August 19, 2016 Joshua Salander, MBA, PMP Consultant · 4Q15 reports were emailed on August 13,...

August 19, 2016

Joshua Salander, MBA, PMP

Consultant

4Q15 reports were emailed on August 13, 2016

Quarterly Reports

Quarterly Trend Charts

2

Reports delivery

MICAHQN Reports Schedule Qtr CMS Data Deadline* Data Extracts Provided By*

1st Qtr August 15 August 31

2nd Qtr November 15 November 30

3rd Qtr February 15 February 28

4th Qtr May 15 May 31

*In event there is an extension to data deadline, vendor provides data extract within 15 days of extension date which in turn will delay Reports Delivered By.

3

4

92.7% 91.5%

100.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Evaluation of LVS Function

Rate

Heart Failure - 4Q15

MICAHQN Rate CAH Only Rate Rural Only Rate

5

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

1Q13 2Q13 3Q13 4Q13 1Q14 2Q14 3Q14 4Q14 1Q15 2Q15 3Q15 4Q15

Ra

te

HF2 - Evaluation of LVS Function

MICAHQN Overall UCL LCL

6

88.8% 87.3%

100.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Initial Antibiotic Selection for PN in Immunocompetent Patient

Ra

te Pneumonia - 4Q15


7

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Ra

te

PN6 - Initial Antibiotic Selection for PN in Immunocompetent Patient


8

90.4% 89.7%

98.4%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Influenza Immunization – Overall Rate

Ra

te

Immunization - 4Q15


9

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Ra

te

IMM2 - Influenza Immunization – Overall Rate


10

88.9%

98.4% 99.0% 98.1%

88.9%

98.1% 98.8% 97.8% 100.0% 100.0% 100.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Fibrinolytic Therapy ReceivedWithin 30 Minutes

Aspirin at Arrival - Overall Rate Aspirin at Arrival - AMI Aspirin at Arrival - Chest Pain

Ra

te

OP AMI/CP Rate Based Measures - 4Q15


11

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Ra

te

OP2 - Fibrinolytic Therapy Received Within 30 Minutes


12

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

Ra

te

OP4a - Aspirin at Arrival - Overall Rate


13

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

Ra

te

OP4b - Aspirin at Arrival - AMI


14

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

Ra

te

OP4c - Aspirin at Arrival - Chest Pain


15

26

59

54.5

76

7

7

7

26

59.5

56

76

7

8

7

38

38

6

6

6

0 10 20 30 40 50 60 70 80

Median Time to Fibrinolysis

Median Time to Transfer to Another Facility for Acute CoronaryIntervention - Overall

Median Time to Transfer to Another Facility for Acute CoronaryIntervention - Reporting Measure

Median Time to Transfer to Another Facility for Acute CoronaryIntervention - QI Measure

Median Time to ECG - Overall Rate

Median Time to ECG - AMI

Median Time to ECG - Chest Pain

Median Time

OP AMI/CP Continuous Measures - 4Q15

Rural Only Values CAH Only Values MICAHQN Values

16

0

5

10

15

20

25

30

35

40

45

Me

dia

n T

ime

OP1 - Median Time to Fibrinolysis


17

0

10

20

30

40

50

60

70

80

Me

dia

n T

ime

OP3a - Median Time to Transfer to Another Facility for Acute Coronary

Intervention - Overall


18

0

10

20

30

40

50

60

70

Me

dia

n T

ime

OP3b - Median Time to Transfer to Another Facility for Acute Coronary Intervention - Reporting

Measure


19

0

10

20

30

40

50

60

70

80

90

100

Me

dia

n T

ime

OP3c - Median Time to Transfer to Another Facility for Acute Coronary Intervention - QI Measure


20

0

1

2

3

4

5

6

7

8

9

Me

dia

n T

ime

OP5a - Median Time to ECG - Overall Rate


21

0

1

2

3

4

5

6

7

8

9

Me

dia

n T

ime

OP5b - Median Time to ECG - AMI


22

0

1

2

3

4

5

6

7

8

9

Me

dia

n T

ime

OP5c - Median Time to ECG - Chest Pain


23

112

105

155

189

16

112

105

151

190

16

109.5

102

272

182.5

14

0 50 100 150 200 250 300

Median Time from ED Arrival to ED Departure for Discharged EDPatients - Overall

Median Time from ED Arrival to ED Departure for Discharged EDPatients - Reporting Measure

Median Time from ED Arrival to ED Departure for Discharged EDPatients - Psychiatric/Mental Health Patients

Median Time from ED Arrival to ED Departure for Discharged EDPatients - Transfer Patients

Door to Diagnostic Evaluation by a Qualified Medical Professional

Median Time

OP Emergency Department Throughput - 4Q15

Rural Only Values CAH Only Values MICAHQN Values

24

106

108

110

112

114

116

118

120

122

124

Me

dia

n T

ime

OP18a - Median Time from ED Arrival to ED Departure for Discharged ED Patients

- Overall


25

98

100

102

104

106

108

110

112

114

116

118

Me

dia

n T

ime

OP18b - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Reporting

Measure


26

0

20

40

60

80

100

120

140

160

180

200

Me

dia

n T

ime

OP18c - Median Time from ED Arrival to ED Departure for

Discharged ED Patients - Psychiatric/Mental Health Patients


27

160

165

170

175

180

185

190

195

200

205

210

215

Me

dia

n T

ime

OP18d - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Transfer

Patients


28

0

5

10

15

20

25

30

Me

dia

n T

ime

OP20 - Door to Diagnostic Evaluation by a Qualified Medical

Professional


29

62%

67

% 80

%

84%

88

%

90%

91

%

92%

93

%

93%

93

%

95%

95

%

96%

96

%

96%

96

%

96%

98

%

98%

98

%

98%

98

%

98%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%23 28 37

1Q15

4Q15

-Nat

ion

al 22

3Q15

4Q15 9 10 12

2Q16 25 16 18 31 40

1Q16 15 5 20 27 30 34 6 7 8 11 39 13 14 17 19 21 24 26 29 32 33 35 36 38

EDTC-1 Administrative Communication - 2Q16

Hospital Q2 2016 MICAHQN (95%)

30

53%

80

%

84%

90

%

93%

94

%

96%

96

%

96%

96

%

96%

97

%

97%

98

%

98%

98

%

98%

98

%

98%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%24 31

1Q15

4Q15

-Nat

ion

al 10 21 13

3Q15 14

4Q15

1Q16

2Q16 22 20 33 34 35 37 40 5 6 7 8 9 11 39 12 15 16 17 18 19 23 25 26 27 28 29 30 32 36 38

EDTC - 2 Patient Information - 2Q16


31

76%

78

%

83%

90

%

91%

93

%

94%

95

%

95%

95

%

96%

96

%

96%

97

%

97%

97

%

98%

98

%

98%

98

%

98%

98

%

98%

98

%

98%

98

%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%24 31

1Q15

4Q15

-Nat

ion

al 10 13 21

3Q15

4Q15 25 8 30

1Q16 12

2Q16 22 6 39 18 27 28 33 34 35 37 14 5 7 9 11 15 16 17 19 20 23 26 29 32 36 38 40

EDTC - 3 Vital Signs - 2Q16


32

28%

56

% 71

%

76%

80

%

81%

87

%

87%

88

%

89%

92

%

93%

93

%

93%

93

%

93%

93

%

93%

95

%

97%

98

%

98%

98

%

98%

98

%

98%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%11 24 31 35 18

1Q15 20 29

4Q15

-Nat

ion

al 7 21

2Q16

4Q15

1Q16 10 13 17 33

3Q15 22 39 30 34 37 40 14 5 6 8 9 12 15 16 19 23 25 26 27 28 32 36 38

EDTC - 4 Medication Information - 2Q16


33

0%

6%

8%

77%

78

%

84%

84

%

87%

87

%

88%

89

%

89%

89

%

90%

90

%

93%

93

%

94%

95

%

95%

96

%

96%

98

%

98%

98

%

98%

98

%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

7 11 23

1Q15 31 10 27

4Q15

-Nat

ion

al

2Q16

3Q15 13

1Q16 14 12

4Q15 18 34 21 22 5 17 20 9 30 33 37 40 6 8 39 15 16 19 24 25 26 28 29 32 35 36 38

EDTC - 5 Physician or Practitioner Generated Information - 2Q16


34

11%

31

% 42

% 56

%

62%

67

%

76%

82

%

82%

87

%

87%

88

%

88%

89

%

90%

90

%

91%

92

%

93%

93

%

93%

93

%

95%

96

%

96%

96

%

96%

98

%

98%

98

%

98%

98

%

98%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%11 22 23 24 28 31

1Q15

4Q15

-Nat

ion

al 39

2Q16 14

3Q15

1Q16 13

4Q15 15 36 21 6 9 10 17 25 18 30 33 26 5 20 27 34 35 37 7 8 12 16 19 29 32 38 40

EDTC - 6 Nurse Generated Information - 2Q16


35

78%

80

%

85%

89

%

89%

92

%

93%

93

%

93%

95

%

95%

96

%

97%

97

%

97%

98

%

98%

98

%

98%

98

%

99%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

100%

10

0%

50%52%54%56%58%60%62%64%66%68%70%72%74%76%78%80%82%84%86%88%90%92%94%96%98%

100%31 24

1Q15 11 18

4Q15

-Nat

ion

al 10 13 14 22

4Q15 21

1Q16

3Q15

2Q16 17 33 34 35 37 23 5 6 7 8 9 39 12 15 16 19 20 25 26 27 28 29 30 32 36 38 40

EDTC - 7 Procedures and Tests - 2Q16


36

0%

0%

1%

6%

31%

40

%

47%

55

%

60%

66

%

66%

67

%

71%

73

%

77%

78

%

80%

80

%

82%

83

%

84%

84

%

86%

87

%

87%

87

%

87%

88

%

89%

89

%

91%

91

%

91%

92

%

93%

93

%

96%

96

%

96%

10

0%

100%

10

0%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%7 35 23 11 22 28 24

1Q15 31

4Q15

-Nat

ion

al

3Q15 18

4Q15

2Q16

1Q16 37 39 20 10 14 13 27 25 9 12 17 29 15 30 40 5 6 36 21 33 34 8 16 26 19 32 38

All EDTC Measures - 2Q16


Key Findings:

Hospital Compare Reporting (45 states reporting)

Inpatient

Michigan = 94.4% (#15)

National = 84.7%

Outpatient

Michigan = 100% (#1)

National = 50.7%

Source: https://gallery.mailchimp.com/cb09edc20d550e3cb621eaf9b/files/Michigan_HC16.pdf

37

Flex Monitoring Team State Data Report

https://gallery.mailchimp.com/cb09edc20d550e3cb621eaf9b/files/Michigan_HC16.pdf





Key Findings:


Significantly better scores = 9 measures

Significantly worse scores = 3 measures

No significant difference = 22 measures

Insufficient data = 4 measures


38




Key Findings:


Significantly better scores = 9 measures

Significantly worse scores = 3 measures

No significant difference = 22 measures

Insufficient data = 4 measures


39




Key Findings:

Significantly better scores = 9 measures HF-2 (Evaluation of LVS function) IMM-2 (Immunization for influenza) OP-27/IMM-3 (Healthcare workers given influenza

vaccination) PN-6 (Initial antibiotic selection for pneumonia patient) SCIP-Inf-1 (Preventative antibiotic(s) 1 hour before incision) STK-1 (VTE prophylaxis) STK-6 (Discharged on statin medications) OP-4 (Aspirin at arrival) OP-22 (Patient left without being seen)


40




Key Findings:

Significantly worse scores = 3 measures VTE-1 (Venous thromboembolism prophylaxis) Michigan = 87.5% (11 CAHs)

National = 89.4% (353 CAHs)

VTE-2 (ICU venous thromboembolism prophylaxis) Michigan = 89.6% (7 CAHs)

National = 93.3% (158 CAHs)

ED-1b (Median time from ED admission to ED departure for admitted patients) Michigan = 238 minutes (11 CAHs)

National = 216 (500 CAHs)


41




Joshua Salander, MBA, PMP

Consultant

[email protected]

(989) 666-7033

August 19, 2016 Joshua Salander, MBA, PMP Consultant · 4Q15 reports were emailed on August 13,...

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