Hospital Check-in We make lives better. Linking hospitals to quality and safety resources December 2014 Stratis Health is part of the Lake Superior Quality Innovation Network, serving Michigan, Minnesota, and Wisconsin, under the CMS QIO Program. Minnesota Data Show Improvement Even as Readmissions Reduction Program Fines Increase The New Year is approaching, and hospitals are resolving to continue their work on reducing hospital readmissions. Last year, nearly 18 percent of Medicare patients who had been hospitalized returned within a month. While a reduction from past years, the Centers for Medicare & Medicaid (CMS) reports almost two Hospitals are feeling a renewed sense of urgency to prevent re-hospitalization of their patients due in part to the Affordable Care Act’s Hospital Readmissions Reduction Program (HRRP), which requires CMS to reduce payments to hospitals with excess readmissions. Initially, the HRRP was focused on readmissions This issue Quality Improvement 2 Quality Reporting 3 Events, Contacts 4 the financial impact of this legislation: In October, 2014, CMS indicated that 2,610 hospitals will receive lower payments, totaling an estimated $428 Minnesota million patients still are readmitted annually, affecting patient quality of life and costing Medicare $26 billion. It is estimated that $17 billion of that is from potentially avoidable readmissions. with pneumonia, heart attacks, and congestive heart failure. In 2015, CMS added hip and knee replacements, and in 2016, it will add chronic obstructive pulmonary disease. Adding weight to the program is the fact that hospitals are starting to feel million, due to readmissions penalties. According to Kaiser Health News, Minnesota ranked in the top 10 of states with the lowest percentage of hospitals penalized for readmissions. Based on the most recent readmission Continued on page 2 Stratis Healthhospital check-in Continued from page 1 payment adjustment factor data from CMS, Minnesota also had a higher percentage of hospitals without a penalty (28.8 percent) than the U.S. as a whole (23.8 percent). Minnesota’s RARE Campaign also reported that in the last quarter of 2013, hospitals in the state reached a collective reduction in readmissions of 19 percent. Collectively, programs such as the Readmissions Reduction, Value-Based Purchasing, and Hospital-Acquired Condition Reduction Programs have prompted providers to try a range of initiatives to manage care more effectively, regardless of the setting. Examples include leveraging EHR technology to more efficiently and effectively discharge patients and community-based approaches to coordinate care post-discharge. Reduce Readmissions at Your Hospital Understanding the Hospital Readmissions Reduction Program Stratis Health, as part of the Lake Superior Quality Innovation Network, is bringing together hospitals and community partners to reduce avoidable readmissions through the CMS Coordination of Care initiative. For information on participating, contact Janelle Shearer, 952-853-8553, [email protected] The Hospital Readmissions Reduction Program requires CMS to reduce payments to IPPS hospitals with excess readmissions. The maximum penalty is two percent this year and increases to three percent in October 2015. Unlike the Value-based Purchasing (VBP) program, this is a penalty program and a hospital cannot get additional monies, only lose money as result of their performance. For more information on the Readmissions Reduction and other pay for performance and improvement programs, visit our website at http://www.stratishealth.org/ providers/hospitals.html or contact Vicki Olson, 952-853-8554, [email protected] View the fact sheet: Understanding the Hospital Readmissions Reduction Program (3-page PDF) Quality Improvement NQF Begins Annual Review of Quality Measures for Use in 20 Federal Programs The NQF-convened Measure Applications Partnership (MAP) received for review 202 standardized performance measures that the U.S. Department of Health and Human Services is considering for use in more than 20 federal health programs. The full list of measures under consideration is now available for review. An early public comment period will be available from December 1–5, 2014. MAP’s full 2 measure recommendations will be available for review and comment starting December 23, 2014 – January 13, 2015. Additional information about upcoming MAP meetings and events and previous MAP reports to HHS are available online. New National Quality Strategy Stakeholder Toolkit Organizations can now use an updated National Quality Strategy (NQS) toolkit to show alignment to and support of the NQS. The updated toolkit includes new graphics, Web content, and social media content that can help organizations advance the mission of the NQS. The Stakeholder Toolkit can be found here. The NQS is a national effort to align public- and private-sector stakeholders to achieve better health and health care for all Americans. It is led by the Agency for Healthcare Research and Quality on behalf of the U.S. Department of Health and Human Services. For more information about the National Quality Strategy, visit www.ahrq.gov/ workingforquality. Stratis Healthhospital check-in quality reporting Contact Guide CMS Measures Data Abstraction and Submission The new Quality Reporting Center website has resources to assist hospitals with quality data reporting. Through this site, you can access: • • • • • • • • • IQR support OQR support Reference and training materials Educational presentations Timelines and calendars Data collection tools Contact information Helpful links to resources Question and answer tools NEW Downloadable Contact Guides This QR Center chart has updated contact information for various quality reporting entities, including IQR, OQR, abstraction, validation, and HCAHPS. Download >> This QR Center Quick Support Reference Card has multiple contact and support options for IQR only. Download >> Statewide Quality Reporting Measurement System (SQRMS) • CMS measures See QR Center above Robyn Carlson [email protected] 952-853-8587 • ED Transfer Communication • CPOE Pharmacist Verification Improvement-Related Topics • Inpatient measures • Outpatient measures • MBQIP measures • VBP measures • Readmission Reduction measures Vicki Olson [email protected] 952-853-8554 • Hospital-Acquired Condition measures Updated 2015 NHSN Protocols and Training Available The updated 2015 protocols, reporting forms, and training have been posted to the NHSN website for your review and use. To access the updates, choose the HAI/surveillance type 3 webpage from the following links, and scroll down to the ‘Protocols’ and ‘Data Collection Forms’ sections to see the new documents dated January 2015. Antimicrobial Use Surveillance CAUTI Surveillance CLABSI Surveillance MDRO/CDI Surveillance SSI Surveillance VAE Surveillance All surveillance types>> EVents LSQIN Webinar: Hospital Incentive Programs: A Basic Understanding December 17, 2014 The Lake Superior Quality Innovation Network (LSQIN) presents a webinar focused on CMS hospital incentive programs. The objectives are to understand the current status of hospital value-based purchasing, readmission reduction and hospitalacquired condition programs; share tools to understand and support CMS hospital incentive programs; and identify tips for improvement. The speakers are Vicki Olson, R.N., M.S., Stratis Health program manager; Donna Modras, RHIT, MPRO hospital data reporting project coordinator; and Pam Clemens, MetaStar hospital valuebased purchasing coordinator. More>> Adverse Drug Event Prevention Jill Kieser Andersen, Program Manager 952-853-8565, [email protected] Coordination of Care Janelle Shearer, Program Manager 952-853-8553, [email protected] Reducing Healthcare-Associated Infections Jill Kieser Andersen, Program Manager 952-853-8565, [email protected] Quality Improvement through VBP Vicki Olson, Program Manager 952-853-8554, [email protected] General Hospital Information Mary Montury, Program Coordinator 952-853-8541, [email protected] Communications Mark Benjamin, Editor 952-853-8578, [email protected] Save the Date! end-of-life care for the people in their community. Please register in advance to attend either in-person or by conference call. More >> Minnesota Statewide Quality Reporting and Measurement System: 2014 Quality Measure Reporting for Minnesota Hospitals. Update on changes for the 2014 slate of measures. Recommended for CNO, CMO, quality directors, and staff. SAFE CARE Action Day Webinar February 5, 2015 SQRMS Webinar January 14, 2015 12:00-1:00 p.m. Rural Palliative Care Networking Group Meeting Hosts: TRUE: A CommunityBased Approach to Increasing Hospice Use January 15, 2015 Three Alexandria-area hospice programs will share their story on how they are working together with their community partners to improve This SAFE CARE Action Day webinar will include medication safety, an ADE update by MHA, and a medication process improvement presentation by Stratis Health. MHA will provide updated rural hospitalspecific benchmarking information, in addition to a patient safety comparison of larger hospitals and critical access hospitals (CAHs). Stratis Health will provide abstracting tips for Minnesota State Measures for CAH. Register>> For more events, visit the Stratis Health website events page. President and CEO Stratis Health is a nonprofit Director, Medical Affairs organization that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities. Jennifer P. Lundblad, PhD, MBA Jane Pederson, MD, MS Board of Directors Donna Anderson, MPH Kathleen D. Brooks, MD, MBA, board chair Connie Delaney, PhD, RN Myron Falken, PhD, MPH Huda Farah, MSc William E. Jacott, MD Ken Johnson, MBA Mary Jo Kreitzer, PhD, RN Clint MacKinney, MD, MS Jan Malcolm Beth Monsrud, CPA Michael Spilane, MD Craig Svendsen, MD Stella Whitney-West, MBA Gary Wingrove Stratis Health represents Minnesota in the Lake Superior Quality Innovation Network serving Michigan, Minnesota, and Wisconsin, under the Centers for Medicare & Medicaid Services Quality Improvement Organization Program. Stratis Health 2901 Metro Drive, Suite 400 Bloomington, MN 55425-1525 952-854-3306 • 952-853-8503 (fax) Email: [email protected] www.stratishealth.org To subscribe to this email, contact Mary Montury, [email protected] This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MN-D1-14-17 121514
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