| 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 |
| 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 |
| 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 |