FLEX GRANT
Kathy McGowan
Vice President, Quality & Safety
Samantha Dulworth
Technical & Customer Specialist
November 13, 2013
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
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
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
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
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
Copyright ©2011 Georgia Hospital Association
Purpose & Goal
• Ensure patient safety
• Deliver expected quality patient care
outcomes
Copyright ©2011 Georgia Hospital Association
Hospital Benefits
•
•
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•
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•
•
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
Copyright ©2011 Georgia Hospital Association
Hospital Benefits
• Resources
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Data collection tools & definitions
CART manuals
Transfer / discharge checklists
Stabilizing core measure data submissions to
Hospital Compare
Copyright ©2011 Georgia Hospital Association
Education / Training
•
•
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•
•
•
Patient and Family Centered Care
Rounding
TeamSTEPPS
Reliable Process Design
Frontline Defects Analysis
Plan-Do-Check-Act (PDCA) Process
Improvement Principles
Copyright ©2011 Georgia Hospital Association
Education & Training
• Organizational Assessment Tool (OAT)
• Culture of Patient Safety Survey
• Continue focus on core measures
 Pneumonia-6
 Heart Failure-1
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
Copyright ©2011 Georgia Hospital Association
Education & Training
• ST Elevated Myocardial Infection (STEMI)
Program
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
Copyright ©2011 Georgia Hospital Association
HeRMES
Samantha Dulworth
Copyright ©2011 Georgia Hospital Association
Products
Copyright ©2011 Georgia Hospital Association
Data Flow using Cart
Copyright ©2011 Georgia Hospital Association
HeRMES
Care Core Submission Deadlines
GHA Deadline
CMS Deadline
Joint Commission Both
Inpatient & Outpatient
Warehouse/Quality Net
Outpatient Only and
Quality Net Inpatient
Populations
CMS/Quality Net Inpatient
OPPS 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
UB04 Deadlines &
Initial Population
counts
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)
Copyright ©2011 Georgia Hospital Association
Looking at Upload Reports
Summary of Data
Running Population Report
Copyright ©2011 Georgia Hospital Association
Population Report
Measures will
show in Red if
there are not
enough cases
submitted for
Global and
Ed throughput
Copyright ©2011 Georgia Hospital Association
Questions?
Copyright ©2011 Georgia Hospital Association
Care Core Reports
Copyright ©2011 Georgia Hospital Association
Creating Report in Care Core
Copyright ©2011 Georgia Hospital Association
Reports (TJC Core Measures)
Copyright ©2011 Georgia Hospital Association
Reports (TJC Core Measures)
Copyright ©2011 Georgia Hospital Association
Reports (Values)
Copyright ©2011 Georgia Hospital Association
Reports (Drill Down)
Copyright ©2011 Georgia Hospital Association
Reports (Run Report)
Copyright ©2011 Georgia Hospital Association
Patient Level Drill Down
Copyright ©2011 Georgia Hospital Association
Patient Detail
Copyright ©2011 Georgia Hospital Association
Reports (TJC Core Measures)
Copyright ©2011 Georgia Hospital Association
Reports (Run Report)
Copyright ©2011 Georgia Hospital Association
HeRMES
Copyright ©2011 Georgia Hospital Association
Data Flow using Cart
Copyright ©2011 Georgia Hospital Association
What CARE Service Line has the
Highest Mortality Rate?
Copyright ©2011 Georgia Hospital Association
What CARE Service Line has the Highest
Mortality Rate?
1.
2.
3.
4.
5.
Pick your Quality Indicator
Pick your Values
Pick CARE Service Line in Drill Down
Click Run Report
Find your highest CARE Service Line
Copyright ©2011 Georgia Hospital Association
Report Outcome
Copyright ©2011 Georgia Hospital Association
HeRMES
Copyright ©2011 Georgia Hospital Association
How many patients left your
Emergency Department against
medical advice?
Copyright ©2011 Georgia Hospital Association
Left Without Being Seen
1. Click on High Risk Patient Safety
2. Click Quality Indicator “ER Patients Who
Leave against medical advice”
3. Click “Run Report”
Copyright ©2011 Georgia Hospital Association
Running Report
Copyright ©2011 Georgia Hospital Association
Report Outcome
Copyright ©2011 Georgia Hospital Association
HeRMES
Copyright ©2011 Georgia Hospital Association
Which Physician has the highest
Mortality Rate?
Copyright ©2011 Georgia Hospital Association
Which Physician has the highest
Mortality Rate?
1. Click on MedEval
2. Click on Mortality under Quality Indicators
3. Click Physician Name and NPI number under
“Drill Down”
4. Click on “Run Report”
Copyright ©2011 Georgia Hospital Association
Report Outcome
Copyright ©2011 Georgia Hospital Association
CoPS
Copyright ©2011 Georgia Hospital Association
CoPS Log in Screen
Copyright ©2011 Georgia Hospital Association
Report Selection
Copyright ©2011 Georgia Hospital Association
Executive Level Dashboard
Copyright ©2011 Georgia Hospital Association
Executive Level Dashboard – line graph
Copyright ©2011 Georgia Hospital Association
Hospital Compare
Copyright ©2011 Georgia Hospital Association
Question Level Drill Down
Copyright ©2011 Georgia Hospital Association
Question Level Drill Down
Copyright ©2011 Georgia Hospital Association
CoPS Links
CoPS Website address
https://cops.gha.org/Account/Login.aspx
CoPS Campaign Request:
http://cops.gha.org/survey/n/CoPSCampaignRequest.aspx
Copyright ©2011 Georgia Hospital Association
Questions?
Copyright ©2011 Georgia Hospital Association
GHA Contact Information
Kathy McGowen, Vice President of Quality & Safety
kmcgowen@gha.org 770-249-4519
Joyce Reid, Vice President of Community Health Connections
jreid@gha.org 770-249-4545
Samantha Dulworth, Customer and Technical Specialist
sdulworth@gha.org 770-249-4550
Copyright ©2011 Georgia Hospital Association