flex grant
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FLEX GRANT . Kathy McGowan Vice President, Quality & Safety Samantha Dulworth Technical & Customer Specialist November 13, 2013. Georgia’s QI Program. - PowerPoint PPT PresentationTRANSCRIPT
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Copyright ©2011 Georgia Hospital Association
FLEX GRANT
Kathy McGowanVice President, Quality & Safety
Samantha DulworthTechnical & Customer Specialist
November 13, 2013
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Copyright ©2011 Georgia Hospital Association
Georgia’s QI Program
• Structured on requirements of Medicare Beneficiary Quality Improvement Project (MBQIP), Culture of Patient Safety, Technical Assistance, Education, and Training for Critical Access Hospitals.
• Georgia Hospital Association Research & Education Foundation serves as sub-grantee for the Georgia FLEX QI Program since 2002
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Copyright ©2011 Georgia Hospital Association
QI Program Participation
• CMS Core Measures• CMS Partnership for Patients• Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS)• Data submission to Hospital Compare• Scheduled education• Scheduled training & technical assistance
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Copyright ©2011 Georgia Hospital Association
QI Objectives
• Public quality reporting• Participation in MBQIP• Raising staff awareness regarding patient
safety• Examining trends in patient safety culture
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Copyright ©2011 Georgia Hospital Association
QI Overall Program Requirements
• Education & training in the use of CART, Core Measures and MBQIP
• Public reporting to Hospital Compare on relevant processes of care quality measures:
Inpatient Outpatient HCAHPS
• Hospital Engagement Network initiative
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Copyright ©2011 Georgia Hospital Association
QI Overall Program Requirements
• Actively work towards staff awareness about safety
• Examine trends in patient safety culture• Identify areas of strength and possible
improvement• Consistently improve the patient quality of
care outcomes in Georgia’s Critical Access Hospitals
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Purpose & Goal
• Ensure patient safety• Deliver expected quality patient care
outcomes
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Copyright ©2011 Georgia Hospital Association
Hospital Benefits
• Quarterly dashboards• Quarterly core measure composite scores• Minimum of two CART trainings annually• HCAHPS and MBQIP training• QI technical assistance• CART technical and customer assistance• Onsite coaching
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Copyright ©2011 Georgia Hospital Association
Hospital Benefits
• Resources Data collection tools & definitions CART manuals Transfer / discharge checklists Stabilizing core measure data submissions to Hospital Compare
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Copyright ©2011 Georgia Hospital Association
Education / Training
• Patient and Family Centered Care• Rounding• TeamSTEPPS• Reliable Process Design• Frontline Defects Analysis• Plan-Do-Check-Act (PDCA) Process
Improvement Principles
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Education & Training
• Organizational Assessment Tool (OAT)• Culture of Patient Safety Survey• Continue focus on core measures
Pneumonia-6 Heart Failure-1
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Copyright ©2011 Georgia Hospital Association
Education & Training
• Phase III of MBQIP (started 9/1/13) Pharmacist/Computerized Physician Order Entry
(CPEO)/Verification of Medication Orders within 24 hours
Outpatient Emergency Department Transfer Communication
• Needs assessment survey to all CAHs to establish baseline
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Copyright ©2011 Georgia Hospital Association
Education & Training
• ST Elevated Myocardial Infection (STEMI) Program
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Copyright ©2011 Georgia Hospital Association
Conflict of Interest
• State Office of Rural Health, Georgia Medical Care Foundation and GHA staff meet once a month
• Work together to avoid duplicating efforts
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Copyright ©2011 Georgia Hospital Association
HeRMES
Samantha Dulworth
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Copyright ©2011 Georgia Hospital Association
Products
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Data Flow using Cart
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HeRMES
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Copyright ©2011 Georgia Hospital Association
GHA Deadline CMS Deadline
UB04 Deadlines &Initial Population counts
Joint Commission Both Inpatient & Outpatient
Warehouse/Quality Net Outpatient Only and Quality Net Inpatient Populations
CMS/Quality Net InpatientOPPS Clinical
Q1 2013June 1st 2013 June 15th 2013 August 1st 2013 August 15th 2013
Q2 2013September 1st 2013 September 15th 2013 November 1st 2013 November 15th 2013
Q3 2013December 1st 2013 December 15th 2013 February 1st 2014 February 15th 2014
Q4 2013March 1st 2014 March 15th 2014 May 1st 2014 May 15th 2014
Care Core Submission Deadlines
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Copyright ©2011 Georgia Hospital Association
CART
Inpatient CART Version 4.14 for Discharges (7/1/2013 -12/31/2013)
Outpatient CART Version 1.10 for Encounters (7/1/2013 - 12/31/2013)
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Looking at Upload Reports
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Summary of Data
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Running Population Report
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Population Report
Measures will show in Red if there are not enough cases submitted for
Global and Ed throughput
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Questions?
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Care Core Reports
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Creating Report in Care Core
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Reports (TJC Core Measures)
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Copyright ©2011 Georgia Hospital Association
Reports (TJC Core Measures)
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Reports (Values)
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Reports (Drill Down)
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Reports (Run Report)
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Patient Level Drill Down
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Patient Detail
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Copyright ©2011 Georgia Hospital Association
Reports (TJC Core Measures)
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Copyright ©2011 Georgia Hospital Association
Reports (Run Report)
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HeRMES
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Copyright ©2011 Georgia Hospital Association
Data Flow using Cart
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What CARE Service Line has the Highest Mortality Rate?
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Copyright ©2011 Georgia Hospital Association
What CARE Service Line has the Highest Mortality Rate?
1. Pick your Quality Indicator2. Pick your Values3. Pick CARE Service Line in Drill Down4. Click Run Report5. Find your highest CARE Service Line
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Report Outcome
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HeRMES
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Copyright ©2011 Georgia Hospital Association
How many patients left your Emergency Department against
medical advice?
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Left Without Being Seen
1. Click on High Risk Patient Safety2. Click Quality Indicator “ER Patients Who
Leave against medical advice”3. Click “Run Report”
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Running Report
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Report Outcome
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HeRMES
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Copyright ©2011 Georgia Hospital Association
Which Physician has the highest Mortality Rate?
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Copyright ©2011 Georgia Hospital Association
Which Physician has the highest Mortality Rate?
1. Click on MedEval2. Click on Mortality under Quality Indicators3. Click Physician Name and NPI number under
“Drill Down”4. Click on “Run Report”
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Report Outcome
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CoPS
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CoPS Log in Screen
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Report Selection
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Executive Level Dashboard
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Executive Level Dashboard – line graph
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Hospital Compare
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Question Level Drill Down
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Question Level Drill Down
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CoPS Links
CoPS Website addresshttps://cops.gha.org/Account/Login.aspx
CoPS Campaign Request: http://cops.gha.org/survey/n/CoPSCampaignRequest.aspx
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Questions?
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Copyright ©2011 Georgia Hospital Association
GHA Contact Information
Kathy McGowen, Vice President of Quality & [email protected] 770-249-4519Joyce Reid, Vice President of Community Health [email protected] 770-249-4545Samantha Dulworth, Customer and Technical [email protected] 770-249-4550