HQIP 2019 Scoring And 2020 Quality Measure Development
HQIP 2019 Scoring and2020 Quality MeasureDevelopmentCHASE BoardAugust 27, 2019Nancy DolsonDepartment of Health Care Policy & Financing
Agenda1. 2019 CO HQIP Scoring2. 2020 CO HQIP Proposed Quality Measures Review of 2019 Measures Proposed Changes for 20202
2019 Scoring:Cesarean SectionThe HQIP Subcommittee has voted to apply the 2018 bounds tothis year’s distribution. Healthy People 2020’s benchmark of23.9% was used as the cutoff for scoring eligibility.C-sectionLower BoundUpper BoundPointsNo. of facilities1st Tercile (lowest)0.0%17.2%4172nd Tercile17.3%20.8%2103rd Tercile20.9%23.8%17 23.9% ible facilities (those that do not provide obstetric services or do not meet the minimum number of qualified deliveries)will have their scores normalized for this measure.3
2019 Scoring:Falls with InjuryFalls with Injury (rate per 1000 inpatient days)Lower BoundUpper BoundPointsNo. of facilities1st Quartile (lowest)0.000.085412nd Quartile0.090.213133rd Quartile0.220.641144th Quartile (highest)0.6538.96014Total824
2019 Scoring:Advance Care PlanningThe HQIP Subcommittee has voted to apply the 2018 bounds tothis year’s distribution. The 2018 method excluded those with0% ACP from calculation and awarded maximum points forthose greater than or equal to 99.5%.Advance Care PlanningUpper Bound100.0%PointsNo. of facilities4th Quartile (highest)Lower Bound99.5%3263rd Quartile86.4%99.4%2322nd Quartile75.0%86.3%131st Quartile (lowest)0%74.9%021Total825
2019 Scoring:HCAHPS, Composite 5The Communication about Medicines measure reflects patients’feedback on how often hospital staff explained the purpose ofany new medicine and what side effects that medicine mighthave.‘Always’ PercentageUpper Bound86%PointsNo. of facilities4th Quartile (highest)Lower Bound70%4153rd Quartile67%69%2112nd Quartile65%66%1161st Quartile (lowest)0%64%020Not Available*20Total82*Not Available group includes those with suppressed scores due to insufficient responses and rehabilitation facilities that arenot required to implement the HCAHPS survey. Scores will be normalized.6
2019 Scoring:HCAHPS, Composite 6The Discharge Information measure summarizes how well the hospitalstaff communicated with patients about the help they would need athome after leaving the hospital. The measure also summarizes howoften patients reported that they were given written information aboutsymptoms or health problems to watch for during their recovery.‘Yes’ PercentageUpper Bound95%PointsNo. of facilities4th Quartile (highest)Lower Bound91%4143rd Quartile90%90%2122nd Quartile89%89%191st Quartile (lowest)0%88%027Not Available*20Total82*Not Available group includes those with suppressed scores due to insufficient responses and rehabilitation facilities that arenot required to implement the HCAHPS survey. Scores will be normalized.7
2019 Scoring:HCAHPS, Composite 7The Care Transition measure evaluates the degree to whichpatients understood their care when they left the hospital.‘Strongly Agree’ PercentageUpper Bound71%PointsNo. of facilities4th Quartile (highest)Lower Bound59%4143rd Quartile56%58%2142nd Quartile53%55%1171st Quartile (lowest)0%52%017Not Available*20Total82*Not Available group includes those with suppressed scores due to insufficient responses and rehabilitation facilities that arenot required to implement the HCAHPS survey. Scores will be normalized.8
2020 Quality MeasuresReview of 2019 MeasuresProposed Changes for 20209
2019 Quality MeasuresMeasure GroupPerinatal and Maternal CarePatient SafetyPatient ExperienceBehavioral HealthSubstance UseAddressing Cost of CareMeasureStatusBreast FeedingExistingC-SectionExistingPregnancy related depression NewMaternal EmergenciesNewFamily PlanningNewDataHospital ReportedHospital ReportedHospital ReportedHospital ReportedHCPF/Hospital ridium difficile (C-Diff)Adverse EventFalls w/InjuryCulture of Safety SurveyHCAHPSAdvanced Care PlanFollow-Up afterHospitalization for MentalIllnessED Utilization MHED Utilization SUDSUB CompositeALTO and Post-SurgHospital PF/Hospital ReportHospital ReportedHospital ReportedHospital ReportedHCPFHospital NewNewNewNewNewNewHCPFHCPFHCPFHospital ReportedHospital come10
2020 Quality MeasuresMeasure GroupPerinatal and Maternal CarePatient SafetyPatient ExperienceMeasureBreast FeedingC-SectionStatusDataExisting Hospital ReportedExisting Hospital ReportedGoalProcessOutcomePregnancy related depressionMaternal EmergenciesFamily PlanningIncidence of EpisiotomyExistingExistingExistingNewHospital ReportedHospital ReportedHCPF/Hospital ReportHCFPProcessProcessProcessProcessClostridium difficile (C-Diff)Adverse EventCulture of Safety SurveySepsisAntibiotics StewardshipHandoffs and SignoutsHCAHPSAdvanced Care ingHCPF/Hospital ReportHospital ReportedHospital ReportedHospital ReportedHospital ReportedHospital ReportedHCPFHospital OutcomeProcess11
2020 Proposed Changes:Retired MeasuresThree measure groups are being removed. These areas are going to be addressed in the HospitalTransformation Program. One measure (falls with injury) is being retired as the measure has topped out. Atotal of 9 measures are being retired. Behavioral Health Follow-up appointments within 7 days after hospital discharge for a mental health condition Follow-up appointments within 7 days after hospital discharge for a mental health condition Emergency department utilization for mental health condition Emergency department utilization for substance use condition Substance use Using Alternatives to Opioids (ALTOs) in Hospital Emergency Departments Post surgical Opioid Prescribing Tobacco and Substance Use Screening and Intervention Addressing Cost of Care Addressing cost of care Patient Safety Falls with injury12
2020 Proposed Changes:New MeasuresFour new measures are being proposed: Maternal Health and Perinatal Care Incidence of episiotomy Patient Safety Sepsis Antibiotics Stewardship Handoffs and Signouts13
Incidence of EpisiotomyArea: Maternal Health and Perinatal CareNQF #0470 Incidence of Episiotomy - Percentage of vaginal deliveries (excluding those coded withshoulder dystocia) during which an episiotomy is performed.Numerator Statement: Number of episiotomy procedures (ICD-9 code 72.1, 72.21, 72.31, 72.71, 73.6; ICD-10PCS:0W8NXZZ performed on women undergoing a vaginal delivery (excluding those withshoulder dystocia ICD-10; O66.0) during the analytic period- monthly, quarterly, yearly etc.Denominator Statement: All vaginal deliveries during the analytic period- monthly, quarterly, yearly etc. excluding thosecoded with a shoulder dystocia ICD-10: O66.0).Exclusions: Women who have a coded complication of shoulder dystocia. In the case of shoulder dystocia,an episiotomy is performed to free the shoulder and prevent/mitigate birth injury to theinfant.14
SepsisArea: Patient SafetySepsis Process Measure: Describe the protocols and alerts your facility has in place for identifying sepsis and fortreating sepsis. If the protocols are different for different levels of care (e.g. ED vsinpatient), please describe the protocols and their differences. Describe and provide evidence of the training that your facility has in place for orientingnew providers and staff to your facility’s systems and protocols for addressing suspectedsepsis cases Describe and provide evidence of the process of providing regular feedback to providers onsepsis identification and treatment results. Provide process measures and/or outcome measures your facility uses for tracking sepsisidentification and treatment as well as any results for the purposes of quality improvement15
Antibiotic StewardshipsArea: Patient SafetyThis measure has four levels corresponding to a tiered point structure. The levels are cumulative, e.g a hospital mustachieve Level I to potentially achieve Level II. This measure is based on the work that the Colorado Department ofPublic Health and Environment (CDPHE), the Colorado Hospital Association (CHA), Colorado Health Care Association(CHCA), and Telligen have done on antibiotic stewardship working towards developing an Antibiotic StewardshipHonor Roll.Level 1, Commitment: The hospital demonstrates leadership support for antibiotic stewardship and has an antibioticstewardship committee that includes a physician and pharmacist that meets at least quarterly.Level 2, Education: The hospital meets criteria for Level 1, as well as the following: Implements facility-specific treatment recommendations for common conditions, including community-acquired pneumonia,urinary tract infection, and skin and soft-tissue infection,Distributes an antibiogram annually or biannually, andProvides education to clinicians and other relevant staff on improving antibiotic prescribing at least annually.Level 3, Guidance: The hospital meets criteria for Level 1 and Level 2, as well as the following: Implements one or more broad interventions to improve antibiotic use, such as antibiotic pre-authorization, prospective auditwith feedback, antibiotic time-outs, or pharmacy-driven interventions designed for the antibiotic stewardship program, such asautomatic alerts for, and de-escalation of, unnecessarily duplicative therapy, or time-sensitive automatic stop orders,Tracks antibiotic use (days of therapy or defined daily doses), andReports antibiotic use to prescribers at least once every 6 months.Level 4, Collaboration: The hospital meets criteria for Level 1, Level 2, and Level 3 as well as the following duringthe measurement period: Collaborates with one or more facilities, such as other hospitals or long-term care facilities, to implement coordinated antibioticstewardship, andReports antibiotic use to the National Healthcare Safety Network (3 or more months).16
Antibiotic Stewardships ContinuedArea: Patient SafetyEach level is cumulative, a hospital has to meet the conditions and provide documentation and supportingevidence for the highest level it wishes to obtain as well as those below it. (e.g. to achieve level 3 hospitals mustmeet the criteria and submit documentation that meets levels 1 – 3).Measure details:Level 1 Hospitals must answer yes to the following questions and provide supporting documentation: Does your hospital have formal, written support from leadership (e.g., a policy statement) that supportsefforts to improve antibiotic use (antibiotic stewardship)? Is there a physician leader responsible for program outcomes of stewardship activities at your hospital? Is there a pharmacist leader responsible for working to improve antibiotic use at your hospital? Is there an antibiotic stewardship committee that meets at least quarterly? Documentation: Document dates of antibiotic stewardship committee meetings and include the names andposition descriptions of attendees (e.g., “physician leader”). Letter of support: The letter must indicate support for improving antibiotic stewardship and attest that there isan antibiotic stewardship committee that includes physician and pharmacist leaders and meets at leastquarterly.17
Antibiotic Stewardships ContinuedArea: Patient SafetyMeasure details:Level 2 Does your hospital have facility-specific treatment recommendations, based on national guidelines and localsusceptibility, to assist with antibiotic selection for the following common conditions (must answer yes to all)? Community-acquired pneumonia Urinary tract infection Skin and soft-tissue infection Does your hospital produce an antibiogram (cumulative antibiotic susceptibility report) and distribute theantibiogram to prescribers annually or every other year? Does your stewardship program provide education to clinicians and other relevant staff on improving antibioticprescribing at least annually? Documentation: Upload evidence of facility-specific treatment guidelines based on national guidelines for communityacquired pneumonia, urinary tract infection, and skin and soft-tissue infection Indicate general references to the national guidelines upon which facility-specific guidelines are based(e.g., Infectious Diseases Society of America). Dates and topics of education to clinicians and staff, must include at least 1 training during themeasurement period. Provide the date of the hospital’s latest antibiogram Letter of support including the information outlined in Level I as well as an attestation to the availabilityof facility-specific treatment guidelines based on national guidelines and attest to the education ofclinicians and staff on antibiotic stewardship at least annually.18
Antibiotic Stewardships ContinuedMeasure details:Area: Patient SafetyLevel 3 Does your hospital conduct any of the following broad interventions to improve antibiotic use? (yesto one or more) Do specified antibiotic agents need to be approved by a designated physician or pharmacistprior to dispensing (i.e., pre-authorization) at your hospital? Does a designated physician or pharmacist routinely review courses of therapy for specifiedantibiotic agents and provide verbal or written feedback to prescribers with 72 hours after theinitial orders (i.e., prospective audit with feedback) at your hospital? Is there a formal antibiotic time-out procedure during which clinicians review theappropriateness of antibiotics within 72 hours after the initial orders? Pharmacy-driven interventions for antibiotic stewardship including at least one of thefollowing:o Automatic alerts and de-escalation of therapy in situations where therapy might beunnecessarily duplicativeo Or time-sensitive automatic stop orders for specified antibiotic prescriptions?19
Antibiotic Stewardships ContinuedArea: Patient SafetyMeasure details:Level 3 Continued Does your hospital monitor antibiotic use (consumption) at the unit and/or hospital-wide level by one of thefollowing metrics? (yes to one or more) By counts of antibiotic(s) administered to patients per day (Days of Therapy; DOT). DOT is defined as anaggregate sum of days for which any amount of a specified antimicrobial agent is administered ordispensed to a particular patient (numerator) divided by a standardized denominator (e.g., patient-days,days present, or admissions). By number of grams of antibiotics used (Defined Daily Dose, DDD)? (DDD is defined as the aggregatenumber of grams of each antibiotic purchased, dispensed, or administered during a period of interestdivided by the World Health Organization-assigned DDD and divided by a standard denominator (e.g.,patient-days, days present, or admissions). Does your hospital report information to staff on improving antibiotic use and resistance? (yes to one or more) Does your stewardship program share facility-specific reports on antibiotic use with prescribers at leastonce every 6 months? Do prescribers receive direct, personalized communication about how they can improve their antibioticprescribing at least once every 6 months?20
Antibiotic Stewardships ContinuedArea: Patient SafetyMeasure details:Level 3 Continued Documentation: Provide a description of the process for the above intervention(s) (pre-authorization, prospective auditwith feedback, antibiotic time-out, or pharmacy-driven intervention), including:o What antimicrobial agents are targeted by the intervention,o Who implements the intervention,o How the intervention is implemented, ANDo When the intervention is implemented (during the course of patient care) Provide a description ofo how DOT or DDD are measured, ando what antibiotic utilization information is reported to prescribers and how. Include examplesof antibiotic utilization reports. Letter of support including the information outlined in Levels I and 2 as well as:o The letter must attest to facility practice of one or more of the above broad interventions toimprove antibiotic use (antibiotic pre-authorization, prospective audit with feedback,antibiotic time-out, or pharmacy interventions), the tracking of antibiotic days of therapy ordefined daily doses, and the report of antibiotic use data to prescribers at least once everysix months.21
Antibiotic Stewardships ContinuedArea: Patient SafetyMeasure details:Level 4In order to achieve this level, the hospital must complete both activities. Has your hospital collaborated with one or more facilities, such as other hospitals or long-term carefacilities, to implement coordinated antibiotic stewardship?o Examples include shared infectious diseases physician or pharmacy oversight of antibioticstewardship activities among multiple facilities, implementation of broad interventions toimprove antibiotic use as defined for Level 3, Guidance, to multiple facilities, multi-facilityefforts to track and report antibiotic use, or participation in a state or national public healthcollaborative. Does your hospital regularly report antibiotic use data to NHSN via the Antibiotic Use and Resistance Module(3 or more months during the measurement period)? Documentation: Description and evidence of the dates of collaboration, the name and facility type of collaboratingfacilities, and a description of the coordinated intervention. Provide the dates of reporting antibiotic use data to NHSN, as well as evidence of the reporting. Letter of support to include all of the information in Levels 1-3 and letter must attest to hospitalparticipation in collaborative antibiotic stewardship efforts with other healthcare facilities and report of 3 months of antibiotic use data to NHSN.22
Handoffs and SignoutsArea: Patient SafetyHospitals had identified this area in their patient safety surveys as an area that neededimprovement. The subcommittee noted that different hospitals may use different tools, anddifferent hospitals may have different areas where they need to improve handoffs and signouts.Based on this feedback this process measure was developed.Three-step Process Measure:Step 1: Hospitals must identify the areas of handoffs and signouts that they need to improve on andfocus on the area that has the most need. Hospitals should look at both areas that have the greatestneed for improvement and areas with the highest severity of potential harm. This can be accomplishedby reviewing the results of their patient safety survey or other means. These handoffs and signouts canbe between different levels of care, between departments, or other areas where providers transitioncare between themselves or other hospital staff.Step 2: Hospitals must describe the process they are using to address handoffs and transitionsStep 3: Hospitals must describe how they will measure the implementation and performance of theprograms and complete the following tasks:23
Handoffs and Signouts ContinuedArea: Patient SafetyThree-step Process Measure:Step 1: Hospitals must identify the areas of handoffs and signouts that they need to improve on and focus on thearea that has the most need. Hospitals should look at both areas that have the greatest need for improvement andareas with the highest severity of potential harm. This can be accomplished by reviewing the results of theirpatient safety survey or other means. These handoffs and signouts can be between different levels of care,between departments, or other areas where providers transition care between themselves or other hospital staff. Hospitals must provide a narrative description of the area they are addressing. They should provide evidence that qualityneeds to be improved in this area. Examples of transitions include:o Operating room to intensive care unito Emergency department to inpatiento Intensive care unit to flooro Perioperative services to next level of careo I
Sepsis New Hospital Reported Process . stewardship committee that includes a physician and pharmacist that meets at least quarterly. Level 2, Education: . antibiotic time-outs, or pharmacy-driven interventions designed for the antibiotic stewardship program, such as automatic alerts
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