Data discussion- Summary to date, QI Showcase and CAH CEO Mid-year meeting
Some PIN regular benchmarking facts:
-The regular benchmarking project began in July 2001
-18 CAHs or 38% have submitted data every quarter since CAH conversion
-22 additional CAHs submitted data at least 90% of the time since CAH conversion
The regular PIN benchmarking project and clinical improvement study programs were originally
established to help MT CAHs meet the following Medicare QA Conditions of Participation: Tags C-332
and C-0336 through C-343.
The CLINICAL benchmarking project allows CAHs to monitor performance on measures from studies that
they wish to monitor internally. Two years ago, this was re-modeled to help CAHs develop processes for
collecting and submitting MBQIP measures.
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Discussion #1-CAH CEO Meeting, January 23-24
General discussion about data collection and reporting overload especially quality measure overlap.
CAHs maxed out; don’t see the value except to satisfy data reporting requests from CMS, HRSA, MHA
and Flex PIN.
ACTION: Gather a group of interested CAH CEOs and additional relevant CAH staff to gain a broader
perspective of issues and perspectives related to PIN data reporting.
Discussion #2-Conference call w/CAH CEOs and other interested CAH staff (QICs and a few providers)
We continued a general discussion about data collection and reporting overload. The group also
discussed the need for CAHs to collect comparative benchmarking data to help them meet their unique
CAH Medicare Condition of Participation requirements. Concerns were expressed about preparing MT
CAHs for value-based purchasing and what that might look like.
RECOMMENDATION: Continue regular PIN Benchmarking project but remodel to meet current needs.
Continue the PIN clinical improvement studies. Discontinue the PIN clinical benchmarking project.
ACTION: Continue the data discussion with the PIN Advisory Board at their March retreat. Continue the
discussion with the CAH QICs at the QI Showcase. Carol to research status of CAH VBP options.
Discussion #3-PIN Advisory Board Retreat, March 26-27
The Advisory Board reviewed recommendations from prior discussions. Carol reported that per her
research, there is no clear picture of what value-based purchasing for CAHs might look like. The most
likely option is that CAH VBP will consist of a blend of the HRSA/Flex sponsored Medicare Beneficiary
Quality Improvement Project which mirrors Hospital Compare and measures collected as part of the
Hospital Engagement Network. The Advisory Board talked about whether or not the PIN benchmarking
project was necessary given that most CAHs can now obtain data more readily through EHRs. However,
the Board also recognized that the PIN benchmarking project served a valuable function for a lot of
CAHs in helping them meet their CoPs and did not want to jeopardize that service.
RECOMMENDATIONS: Consider eliminating the PIN benchmarking project but not before carefully
exploring possible unintended consequences. The PIN Advisory Board recommended that PIN staff use
the clinical benchmarking for gathering MBQIP data from the QIO and reporting that back to the CAHs.
They also recommended that PIN staff base clinical improvement studies on MBQIP to help minimize
excessive data collection. The PIN Advisory Board appreciates peer group comparisons. Any changes to
PIN benchmarking projects will occur at the beginning of the next Flex grant year which starts
September 1, 2013.
ACTION: Arrange time at MHA Mid-year for CAH CEOs to discuss again. Continue the discussion with
the CAH QICs at the QI Showcase.
Discussion #4-QI Showcase, April 2013
In summary, most of the CAH Quality Improvement Coordinators use the regular benchmarking project
to help them complete the required annual program review and prepare facility dashboards. For some,
they can’t get the data they need for these reports anywhere else. Most use the PIN regular
benchmarking data for board and department manager reporting. The PIN benchmarking data is easy to
report and the information back is easy to decipher. All agree that they spend too much time reporting
data, not enough time for projects acting on the data. All find the peer grouping valuable.
ISSUES:
No consistent reporting across data collection programs (PIN, HEN, Databank, Compdata and Hospital
Compare-only 5 CAHs report to all)
HEN facilities are all over the board on which measures they report leaving little room for comparison.
RECOMMENDATIONS:
Utilize data sharing agreements so PIN can pull from other places to reduce data reporting.
Move MBQIP measures to the clinical benchmarking and remove other elements.
All agree the regular benchmarking project should continue but it needs remodeling being careful to not
lose critical data elements.
Continue the regular and clinical benchmarking and clinical improvement study projects but remodel to
improve relevancy and reduce redundancy while not losing critical core elements and peer review
comparison.
ACTION:
Continue to blend the MBQIP and MPQH-QIO Red Light/Green Light reports to minimize data reporting
redundancy.
Encourage more CAHs that report to Databank to use the shortened submission form.
Discussion #5-MHA Mid-year, May 2013
RECOMMENDATIONS:
Move PIN benchmarking projects to a higher level by providing more assistance in helping MT CAHs
actually move the needle in changed behavior that results in improved outcomes.
Relate quality measures to cost.
ACTION:
Proceed with PIN data project remodeling.