

6 10 RBC to Plasma Ratio in Massive Transfusion (18 mo: 1/1/19-6/30/20) Weighted Mean Points in Patients Transfused ≥ 5 Units 1st 4 hr

0-10

7 10

Serious Complication Z-Score Trend in Trauma Service Admits (3 yr: 7/1/17-6/30/20) < -1 (major improvement) -1 to 1 or serious complications low-outlier (average or better rate) > 1 (rates of serious complications increased)

10 7 5

8 10

Mortality Z-Score Trend in Trauma Service Admits (3 yr: 7/1/17-6/30/20) < -1 (major improvement) -1 to 1 or mortality low-outlier (average or better) > 1 (rates of mortality increased)

10 7 5

9 10

Timely Head CT in TBI Patients on Anticoagulation Pre-Injury (12 mo: 7/1/19-6/30/20) ≥ 90% patients (≤ 120 min) ≥ 80% patients (≤ 120 min) ≥ 70% patients (≤ 120 min) < 70% patients (≤ 120 min)

10 7 5 0

10 10

Timely Antibiotic in Femur/Tibia Open Fractures - Collaborative Wide Measure (12 mo: 7/1/19-6/30/20) ≥ 85% patients (≤ 120 min) < 85% patients (≤ 120 min)

10 0

Total (Max Points) 100


Additional Information Measure 1: Data Submission: Partial/incomplete submissions receive no points Measure 2: Meeting Participation: Surgeon represents 1 center only, Alternate must be equivalent attending level Measure 3: Data Validation Error Rate: Centers not selected for validation this year will receive full points. Center’s that are selected, but do not schedule a visit will receive 0 points for the validation measure. Measure 6: RBC to Plasma Ratio in Massive Transfusion

Step 1: Assign (weight) to each individual patient’s 4 hr PRBC/FPP ratio to designated tier/points using chart below Step 2: Add the points and divide by number of patients (weighted average) See example below:

Measure 7 & 8: Z-Score Trend Calculation The z-score is a measure of 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. The score indicates whether the hospital’s performance is flat or trending upwards or 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). Scores >1 are worsening, scores between 1 to -1 are staying the same, and scores < -1 are improving.

Measure 7: Serious Complication is Any Complication with Severity Grade of 2 or 3 (Defined Below) Complication Severity Grade 2 Definition: Potentially life-threatening complications Complications: C. difficile colitis, decubitus ulcer, DVT, enterocutaneous fistula, extremity compartment syndrome, pneumonia, pulmonary embolism, unplanned admission to ICU, unplanned return to OR Complication Severity Grade 3 Definition: Life-threatening complications with residual or lasting disability or mortality Complications: ARDS, acute renal failure, cardiac arrest, myocardial infarction, renal insufficiency, stroke/CVA, systemic sepsis, unplanned intubation

Collaborative Wide Measure: Points awarded based on total collaborative result, not individual hospital result Scoring When Center Has No Patients Meeting Measure Criteria When a center has no patients to score for a measure, that measure will be excluded from their performance index denominator. Example: A center with no massive transfusion patients will have the measure (worth 10 points) excluded and their maximum total numerator will be 90 points, the denominator will be 90 points and a new % (points) calculated by dividing the numerator by the denominator.

Step One Step Two (Example) PRBC to Plasma Ratio Tier Points Patient PRBC FFP PRBC/FFP Tier Points

<1.5 1 10 1 10 10 1.0 1 10 1.6 – 2.0 2 10 2 5 2 2.5 3 5 2.1 – 2.5 3 5 3 9 2 4.5 4 0

>2.5 4 0 Total 15 Total Points/Total #Patients = 15/3 = 5 points earned


Filters

#4: Timely LMWH VTE Prophylaxis in Trauma Service Admits Practices > VTE Prophylaxis Metric LMWH ≤ 48 hr Cohort: 2 (Admit to Trauma Service) > 2 day LOS No Signs of Life: Exclude DOAs Transfers Out: Exclude Transfers Out Default Period: Custom (1/1/19 to 6/30/20) #5: Timely Surgical Repair in Geriatric (Age ≥ 65) Isolated Hip Fracture Cohort: 8 (Isolated hip fracture) Age: ≥ 65 No Signs of Life: Exclude DOAs Transfers out: Exclude Transfers Out Default Period: Custom (7/1/19 to 6/30/20) #6: Red Blood Cell to Plasma Ratio in Massive Transfusion Hemorrhage Cohort: 1 (All) No Signs of Life: Include DOAs Transfers Out: Include Transfers Out Default Period: Custom (1/1/19 to 6/30/20)

#7: Serious Complication Cohort: 2 (Admit to Trauma Service) No Signs of Life: Exclude DOA Transfers Out: Exclude Transfers Out Default Period: Custom (7/1/17 to 6/30/20)

#8: Mortality Cohort: 2 (Admit to Trauma Service) No Signs of Life: Exclude DOA Transfers Out: Exclude Transfers Out Default Period: Custom (7/1/17 to 6/30/20)

#9: Timely Head CT in Anticoagulated TBI Head CT scan done in ED, date, time from procedures data Eligible: Presence of pre-injury anticoagulation and/or aspirin/anti-platelet medication (Anticoagulant therapy=Yes or Aspirin=Yes or Plavix=Yes) Presence of a head injury with blunt mechanism based on AIS codes (list available on request) Cohort: 1 (All) Exclude: Direct admissions and Transfers in No Signs of Life: Exclude DOAs Transfers Out: Include Transfers Out Default Period: Custom (7/1/19 to 6/30/20) #10: Timely Antibiotic in Femur/Tibia Open Fractures - Collaborative Wide Measure Points awarded based on total collaborative result, not individual hospital result. Type of antibiotic administered along with date and time for open fracture of femur or tibia. Eligible: Presence of acute open femur or tibia fracture based on AIS or ICD10 codes (available on MTQIP.org) Exclude: Direct admissions and Transfers in Cohort: 1 (All) No Signs of Life: Exclude DOAs Transfers Out: Include Transfers Out Default Period: Custom (7/1/19 to 6/30/20)

Postop Order - Use of Multimodal Pain Management Intent of Variable: To capture whether multimodal approaches to pain management were ordered and administered within the first 24 hours following “Out of Room Time”.

Definition: Multimodal pain management refers to the use of non-opioid analgesics to reduce the use of opioids and improve analgesia. Two or more analgesic agents with different mechanisms of action are simultaneously administered with this approach.

Criteria: First indicate whether or not there were at least 2 medications or strategies ordered. Then indicate if 2 or more were administered postoperatively and select the specific type. Variable Options:

Multimodal Pain Management ordered within the first 24 hours following surgery? 1. No: Multimodal approach to pain management was not ordered 2. Yes: 2 or more non-opioid analgesic agents with different mechanisms of action were ordered

If Yes, was Multimodal Pain Management administered? 1. No: Multimodal approach to pain management was not administered 2. Yes: 2 or more non-opioid analgesic agents with different mechanisms of action were administered

If Yes: Postoperative multimodal pain management types (select all that apply):

o Non-steroids anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen, ketorolac/Toradol, cyclooxygenase-inhibitors- Celebrex)

o Acetaminophen PO

o Acetaminophen IV

o Gabapentinoids (gabapentin or pregabalin)

o Ketamine

o Intravenous lidocaine (infusion)

o Thoracic epidural (with local anesthetic- e.g., bupivicaine)

o Spinal analgesia (with local anesthetic- e.g., bupivacaine, lidocaine)

o Regional block (e.g., Transversus Abdominis Plane (TAP) block, or local analgesia wound infiltration)

• Preoperative/Intraoperative TAP blocks reduce the need for postop opioids for about 24 hours after surgery. TAP blocks placed before or near the start of the surgery are included as one type of intraoperative multimodal pain management. TAP blocks or local analgesia placed at the end of surgery would count as one type of postoperative multimodal pain management.

o Continuous wound infusion with local anesthetics (e.g., Marcaine pump, bupivacaine pump)

o Other non-opioid analgesic (e.g., Clonidine, dexmedetomidine/Precedex, dexamethasone)

Preadmission Teaching/Counseling Intent of Variable: To identify whether or not preadmission patient teaching/counseling was provided.

Definition: Detailed teaching including written and verbal instructions for patients to follow throughout

the stages of surgical preparation and recovery increases the likelihood that patients will adhere to a prescribed plan of care leading to optimal recovery and early discharge. Patient instruction and handout(s) include information about the surgery and hospitalization, as well as goals for preoperative conditioning and early recovery.

Criteria: Indicate whether or not the patient received verbal and written preadmission counseling/ teaching. If ‘yes’ select the types of teaching/counseling patient received. Variable Options: 1. No

• Written documents did not accompany the patient instruction • There is no indication that the patient received any preop counseling or teaching for enhanced recovery

2. Yes • “…received Enhanced Recovery packet”, “ERP booklet given to patient” documentation available • Attended preop teaching class • Any documentation available specific to Enhanced Recovery such as food intake, oral nutritional

supplements, mobilization • If the office protocol for “standardized teaching” for the Enhanced Recovery Program is known but it is

not documented

If Yes: Preadmission counseling/teaching type (select all that apply):

o Incentive Spirometer

o Pedometer/Exercise Program

o Nutrition/Diet – can include education on carb loading or protein beverages before surgery, postoperative expectations for nutrition

o Tobacco Cessation

o Preoperative showering guidelines- can include instruction on CHG wipes, CHG bath, antibacterial soap, clean clothes, etc.

o Postoperative expectations – pain, length of stay, etc.

o Postoperative wound care teaching

Notes:

1. In the course of obtaining 30-day follow up, if you learn that the patient received specific preoperative/ preadmission information and counseling specific to Enhanced Recovery, which included receipt of handouts, you may select “yes” for any and all variables that are applicable.

2. In the absence of provider/hospital documentation, you may obtain the information directly from the patient. Patients may reference an ERP teaching document itself, or may mention ERP specific principles they participated in (e.g., carb loading) that would evidence that preoperative teaching was completed.

Intraop Order - Use of Multimodal Pain Management

Intent of Variable: To capture whether multimodal approaches to pain management were ordered and administered in the preoperative holding area or intraoperatively.

Definition: Multimodal pain management refers to the use of non-opioid analgesics to reduce the use of opioids and improve analgesia. Two or more analgesic agents with different mechanisms of action are simultaneously administered with this approach.

Criteria: First indicate whether or not there were at least 2 medications or strategies ordered. Then indicate if 2 or more were administered in the preoperative holding area and/or intraoperatively and select the specific type.

Variable Options:

Multimodal Pain Management ordered Preop/Intraop? 1. No: Multimodal approach to pain management was not ordered 2. Yes: 2 or more non-opioid analgesic agents with different mechanisms of action were ordered

If Yes, was Multimodal Pain Management administered? 1. No: Multimodal approach to pain management was not administered 2. Yes: 2 or more non-opioid analgesic agents with different mechanisms of action were administered

If Yes: Intraoperative multimodal pain management types (select all that apply):

o Non-steroids anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen, ketorolac/Toradol, cyclooxygenase-2 inhibitors- Celebrex)

o Acetaminophen PO

o Acetaminophen IV

o Gabapentinoids (gabapentin or pregabalin)

o Ketamine

o Intravenous lidocaine (infusion)

o Thoracic epidural (with local anesthetic- e.g., bupivicaine)

o Spinal analgesia (with local anesthetic- e.g., bupivacaine, lidocaine)

o Regional block (e.g., Transversus Abdominis Plane (TAP) block, or local analgesia wound infiltration) • Preoperative/Intraoperative TAP blocks reduce the need for postop opioids for about 24 hours after

surgery. TAP blocks placed before or near the start of the surgery are included as one type of intraoperative multimodal pain management. TAP blocks or local analgesia placed at the end of surgery would count as one type of postoperative multimodal pain management, not intraoperative.

o Continuous wound infusion with local anesthetics (e.g., Marcaine pump, bupivacaine pump)

o Other non-opioid analgesic (e.g., Clonidine, dexmedetomidine/Precedex, dexamethasone)

Measure Weight Measure Description PointsCollaborative Meeting Participation: ASPIRE Quality Champion and Anesthesiology Clinical

Quality Reviewer (ACQR) combined attendance at collaborative meetings. Three total meetings

with six opportunities for attendance.5‐6/6 Meetings 104/6 Meetings 5

3 or less Meetings 0Attend Webex ASPIRE Quality Committee Meetings: ASPIRE Quality Champion or ACQR

attendance across five meetings5 Meetings 5

4 or less Meetings 0ACQR/ASPIRE Quality Champion perform data validation, case validation and submit data by the

third Wednesday of each month for January through November and by the second Wednesday

of the month for December10 ‐ 11/12 Months 5

Site Based Quality Meetings: Sites to hold an onsite meeting following the three ASPIRE

Collaborative meetings to discuss the data and plans for quality improvement at their site

3 Meetings 102 Meetings 5

1 or less Meeting 0Performance Measure: Cross Cohort Measure Pulmonary 02 (PUL 02) ‐ percentage of patients

with median tidal volumes less than or equal to 8 ml/kg (cumulative score January 1, 2020

through December 31, 2020)

13 ‐ 15 sites (out of 15 total sites) ≥ 90% 2513 ‐ 15 sites (out of 15 total sites) ≥ 80% 15

Less than 12 sites (out of 15 total sites) ≥ 80% 0Performance Measure: Blood Pressure (BP 03) ‐ Percentage of cases where intraoperative

hypotension (MAP < 65 mmHg) was sustained for less than 15 minutes (cumulative score

January 1, 2020 through December 31, 2020)

Performance is ≥ 90% 25Performance is ≥ 85% 15Performance is ≥ 80% 10Performance is < 80% 0

Site Directed Measure: Sites choose a measure they are performing below national ASPIRE

threshold by December 13, 2019

(cumulative score January 1, 2020 through December 31, 2020)

Performance is ≥ 90%; 10% or 5% 20Performance is ≥ 80%; 15% or 10% 10Performance is < 80%; 15% or 10% 0

2020 Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

Collaborative Quality Initiative Performance Index Scorecard

Cohort 1 ‐ 4: 15 Sites (excludes Trinity sites)

Measurement Period: 01/01/2020 ‐ 12/31/2020

6 30%

9 or Less Months0

1 10%

3

2 5%

5

5%

10%

20%

4

7 20%



Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) 2020 Performance Index Scorecard

Measure Explanation: Cohorts 1 – 4: 15 Sites (excludes Trinity sites)

Measure #1: The ASPIRE Quality Champion (or a designated representative who must be an anesthesiologist) and the Anesthesiology Clinical Quality Reviewer (ACQR), combined must attend ASPIRE Collaborative Meetings in 2020. There are three total meetings with six opportunities for attendance. 2020 meeting dates:

1. Friday, March 27, 2020: MSQC/ASPIRE Collaborative meeting, Schoolcraft College, Livonia, Michigan 2. Friday, July 17, 2020: ASPIRE Meeting, Henry Executive Center at MSU, Lansing, Michigan 3. Friday, October 2, 2020: MPOG Retreat at ASA, Washington DC

Measure #2: There will be five Webex ASPIRE Quality Committee meetings in 2020. One representative (ASPIRE Quality Champion or ACQR) must attend the meetings. The 2020 meeting dates are as follows:

1. Monday, February 24, 2020 at 10:00 a.m. 2. Monday, April 27, 2020 at 10:00 a.m. 3. Monday, June 22, 2020 at 10:00 a.m. 4. Monday, August 24, 2020 at 10:00 a.m. 5. Monday, October 26, 2020 at 10:00 a.m.

Measure #3: Refer to the Maintenance Schedule located on MPOG website in the resources tab of the quality section. Measure #4: The site is expected to schedule a local meeting following each ASPIRE/MPOG collaborative meeting (dates in Measure #1) to discuss site based and collaborative quality outcomes with clinical providers at their site. Sites must send the coordinating center the site-based collaborative meeting report located on the MPOG website in the P4P sub-tab of the quality section. Measure #5: Sites will be awarded points for compliance with the cross cohort pulmonary measure PUL 02: percentage of patients with median tidal volumes less than or equal to 8 ml/kg (cumulative score January 1, 2020 through December 31, 2020). Points will be determined across 15 Cohort 1 – 4 dashboards (excluding Trinity) on the following scale:

• 25 Points: 13 – 15 sites are performing equal to or above 90%, all 15 sites will receive 25 points • 15 Points: 13 – 15 sites are performing equal to or above 80%, all 15 sites will receive 15 points • 0 Points: 12 sites or less are performing equal to or above 80%, all 15 sites will receive 0 points

Measure #6: Sites will be awarded points for compliance with the blood pressure measure BP 03: Percentage of cases where intraoperative hypotension (MAP < 65 mmHg) was sustained for less than 15 minutes (cumulative score January 1, 2020 through December 31, 2020). Points will be determined on the following scale:

• 25 Points: Performance is ≥ 90% • 15 Points: Performance is ≥ 85% • 10 Points: Performance is ≥ 80% • 0 Points: Performance is < 80%

Measure #7: Sites will choose a measure they are performing below the ASPIRE threshold. Sites must submit the measure to the coordinating center by Friday, December 13. 2019 for review and approval (cumulative score January 1, 2020 through December 31, 2020). Points will be determined on the following scale:

Measures with Threshold 90% Measures with Threshold 10% Measures with Threshold 5% • 20 Points: Performance is ≥ 90% • 20 Points: Performance is <10% • 20 Points: Performance is <5% • 10 Points: Performance is ≥ 80% • 10 Points: Performance is <15% • 10 Points: Performance is <10% • 0 Points: Performance is < 80% • 0 Points: Performance is > 15% • 0 Points: Performance is >10%


Collaborative Meeting Participation: ASPIRE Quality Champion and Anesthesiology

Clinical Quality Reviewer (ACQR) combined attendance at collaborative meetings. Three

total meetings with six opportunities for attendance.

5‐6/6 Meetings 204/6 Meetings 10

3 or less Meetings 0

ASPIRE Champion or ACQR attend Monthly Webex ASPIRE Quality Committee Meetings

5 Meetings 10 4 Meetings 5

3 or Less Meetings 0

Timeliness of Regulatory/Legal documentation: Business Associate Agreement (BAA),

Data Use Agreement (DUA), Multicenter Perioperative Outcomes Group (MPOG)

Bylaws & IRB

Submitted by April 1, 2020 10Submitted by July 1, 2020 5

Hiring an ACQR

ACQR Start Date on or before February 1, 2020 10ACQR Start Date on or before April 1, 2020 5ACQR Start Date on or after April 2, 2020 0

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

Attestations Completed)

Data Submitted by September 1, 2020 20Data Submitted by December 1, 2020 10

Data Submitted after December 2, 2020 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 10Within 5 business days 5

Greater than 5 business days 0

Submitted after July 2, 2020 0

2020 Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

Collaborative Quality Initiative

Performance Index Scorecard

Cohort 5 ‐ Year 1 (start 2020)


1 20%

10%2

10%7

6 20%

10%3

4 10%

5 20%



Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) 2020 Performance Index Scorecard Measure Description

Cohort 5 – Year 1 (start 2020)

Measure #1: The ASPIRE Quality Champion (or a designated representative who must be an anesthesiologist) and the Anesthesiology Clinical Quality Reviewer (ACQR), combined must attend ASPIRE Collaborative Meetings in 2020. There are three total meetings with six opportunities for attendance.

Meeting Dates: 1. Friday, March 27, 2020: MSQC / ASPIRE Collaborative meeting, Schoolcraft Community

College, Livonia, Michigan 2. Friday, July 17, 2020: ASPIRE Meeting, Henry Executive Center / MSU, Lansing, Michigan 3. Friday, October 2, 2020: MPOG Retreat at ASA, Washington DC

Measure #2: There will be five Webex ASPIRE Quality Committee meetings in 2020. One representative (ASPIRE Quality Champion or ACQR) must attend the meetings. The 2020 meeting dates are as follows:

1. Monday, February 24, 2020 at 10:00 a.m. 2. Monday, April 27, 2020 at 10:00 a.m. 3. Monday, June 22, 2020 at 10:00 a.m. 4. Monday, August 24, 2020 at 10:00 a.m. 5. Monday, October 26, 2020 at 10:00 a.m.

Measure #3: All regulatory/legal documentation must be finalized by April 1, 2020. This includes the following documents:

1. Business Associate Agreement (BAA) 2. Data Use Agreement (DUA) 3. IRB 4. MPOG Bylaws

Measure #4: Must hire Anesthesiology Clinical Quality Reviewer (ACQR) by February 1, 2020. The success of the program is greater when the ACQR is hired early in the process. Measure #5: The minimum data requirements must be uploaded into the Multicenter Perioperative Outcomes Group (MPOG) central repository by September 1, 2020. MPOG minimum data requirements can be found on the MPOG website. Measure #6: Data must be of high quality before the September 1, 2020 upload. The ASPIRE team will assist in determining if data is approved for upload to MPOG. Measure #7: Timeliness of responses to the coordinating center requests. The ASPIRE team will evaluate response rates.

https://mpog.org/join-55/mindataelements/

https://mpog.org/join-55/mindataelements/

Measure Weight Measure DescriptionPCI

PointsVS

Points2020 Meeting Participation ‐ Clinician Lead

2 Meetings 5 51 Meeting 2.5 2.5Did not participate 0 0

Meets all expectations (1 Year FU >80%) 2.5 2.5Meets most expectations (1 Year FU 60‐79%) 1 1Does not meet expectations (1 Year FU <60%) 0 0PCI Participation Goal ‐ Internal Case Reviews

Submitted reviews for ≥90% of cases 5 NASubmitted reviews for <90% of cases 0 NAPCI Participation Goal ‐ Physicians Complete Cross Site Review of Assigned Cases for

Procedural Indications and Technical Quality

Submitted reviews for 100% of cases 5 NASubmitted reviews for <100% of cases 0 NANEW ‐Vascular Surgery Collaborative Goal ‐ Statin at Discharge

≥95% NA 12.5<95% ≥93% NA 10<93% ≥90% NA 5<90% NA 0

≥70% NA 10<70% ≥65% NA 7.5<65% ≥60% NA 5<60% NA 0NA (No EVAR discharges) NA 0

≥70% NA 10<70% ≥65% NA 7.5<65% ≥60% NA 5<60% NA 0NEW ‐ PCI Performance Goal: Peak Intra‐Procedure ACT recorded

≥90% 12.5 NA<90% ≥80% 10 NA<80% ≥70% 5 NA<70% 0 NANEW ‐ PCI Performance Goal ‐ Percent of cases with peak ACT ≥350 seconds for Heparin‐only cases

≤15% 10 NA>15% ≤25% 7.5 NA>25% ≤35% 5 NA>35% 0 NA

2020 BMC2 (PCI & Vascular Surgery) Collaborative Quality Initiative



3

5

5

1 10

2

2020 Data Coordinator Expectations (Vascular Surgery: Includes 1 year follow‐up ≥80%)

5

4

6

8 12.5

5

7 10

12.5

10

NEW ‐ Vascular Surgery Performance Goal – Surgeons to prescribe a maximum of 10 Opioid pills for CEA and

consider using the Pain Control Optimization Pathway and prescribing 4 pills:

NEW ‐ Vascular Surgery Performance Goal – Surgeons to prescribe a maximum of 10 Opioid pills for EVAR

and consider using the Pain Control Optimization Pathway and prescribing 4 pills:

9 10


Measure Weight Measure DescriptionPCI

PointsVS

Points

2020 BMC2 (PCI & Vascular Surgery) Collaborative Quality Initiative



NEW ‐ PCI Performance Goal ‐ Percent of cases with peak ACT ≥300 seconds for Heparin+GPI cases

≤15% 10 NA>15% ≤25% 7.5 NA>25% ≤35% 5 NA>35% 0 NANEW ‐ PCI Collaborative Goal ‐ Lipid Lowering Agent prescribed at discharge

≥98% 10 NA<98% ≥ 94% 7.5 NA<94% 0 NA

11 10

10 10

28 sites participate in PCI & Vascular Surgery


Measure Weight Measure Description PCI Points

2020 Meeting Participation ‐ Clinician Lead

2 Meetings 51 Meeting 2.5Did not participate 0

2020 Data Coordinator Expectations

Meets all expectations 5Meets most expectations 2.5Does not meet expectations 0

PCI Participation Goal ‐ Internal Case Reviews

Submitted reviews for ≥90% of cases 10Submitted reviews for <90% of cases 0

PCI Participation Goal ‐ Physicians Complete Cross Site Review of Assigned Cases for

Procedural Indications and Technical Quality (based on 2018 cases)

Submitted reviews for 100% of cases 10Submitted reviews for <100% of cases 0

NEW ‐ PCI Performance Goal: Peak Intra‐Procedure ACT recorded

≥90% 17.5<90% ≥80% 15<80% ≥70% 10<70% 0NEW ‐ PCI Performance Goal ‐ Percent of cases with peak ACT ≥350 seconds for Heparin‐only cases

≤15% 17.5>15% ≤25% 15>25% ≤35% 10>35% 0NEW ‐ PCI Performance Goal ‐ Percent of cases with peak ACT ≥300 seconds for Heparin+GPI cases

≤15% 17.5>15% ≤25% 15>25% ≤35% 10>35% 0

NEW ‐ PCI Collaborative Goal ‐ Lipid Lowering Agent prescribed at discharge

≥98% 17.5<98% ≥94% 10<94% 0

10 17.5

11 17.5

5 sites participate in PCI only

8 17.5

9 17.5

4 10

3 10

2020 BMC2 (PCI Only) Collaborative Quality Initiative



1 5

2 5


Measure Weight Measure Description VS Points

2020 Meeting Participation ‐ Clinician Lead

2 Meetings 151 Meeting 10Did not participate 0

2020 Data Coordinator Expectations (Vascular Surgery: Includes 1 year follow‐up ≥80%)

Meets all expectations (1 Year FU ≥80%) 15Meets most expectations (1 Year FU 60‐79%) 10Does not meet expectations (1 Year FU <60%) 0

NEW ‐Vascular Surgery Collaborative Goal ‐ Statin at Discharge

≥95% 20<95% ≥93% 15<93% ≥90% 10<90% 0

NEW ‐ Vascular Surgery Performance Goal – Surgeons to prescribe a maximum of 10 Opioid

pills for EVAR and consider using the Pain Control Optimization Pathway and prescribing 4

pills:

≥70% 25<70% ≥65% 20<65% ≥60% 15<60% 0NA (no EVAR discharges) 0

NEW ‐ Vascular Surgery Performance Goal – Surgeons to prescribe a maximum of 10 Opioid

pills for CEA and consider using the Pain Control Optimization Pathway and prescribing 4 pills:

≥70% 25<70% ≥65% 20<65% ≥60% 15<60% 0NA (No CEA discharges) 0

1 15

2

2020 BMC2 (Vascular Surgery Only) Collaborative Quality Initiative



6 sites participate in Vascular Surgery only

15

205

7 25

6 25



2020 Michigan Hospital Medicine Safety Consortium Collaborative Quality Initiative Performance Index – Supporting Documentation

1 Registry data assessed at year end based on data submitted during calendar year 2020. All required cases must be completed by year end. Final due date will be announced by Coordinating Center. Both semi-annual QI activity surveys must be completed by due dates announced by Coordinating Center.

2 Assessed based on scores received for site audits conducted during calendar year 2020. Scores are averaged if multiple audits take place during the year.

3 For audits conducted during the calendar year, audit case corrections must be completed or discrepancies addressed within 3 months of audit summary receipt (due date for case corrections provided in audit summary).

4 Based on all meetings scheduled during calendar year 2020. Clinician lead or designee must be a physician as outlined in Hospital Expectations.

5 Assessed at year end based on final quarter of data entered (per the data collection calendar) in the data registry during the performance year 2020. To determine the final score, an adjusted statistical model will be utilized. The method for obtaining each hospital’s adjusted performance measurement utilizes all available data from the most recent 4 quarters. The collaborative wide average and collaborative wide improvement or decline, as well as the average rate change over time of each individual hospital are incorporated into the final adjusted rate. Each hospital’s adjusted rate reflects both change in performance over time and overall performance relative to the collaborative averages. The adjusted performance is a more stable and reliable estimate of each hospitals current performance, their performance relative to collaborative as a whole, and reflects the improvement work each hospital is doing over a given performance year. 6 Considered appropriate if 6 or few days of antibiotic treatment 7Rate of change is based on the adjusted method and may not reflect raw rates from quarter to quarter 8Non preferred Fluoroquinolone use is either due to treatment of Asymptomatic Bacteriuria (ASB) or treatment of UTI when there is a safer oral antibiotic alternative

9 Assessed based on treatment on day 2 or later of the entire hospital encounter. 10 Out of all positive urine culture cases

11Assessed based on all patients with eGFR available. If eGFR is not entered into the data registry, the Coordinating Center will calculate it if all elements necessary to do the calculation are available. 12 Assessed at year end based on the collaborative-wide average for the final quarter of data entered (per the data collection calendar) in the data registry during the calendar year 2020. This is different than the other performance measures in the index, which are applied to each individual hospital. New hospitals joining HMS in 2020 will not be used to calculate the collaborative average.


Timeliness of HMS Data 1

On time > 95% 5On time < 95% 0

Completeness1 and Accuracy2,3of HMS Data

≥ 95% of registry data complete & accurate, semi‐annual QI activity surveys completed, AND audit case corrections completed by due date

5

< 95% of registry data complete & accurate, semi‐annual QI activity survey not completed OR audit case corrections not completed by due date 0

Consortium‐wide Meeting Participation4 – clinician lead or designee

3 meetings 102 meetings 51 meeting 0No meetings 0

Consortium‐wide Meeting Participation4 – data abstractor, QI staff, or other


Increase Use of 5 Days of Antibiotic Treatment6 in Uncomplicated CAP (Community Acquired

Pneumonia) Cases5 (i.e. reduce excess durations)

≥ 50% uncomplicated CAP cases receive 5 days6 of antibiotics OR≥ 50% relative increase in the number of uncomplicated CAP cases that receive 5 days of antibiotics during the current performance year7

15

35‐49% uncomplicated CAP cases receive 5 days6 of antibiotics OR25‐49% relative increase in the number of uncomplicated CAP cases that receive 5 days of antibiotic during the current performance year7

10

< 35% uncomplicated CAP cases receive 5 days6 of antibiotics AND< 25% relative increase during the current performance year7

0

Reduce Fluoroquinolone Use8 in Patients with a Positive Urine Culture5

< 15% of positive urine culture cases receive non‐preferred Fluoroquinolone 1016‐25% of positive urine culture cases receive non‐preferred Fluoroquinolone 5> 25% of positive urine culture cases receive non‐preferred Fluoroquinolone 0

≤ 15% of positive urine culture cases treated with an antibiotic are ASB cases 10 16‐25% of positive urine culture cases treated with an antibiotic are ASB cases 5> 25% of positive urine culture cases treated with an antibiotic are ASB cases 0

Reduce PICCs (Peripherally‐Inserted Central Catheters) in for ≤ 5 Days (excluding deaths)5

≤ 10% of PICC cases in for ≤ 5 Days 1511‐15% of PICC cases in for ≤ 5 Days 10> 15% of PICC cases in for ≤ 5 Days 0

≥ 80% of non‐ICU PICC cases have a single lumen 15 60‐79% of non‐ICU PICC cases have a single lumen 10< 60% of non‐ICU PICC cases have a single lumen 0

4 10

2020 Michigan Hospital Medicine Safety Consortium Collaborative Quality Initiative


Measurement Period: 08/06/2020‐11/11/2020 (PICC Insertions/Hospital Discharges)

6 10

5 15

1 5

2 5

3 10

8 15

7 10

Reduce Use of Antibiotics9 in Patients with ASB (Asymptomatic Bacteriuria) 5,10

159

Increase Use of Single Lumen PICCs in Non‐ICU (Intensive Care Unit) Cases5





Measurement Period: 08/06/2020‐11/11/2020 (PICC Insertions/Hospital Discharges)

Reduce PICCs in Patients with eGFR (estimated glomerular filtration rate) < 45 (without

Nephrology approval)11,12

< 5% collaborative‐wide average of PICC cases have eGFR < 45 without Nephrology approval 5

> 5% collaborative‐wide average of PICC cases have eGFR < 45 without Nephrology approval 0

10 5



Timeliness of HMS Data 1

On time > 95% 25On time < 95% 0

Completeness1 and Accuracy2,3of HMS Data

≥ 95% of registry data complete & accurate, semi‐annual QI activity surveys completed, AND audit case corrections completed by due date

25

< 95% of registry data complete & accurate, semi‐annual QI activity survey not completed OR audit case corrections not completed by due date

0

Consortium‐wide Meeting Participation4 – clinician lead or designee


Consortium‐wide Meeting Participation4 – data abstractor, QI staff, or other


Total (Max points=100)

3 10

4 10



Cohort 2020 (Sites Starting in 2020)

Measurement Period: 01/01/2020‐12/31/2020

1 5

2 5



Project Associate Only Conference Calls (Participation) ‐ 4 calls per year1,2

Project Associate misses no more than 1/4 required calls per calendar year. 5ptsProject Associate misses no more than 2/4 required calls per calendar year. 2ptsProject Associate misses >2/4 required calls per calendar year. 0 pts

Collaborative‐wide Conference Calls (Participation) ‐ 4 calls per year1,2

The cluster has at least one representative from each organization in the cluster, PLUS a Project Associate, present on 4/4 calls per calendar year.

5pts


2pts

The cluster has at least one representative from each organization in the cluster, PLUS a Project Associate, on <3 required calls per calendar year.

0 pts

Collaborative‐wide meetings (Participation) ‐ 3 meetings per year1,3

The cluster has at least one representative from each organization in the cluster, PLUS a Project Associate, in attendance at all three meetings per calendar year.

5pts

The cluster has at least one representative from each organization in the cluster, PLUS a Project Associate, in attendance at 2 of 3 meetings per calendar year.

2pts

The cluster has at least one representative from each organization in the cluster, PLUS a Project Associate, in attendance at <2 of 3 meetings per calendar year.

0pts

Timely Submission of Data (Participation)

The required # of cases for the cluster is submitted on time 11 of 12 months. 5ptsThe required # of cases for the cluster is submitted on time 10 of 12 months. 3ptsThe required # of cases for the cluster is submitted on time <9 of 12 months. 0pts

Data Accuracy (Participation)

Cluster achieves ≥ 90% accuracy on annual audit(s). 10ptsCluster achieves >80% but <90% data accuracy on annual audit(s). 5ptsCluster achieves <80% data accuracy on annual audit(s). 0pts

Intervention Deployment for target population (Participation) 4

Cluster implements and maintains interventions on 80% or > of the target population, in 4/4 quarters throughout 2020, as measured by registry data entered during January‐December 2020.

5pts

Cluster implements and maintains interventions on 80% or > of the target population, in 3/4 quarters of 2020, as measured by registry data entered during January‐December 2020.

2pts

Cluster fails to implement interventions in 80% or > of the target population in a minimum of 3/4 quarters of 2020, as measured by registry data entered during January‐December 2020.

0pts

Site Specific QI Log (Participation)

Both QI logs completed/updated fully and submitted on time AND changes requested by I‐MPACT CC submitted on time.

5pts

1 or more QI logs completed/updated fully and submitted ≤7 calendar days past initial deadline and/or changes requested by I‐MPACT CC submitted ≤7 calendar days past deadline.

2pts

1 or more QI logs completed/updated fully and submitted >7 calendar days past initial deadline and/or changes requested by I‐MPACT CC submitted >7 calendar days past deadline.

0pts

5%

5%

1

2

3

6

5%

5%

5 10%

2020 Integrated Michigan Patient‐centered Alliance in Care Transitions (I‐MPACT) Collaborative Quality Initiative

Performance Index Scorecard ‐ I‐MPACT Year 4/5 (Cohorts 1‐4)


4 5%

7 5%



Patient/Caregiver Engagement (Participation)

Cluster provides at least 2 NEW examples of patient/caregiver advisor utilization/engagement with submission of each QI log (exclusive of advisors coming to collaborative‐wide meetings or participating in monthly calls).

5pts

Cluster provides only one NEW example of patient/caregiver advisor utilization/engagement on 1 or more QI log submissions (exclusive of advisors coming to collaborative‐wide meetings or participating in monthly calls).

2pts

Cluster fails to provide any new examples of patient/caregiver advisor utilization/engagement on 1 or more QI log submissions (exclusive of advisors coming to collaborative‐wide meetings or participating in monthly calls).

0pts

Provider Follow‐up Visits (Performance) 5,6

Based on data entered into the registry during January‐December 2020, Cluster achieves the required 20% increase in follow‐up appointments using the formula below6, compared to the average from data entered during January‐December 2019, unless 90% of all patients have follow‐up appointments scheduled to occur within 7 days of discharge from the hospital; then at least 90% must be maintained.

25pts

Based on data entered into the registry during January‐December 2020, Cluster achieves ≥ 15% but < 20% of the required increase in follow‐up appointments for the year, based on the formula below6, compared to the average from data entered during January‐December 2019.

15pts


7pts

Based on data entered into the registry during January‐December 2020, Cluster achieves < 10% of the required increase in follow‐up appointments for the year, based on the formula below6, compared to the average from data entered during January‐December 2019 OR rate of PCP follow‐up visits drops compared to the average from data entered during January‐December 2019 OR once a cluster reaches 90% or greater, they fall below 90%.

0pts

Emergency Department Utilization (Performance)7

Based on data entered into the registry during January‐December 2020, Cluster achieves a 5% relative reduction in ED utilization in comparison to the average from data entered during January‐December 2019 (ex. If ED utilization is 23% then a 5% relative reduction would be 1.15% resulting in a new ED utilization rate of 21.85%).

15pts

Based on data entered into the registry during January‐December 2020, Cluster achieves a ≥3 but <5% relative reduction in ED utilization each year in comparison to the average from data entered during January‐December 2019 (ex. If ED utilization is 23% then a relative reduction of ≥3 but <5% would equal between .69% and 1.14% resulting in a new ED utilization rate between 22.31% and 21.86%).

7.5pts

Based on data entered into the registry during January‐December 2020, Cluster achieves a >0 and <3% relative reduction in ED utilization each year in comparison to the average from data entered during January‐December 2019 (ex. If ED utilization is 23% then a relative reduction of >0 and <3% would equal between .01% and 0.68% resulting in a new ED utilization rate between 22.99% and 22.32%).

3pts




15%

8 5%

9 25%

10



Based on data entered into the registry during January‐December 2020, Cluster maintains ED utilization (e.g. 0% relative reduction in ED utilization) in comparison to the average from data entered during January‐December 2019 OR ED utilization rate increases over the average for data entered during January‐December 2019.

0pts

Readmission (Performance)8

Based on data entered into the registry during January‐December 2020, Cluster achieves a 5% relative reduction in 30‐day all‐cause readmission rates each year in comparison to the average from data entered during January‐December 2019. (ex. If readmission rate is 23% then a 5% relative reduction would be 1.15% resulting in a new readmission rate of 21.85%).

15pts

Based on data entered into the registry during January‐December 2020, Cluster achieves a ≥3% but <5% relative reduction in 30‐day all‐cause readmission rates each year in comparison to the average from data entered during January‐December 2019. (ex. If readmission rate is 23% then a relative reduction of ≥3 but <5% would equal between .69% and 1.14% resulting in a new readmission rate between 22.31% and 21.86%).

7.5pts

Based on data entered into the registry during January‐December 2020, Cluster achieves a >0 but < 3% relative reduction in 30‐day all‐cause readmission rates each year in comparison to the average from data entered during January‐December 2019 (ex. If readmission rate is 23% then a relative reduction of >0 and <3% would equal between .01% and 0.68% resulting in a new readmission rate between 22.99% and 22.32%).

3pts

Based on data entered into the registry during January‐December 2020, Cluster achieves a 0% relative reduction in 30‐day readmission rates each year in comparison to the average from data entered during January‐December 2019 OR readmission rate increases over the average for data entered during January‐December 2019.

0pts




15%11


7Numerator will count patients abstracted for the registry during 2019 only once i.e. if one patient has multiple ED visits, they will be counted only once. Numerator will be based only on registry data for treat and release ED visits within 30 days of discharge from the index admission. Patients abstracted during the calendar year going to all discharge destinations will be included in the denominator except those discharged against medical advice (AMA).

Comparison will be made to the average ED visit rate for all registry patients abstracted during the prior year.

8 Numerator will count patients abstracted for the registry during 2019 only once i.e. if one patient has multiple unplanned readmissions, they will be counted only once. Patients abstracted during the calendar year going to all discharge destinations will be included in the denominator except those discharged against medical advice (AMA). Planned readmissions will be excluded. Unplanned readmissions during the 30‐day period that follow a planned readmission are counted in the outcome.

Comparison will be made to the average readmission rate for all registry patients abstracted during the prior year.

4The numerator for this measure is patients entered into the registry during the calendar year who were scheduled to receive a 7‐day follow‐up appointment or were identified as receiving any other I‐MPACT related interventions (response options: yes, screened but didn't qualify); the denominator is all patients entered into the registry during the calendar year except those discharged against medical advice (AMA).

5Provider can be Primary Care Physician, Specialist, or NP/PA.

6 To calculate this metric, determine the difference between the cluster’s rate for patients abstracted during 2019 and the threshold of 90%; then add 20% of that difference to the 2019 rate to determine the goal for improvement in 2020. Example: if baseline rate of f/u appointments is 20%, then the formula would be: 90%‐20%=70%; then calculate 20% of that 70% difference = 14%; so the cluster’s target goal for the next year would be 20% + 14% for a total f/u appointment rate of 34%.

The numerator will be all patients in the registry that were abstracted during the calendar year and who were scheduled to see a provider within 7 days of discharge from the hospital or, for the SNF target population, within 7 days of discharge from the SNF.

The denominator for this metric will be all patients in the registry that were abstracted during the calendar year with a discharge destination of Home (with or without Home Health) plus those with a discharge destination of Assisted Living (with or without Home Health).

Footnotes

1If a cluster only has one Project Associate (PA), they must be present for calls and meetings to fulfill the requirements above. If a cluster has more than one PA (i.e. the hospital has their own and the PO has their own), then at least one must be present for calls and meetings to fulfill the requirements above. Participants must be present for 75% of the call to get credit for attendance.

2 Required participants must be present for 75% of the call for it to get credit for attendance.

3Required participants must be present for 75% of the meeting to get credit for attendance.



Project Associate Only Conference Calls (Participation) ‐ 4 calls per year1,2

Project Associate misses no more than 1/4 required calls per calendar year. 7.5ptsProject Associate misses no more than 2/4 required calls per calendar year. 3ptsProject Associate misses >2/4 required calls per calendar year 0 pts

Collaborative‐wide Conference Calls (Participation) ‐ 4 calls per year1,2


7.5pts


3pts

The cluster has at least one representative from each organization in the cluster, PLUS a Project Associate, on <3 required calls per calendar year.

0 pts

Collaborative‐wide meetings (Participation) ‐ 3 per year1,3

The cluster has at least one representative from each organization in the cluster, PLUS a Project Associate, in attendance at all three meetings per calendar year. 10pts

The cluster has at least one representative from each organization in the cluster, PLUS a Project Associate, in attendance at 2 of 3 meetings per calendar year.

5pts

The cluster has at least one representative from each organization in the cluster, PLUS a Project Associate, in attendance at <2 of 3 meetings per calendar year.

0pts

Timely Submission of Data (Participation)

The required # of cases for the cluster is submitted on time 11 of 12 months. 10ptsThe required # of cases for the cluster is submitted on time 10 of 12 months. 5ptsThe required # of cases for the cluster is submitted on time 9 of 12 months. 2ptsThe required # of cases for the cluster is submitted on time <9 of 12 months. 0ptsData Accuracy (Participation)

Cluster achieves ≥ 90% accuracy on annual audit(s). 10ptsCluster achieves >80% but <90% data accuracy on annual audit(s). 5ptsCluster achieves <80% data accuracy on annual audit(s). 0pts

Intervention Deployment for target population (Participation) 4

Cluster implements and maintains interventions on 65% or > of the target population, in 4/4 quarters throughout 2020, as measured by registry data entered during January‐December 2020.

5pts

Cluster implements and maintains interventions on 65% or > of the target population, in 3/4 quarters of 2020, as measured by registry data entered during January‐December 2020.

2pts

Cluster fails to implement interventions in 65% or > of the target population in a minimum of 3/4 quarters of 2020, as measured by registry data entered during January‐December 2020.

0pts

Site Specific QI Log (Participation)

Both QI logs completed/updated fully and submitted on time AND changes requested by I‐MPACT CC submitted on time.

5pts

1 or more QI logs completed/updated fully and submitted ≤7 calendar days past initial deadline and/or changes requested by I‐MPACT CC submitted ≤7 calendar days past deadline.

2pts

1 or more QI logs completed/updated fully and submitted >7 calendar days past initial deadline and/or changes requested by I‐MPACT CC submitted >7 calendar days past deadline.

0pts

5%

10%


Performance Index Scorecard ‐ Site Participation Year 2 (Cohort 5)


3

4

5%7

5

1

2

7.5%

7.5%

10%

10%

6



Patient/Caregiver Engagement (Participation)

Cluster provides at least 2 NEW examples of patient/caregiver advisor utilization/engagement with submission of each QI log (exclusive of advisors coming to collaborative‐wide meetings or participating in monthly calls).

5pts

Cluster provides only one NEW example of patient/caregiver advisor utilization/engagement on 1 or more QI log submissions (exclusive of advisors coming to collaborative‐wide meetings or participating in monthly calls).

2pts

Cluster fails to provide any new examples of patient/caregiver advisor utilization/engagement with submission of each QI log (exclusive of advisors coming to collaborative‐wide meetings or participating in monthly calls).

0pts

Provider Follow‐up Visits (Performance) 5,6

Based on data entered into the registry during January‐December 2020, Cluster achieves the required 20% increase in follow‐up appointments using the formula below6, compared to the average from data entered during January‐December 2019, unless 90% of all patients have follow‐up appointments scheduled to occur within 7 days of discharge from the hospital; then at least 90% must be maintained.

20pts


10pts

Based on data entered into the registry during January‐December 2020, Cluster achieves ≥ 10% but < 15% of the required increase in follow‐up appointments for the year, based on the formula below6 compared to the average from data entered during January‐December 2019.

4pts

Based on data entered into the registry during January‐December 2020, Cluster achieves < 10% of the required increase in follow‐up appointments for the year, based on the formula below6, compared to the average from data entered during January‐December 2019 OR rate of PCP follow‐up visits drops compared to the average from data entered during January‐December 2019 OR once a cluster reaches 90% or greater, they fall below 90%.

0pts

Emergency Department Utilization (Performance)7

Based on data entered into the registry during January‐December 2020, Cluster achieves a 5% relative reduction in ED utilization in comparison to the average from data entered during January‐December 2019 (ex. If ED utilization is 23% then a 5% relative reduction would be 1.15% resulting in a new ED utilization rate of 21.85%).

20pts

Based on data entered into the registry during January‐December 2020, Cluster achieves a ≥3 but <5% relative reduction in ED utilization each year in comparison to the average from data entered during January‐December 2019 (ex. If ED utilization is 23% then a relative reduction of ≥3 but <5% would equal between .69% and 1.14% resulting in a new ED utilization rate between 22.31% and 21.86%).

10pts

Based on data entered into the registry during January‐December 2020, Cluster achieves a >0 and <3% relative reduction in ED utilization each year in comparison to the average from data entered during January‐December 2019 (ex. If ED utilization is 23% then a relative reduction of >0 and <3% would equal between .01% and 0.68% resulting in a new ED utilization rate between 22.99% and 22.32%).

4pts




8

25%9

10 15%

5%



Based on data entered into the registry during January‐December 2020, Cluster maintains ED utilization (e.g. 0% relative reduction in ED utilization) in comparison to the average from data entered during January‐December 2019 OR ED utilization rate increases over the average for data entered during January‐December 2019.

0pts





6 To calculate this metric, determine the difference between the cluster’s rate for patients abstracted during 2019 and the threshold of 90%; then add 20% of that difference to the 2019 rate to determine the goal for improvement in 2020. Example: if baseline rate of f/u appointments is 20%, then the formula would be: 90%‐20%=70%; then calculate 20% of that 70% difference = 14%; so the cluster’s target goal for the next year would be 20% + 14% for a total f/u appointment rate of 34%.

The numerator will be all patients in the registry that were abstracted during the calendar year and who were scheduled to see a provider within 7 days of discharge from the hospital or, for the SNF target population, within 7 days of discharge from the SNF.

The denominator for this metric will be all patients in the registry that were abstracted during the calendar year with a discharge destination of Home (with or without Home Health) plus those with a discharge destination of Assisted Living (with or without Home Health).

7Numerator will count patients abstracted for the registry during 2019 only once i.e. if one patient has multiple ED visits, they will be counted only once. Numerator will be based only on registry data for treat and release ED visits within 30 days of discharge from the index admission. Patients abstracted during the calendar year going to all discharge destinations will be included in the denominator except those discharged against medical advice (AMA).

4The numerator for this measure is patients entered into the registry during the calendar year who were scheduled to receive a 7‐day follow‐up appointment or were identified as receiving any other I‐MPACT related interventions (response options: yes, screened but didn't qualify); the denominator is all patients entered into the registry during the calendar year except those discharged against medical advice (AMA).

5Provider can be Primary Care Physician, Specialist, or NP/PA.

Footnotes

1If a cluster only has one Project Associate (PA), they must be present for calls and meetings to fulfill the requirements above. If a cluster has more than one PA (i.e. the hospital has their own and the PO has their own), then at least one must be present for calls and meetings to fulfill the requirements above. Participants must be present for 75% of the call to get credit for attendance.

2 Required participants must be present for 75% of the call for it to get credit for attendance.

3Required participants must be present for 75% of the meeting to get credit for attendance.



DOAC Dashboard implementation

Fully functional dashboard and clinical workflow* 20 Alpha version of Dashboard completed with approved preliminary clinical workflow 15 Dashboard programming and development of clinical workflow underway 10 Dashboard programming approved and added to IT project list 5 Unable to gain approval for Dashboard development 0Inappropriate aspirin use in warfarin patients (consortium‐wide measure)

≤7% of active patients 208‐9% of active patients 1510‐11% of active patients 1012‐13% of active patients 5≥14% of active patients 0Inappropriate aspirin use in warfarin patients (site‐level)

≤7% of active patients 208‐9% of active patients 1510‐11% of active patients 1012‐13% of active patients 5≥14% of active patients 0Achievement of 2019 National Patient Safety Goals for Anticoagulation Management

8 goals fully achieved and documented 10 7 goals fully achieved and documented 8 6 goals fully achieved and documented 6 ≤5 goals fully achieved and documented 0Quarterly Meetings participation ‐Clinical Champion

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 0Quarterly Meeting participation – Coordinator/Lead Abstractor

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 0Completeness and Accuracy of data

Critical data elements are complete/accurate in >90% of cases 10 Critical data elements are complete/accurate in 70‐89% of cases 5 Critical data elements are complete/accurate in <70% of cases 0

* The expectation for fully functional dashboard is dependent on the Coordinating Center providing sites with the necessary EPIC source code and instructions before the end of 2019.

6

7

20

10

10

10

5

2020 MAQI Collaborative Quality Initiative

Performance Index Scorecard (EPIC EMR sites*)


4 10

3

2 20

1 20



Inappropriate aspirin use in warfarin patients (consortium‐wide measure)

≤7% of active patients 308‐9% of active patients 2010‐11% of active patients 1012‐13% of active patients 5≥14% of active patients 0

Inappropriate aspirin use in warfarin patients (site‐level)

≤7% of active patients 308‐9% of active patients 2010‐11% of active patients 1012‐13% of active patients 5≥14% of active patients 0

Achievement of 2019 National Patient Safety Goals for Anticoagulation Management

8 goals fully achieved and documented 10

7 goals fully achieved and documented 8

6 goals fully achieved and documented 6 ≤5 goals fully achieved and documented 0

Quarterly Meetings participation ‐Clinical Champion

attended all 4 meetings 10

attended 3 out of 4 meetings 8


attended 1 out of 4 meetings 4did not attend any meetings 0

Quarterly Meeting participation – Coordinator/Lead Abstractor

attended all 4 meetings 10



attended 1 out of 4 meetings 4did not attend any meetings 0

Completeness and Accuracy of data

Critical data elements are complete/accurate in >90% of cases 10

Critical data elements are complete/accurate in 70‐89% of cases 5 Critical data elements are complete/accurate in <70% of cases 0

5

6

30

10

10

10

4

2020 MAQI Collaborative Quality Initiative

Performance Index Scorecard (non‐EPIC EMR sites*)


3 10

2

1 30



MAQI2 2019 P4P Index Supporting Info 2019 National Patient Safety Goals for Anticoagulation Management

1. Use approved protocols and evidence-based practice guidelines for the initiation and maintenance of anticoagulant therapy that address medication selection; dosing, including adjustments for age and renal or liver function; drug–drug interactions; and other risk factors as applicable.

2. Use approved protocols and guidelines for reversal of anticoagulation and management of bleeding events related to each anticoagulant medication, including the use of reversal agents and bleeding management modalities.

3. Before starting a patient on warfarin, assess the patient’s baseline coagulation status; for all patients receiving warfarin therapy, use a current International Normalized Ratio (INR) to monitor and adjust this therapy. The baseline status and current INR are documented in the clinical record.

4. Use evidence-based resources and guidelines to manage potential drug–drug and drug–food interactions for patients receiving oral anticoagulants.

5. Before starting a patient on a direct oral anticoagulant (DOAC), follow evidence-based practice guidelines regarding the need for any baseline and ongoing laboratory tests that may be required to monitor the patient on a DOAC. The organization has a written policy concerning the need to monitor laboratory tests for these patients.

6. The organization has a process developed using evidence-based practice guidelines for perioperative management of all patients on oral anticoagulants. The process addresses the following for each oral anticoagulant:

• Situations in which the anticoagulant is stopped prior to the procedure

• Timing for stopping the anticoagulant and length of time it should be held

• Timing and dosing for restarting the anticoagulant

7. Provide education to patients and families specific to the anticoagulant medication prescribed, including the following:

• Adherence to medication dosing and schedule

• Importance of follow-up laboratory testing (if applicable) and physician appointments

• Potential drug–drug and drug–food interactions

• The potential for adverse drug reactions

8. The organization has a written policy that addresses anticoagulation safety practices, including the following:

• The identification and reporting of adverse drug events, including outcomes and actions taken

• Evaluation of the effectiveness of those actions in a time frame determined by the organization


% of Opioid naïve THA patients in the COLLABORATIVE meeting the MARCQI Pain Optimization

Prescribing guidelines ( <240 OME ) * 1/1/20‐6/30/20

guidelines ( <240 OME ) * 1/1/20‐6/30/20

75% or greater of THA patients meet the guidelines of 240 OME or less 550‐74% of THA patients prescribed <240 OME 2.5Less than 50% of patients meet the prescribing criteria 0% of Opioid naïve TKA patients at the SITE meeting the MARCQI Pain Optimization Protocol

2020 MARCQI Collaborative Quality Initiative


Measurement Period: 07/01/2019‐06/30/2020OME Metric measurement period: 01/01/2020‐06/30/2020

5

10

10

5


Prescribing guidelines ( <320 OME)* 1/1/20‐6/30/20

75% or greater of TKA patients meet the guidelines of 320 OME or less 550‐74% of TKA patients prescribed <320 OME or less 2.5Less than 50% of patients meet the prescribing criteria 0

75% or greater of THA patients meet the guidelines of 240 OME or less 1050‐74% of THA patients prescribed <240 OME 5Less than 50% of patients meet the prescribing criteria 0% of Opioid naïve TKA patients in the COLLABORATIVE meeting the MARCQI Pain Optimization

Protocol Prescribing guidelines (<320 OME)* 1/1/20‐6/30/20

75% or greater of TKA patients meet the guidelines of 320 OME or less 1050‐74% of TKA patients prescribed <320 OME or less 5Less than 50% of patients meet the prescribing criteria 0% of Opioid naïve THA patients at the SITE meeting the MARCQI Pain Optimization Prescribing

1

2

3

4


PROS Collection: Pre‐op and post‐op HOOS ‐JR or KOOS‐JR + PROMIS (Overall average

as of 6/30/20. 2‐16 week post‐op accepted. )

The site is awarded full points for collection rates of 60%+ 20The site is awarded partial points for collection rates >35%‐<60 10The site is not awarded points if collection is less than 35% 0

2020 MARCQI Collaborative Quality Initiative



9 20



Grade 1 Complication: (October 1, 2019‐September 30, 2020) *Adjusted; Rounded to nearest whole number*

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

Serious Complication Rate: (October 1, 2019‐September 30, 2020) *Adjusted; Rounded to one decimal point*

0% to ≤2.4% rate 10>2.4% to ≤2.7% rate 5>2.7% rate 0Improvement/Excellence In Grade 1 Complication Rate: (Data trended over a 3‐yr period from October 1, 2017 to September 30, 2020)*Z-Score rounded to nearest whole number*Major improvement (z-score less than -1 or Grade 1 complication rate ≤4%) 10Moderate improvement/maintained complication rate (z-score between 0 and -1) 5No 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, 2017 to September 30, 2020)*Z-Score rounded to nearest whole number*Major improvement (z-score less than -1 or serious complication rate ≤2.4%) 10Moderate improvement/maintained complication rate (z-score between 0 and -1) 5No improvement/rates of serious complications increased (z-score ≥0) 01-Year Follow-up Rates (For OR dates of October 1, 2018 to September 30, 2019) *Adjusted; Rounded to nearest whole number*≥63% OR > 5% relative improvement from previous year (10/1/2016-9/30/2017) 10Maintained 1-year follow-up rate/ >0 to <5% relative improvement from previous year (10/1/2016-9/30/2017) 51-year follow-up rate decreased/No improvement in 1-year follow-up rate (10/1/2016-9/30/2017) 0Compliance with VTE prophylaxis - Pre-operatively: (Calendar Year 2020) *Unadjusted; Rounded to nearest whole number*

≥92% compliance with guidelines 2.50 to 91% compliance with guidelines 0Compliance with VTE prophylaxis - Post-operatively:(Calendar Year 2020) *Unadjusted; Rounded to nearest whole number*

≥91% compliance with guidelines 2.50 to 90% compliance with guidelines 0

Opioid Use - Opioid prescriptions within 30 days ***Collaborative wide measure, (October 1, 2019 to September 30, 2020)

> 10% relative reduction in opioid use 105‐9% relative reduction in opioid use 5< 5% relative reduction 0

7 5

108

5

6

2020 Michigan Bariatric Surgery



10

10

10

5

4

1 15

3

2 10



2020 Michigan Bariatric Surgery



Meeting Attendance - Surgeon: (Calendar Year 2020) **In order for a surgeon to earn meeting attendance credit for a hospital, they must complete 10 bariatric surgery cases at that hospital for the dates of 1/1/2020 to 12/31/2020

Attended 3 out of 3 meetings 5Attended 2 out of 3 meetings 3Attended fewer than 2 meetings 0Meeting Attendance - Abstractor/Coordinator: (Calendar Year 2020)Attended 3 out of 3 meetings 5Attended 2 out of 3 meetings 3Attended fewer than 2 meetings 0

Timely Monthly Data Submissions (30-day information & registry paperwork): (Submitted to coordinating center by the last business day of each month ‐ Please refer to 2019 Data Entry Deadlines Spreadsheet) (Calendar Year 2020) *****In order to be eligible for this measure, you must achieve >90% on the 2019 yearly audit when applicable. If the hospital does not reach >90% for the yearly audit, they will receive 0 points for this measure.

On time 11-12 months 5On time 10 months 3On time 9 months or less 0Consent Rate: (October 1, 2019 to September 30, 2020) *Unadjusted; Rounded to nearest whole number*≥90% consented patients 580-89% consented patients 3<80% consented patients 0Physician Engagement: (January 1, 2020 to December 31, 2020) 10

** 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.** ***In order for a surgeon to earn points for a hospital, they must complete 10 bariatric surgery cases at that hospital for the dates of 1/1/2020 to 12/31/2020

Following items count as 1 activity point:

Committee participation

MBSC survey response

Coauthor a paperAttend or present at the Education Committee session on the day of the MBSC tri-annual meetingPresent MBSC data at a MBSC tri-annual meeting

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

Following items count as 2 activity points:

Present MBSC data at a national meeting

Lead author on an MBSC publication

No participation 0Total 100

12 5

1013

9 5

10 5

11 5



Data Delivery: Timeliness

All data transfers on time 1275‐99% of data transfers on time 6< 75% of data transfers on time 0Data Delivery: Adherence & Accuracy

All data transfers adhere to MEDIC data dictionary and are accurate 1275‐99% of data transfers adhere to MEDIC data dictionary and are accurate 6< 75% of data transfers adhere to MEDIC data dictionary and are accurate 0Abstraction: Timeliness

All cohort cases abstracted within 30 days of load and/or <2 weeks worth of backlogged data 12

75‐99% of cohort cases abstracted within 30 days of load and/or > 2 weeks worth of backlogged data

6

<75% of cohort cases abstracted within 30 days of load and/or >2 weeks worth of backlogged data

0

Meeting Attendance: Clinical Champion

Attend All Meetings 12Miss 1 Meeting 6Miss >1 Meeting 0Meeting Attendance: Data Abstractor

Attend All Meetings 12Miss 1 Meeting 6Miss >1 Meeting 0Completion of Agreements (including but not limited to Particiation Agreement, Business

Associates Agreement, Data Use Agreement, and IRB if necessary)

Agreements signed and returned to MEDIC within 30 days of receipt 8Agreements signed and returned to MEDIC >30 days of receipt 0Time from Agreement being signed to hiring date of data abstractor

<90 days 1291‐120 days 6>120 days 0Time from Agreements signed to successful submission of electronic production data

<90 days 1291‐120 days 6>120 days 0Intervention Planning for Year 2, including PATH work (Intervention Templates, etc.)

All Year 2 materials complete and submitted on time 8Year 2 materials incomplete and/or submitted late 0

12

2020 Michigan Emergency Department Improvement Collaborative (MEDIC)

Quality Initiative Performance Index Scorecard

Year 1

9

8

12

12

12

12

12

8

6

7

1

2

3

4

5 12

8



Data Delivery: Timeliness

All 12 months of data transfers on time 159‐11 months of data transfers on time 10< 9 months of data transfers on time 5Data Delivery: Adherence & Accuracy

All 12 months of data transfers adhere to MEDIC data dictionary and are accurate 159‐11 months of data transfers adhere to MEDIC data dictionary and are accurate 10< 9 months of data transfers adhere to MEDIC data dictionary and are accurate 5Abstraction: Timeliness

All cohort cases abstracted within 30 days of load and <2 weeks worth of backlogged data 1075‐99% of cohort cases abstracted within 30 days of load and/or > 2 weeks worth of backlogged data

5


0



Attend All Meetings 10Miss 1 Meeting 5Miss >1 Meeting 0Abstraction: Accuracy of Annual Data Audit

>97% of abstracted registry data accurate 10<97% of abstracted registry data accurate 5Site Specific ‐ Alternatives to Hospitalization Improvement Initiative *Measures and targets

identified in AppendixQI Project developed and implemented and site increased safe discharge rate for chosen condition relative to baseline

20

QI Project developed and implemented but site did not increase safe discharge rate for chosen condition relative to baseline

15

QI Project not developed or implemented 0Collaborative‐Wide Measure: Adult Minor Head Injury *Measures and targets identified in

Appendix

Met Adult Minor Head Injury Target 5Did not meet target 0Collaborative‐Wide Measure: Pediatric Minor Head Injury *Measures and targets identified in

Appendix

Met Pediatric Minor Head Injury Target 5Did not meet target 0

8 5

9 5

2020 Michigan Emergency Department Improvement Collaborative (MEDIC) Quality Initiative


Year 2


4

5

10

20

10

10

6

7

1

2

3

15

15

10


Measure Weight Measure Description PointsData Delivery: Timeliness

All 12 months of data transfers on time 59‐11 months of data transfers on time 3< 9 months of data transfers on time 0Data Delivery: Adherence & Accuracy

All 12 months of data transfers adhere to MEDIC data dictionary and are accurate 59‐11 months of data transfers adhere to MEDIC data dictionary and are accurate 3< 9 months of data transfers adhere to MEDIC data dictionary and are accurate 0Abstraction: Timeliness

All cohort cases abstracted within 30 days of load and <2 weeks worth of backlogged data 575‐99% of cohort cases abstracted within 30 days of load and/or > 2 weeks worth of backlogged data

3


0



Attend All Meetings 5Miss 1 Meeting 3Miss >1 Meeting 0Abstraction: Accuracy of Annual Data Audit

>97% of abstracted registry data accurate 5<97% of abstracted registry data accurate 3

Site Specific ‐ Alternatives to Hospitalization Improvement Initiative *Measures and targets

identified in Appendix

QI Project developed and implemented and site increased safe discharge rate for chosen condition relative to baseline

30

QI Project developed and implemented but site did not increase safe discharge rate for chosen condition relative to baseline

20

QI Project not developed or implemented 0Collaborative‐Wide Measure: Adult Minor Head Injury *Measures and targets identified in

Appendix

Met Adult Minor Head Injury Target 5Did not meet target 0Collaborative‐Wide Measure: Pediatric Minor Head Injury *Measures and targets identified in

Appendix

Met Pediatric Minor Head Injury Target 5Did not meet target 0

1

2

3

5

5

5

9 5



Years 3+

4

5

6

5

5

5

5

307

8





Years 3+

Site Specific ‐ Quality Improvement Initiative *Measures and targets identified in Appendix

QI Project developed and implemented and site met or exceeded target 30QI Project developed and implemented and site made improvement to the target 20QI Project developed and implemented but there was no improvement to the target 10QI Project not developed or implemented 0

*Cohort 3 sites that have not worked on either QI initiative yet

3010

For site‐specific quality improvement initiatives for which you have already met or exceeded the target and are not actively working on in this performance period, it is expected that your site will maintain performance to within a relative 10% of the target. If you fail to do so your site will lose 5 points. (e.g. if the target is above 25% then your site will lose points if you achieve <22.5%.)



High Quality Clinical and Physics Data Submission¹

Four Metrics Met 10Three Metrics Met 8Two Metrics Met 4One Metric Met 2None Met 0Submission of Technical Data (Full DICOM‐RT data and Physics Radiotherapy Technical Details

Survey)

>85% of technical data submitted within six weeks of treatment completion 5>85% of technical data submitted within eight weeks 4>85% of technical data submitted within twelve weeks 3>85% of technical data submitted after twelve weeks 2<85% of technical data submitted after twelve weeks 0Collaborative‐wide Measure: Omission of breast boost in women age 70 years or older with

early‐stage breast cancer²30% or fewer of select patients receive boost 1431‐50% of select patients receive boost 7>50% of select patients receive boost 0

Mean heart dose achieved in breast patients not receiving radiotherapy to regional nodes

85% or more of patients meet the appropriate threshold³ 1460‐84% of patients meet the appropriate threshold 7<60% of patients meet the appropriate threshold 0

80% or greater compliance for the specified structures 760‐79% compliance for the specified structures 3<60% compliance for the specified structures 0

65% or more patients meet target coverage and heart sparing goals 1450‐64% of patients meet target coverage and heart sparing goals 7<50% of patients meet target coverage and heart sparing goals 0

50% or greater compliance for the specified structures 730‐49% compliance for the specified structures 3<30% compliance for the specified structures 0Rate of single fraction treatment of uncomplicated⁶ bone metastasis

>20% of patients with an uncomplicated bone metastasis are treated with a single fraction 14

11‐20% of patients with an uncomplicated bone metastasis are treated with a single fraction 7

≤10% of patients with an uncomplicated bone metastasis are treated with a single fraction 0

8 14

3 14

2020 Michigan Radiation Oncology Quality Consortium (MROQC) Collaborative Quality Initiative



1 10

2 5

7

6 14

7 7

4 14

For lung cancer patients: evaluate Task Group‐263 compliance for the specified structures (heart, PTV,

esophagus, spinal cord or canal, and normal lung⁵) for the initial DICOM entry

For lung cancer patients, ≥ 95% of the Planning Target Volume (PTV) receives ≥100% of the prescription

dose AND the heart mean dose is ≤20 Gray (Gy)

For breast cancer patients: evaluate Task Group‐263 compliance for the specified structures (heart,

breast PTV, lumpectomy cavity PTV, and ipsilateral lung⁴) for the initial DICOM entry

5



Meeting Participation – Clinical Champion (per MROQC CC Attendance Policy)*

All meetings or two meetings with one meeting attended by an acceptable designee 5

Two meetings only 3One meeting or none attended 0Meeting Participation – Physics Lead (or designee)

All meetings 5Two meetings 3One meeting or none attended 0Meeting Participation – Clinical Data Abstractor (or designee)

All meetings 5Two meetings 3One meeting or none attended 0

100

Fewer than 5% of 2020 patients have a quality report error as of 12/31/20.

11 5

AWBI: ≤1.2 Gy (left) ≤.7 Gy (right)

9 5

2020 Michigan Radiation Oncology Quality Consortium (MROQC) Collaborative Quality Initiative



10 5

⁴Ipsilateral lung:

Lung_L Lung_R

¹Data quality metrics

A. Highly accurate data:

Overall data accuracy determined by audit of breast, lung, and bone mets data is ≥95%.B. Sufficient audit preparation and follow‐up:

Audit materials are available for review at the time of auditAppropriate staff member (CDA for clinical data audit and physicist or dosimetrist for physics data audit) is in attendance at the auditCorrections identified during clinical or physics data audit are made within 2 weeks of the audit date.

D. Active use of data quality reports in the Bone Mets database

Fewer than 5% of 2020 patients have a quality report error as of 12/31/20.

² Age ≥70, ER Positive tumors, T1N0/X/M0/X, Grade 1 or 2, Negative (≥2mm) Margins

³2020 Cardiac Dose Thresholds:

Conventional: ≤1.7 Gy (left) ≤1 Gy (right)

C. Active use of data quality reports in the Breast & Lung database

⁵Normal lung ‐one of the following:

Lungs‐GTVLungs‐IGTVLungs‐ITV


⁶ Uncomplicated bone mets definition:

A non‐curative treatment intention

No prior radiation to same anatomic siteNo cord compression, cauda compression or radicular pain at the site being treatedNo prior surgery at the site being treatedNo associated soft tissue massPatient reports any pain



Collaborative Meeting (3) ‐ Surgical Clinical Quality Reviewer (SCQR)

3 meetings 82 meetings 41 meeting 0

Collaborative Meeting (3) ‐ Surgican Champion (SC)

3 meetings 82 meetings 41 meeting 0

2 or more calls 41 call 20 calls 0

2 or more calls 41 call 20 calls 0Accuracy and Completeness of Data

Biennial IRR with score ≥ 95%; or if no IRR in current year, > 90% of eligible cases are captured on case upload for a targeted cycle

3

Sampled and incomplete cases < 0.5% total volume 3Collaborative Wide Measure ‐ Increase Response Rate to PROs survey at 30 days post‐surgery

>45% 2040‐45% 1535‐39% 10<35% 0Quality Improvement Initiative

90‐100% 5080‐89% 4070‐79% 3060‐69% 2050‐59% 10<50% of total points earned on QII project 0

7

6

Conference Calls (3) ‐ Surgeon Champion

5

20

50

4

6

4

Conference Calls (3) ‐ SCQR

4

2020 Michigan Surgical Quality Collaborative


Measurement Period: 01/01/2020‐ 12/31/2020

1 8

3

2 8



Quality Improvement Implementation Postoperative Opioid Prescribing

Project Time Period: 1/1/2020 - 12/31/2020 Summary: For the past several years MSQC has worked closely with Michigan OPEN to reduce the number of opioids prescribed after surgery. We have included opioid prescribing QII projects in our P4P program for both 2018 and 2019, which have proven successful in decreasing prescribing over and above the improvements that followed the dissemination of the recommendations to the collaborative. Simultaneously, MSQC has been focused on the development and implementation of care pathways for surgical procedures. Each of the care pathways that have been developed to date (inguinal/femoral hernia, cholecystectomy, colectomy, and hysterectomy) have included similar elements of pain management, which are vital to supporting the practice of reduced opioid prescribing. Michigan OPEN monitors the Patient Reported Outcomes (PROS) data collected from patients at 30 and 90 days postop, in order to monitor that prescribing recommendations have not been lowered to the point that they have had a detrimental effect on patient’s pain and patient satisfaction scores. QI Implementation Requirements: In 2020 each hospital will be asked to identify two procedures for which an MSQC care pathway has been developed, and then undertake a “rapid improvement QI implementation cycle” focused on improving the following for those two procedures: • Preoperative pain management teaching (elective cases only) • Pre/intraop multimodal pain management (all surgical priority) • Postop multimodal pain management (all surgical priority) • Postop pain management teaching (all surgical priority)

The implementation cycle will last approximately six months, encompassing the first half of calendar year 2020. Hospitals will be asked to review their 2019 performance on the four performance measures for the two procedures chosen, and design an intervention aimed at improving their performance in at least two areas in which they are underperforming. For example, a site could choose to focus on both preoperative and postoperative pain management teaching to count as two areas. For sites who focused on the Colectomy Care Pathway project in 2019, work can continue to focus on this pathway, with specific effort devoted to the measures above, with sites choosing one additional procedure to add. For those sites who created pain management pathways as part of their 2019 Opioid prescribing project, this work will be a continuation of that process, now implementing steps identified to be part of those pain pathways. Throughout the year the site will be expected to monitor their performance on patient reported pain and patient satisfaction scores as reported on the 30-day PROs responses.


QI Implementation Goals - 100 total points

Improve the following process measures for the two procedures chosen by the site:

• Close the gap between prescribing at 90% the Michigan OPEN target for each procedure chosen, and baseline performance from quarters 2-3, 2019 to quarters 2-3, 2020 [20 points] − If site is at 90% goal during quarters 2-3 of 2019 (90%) for prescribing at the Michigan OPEN

recommendations for all surgical procedures included in the project (inguinal/femoral hernia, cholecystectomy, colectomy, and hysterectomy), maintain prescribing at this level through quarters 2-3 of 2020.

• 100% of patients (all procedures) will have a complete discharge opioid prescription in the workstation. [10 points]

• For quarters 2-3, 2020, reach 80% compliance on the targeted performance metrics, for the targeted procedures [10 points each measure = 40 total]: − Preoperative pain management teaching (elective cases only) − Pre/intraop multimodal pain management (all surgical priority) − Postop multimodal pain management (all surgical priority) − Postop pain management teaching (all surgical priority)

• Maintain or improve surgical site pain scores reported at 30 day postop, during quarters 2-3, for patients in both procedure groups of focus [10 points each group = 20 points total].

• Complete project report that includes preop and post op education materials to address pain management teaching; document order set and/or the practice model for providing intraop pain management [10 points].

Total points possible = 100

Preoperative Pain Mgt. Teaching

Use of Multimodal pain management

Order of multimodal pain mgt

Postop pain mgt. teaching

Tab: ERP Variable: Preadmission Counseling/Teaching Option: Yes -> Postoperative expectations

Tab: ERP Variable: Intraoperative use of multimodal pain management Option: Yes

Tab: ERP Variable: Order of Postoperative Multimodal Pain Management Option: Yes

Tab: ERP Variable: Postop Teaching Option: Yes ->Pain Management


Meeting participation ‐ Surgeon Champion

Attended all 3 meetings 5Attended 2 out of 3 meetings 3Attended 1 out of 3 meetings 1No Attendance 0Meeting and Abstractor Symposium participation – Clinical Data Abstractor. (If > 1 abstractor

at site, only 1 abstractor need attend tri‐annual meetings, however, all abstractors are

required to attend the annual Abstractor Symposium)

Attended all 4 3Attended 3 out of 4 2Attended 2 out of 4 1Attend 1 or none 0Conference Calls Surgeon Champion (3 calls/year)

Attended 3 calls 5Attended 2 calls 3Attended 1 call 1No Calls 0Conference Calls ‐ Clinical Data Abstractor (8 calls/year)

Participate on 8 calls 3Participate on 7 calls 2Participate on 6 calls 1Participate on less than 6 calls 0Meeting participation ‐ Administrative Lead (no designee)

Attend at least one tri‐annual MSSIC meeting 4No Attendance 0Annual Audit Review – Data Review: Accuracy of data ‐

Complete and accurate 95‐100% of the time 10Complete and accurate 90‐94.9% of the time 5Complete and accurate < 90% of the time 0

Each site: Collection rate of Baseline Patient Reported questionnaires (rates rounded to the

nearest whole number) for PROs due 1/1/20 – 12/31/20

80% or greater 1060%‐79% 5< 60% 0

Each site: Combined collection average rate of Post‐operative Patient Report Outcome (PRO)

questionnaires (rates rounded to the nearest whole number) for PROs due 1/1/20 – 12/31/20

65% or greater 1045%‐64% 5< 45% 0

6 10%

7 10%

8 10%

1 5%

2 3%

2020 Michigan Spine Surgery Improvement Collaborative Quality Initiative

Performance Index Scorecard, Cohort 1, 2, 3

Measurement Period: 10/01/2019‐09/30/2020, unless otherwise stated

3 5%

4 3%

5 4%



2020 Michigan Spine Surgery Improvement Collaborative Quality Initiative

Performance Index Scorecard, Cohort 1, 2, 3


Collaborative‐wide Measure Goal: MSSIC‐All Early Ambulation‐ % of all spine patients

(cervical and lumbar) with first ambulation within 8 hours of surgery stop time (rates rounded

to the nearest whole number)

MSSIC‐All Early Ambulation 70% or greater 20MSSIC‐All Early Ambulation 54‐69% 10MSSIC‐All Early Ambulation < 54% 0

Site Specific: Implementation of one Quality Improvement Initiative using MSSIC data. If a site's lumbar SSI rate is > 2.0% for OR dates 7/1/18 – 6/30/19, they must choose lumbar SSI for their QI Initiative. Otherwise, they may choose a site‐specific initiative approved by the Coordinating Center. The percentage goal of improvement is determined by the Coordinating Center. The time frame to establish a site's baseline rate is 7/1/18 – 6/30/19. The measurement period for improvement is 10/1/19‐9/30/20.

The QI Plan was developed, implemented and there was improvement in the target goal. In addition, both QI Reports were submitted on time. The breakdown is as follows: Site met 100% or greater of the target goal 30Site met 75‐99% of the target goal 26Site met 50‐74% of the target goal 23Site met 1‐49% of the target goal 20The QI Plan was developed and implemented, but there was no improvement to the target goal. In addition, both QI reports were submitted on time.

15

The QI Plan was developed and implemented, but one of the QI reports was not submitted on time.

7

The QI Plan was not developed or implemented; or both QI reports were not submitted on time. 0

9 20%

10 30



Meeting participation ‐ Surgeon Champion

Attended all 3 meetings 15Attended 2 out of 3 meetings 10Attended 1 out of 3 meetings 5No Attendance 0Meeting and Abstractor Symposium participation – Clinical Data Abstractor. (If > 1 abstractor

at site, only 1 abstractor need attend tri‐annual meetings, however, all abstractors are

required to attend the annual Abstractor Symposium)

Attended all 4 10Attended 3 out of 4 6Attended 2 out of 4 3Attend 1 or none 0Conference Calls Surgeon Champion (3 calls/year)

Attended 3 calls 15Attended 2 calls 10Attended 1 call 5No Calls 0Conference Calls ‐ Clinical Data Abstractor (8 calls/year)

Participate on 8 calls 10Participate on 7 calls 6Participate on 6 calls 3Participate on less than 6 calls 0Meeting participation ‐ Administrative Lead (no designee)

Attend at least one tri‐annual MSSIC meeting 10No Attendance 0Annual Audit Review – Data Review: Accuracy of data ‐

Complete and accurate 95‐100% of the time 10Complete and accurate 90‐94.9% of the time 5Complete and accurate < 90% of the time 0All official documents signed: IRB, Data Use Agreement, Business Associate Agreement, and

Software Agreement

Within 2 months of Coordinating Center approval date to proceed 15Within 3 months of Coordinating Center approval date to proceed 12Within 4 months of Coordinating Center approval date to proceed 8Within 5 months of Coordinating Center approval date to proceed 46 or more months of Coordinating Center approval date to proceed 0Hire Data Abstractor in a timely manner

Within 2 months of Coordinating Center approval date to proceed 15Within 3 months of Coordinating Center approval date to proceed 12Within 4 months of Coordinating Center approval date to proceed 8Within 5 months of Coordinating Center approval date to proceed 46 or more months of Coordinating Center approval date to proceed 0

6 10%

7 15%

8 15%

1 15%

2 10%

2020 Michigan Spine Surgery Improvement Collaborative (MSSIC) Quality Initiative

Performance Index Scorecard, Cohort 4, Year 1


3 15%

4 10%

5 10%



Accuracy of data

5‐star audit score 104‐star audit score 83‐star audit score 6

≤ 2‐star audit score 0Quarterly collaborative meeting participation ‐ surgeon lead Attended 4 quarterly meetings; one alternate surgeon * 10 Attended 4 quarterly meetings 8 Attended 3 quarterly meetings; one alternate surgeon 7 Attended 3 quarterly meetings 6

Attended 2 quarterly meetings; one alternate surgeon 5 Attended 2 quarterly meetings 4 Attended 1 quarterly meeting; one alternate surgeon 3 Attended 1 quarterly meeting 2 Attended 0 quarterly meetings 0Quarterly collaborative meeting participation ‐ data manager/representative Attended 4 quarterly meetings 5 Attended 3 quarterly meetings 3

Attended < 3 quarterly meetings 0Quarterly data manager educational meeting ‐ data manager Attended 4 data manager meetings 5 Attended 3 data manager meetings 3

Attended < 3 data manager meetings 0Collaborative‐wide quality initiative 2020: Left atrial appendage ligation for patients with history of atrial fibrillation/flutter. (January 1, 2020–December 31, 2020) Collaborative mean LA ligation rate > 75% 15

Collaborative mean LA ligation 60 ‐ 75 % 5 Collaborative mean LA ligation rate < 60% 0Site specific quality initiative Met improvement goal 15 Improved but did not meet goal 10 Implemented plan but did not improve 5

Unable to implement plan 0Isolated CABG: O/E mortality for 12 months (January 1, 2020–December 31, 2020) O/E ≤ 1.0 20 O/E ≤ 1.5 10

O/E > 1.5 0Isolated AVR: O/E mortality for 36 months (January 1, 2018–December 31, 2020) O/E ≤ 1.0 20 O/E ≤ 1.5 10

O/E > 1.5 0

1 10

2020 Michigan Society of Thoracic and Cardiovascular Surgeons (MSTCVS) Collaborative Quality Initiative



2 10

* alternate surgeon is a non physician champion who performes cardiac surgery at the site

3 5

4 5

5 15

15

7 20

8 20

6



Data Submission

On time and complete 3 of 3 times 10On time and complete 2 of 3 times 5On time and complete 1 of 3 times 0

Meeting Participation

Surgeon, and TPM or MCR participate in 3 of 3 meetings 9Surgeon, and TPM or MCR participate in 2 of 3 meetings 6Surgeon, and TPM or MCR participate in 0‐1 of 3 meetings 0Registrar or MCR participate in annual data abstractor meeting 1

Data Validation Error Rate

0‐4.0% 104.1‐5.0% 85.1‐6.0% 56.1‐7.0% 3> 7.0% 0

Timely LMWH VTE Prophylaxis Trauma Admits (18 mo: 1/1/19‐6/30/20)≥ 50% of patients (≤ 48 hr) 10≥ 45% of patients (≤ 48 hr) 8≥ 40% of patients (≤ 48 hr) 5< 40% of patients (≤ 48 hr) 0

Timely Surgical Repair Geriatric (Age ≥ 65) Isolated Hip Fxs (12 mo: 7/1/19‐6/30/20)

≥ 90% of patients (≤ 48 hr) 10≥ 85% of patients (≤ 48 hr) 8≥ 80% of patients (≤ 48 hr) 5< 80% of patients (≤ 48 hr) 0

6 10 RBC to Plasma Ratio in Massive Transfusion (18 mo: 1/1/19‐6/30/20)

Weighted Mean Points in Patients Transfused ≥ 5 Units 1st 4 hr 0‐10

Serious Complication Z‐Score Trend Trauma Admits (3 yr: 7/1/17‐6/30/20)< ‐1 (major improvement) 10‐1 to 1 or serious complications low‐outlier (average or better rate) 7> 1 (rates of serious complications increased) 5Mortality Z‐Score Trend Trauma Admits (3 yr: 7/1/17‐6/30/20)< ‐1 (major improvement) 10‐1 to 1 or mortality low‐outlier (average or better) 7> 1 (rates of mortality increased) 5

Timely Head CT TBI Patients on Anticoagulation Pre‐Injury (12 mo: 7/1/19‐6/30/20)

≥ 90% patients (≤ 120 min) 10≥ 80% patients (≤ 120 min) 7≥ 70% patients (≤ 120 min) 5< 70% patients (≤ 120 min) 0

7 10

8 10

9 10

5

10

10

10

4

2020 Michigan Trauma Quality Improvement Project (MTQIP) Collaborative Quality Initiative



1 10

3

2 10



2020 Michigan Trauma Quality Improvement Project (MTQIP) Collaborative Quality Initiative



Collaborative Wide Measure: Timely Antibiotic Femur/Tibia Open Fractures

(12 mo: 7/1/19‐6/30/20)≥ 85% patients (≤ 120 min) 10< 85% patients (≤ 120 min) 0

Total

10 10



MI AIM/ OBI Hospital Annual Survey

Complete the 2019 MI AIM/ OBI Hospital Annual Survey 3.5Complete the 2020 MI AIM/ OBI Hospital Annual Survey 3.5

Attendance at the OBI Collaborative‐wide Meetings

SemiAnnual Collaborative Meeting Attendance‐ At least one Multistakeholder Team Member

2 meetings: March AND November 2020 6

SemiAnnual Collaborative Meeting Attendance‐ Clinical Data Abstractor (CDA) or Designee

2 meetings: March AND November 2020 6Education

Educational Webinar Attendance

At least three members of the Hospital team have watched 7 out of 10 webinars 12At least three members of the Hospital team have watched 5 out of 10 webinars 7At least three members of the Hospital team have watched 3 out of 10 webinars 3

2020 Provider Education Webinar

Disseminate the OBI recorded Labor Support webinar link to maternity care providers and Labor & Delivery (L&D) staff. > 80% of your your maternity care providers and L&D staff have watched

the recorded webinar by May 31, 202012

Disseminate the OBI recorded Labor Support webinar link to maternity care providers and L&D staff. 50‐80% of your maternity care providers and L&D staff have watched the recorded

webinar by May 31, 20207

Disseminate the OBI recorded Labor Support webinar link to maternity care providers and L&D staff. 20‐49% of your maternity care providers and L&D staff have watched the recorded

webinar by May 31, 20203

Hospital Engagement

Culture Survey

>50% staff completed the culture survey by April 30, 2020 12>30% staff completed the culture survey by April 30, 2020 7

Made the Culture survey available in 2019 or 2020 3Peer‐to‐Peer Engagement: Video Workgroups

March 2020 Workgroup attendance by the team member whose workflow is most directly impacted by that month's subject.

3

June 2020 Workgroup attendance by the team member whose workflow is most directly impacted by that month's subject.

3

September 2020 Workgroup attendance by the team member whose workflow is most directly impacted by that month's subject.

3

October 2020 Workgroup attendance by the team member whose workflow is most directly impacted by that month's subject.

3

2020 Clinical Data Abstractor Participation

Timeliness and completeness of data submission

Submit the complete required case load of Term Singleton Vertex patients from October ‐ December 2019 via OBI online portal by April 30, 2020.

3

Submit the complete required case load of Term Singleton Vertex patients from January ‐ March 2020 via OBI online portal by June 30, 2020.

3

Submit the complete required case load of Term Singleton Vertex patients from April ‐ June 2020 via OBI online portal by September 30, 2020.

3

1 5%

4 25%

2 15%

30%3

2020 Obstetrics Initiative (OBI) Collaborative Quality Initiative



5 15%



2020 Obstetrics Initiative (OBI) Collaborative Quality Initiative



5 15%Submit the complete required case load of Term Singleton Vertex patients from

July ‐ September 2020 via OBI online portal by December 31, 2020.3

Implementation of Option A or B

OPTION A: OBI CHECKLIST

Report implementation progress of the OBI Checklist by March 31st, June 30th, andSeptember 30th, 2020 via OBI online portal.

9

OR

OPTION B: Promoting Spontaneous Progress in Labor Bundle

Report implementation progress of the Spontaneous Labor Bundle by March 31st, June 30th, and September 30th, 2020 via OBI online portal.

9

TOTAL 115% 100

6b

10%

6a


W000202

2020 cqi performance index - bcbsm

Documents