spreadsheet version of the measures

Attachment C_PIMSOMBmeasures.xlsx

Medicare Rural Hospital Flexibility Grant Program Performance Measures

spreadsheet version of the measures

OMB: 0915-0363

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Overview

QI
FO
HSD
CAH


Sheet 1: QI

Required Perfomance Improvement Measurement Systems (PIMS) Reporting
Quality Improvement
Objective: Medicare Beneficiary Quality Improvement Project (MBQIP)
Measure: Number of Critical Access Hospitals (CAHs) participating in the MBQIP
Calculation: Number of CAHs participating/Total Number of CAHs
Denominator: Total Number of CAHs in State as of August 31 of each budget year
August 31st is the end of the budget year and the number of CAHs in any given state will flucuate with the economic conditions of the state. It is possible to add and lose a CAH within the same year and August 31 was chosen as a static point in time.
Numerator: Total Number of CAHs in State with a signed MOU and actively reporting to Qnet
To participate in MBQIP, CAHs must have a signed MOU that allows ORHP to acquire their submission to Qnet to be shared with the Office. The data provided is not patient specific but is incident specific. Numerator represents number of CAHs with signed MOUs reporting to Qnet.
Measure: Total Number of CAHs in State as of August 31 of each year
Calculation: None
Collection is to determine baseline number to be applied in other calculations.
Measure: Number of new CAHs participating in MBQIP
Calculation: Total Number of CAHs paricipating in MBQIP as of Aug 31- Total Number of CAHs participating the previous year
Measure: Number of CAHs continuing participation in MBQIP from the prior year
Calculation: Number of CAHs participating in MBQIP this year that participated in the previous year-number of CAHs that participated previous year
Measure: Number of CAHs no longer participating in MBQIP this year
Calculation: Total number of CAHS participating in MBQIP last year - Total Number of CAHs from Last still participating
Measure: Number of CAHs that reported improvement in one or more MBQIP clinical measure
Calculation: Current CAHs with improvement - initial baseline CAH data
Measure: Number of total CAHs participating in Hospital Compare
Calculation: None, measure represents Total Number of CAHs reporting to Hospital Compare as of August 31
Measure: Number of new CAHs participating in Hospital Compare this grant budget year
Calculation: Number of CAHs reporting to Hospital Compare as of August 31- Number of CAHs reporting to Hospital Compare the previous year (August 31)
Measure: Change in number of CAHs participating in Hospital Compare based on total number of CAHs within the State
Calculation: (Total Number of CAHs reporting this year-total reporting last year)
Measure: Number of medication orders directly entered by a pharmacist or verified by a pharmacist for a patient admitted to a CAH as an inpatient (acute or swingbed) within 24 hours
Measure: Total number of medication orders entered (using electronic order entry) for a patient admitted to a CAH as an inpatient (acute or swingbed) during the reporting period
Measure: Medical Record documentation indicates that there was nurse to nurse communication prior to the transfer of the patient from the ER to another facility, Y/N/NA. Provide the aggregate of all facilities participating in MBQIP.
Measure: Medical Record documentation indicates that there was physician to physician communication prior to the transfer of the patient from the ER to another facility, Y/N/NA. Provide the aggregate of all facilities participating in MBQIP.
Measure: Medical Record documentation indicates that patient information including name, address, age, gender was sent with the patient, Y/N/NA. Provide the aggregate of all facilities participating in MBQIP.
Measure: Medical Record documentation indicates that contact information for significant other and/or family member was sent with the patient, Y/N/NA. Provide the aggregate of all facilities participating in MBQIP.
Measure: Medical Record documentation indicates that insurance information was sent with the patient, Y/N/NA. Provide the aggregate of all facilities participating in MBQIP.
Measure: Medical Record documentation indicates that vital signs taken and were sent with the patient, Y/N/NA. Provide the aggregate of all facilities participating in MBQIP.
Measure: Medical Record documentation indicate that neuro assessments were done, as appropriate, and sent with the patient, Y/N/NA. Provide the aggregate of all facilities participating in MBQIP.
Measure: Medical Record documentation indicates that the following physician communications were sent with the patient, Y/N/NA. Provide the aggregate of all facilities participating in MBQIP.
Measure: Medical Record documentation indicate that the following nursing communications were sent with the patient, Y/N/NA. Provide the aggregate of all facilities participating in MBQIP.
Measure: Medical Record documentation indicates that information was sent on the treatment provided in the originating hospital, Y/N/NA. Provide the aggregate of all facilities participating in MBQIP.
Measure: Medical Record documentation indicates that information was sent on the tests and procedures that were done in the ER, Y/N/ NA. Provide the aggregate of all facilities participating in MBQIP.
Measure: Medical Record documentation indicates that the results from completed tests and procedures were sent with the patient, Y/N/NA. Provide the aggregate of all facilities participating in MBQIP.
Objective: Multi-Hospital Quality Improvement and CAH Quality Reporting
Measure: Number of CAHS actively participating in a Flex-funded multi-hospital QI initiative
Measure will be captured by counting the number of CAHs in a Flex-Funded QI Initiative
Measure: Number of CAHs with an improvement in one or more measure based on active participation in a QI project
Calculation: Current CAHs with improvement - initial baseline CAH data
Measure: Number of other rural providers actively participating in a Flex-funded multi-hospital QI initiative
Measure will be captured by counting the number of other rural providers in a Flex-Funded QI Initiative
Multi-organizational PI/QI leadership Project and Optional education and training
Measure: Number of CAHs actively participating in the QI/PI project
Measure will consist of a count of CAHs involved in the QI/PI project
Measure: Total hours dedicated to the project
Measure will reflect front end, middle, and back end time devoted to the projects. The measure should cover pre-planning through project completion.
Measure: Number of Total Participants in the project
Measure is defined as total personnel working on the QI/PI project
Measure: QI education/training programs for managers, staff and/or board members of CAHs
Sub-measures to be reported on trainings/workshops in excess of 3 hours
Sub-measure: Total number of CAHs participating in the workshop/training
Sub-Measure: Total number of CAH staff participating
Staff is defined as anyone employed by CAH directly or by contract
Sub-Measure: Number of staff answering 9 or more out of 10 correctly post-training
Post-test to be administered at the end of training, multiple choice.
Sub-Measure: Number of staff answering 9 or more out of 10 correctly post-training four months later
Post-test to be administered four months later, same test, multiple choice.
Sub-Measure: Total Number of staff contacted to complete post-test four months later
Sub-Measure: Total Number of staff that completed the post-test four months later
Sub-measure: Number of other rural providers participating in the training
Other rural providers is defined as any health care entity responsible for any part of the continuum of care, (i.e. RHCs, Rural PPS, and EMS)
Sub-measure: Number of other rural providers answering 9 or more post-test questions correctly post-training
Sub-measure: Number of other rural providers answering 9 or more post-test questions correctly four months post-training
Sub-Measure: Total Number of Other Rural Providers contacted to fill out the post-test
Sub-Measure: Total Number of Other Rural Providers contacted to fill out the post-test four months later
Interventions
Interventions and the collection of PIMS measures will only be applicable to those programs that choose a specific intervention. For every intervention chosen the appropriate measures should be reported.
1. Encourage CAHs in state to publicly report Hospital Compare on relevant inpatient and outpatient measures and HCAHPS patient assessment of care survey measures.
Measure: Total number of CAHs reporting data on at least one inpatient measure
Measure: Total number of CAHs in state reporting data on at least one outpatient measure
Measure: Change in CAHs reporting on at least one outpatient measure
Calculation: the difference of Current outpatient measure reporting (Aug 31) and the baseline previous year outpatient measure report.
Measure: Number of CAHs reporting HCAHPS data
Measure: Number of new CAHs reporting HCAHPS data
Measure: Number of CAHs reporting a quality improvement initiative based on HCAHPS data
2. Encourage CAHs in state to participate in MBQIP
Phase 1
Measure: Number of CAHs in state implementing a quality improvement initiative based on MBQIP pneumonia data
Measure: Number of CAHs in state implementing a quality improvement initiative based on MBQIP heart failure data
Phase 2
Measure: Number of CAHs reporting all MBQIP outpatient quality measures
Measure: Number of CAHs implementing a QI project based on HCAHPS data
Measure: Number of CAHs implementing a QI project based on outpatient data
Phase 3
Measure: Number of CAHs in the process of implemetning the Emergency Department (ED) transfer measure
Measure: Number of CAHS that implemented and are reporting on ED transfer measures
Measure: Number of CAHs that have provided education for ED staff and and on the use of ED transfer measures
Measure: Number of CAHs with electronic medication order entry
Measure: Number of CAHs conducting medication order review within 24 hours
3. Support for Quality Network/ Work Group Quality Benchmarking and Quality Improvement Activities
Measure: Number of CAHs in the state actively participating in quality benchmarking activities (non-MBQIP)
4. Support for Evidence-Based Protocol Implementation
Measure: Total number of hospitals implementing evidence-based practices for quality improvement this budget year
Measure: Total number of EMS units implementing evidence-based practices to improve rural response times this budget year
Measure: Number of of CAHs in state implementing evidence-based protocols for a serious medical condition (e.g., stroke)
Measure: The change in CAH performance based on evidence-based protocol implementation
Calculation: Current CAHs perfomance- pre-implementation of protocol
Measure: After evidence-based practice was implemented how may continue to use it?
5. Support Care Transitions and/or reduction of Hospital Readmissions
Measure: Number of hospitals participating in a care transitions project
Measure: Number of hospitals participating in a readmission reduction project
Measure: Change in readmissions for each CAH associated with the project
Calculation will be based on the difference in the baseline data capture and the completed project
6. AHRQ Patient Safety Survey/Team STEPPS
Measure: Number of CAHs in state implementing pre and post patient safety culture surveys
Measure: Number of survey responses
Measure: Number CAHs continuing to use patient safety surveys at six(6) months
Measure: Number of CAHs actively participating in TeamSTEPPS training

Sheet 2: FO

Required Perfomance Improvement Measurement Systems (PIMS) Reporting
Financial and Operational Improvement
Objective: Assist CAHs in identifying potential areas of financial and operational performance improvement
Measure: The number of CAHs undergoing financial and operational performance assessments
Measure: The number of CAHs who implemented changes to process based on the recommendations
Measure: Number of financial and/or operational improvement Networks
Measure: Number of critical access hospitals participating in the network
Measure: Total number of other rural providers in the networks
Measure: The number of CAH staff (including part-time, contractors, and governing board) attending network or user group meetings related to financial and operational performance assessment
Measure: Number of improvement activities based on meetings
Measure: The number of CAHs with identified outcomes derived from the meetings
For any Flex program providing Financial and Operational Performance Assessments, a post evaluation directly related to the assistance should occur at the conclusion of the intervention, with a follow-up behavioral acceptance evaluation occurring at some point following the assistance. Flex Programs are encouraged to work with CAHs within their States to improve their financial and operational indicators through measurement of change in the performance of the State’s CAHs.
Measure: The number of CAHs demonstrating behavioral change based on the assessment
Measure: The number of other rural providers demonstrating behavioral change based on the assessment
Measure: Total number of CAHs still using the new processes 90 days after implementation
Measure: Number of other rural providers still using the new processes 90 days after implementation
Measure: Number of recommendations implemented after the assessments
Measure: Number of new, needed services developed after the assessment
Objective: Support CAHs in planning and implementing interventions for improving financial or operational performance. Support may include technical assistance, educational programs/seminars, user group meetings, and consultation, facilitated or funded by the State Flex Program. These interventions relate to technical assistance applied through direct consultation.
Measure: Number of CAHs receiving Flex-funded financial consultations
Measure: Number of CAHs receiving Flex-funded operational consultations
ORHP has identified an initial activity and measure to be collected because there is a known relationship between Days in Account Receivable and profitability, we have selected the following measures to be collected for each direct consultation with a CAH:
Measure: Number of CAHs who reported improvement in Days in AR based on Flex-Funded activity
Sub-measure: Number of CAHs that performed a Business Office Assessment
Sub-measure: Number of CAHS that implemented a revenue cycle management program
Sub-measure: Number of CAHs providing education for staff and department heads on documenting charity care
Sub-measure: Number of staff and department heads showing 90% information retention four months after education on documenting charity care
Measure: Number of CAHs that used Flex funding for updating their chargemaster this year
Sub-measure: Revenue prior to chargemaster update?
Sub-measure: Revenue after chargemaster update?
Sub-measure: Number of claims denied prior to chargemaster update?
Sub-measure: Number of claims denied after chargemaster update?
Objective: State Flex Programs providing Educational Programs and Seminars should describe the type and topic of the programs and seminars and demonstrate the impact of the trainings
Measure: Number of seminars & workshops sponsored
Measure: The number of CAHs attending each seminar &/or workshop
Measure: The number of total participants in each seminar &/or workshop
Measure: Total cost of seminars & workshops
Measure: Average cost per seminar
Measure: Average cost per workshop
Interventions and the collection of PIMS measures will only be applicable to those programs that choose a specific intervention. For every intervention chosen the appropriate measures should be reported.
1.    Financial Assessments
Measure: Average Days in Net Account Receivable
Measure: Average Days in Gross Accounts Receivable
Measure: Average Days Cash on Hand
Measure: Average Total Margin
Measure: Average Operating Margin
Measure: Average Debt Service Coverage Ratio
Measure: Average Salaries to Net Patient Revenue
Measure: Average Payor Mix Percentage
Measure: Average Age of Plant
Measure: Average Long Term Debt to Capitalization
2. Revenue Cycle Management
Measure: Change in Bad Debt
Measure: Amount of gross charges
Measure: Net patient revenue
Measure: Number of CAHs completing analysis
Measure: Point of service collection baseline
Measure: Point of service collection current
Measure: Total revenue
Measure: Baseline claims reduction
Measure: Current claims reduction
Measure: Number of Baseline claim denials
Measure: Number of Current claim denials
Measure: Baseline days in AR
Measure: Current days in AR
Measure: Baseline Gross Revenue
Measure: Current Gross Revenue
Measure: Baseline Clean Claims
Measure: Current Clean Claims
3. Charge Master Review
Measure: Number of line items with CPT/HCPCS code changes added, deleted or revised
Measure: Number of CDM deleted
Measure: Number of CDM items added
Measure: Number of CDM items revised
Measure: Number of CDM CPT codes deleted
Measure: Number of CDM CPT codes added
Measure: Number of CDM CPT codes revised
Measure: Number of line items with revenue code changes recommended
Measure: Number of line items with revenue code changes implemented
Measure: Number of CDM codes revised
Measure: Number of CDM errors baseline
Measure: Number of CDM errors current
Measure: Number of cost-report errors baseline
Measure: Number of Cost-report errors current
4. Emergency Department Operational Improvement
Measure:Number of participating CAHs
Measure: Total ED wait time baseline
Measure: Total ED wait time current (after intervention)
Measure: Time it takes to get from ED to medical screening exam baseline
Measure: Time it takes to get from ED to medical screening exam current
Measure: ED education satisfaction scores
5. Lean Training and Implementation
Measure: Number of hospitals completing the Lean readiness assessments
Measure: Number of hospitals participating in a Lean collaborative
Measure: Total revenue at start of Lean Project in targeted area
Measure: Total number of dollars normally spent on activity targeted for Lean implentation
Measure: Total number of dollars spent after Lean implementation
Measure: Total amount of staff required for operations prior to Lean
Measure: Total amount of staff required for operations after Lean implemented
Measure: Average patient wait time prior to Lean implementation
Measure: Average patient wait time after Lean Implementation
Measure: Number of Lean initiatives and events that took place in each hospital
Measure: Baseline operations numbers for any Lean Initiatives and/or events
Measure: Current operations numbers for any Lean Initiatives and/or events
Measure: CMA score
6. Billing and Coding Education
Measure: Number of coding errors prior to training
Measure: Number of coding errors after training
Measure: Number of Baseline claim denials
Measure: Number of Current claim denials
Measure: Baseline Gross AR
Measure: Current Gross AR
Measure: Number of CAHs in the state
Measure: Number of CAHs participating in the coding training
Measure: Total Number of CAH staff participating in training
Measure: Number of Baseline claim denials
Measure: Number of Current claim denials
Measure: Average number of claims per month
Measure: Average number of coding denials per month
Measure: Average number of billing denials per month
7. Board Education and Leadership Development
Measure: Number of CAHs actively participating in CAH governance events
Measure: Number of CAHs developing financial components in their board education programs
Measure: CAH Board members Pre-test scores
Measure: CAH Leaders' Pre-test scores
Measure: CAH Board members Post-test scores
Measure: CAH Leaders' Post-test scores
Measure: Number of CAH leaders and managers participating in financial education workshops and collaboratives
8. Financial Improvement Collaborative
Measure: Number of CAHs participating in the financial collaborative
Measure: Number of contact hours (meeting hours times number of people attending)
Measure: Education Pre-test Outcome survey scores
Measure: Education Post-test Outcome survey scores
Measure: Average Survey Score
Measure: Education Satifaction Pre-test Average score
Measure: Education Satifaction Post-test Average score
Sub-measure: Total number of CAHs participating in the workshop/training
Sub-Measure: Total number of CAH staff participating
Staff is defined as anyone employed by CAH directly or by contract
Sub-Measure: Number of staff answering 9 or more out of 10 correctly post-training
Post-test to be administered at the end of training, multiple choice.
Sub-Measure: Number of staff answering 9 or more out of 10 correctly post-training four months later
Post-test to be administered four months later, same test, multiple choice.
Sub-Measure: Total Number of staff contacted to complete post-test four months later
Sub-Measure: Total Number of staff that completed the post-test four months later
Sub-measure: Number of other rural providers participating in the training
Other rural providers is defined as any health care entity responsible for any part of the continuum of care, (i.e. RHCs, Rural PPS, and EMS)
Sub-measure: Number of other rural providers answering 9 or more post-test questions correctly post-training
Sub-measure: Number of other rural providers answering 9 or more post-test questions correctly four months post-training
Sub-Measure: Total Number of Other Rural Providers contacted to fill out the post-test
Sub-Measure: Total Number of Other Rural Providers contacted to fill out the post-test four months later

Sheet 3: HSD

Required Perfomance Improvement Measurement Systems (PIMS) Reporting
Health System Development and Community Engagement
Measure: Number of Trained or recruited EMS medical directors
Measure: Number of EMS recruitment/retention projects initiated
Measure: Number of EMS (Ambulance) budget model courses conducted
Measure: Number of Managers trained in EMS (Ambulance) budget model courses
Measure: Number of EMS (Ambulance) services supported to join a network
Measure: Number of Services supported for group billing
Measure: Number of EMS assessments and strategic planning sessions conducted
Measure: Number of EMS leadership courses conducted
Measure: Number of Managers trained in EMS leadership courses
Measure: Number and variety of EMS-based Community Healthcare Models projects initiated
Measure: Number of Rural Trauma Team Development or Comprehensive Advanced Life Support (CALS) courses taught
Measure: Number of personnel trained
Measure: Number of communities affected
Measure: Number of facilitated BIS assessments conducted
Measure: Number of quality improvement activities implemented. A reassessment of BIS scores compared to the baseline score for that system
Measure: Number of Trauma System Consultations performed
Measure: Number of quality improvement activities directly linked to Trauma System Consultation report recommendations
Objective: Support CAHs, communities, rural and urban hospitals, EMS, and other community providers in developing local and/or regional health systems of care and the inclusion of EMS services into local and/or regional systems of care and/or regional and state trauma systems.
Measure: Number of CAHs engaged in STEMI
Measure: Number of STEMI patients in total
Measure: Number of STEMI patients receiving aspirin within 24-hours in total
Measure: Number of STEMI patients not receiving aspirin within 24 hours in total
Measure: Number of STEMI patients with a STEMI Referral Hospital door-to-balloon (first device used) time within 90 minutes upon transfer
Measure: Number of CAHs engaged in regional and/or national stroke programs
Measure: Number of CAHs obtaining trauma designation this budget year
Measure: Number of CAHs rated Trauma Level III? Level IV? Level V?
Measure: Number of CAHs that enhanced their trauma designation
Measure: Number of CAHs that reduced their Trauma designation
Objective: Support CAHs, communities, rural and urban hospitals, EMS, and other community providers in developing local and/or regional health systems of care and the support for the sustainability and viability of EMS within the community.
Measure: Number of EMS units or providers participating in Flex-funded activities to improve EMS financial/operational performance
Measure: Number of EMS units engaged in group purchasing arrangements
Measure: Number of EMS personnel participating in billing/coding programs
Measure: Number of EMS personnel reporting that participation in the activities was valuable
Measure: Number of EMS units that changed procedures based on activities
Measure: Number of EMS units reporting a positive change in revenue
Measure: Number of EMS personnel participating leadership training
Measure: Number of EMS units participating in recruitment and retention programs
Objective: Support CAHs and communities in conducting or collaborating on assessments to identify unmet community health and health service needs and support CAHs and communities in developing collaborative projects/initiatives to address unmet health and health service needs.
Measure: Number of CAHs receiving support and/or TA to support them in conducting community health needs assessments
Measure: Number of CAHs that have completed a community needs assessment
Measure: Number of interventions implemented as a result of needs identified by CAHs conducting community needs assessment
Measure: Number of interventions implemented to address new and ongoing community needs
Measure: Number of CAHs that report improvements in conditions addressed by their community health needs interventions at subsequent needs assessments
Measure: Number of community paramedicine programs identified as a potential intervention based on the community needs assessment
Measure: Number of communities that have begun piloting community paramedicine programs

Sheet 4: CAH

Required Perfomance Improvement Measurement Systems (PIMS) Reporting
Critical Acces Hospital Conversion
Objective: Flex programs must assist hospitals in evaluating the effects of conversion to critical access status.
Measure: Number of new CAHs
Measure: Number of hospitals eligible for CAH conversion
Measure: Number of hospitals requested assistance in conversion to CAH status
Measure: Number of hospitals helped in conversion to CAH status
Measure: Number of hospitals unsuccessful in their attempt to convert to CAH status
Measure: Number of CAHs de-designating
Measure: Number of CAHs closed
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