Form 1 Medicare Rural Hospital Flexibility Grant Program Perfor

Core Area I: Quality Improvement

Grantees are only required to select one Objective and one intervention related to the Core Area, along with measures associated with the Objective/Intervention. With that in mind, the tool under development will only provide access to the measures applicable at the time of reporting and will remove the non-applicable selections from view.

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

Core Area II: Financial and Operational Improvement

Grantees are required to complete the first Objective and to choose an additional Objective as well as one intervention with all associated measures for the Objectives/Interventions. With that in mind, the tool under development will only provide access to the measures applicable at the time of reporting and will remove the non-applicable selections from view.

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 Satisfaction Pre-test Average score

Measure: Education Satisfaction 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

Core Area III: Health System Development and Community Engagement

Grantees are required to select one Objective without any specified interventions as well as the measures that coincide with the activities of the Objective. Those activities not applicable will be greyed out.

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

Core Area IV: Critical Access Hospital Conversion

The final Core Area revolves around assisting hospitals in determining if CAH status is appropriate for them and to help the hospitals outline a course of action. This element does not occur as often because the vast majority of qualified critical access hospital candidates have already converted. These measures are to capture the current state status of CAHs within the each state.

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