| Section |
Subsection |
Item (Measure) |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
Critical Access Hospitals |
1. Number of Critical Access Hospitals (CAHs) participating in the MBQIP |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
Critical Access Hospitals |
a. Numerator: Total Number of CAHs in State with a signed MOU and actively reporting to Qnet |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
Critical Access Hospitals |
b. Denominator: Total Number of CAHs in State as of August 31 of each budget year |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
Critical Access Hospitals |
Measures |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
Critical Access Hospitals |
2. Total Number of CAHs in State as of August 31 of each year |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
Critical Access Hospitals |
3. Number of new CAHs participating in MBQIP |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
Critical Access Hospitals |
Measures |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
Critical Access Hospitals |
4. Number of CAHs continuing participation in MBQIP from the prior year |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
Critical Access Hospitals |
5. Number of CAHs no longer participating in MBQIP this year |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
Critical Access Hospitals |
6. Number of CAHs that reported improvement in one or more MBQIP clinical measure |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
Critical Access Hospitals |
Measures |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
Critical Access Hospitals |
7. Number of total CAHs participating in Hospital Compare - Baseline |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
Critical Access Hospitals |
8. Number of CAHs participating in Hospital Compare this grant budget year |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
Critical Access Hospitals |
Measures |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
Critical Access Hospitals |
9. Change in number of CAHs participating in Hospital Compare based on total number of CAHs within the State |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
Critical Access Hospitals |
Measures |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
Critical Access Hospitals |
10. 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. |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
Critical Access Hospitals |
11. 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 |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
12. Medical Record documentation indicates that there was nurse to nurse communication prior to the transfer of the patient from the ER to another facility. |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
Aggregate total number of CAHs |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
13. Medical Record documentation indicates that there was physician to physician communication prior to the transfer of the patient from the ER to another facility. |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
Aggregate total number of CAHs |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
14. Medical Record documentation indicates that patient information including name, address, age, gender was sent with the patient. |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
Aggregate total number of CAHs |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
15. Medical Record documentation indicates that contact information for significant other and/or family member was sent with the patient. |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
Aggregate total number of CAHs |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
16. Medical Record documentation indicates that insurance information was sent with the patient. |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
Aggregate total number of CAHs |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
17. Medical Record documentation indicates that vital signs taken and were sent with the patient. |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
Aggregate total number of CAHs |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
18. Medical Record documentation indicate that neuro assessments were done, as appropriate, and sent with the patient. |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
Aggregate total number of CAHs |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
19. Medical Record documentation indicate that the following nursing communications were sent with the patient. |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
Aggregate total number of CAHs |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
20. Medical Record documentation indicates that information was sent on the treatment provided in the originating hospital, Y/N/NA. |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
Aggregate total number of CAHs |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
21. Medical Record documentation indicates that information was sent on the tests and procedures that were done in the ER, Y/N/ NA. |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
Aggregate total number of CAHs |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
22. Medical Record documentation indicates that the results from completed tests and procedures were sent with the patient, Y/N/NA. |
| Objective 1: Medicare Beneficiary Quality Improvement Project (MBQIP) |
ED Transfer |
Aggregate total number of CAHs |
| Objective 2: Multi-Hospital Quality Improvement and CAH Quality Reporting |
|
1. Number of CAHS actively participating in a Flex-funded multi-hospital QI initiative. |
| Objective 2: Multi-Hospital Quality Improvement and CAH Quality Reporting |
|
2. Number of CAHs with an improvement in one or more measure based on active participation in a QI project |
| Objective 2: Multi-Hospital Quality Improvement and CAH Quality Reporting |
|
Percentage of CAHs Reporting an Improvement in One or More Measure Based on Active Participation in a QI Project. |
| Objective 2: Multi-Hospital Quality Improvement and CAH Quality Reporting |
|
3: Number of other rural providers actively participating in a Flex-funded multi-hospital QI initiative. |
| Objective 3: Multi-organizational PI/QI leadership Project and Optional education and training |
|
1. Number of CAHs actively participating in the QI/PI project. |
| Objective 3: Multi-organizational PI/QI leadership Project and Optional education and training |
|
2.Total hours dedicated to the project. |
| Objective 3: Multi-organizational PI/QI leadership Project and Optional education and training |
|
3. Number of Total Participants in the project |
| Objective 3: Multi-organizational PI/QI leadership Project and Optional education and training |
QI Training/Workshops |
4. QI education/training programs for managers, staff and/or board members of CAHs. |
| Objective 3: Multi-organizational PI/QI leadership Project and Optional education and training |
QI Training/Workshops |
Did you have any trainings/workshops in excess of 3 hours for this reporting period? |
| Objective 3: Multi-organizational PI/QI leadership Project and Optional education and training |
QI Training/Workshops |
Sub-measure 1. Total number of CAHs participating in the workshop/training |
| Objective 3: Multi-organizational PI/QI leadership Project and Optional education and training |
QI Training/Workshops |
Sub-measure 2. Total number of CAH staff participating |
| Objective 3: Multi-organizational PI/QI leadership Project and Optional education and training |
QI Training/Workshops |
Sub-measure 3. Number of staff answering 9 or more out of 10 correctly post-training |
| Objective 3: Multi-organizational PI/QI leadership Project and Optional education and training |
QI Training/Workshops |
Sub-measure 4. Number of staff answering 9 or more out of 10 correctly post-training four months later |
| Objective 3: Multi-organizational PI/QI leadership Project and Optional education and training |
QI Training/Workshops |
Sub-measure 5. Total Number of staff contacted to complete post-test four months later |
| Objective 3: Multi-organizational PI/QI leadership Project and Optional education and training |
QI Training/Workshops |
Sub-measure 6. Total Number of staff that completed the post-test four months later |
| Objective 3: Multi-organizational PI/QI leadership Project and Optional education and training |
QI Training/Workshops |
Sub-measure 7. Number of other rural providers participating in the training |
| Objective 3: Multi-organizational PI/QI leadership Project and Optional education and training |
QI Training/Workshops |
Sub-measure 8: Number of other rural providers answering 9 or more post-test questions correctly post-training |
| Objective 3: Multi-organizational PI/QI leadership Project and Optional education and training |
QI Training/Workshops |
Sub-measure 9. Number of other rural providers answering 9 or more post-test questions correctly four months post-training |
| Objective 3: Multi-organizational PI/QI leadership Project and Optional education and training |
QI Training/Workshops |
Sub-measure 10. Total Number of Other Rural Providers contacted to fill out the post-test |
| Objective 3: Multi-organizational PI/QI leadership Project and Optional education and training |
QI Training/Workshops |
Sub-measure 11. Total Number of Other Rural Providers contacted to fill out the post-test four months later |
| QI Intervention 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 1. Total number of CAHs reporting data on at least one inpatient measure. |
| QI Intervention 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 2. Total number of CAHs in state reporting data on at least one outpatient measure. |
| QI Intervention 1. Encourage CAHs in state to publicly report Hospital Compare on relevant inpatient and outpatient measures and HCAHPS patient assessment of care survey measures. |
|
(2A.)Current Year - Total number of CAHs in state reporting data on at least one outpatient measure. |
| QI Intervention 1. Encourage CAHs in state to publicly report Hospital Compare on relevant inpatient and outpatient measures and HCAHPS patient assessment of care survey measures. |
|
(2B.)Baseline - Total number of CAHs in state reporting data on at least one outpatient measure. |
| QI Intervention 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 3. Change in CAHs reporting on at least one outpatient measure. |
| QI Intervention 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 4. Number of CAHs reporting HCAHPS data. |
| QI Intervention 1. Encourage CAHs in state to publicly report Hospital Compare on relevant inpatient and outpatient measures and HCAHPS patient assessment of care survey measures. |
|
(4A.)Current Year - Total number of CAHs in state reporting HCAHPS data. |
| QI Intervention 1. Encourage CAHs in state to publicly report Hospital Compare on relevant inpatient and outpatient measures and HCAHPS patient assessment of care survey measures. |
|
(4B.)Baseline - Total number of CAHs in state reporting HCAHPS data." Valid values shall be whole numbers from zero (0) to 999 and N/A. |
| QI Intervention 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 5. Number of new CAHs reporting HCAHPS data. |
| QI Intervention 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 6. Number of CAHs reporting a quality improvement initiative based on HCAHPS data. |
| QI Intervention 2. Encourage CAHs in state to participate in MBQIP |
Phase 1 |
Measure 1. Number of CAHs in state implementing a quality improvement initiative based on MBQIP pneumonia data |
| QI Intervention 2. Encourage CAHs in state to participate in MBQIP |
Phase 1 |
Measure 2. Number of CAHs in state implementing a quality improvement initiative based on MBQIP heart failure data |
| QI Intervention 2. Encourage CAHs in state to participate in MBQIP |
Phase 2 |
Measure 3. Number of CAHs reporting all MBQIP outpatient quality measures |
| QI Intervention 2. Encourage CAHs in state to participate in MBQIP |
Phase 2 |
Measure 4. Number of CAHs implementing a QI project based on HCAHPS data |
| QI Intervention 2. Encourage CAHs in state to participate in MBQIP |
Phase 2 |
Measure 5. Number of CAHs implementing a QI project based on outpatient data |
| QI Intervention 2. Encourage CAHs in state to participate in MBQIP |
Phase 3 |
Measure 6. Number of CAHs in the process of implemetning the Emergency Department (ED) transfer measure |
| QI Intervention 2. Encourage CAHs in state to participate in MBQIP |
Phase 3 |
Measure 7. Number of CAHS that implemented and are reporting on ED transfer measures |
| QI Intervention 2. Encourage CAHs in state to participate in MBQIP |
Phase 3 |
Measure 8. Number of CAHs that have provided education for ED staff and and on the use of ED transfer measures |
| QI Intervention 2. Encourage CAHs in state to participate in MBQIP |
Phase 3 |
Measure 9. Number of CAHs with electronic medication order entry |
| QI Intervention 2. Encourage CAHs in state to participate in MBQIP |
Phase 3 |
Measure 10. Number of CAHs conducting medication order review within 24 hours |
| QI Intervention 3. Support for Quality Network/ Work Group Quality Benchmarking and Quality Improvement Activities |
|
Measure 1. Number of CAHs in the state actively participating in quality benchmarking activities (non-MBQIP) |
| QI Intervention 4. Support for Evidence-Based Protocol Implementation |
|
Measure 1. Total number of hospitals implementing evidence-based practices for quality improvement this budget year |
| QI Intervention 4. Support for Evidence-Based Protocol Implementation |
|
Measure 2. Total number of EMS units implementing evidence-based practices to improve rural response times this budget year |
| QI Intervention 4. Support for Evidence-Based Protocol Implementation |
|
Measure 3. Number of of CAHs in state implementing evidence-based protocols for a serious medical condition (e.g., stroke) |
| QI Intervention 4. Support for Evidence-Based Protocol Implementation |
Medical Condition 1 |
Condition |
| QI Intervention 4. Support for Evidence-Based Protocol Implementation |
Medical Condition 1 |
# CAHs |
| QI Intervention 4. Support for Evidence-Based Protocol Implementation |
Medical Condition 1 |
Change in Performance |
| QI Intervention 4. Support for Evidence-Based Protocol Implementation |
Medical Condition 2 |
Condition |
| QI Intervention 4. Support for Evidence-Based Protocol Implementation |
Medical Condition 2 |
# CAHs |
| QI Intervention 4. Support for Evidence-Based Protocol Implementation |
Medical Condition 2 |
Change in Performance |
| QI Intervention 4. Support for Evidence-Based Protocol Implementation |
Medical Condition 3 |
Condition |
| QI Intervention 4. Support for Evidence-Based Protocol Implementation |
Medical Condition 3 |
# CAHs |
| QI Intervention 4. Support for Evidence-Based Protocol Implementation |
Medical Condition 3 |
Change in Performance |
| QI Intervention 4. Support for Evidence-Based Protocol Implementation |
Medical Condition 4 |
Condition |
| QI Intervention 4. Support for Evidence-Based Protocol Implementation |
Medical Condition 4 |
# CAHs |
| QI Intervention 4. Support for Evidence-Based Protocol Implementation |
Medical Condition 4 |
Change in Performance |
| QI Intervention 4. Support for Evidence-Based Protocol Implementation |
Medical Condition 5 |
Condition |
| QI Intervention 4. Support for Evidence-Based Protocol Implementation |
Medical Condition 5 |
# CAHs |
| QI Intervention 4. Support for Evidence-Based Protocol Implementation |
Medical Condition 5 |
Change in Performance |
| QI Intervention 5. Support Care Transitions and/or reduction of Hospital Readmissions |
|
Measure 1. Number of hospitals participating in a care transitions project |
| QI Intervention 5. Support Care Transitions and/or reduction of Hospital Readmissions |
|
Measure 2. Number of hospitals participating in a readmission reduction project |
| QI Intervention 5. Support Care Transitions and/or reduction of Hospital Readmissions |
|
Measure 3. Change in readmissions for each CAH associated with the project |
| QI Intervention 5. Support Care Transitions and/or reduction of Hospital Readmissions |
|
(3A.)Current Year Readmission Rate |
| QI Intervention 5. Support Care Transitions and/or reduction of Hospital Readmissions |
|
(3B.)Baseline [Prior Year] Readmission Rate |
| QI Intervention 5. Support Care Transitions and/or reduction of Hospital Readmissions |
|
Measure |
| QI Intervention 6. AHRQ Patient Safety Survey/Team STEPPS |
|
Measure 1. Number of CAHs in state implementing pre and post patient safety culture surveys |
| QI Intervention 6. AHRQ Patient Safety Survey/Team STEPPS |
|
Measure 2. Number of survey responses |
| QI Intervention 6. AHRQ Patient Safety Survey/Team STEPPS |
|
Measure 3. Number CAHs continuing to use patient safety surveys at six(6) months |
| QI Intervention 6. AHRQ Patient Safety Survey/Team STEPPS |
|
Measure 4. Number of CAHs actively participating in TeamSTEPPS training |
| Objective 1: Assist CAHs in identifying potential areas of financial and operational performance improvement. |
|
Measure 1. The number of CAHs undergoing financial and operational performance assessments. |
| Objective 1: Assist CAHs in identifying potential areas of financial and operational performance improvement. |
|
Measure 2. The number of CAHs who implemented changes to process based on the recommendations. |
| Objective 1: Assist CAHs in identifying potential areas of financial and operational performance improvement. |
|
Measure 3. Number of financial and/or operational improvement Networks. |
| Objective 1: Assist CAHs in identifying potential areas of financial and operational performance improvement. |
|
Measure 4. Number of critical access hospitals participating in the network. |
| Objective 1: Assist CAHs in identifying potential areas of financial and operational performance improvement. |
|
Measure 5. Total number of other rural providers in the networks. |
| Objective 1: Assist CAHs in identifying potential areas of financial and operational performance improvement. |
|
Measure 6. 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. |
| Objective 1: Assist CAHs in identifying potential areas of financial and operational performance improvement. |
|
Measure 7. Number of improvement activities based on meetings. |
| Objective 1: Assist CAHs in identifying potential areas of financial and operational performance improvement. |
|
Measure 8. The number of CAHs with identified outcomes derived from the meetings. |
| Objective 1: Assist CAHs in identifying potential areas of financial and operational performance improvement. |
|
Measure 9. The number of CAHs demonstrating behavioral change based on the assessment. |
| Objective 1: Assist CAHs in identifying potential areas of financial and operational performance improvement. |
|
Measure 10. The number of other rural providers demonstrating behavioral change based on the assessment. |
| Objective 1: Assist CAHs in identifying potential areas of financial and operational performance improvement. |
|
Measure 11. Total number of CAHs still using the new processes 90 days after implementation. |
| Objective 1: Assist CAHs in identifying potential areas of financial and operational performance improvement. |
|
Measure 12. Number of other rural providers still using the new processes 90 days after implementation. |
| Objective 1: Assist CAHs in identifying potential areas of financial and operational performance improvement. |
|
Measure 13. Number of recommendations implemented after the assessments. |
| Objective 1: Assist CAHs in identifying potential areas of financial and operational performance improvement. |
|
Measure 14. Number of new, needed services developed after the assessment |
| 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. |
|
You must select and report on at least one objective in addition to objective 1 (either objective 2, objective 3 or both). Please select the objective(s) that apply to this reporting period, and enter all measure data associated with the selected objective(s). |
| 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 1. Number of CAHs receiving Flex-funded financial consultations. |
| 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 2. Number of CAHs receiving Flex-funded operational consultations. |
| 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 3. Number of CAHs who reported improvement in Days in AR based on Flex-Funded activity. |
| 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. |
|
Sub-Measure 1. Number of CAHs that performed a Business Office Assessment. |
| 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. |
|
Sub-Measure 2. Number of CAHS that implemented a revenue cycle management program. |
| 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. |
|
Sub-Measure 3. Number of CAHs providing education for staff and department heads on documenting charity care. |
| 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. |
|
Sub-Measure 4. Number of staff and department heads showing 90% information retention four months after education on documenting charity care. |
| 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 4. Number of CAHs that used Flex funding for updating their chargemaster this year. |
| 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. |
|
Sub-Measure 1. Revenue prior to chargemaster update? |
| 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. |
|
Sub-Measure 2. Revenue after chargemaster update? |
| 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. |
|
Sub-Measure 3. Number of claims denied prior to chargemaster update? |
| 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. |
|
Sub-Measure 4. Number of claims denied after chargemaster update? |
| Objective 3: 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. |
|
You must select and report on at least one objective in addition to objective 1 (either objective 2, objective 3 or both). Please select the objective(s) that apply to this reporting period, and enter all measure data associated with the selected objective(s). |
| Objective 3: 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 1. Number of seminars & workshops sponsored. |
| Objective 3: 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 2. The number of CAHs attending each seminar &/or workshop. |
| Objective 3: 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. |
|
Duplicated Count of CAHs attending at least one seminar or workshop. |
| Objective 3: 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. |
|
Unduplicated Count of CAHs attending at least one seminar or workshop. |
| Objective 3: 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 3. The number of total participants in each seminar &/or workshop. |
| Objective 3: 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 4. Total cost of seminars & workshops. |
| Objective 3: 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 5. Average cost per seminar. |
| Objective 3: 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 6. Average cost per workshop |
| Intervention 1. Financial Assessments |
|
Measure 1. Average Days in Net Account Receivable. |
| Intervention 1. Financial Assessments |
|
Measure 2. Average Days in Gross Accounts Receivable. |
| Intervention 1. Financial Assessments |
|
Measure 3. Average Days Cash on Hand. |
| Intervention 1. Financial Assessments |
|
Measure 4. Average Total Margin. |
| Intervention 1. Financial Assessments |
|
Measure 5. Average Operating Margin. |
| Intervention 1. Financial Assessments |
|
Measure 6. Average Debt Service Coverage Ratio. |
| Intervention 1. Financial Assessments |
|
Measure 7. Average Salaries to Net Patient Revenue. |
| Intervention 1. Financial Assessments |
|
Average Salary |
| Intervention 1. Financial Assessments |
|
Net Patient Revenue |
| Intervention 1. Financial Assessments |
|
Measure 8. Average Payor Mix Percentage. |
| Intervention 1. Financial Assessments |
|
Medicare |
| Intervention 1. Financial Assessments |
|
Medicaid |
| Intervention 1. Financial Assessments |
|
Private Insurance |
| Intervention 1. Financial Assessments |
|
Charity |
| Intervention 1. Financial Assessments |
|
Slide Fee/Self-Pay |
| Intervention 1. Financial Assessments |
|
Other |
| Intervention 1. Financial Assessments |
|
Measure 9. Average Age of Plant. |
| Intervention 1. Financial Assessments |
|
Measure 10. Average Long Term Debt to Capitalization. |
| Intervention 2. Revenue Cycle Management |
|
Measure 1. Change in Bad Debt. |
| Intervention 2. Revenue Cycle Management |
|
Bad debt before intervention |
| Intervention 2. Revenue Cycle Management |
|
Bad debt after intervention |
| Intervention 2. Revenue Cycle Management |
|
Measure |
| Intervention 2. Revenue Cycle Management |
|
Measure 2. Amount of Gross Charges. |
| Intervention 2. Revenue Cycle Management |
|
Measure 3. Net patient revenue. |
| Intervention 2. Revenue Cycle Management |
|
Measure 4. Number of CAHs completing analysis. |
| Intervention 2. Revenue Cycle Management |
|
Measure 5. Point of service collection baseline. |
| Intervention 2. Revenue Cycle Management |
|
Measure 6. Point of service collection current. |
| Intervention 2. Revenue Cycle Management |
|
Measure 7. Total revenue. |
| Intervention 2. Revenue Cycle Management |
|
Measure 10. Number of Baseline claim denials. |
| Intervention 2. Revenue Cycle Management |
|
Measure 11. Number of Current claim denials. |
| Intervention 2. Revenue Cycle Management |
|
Measure 12. Baseline days in AR. |
| Intervention 2. Revenue Cycle Management |
|
Measure 13. Current days in AR. |
| Intervention 2. Revenue Cycle Management |
|
Measure 14. Baseline Gross Revenue. |
| Intervention 2. Revenue Cycle Management |
|
Measure 15. Current Gross Revenue. |
| Intervention 2. Revenue Cycle Management |
|
Measure 16. Baseline Clean Claims. |
| Intervention 2. Revenue Cycle Management |
|
Measure 17. Current Clean Claims |
| Intervention 3. Charge Master Review |
|
Measure 1. Number of line items with CPT/HCPCS code changes added, deleted or revised. |
| Intervention 3. Charge Master Review |
|
Measure 2. Number of CDM deleted. |
| Intervention 3. Charge Master Review |
|
Measure 3. Number of CDM items added. |
| Intervention 3. Charge Master Review |
|
Measure 4. Number of CDM items revised. |
| Intervention 3. Charge Master Review |
|
Measure 5. Number of CDM CPT codes deleted. |
| Intervention 3. Charge Master Review |
|
Measure 6. Number of CDM CPT codes added. |
| Intervention 3. Charge Master Review |
|
Measure 7. Number of CDM CPT codes revised. |
| Intervention 3. Charge Master Review |
|
Measure 8. Number of line items with revenue code changes recommended. |
| Intervention 3. Charge Master Review |
|
Measure 9. Number of line items with revenue code changes implemented. |
| Intervention 3. Charge Master Review |
|
Measure 10. Number of CDM codes revised. |
| Intervention 3. Charge Master Review |
|
Measure 11. Number of CDM errors baseline. |
| Intervention 3. Charge Master Review |
|
Measure 12. Number of CDM errors current. |
| Intervention 3. Charge Master Review |
|
Measure 13. Number of cost-report errors baseline. |
| Intervention 3. Charge Master Review |
|
Measure 14. Number of Cost-report errors current. |
| Intervention 4. Emergency Department Operational Improvement |
|
Measure 1. Number of participating CAHs. |
| Intervention 4. Emergency Department Operational Improvement |
|
Measure 2. Total ED wait time baseline |
| Intervention 4. Emergency Department Operational Improvement |
|
Measure 3. Total ED wait time current (after intervention). |
| Intervention 4. Emergency Department Operational Improvement |
|
Measure 4. Time it takes to get from ED to medical screening exam baseline. |
| Intervention 4. Emergency Department Operational Improvement |
|
Measure 5. Time it takes to get from ED to medical screening exam current. |
| Intervention 4. Emergency Department Operational Improvement |
|
Measure 6. ED education satisfaction scores. |
| Intervention 5. Lean Training and Implementation |
|
Measure 1. Number of hospitals completing the Lean readiness assessments. |
| Intervention 5. Lean Training and Implementation |
|
Measure 2. Number of hospitals participating in a Lean collaborative. |
| Intervention 5. Lean Training and Implementation |
|
Measure 3. Total revenue at start of Lean Project in targeted area. |
| Intervention 5. Lean Training and Implementation |
|
Measure 4. Total number of dollars normally spent on activity targeted for Lean implentation. |
| Intervention 5. Lean Training and Implementation |
|
Measure 5. Total number of dollars spent after Lean implementation. |
| Intervention 5. Lean Training and Implementation |
|
Measure 6. Total amount of staff required for operations prior to Lean. |
| Intervention 5. Lean Training and Implementation |
|
Measure 7. Total amount of staff required for operations after Lean implemented. |
| Intervention 5. Lean Training and Implementation |
|
Measure 8. Average patient wait time prior to Lean implementation. |
| Intervention 5. Lean Training and Implementation |
|
Measure 9. Average patient wait time after Lean Implementation. |
| Intervention 5. Lean Training and Implementation |
|
Measure 10. Number of Lean initiatives and events that took place in each hospital. |
| Intervention 5. Lean Training and Implementation |
|
Number of Lean initiatives. |
| Intervention 5. Lean Training and Implementation |
|
Number of CAHs at which Lean initiatives were implemented. |
| Intervention 5. Lean Training and Implementation |
|
Measure 13. CMA score. |
| Intervention 6. Billing and Coding Education |
|
Measure 1. Number of coding errors prior to training. |
| Intervention 6. Billing and Coding Education |
|
Measure 2. Number of coding errors after training |
| Intervention 6. Billing and Coding Education |
|
Measure 3. Number of Baseline claim denials. |
| Intervention 6. Billing and Coding Education |
|
Measure 4. Number of Current claim denials. |
| Intervention 6. Billing and Coding Education |
|
Measure 5. Baseline Gross AR. |
| Intervention 6. Billing and Coding Education |
|
Measure 6. Current Gross AR. |
| Intervention 6. Billing and Coding Education |
|
Measure 7. Number of CAHs in the state |
| Intervention 6. Billing and Coding Education |
|
Measure 8. Number of CAHs participating in the coding training. |
| Intervention 6. Billing and Coding Education |
|
Measure 9. Total Number of CAH staff participating in training. |
| Intervention 6. Billing and Coding Education |
|
Measure 13. Average number of coding denials per month. |
| Intervention 6. Billing and Coding Education |
|
Measure 14. Average number of billing denials per month. |
| Intervention 7. Board Education and Leadership Development |
|
Measure 1. Number of CAHs actively participating in CAH governance events. |
| Intervention 7. Board Education and Leadership Development |
|
Measure 2. Number of CAHs developing financial components in their board education programs. |
| Intervention 7. Board Education and Leadership Development |
|
Measure 3. CAH Board members Pre-test scores. |
| Intervention 7. Board Education and Leadership Development |
|
3A. Number Taking Pre-Test. |
| Intervention 7. Board Education and Leadership Development |
|
3B. Aggregate Total of All Pre-Test Scores. |
| Intervention 7. Board Education and Leadership Development |
|
Measure 4. CAH Leaders' Pre-test scores. |
| Intervention 7. Board Education and Leadership Development |
|
4A. Number Taking Pre-Test. |
| Intervention 7. Board Education and Leadership Development |
|
4B. Aggregate Total of All Pre-Test Scores. |
| Intervention 7. Board Education and Leadership Development |
|
Measure 5. CAH Board members Post-test scores. |
| Intervention 7. Board Education and Leadership Development |
|
5A. Taking Post-Test. |
| Intervention 7. Board Education and Leadership Development |
|
5B. Aggregate Total of All Post-Test Scores. |
| Intervention 7. Board Education and Leadership Development |
|
Measure 6. CAH Leaders' Post-test scores. |
| Intervention 7. Board Education and Leadership Development |
|
6A. Taking Post-Test. |
| Intervention 7. Board Education and Leadership Development |
|
6B. Aggregate Total of All Post-Test Scores. |
| Intervention 7. Board Education and Leadership Development |
|
Measure 7. Number of CAH leaders and managers participating in financial education workshops and collaboratives. |
| Intervention 8. Financial Improvement Collaborative |
|
Measure 1. Number of CAHs participating in the financial collaborative |
| Intervention 8. Financial Improvement Collaborative |
|
Measure 2. Number of contact hours (meeting hours times number of people attending) |
| Intervention 8. Financial Improvement Collaborative |
|
Measure 3. Education Pre-test Outcome survey scores. |
| Intervention 8. Financial Improvement Collaborative |
|
3A. Number Taking Pre-Test. |
| Intervention 8. Financial Improvement Collaborative |
|
3B. Aggregate Total of All Pre-Test Outcome Survey Scores |
| Intervention 8. Financial Improvement Collaborative |
|
3C. Pre-Test Average Score: |
| Intervention 8. Financial Improvement Collaborative |
|
Measure 4. Education Post-test Outcome survey scores. |
| Intervention 8. Financial Improvement Collaborative |
|
4A. Taking Post-test Outcome Survey. |
| Intervention 8. Financial Improvement Collaborative |
|
4B. Aggregate Total of All Post-Test Outcome Survey Scores. |
| Intervention 8. Financial Improvement Collaborative |
|
4C. Post-Test Average Score: |
| Intervention 8. Financial Improvement Collaborative |
|
Measure 5. Average Survey Score. |
| Intervention 8. Financial Improvement Collaborative |
|
Measure 6. Education Satifaction Pre-test Average score. |
| Intervention 8. Financial Improvement Collaborative |
|
6A. Number Taking Education Satisfaction Pre-Test. |
| Intervention 8. Financial Improvement Collaborative |
|
6B. Aggregate Total of All Education Satisfaction Pre-Test Scores. |
| Intervention 8. Financial Improvement Collaborative |
|
6C. Post-Test Average Score: |
| Intervention 8. Financial Improvement Collaborative |
|
Measure 7. Education Satifaction Post-test Average score. |
| Intervention 8. Financial Improvement Collaborative |
|
7A. Number Taking Education Satisfaction Post-Test. |
| Intervention 8. Financial Improvement Collaborative |
|
7B. Aggregate Total of All Education Satisfaction Post-Test Scores. |
| Intervention 8. Financial Improvement Collaborative |
|
7C. Post-Test Average Score: |
| Intervention 8. Financial Improvement Collaborative |
|
Sub-Measure 1. Total number of CAHs participating in the workshop/training. |
| Intervention 8. Financial Improvement Collaborative |
|
Sub-Measure 2. Total number of CAH staff participating. |
| Intervention 8. Financial Improvement Collaborative |
|
Sub-Measure 3. Number of staff answering 9 or more out of 10 correctly post-training. |
| Intervention 8. Financial Improvement Collaborative |
|
Sub-Measure 4. Number of staff answering 9 or more out of 10 correctly post-training four months later. |
| Intervention 8. Financial Improvement Collaborative |
|
Sub-Measure 5. Total Number of staff contacted to complete post-test four months later. |
| Intervention 8. Financial Improvement Collaborative |
|
Sub-Measure 6. Total Number of staff that completed the post-test four months later. |
| Intervention 8. Financial Improvement Collaborative |
|
Sub-Measure 7. Number of other rural providers participating in the training. |
| Intervention 8. Financial Improvement Collaborative |
|
Sub-Measure 8. Number of other rural providers answering 9 or more post-test questions correctly post-training. |
| Intervention 8. Financial Improvement Collaborative |
|
Sub-Measure 9. Number of other rural providers answering 9 or more post-test questions correctly four months post-training. |
| Intervention 8. Financial Improvement Collaborative |
|
Sub-Measure 10. Total number of other rural providers contacted to fill out the post-test. |
| Intervention 8. Financial Improvement Collaborative |
|
Sub-Measure 11. Total number of other rural providers contacted to fill out the post-test four months later. |
| Core Measure |
|
Core Measure 1. Number of Trained or recruited EMS medical directors. |
| Core Measure |
|
Core Measure 2. Number of EMS recruitment/retention projects initiated. |
| Core Measure |
|
Core Measure 3. Number of EMS (Ambulance) budget model courses conducted. |
| Core Measure |
|
Core Measure 4. Number of Managers trained in EMS (Ambulance) budget model courses. |
| Core Measure |
|
Core Measure 5. Number of EMS (Ambulance) services supported to join a network. |
| Core Measure |
|
Core Measure 6. Number of Services supported for group billing. |
| Core Measure |
|
Core Measure 7. Number of EMS assessments and strategic planning sessions conducted. |
| Core Measure |
|
Core Measure 8. Number of EMS leadership courses conducted. |
| Core Measure |
|
Core Measure 9. Number of Managers trained in EMS leadership courses. |
| Core Measure |
|
Core Measure 10. Number and variety of EMS-based Community Healthcare Models projects initiated. |
| Core Measure |
|
Core Measure 11. Number of Rural Trauma Team Development or Comprehensive Advanced Life Support (CALS) courses taught. |
| Core Measure |
|
Core Measure 12. Number of personnel trained. |
| Core Measure |
|
Core Measure 13. Number of communities affected. |
| Core Measure |
|
Core Measure 14. Number of facilitated BIS assessments conducted. |
| Core Measure |
|
Core Measure 15. Number of quality improvement activities implemented. A reassessment of BIS scores compared to the baseline score for that system. |
| Core Measure |
|
Core Measure 16. Number of Trauma System Consultations performed. |
| Core Measure |
|
Core Measure 17. Number of quality improvement activities directly linked to Trauma System Consultation report recommendation. |
| 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. |
|
Measure 1. Number of CAHs engaged in STEMI. |
| 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. |
|
Measure 2. Number of STEMI patients in total. |
| 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. |
|
Measure 3. Number of STEMI patients receiving aspirin within 24-hours in total. |
| 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. |
|
Measure 4. Number of STEMI patients not receiving aspirin within 24 hours in total. |
| 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. |
|
Measure 5. Number of STEMI patients with a STEMI Referral Hospital door-to-balloon (first device used) time within 90 minutes upon transfer. |
| 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. |
|
Measure 6. Number of CAHs engaged in regional and/or national stroke programs. |
| 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. |
|
Measure 7. Number of CAHs obtaining trauma designation this budget year. |
| 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. |
|
Measure 8. Number of CAHs rated Trauma Level III? Level IV? Level V? |
| 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. |
|
Trauma Level III. |
| 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. |
|
Trauma Level IV. |
| 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. |
|
Trauma Level V. |
| 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. |
|
Measure 9. Number of CAHs that enhanced their trauma designation. |
| 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. |
|
Measure 10. Number of CAHs that reduced their Trauma designation. |
| 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 1. Number of EMS units or providers participating in Flex-funded activities to improve EMS financial/operational performance. |
| 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 2. Number of EMS units engaged in group purchasing arrangements. |
| 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 3. Number of EMS personnel participating in billing/coding programs. |
| 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 4. Number of EMS personnel reporting that participation in the activities was valuable. |
| 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 5. Number of EMS units that changed procedures based on activities. |
| 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 6. Number of EMS units reporting a positive change in revenue. |
| 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 7. Number of EMS personnel participating leadership training. |
| 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 8. Number of EMS units participating in recruitment and retention programs. |
| Support CAHs and communities in conducting/collaborating on assessments to identify unmet community health and health service needs and support CAHs and communities in developing projects/initiatives. |
|
Measure 1. Number of CAHs receiving support and/or TA to support them in conducting community health needs assessments. |
| Support CAHs and communities in conducting/collaborating on assessments to identify unmet community health and health service needs and support CAHs and communities in developing projects/initiatives. |
|
Measure 2. Number of CAHs that have completed a community needs assessment. |
| Support CAHs and communities in conducting/collaborating on assessments to identify unmet community health and health service needs and support CAHs and communities in developing projects/initiatives. |
|
Measure 3. Number of interventions implemented as a result of needs identified by CAHs conducting community needs assessment. |
| Support CAHs and communities in conducting/collaborating on assessments to identify unmet community health and health service needs and support CAHs and communities in developing projects/initiatives. |
|
Measure 4. Number of interventions implemented to address new and ongoing community needs. |
| Support CAHs and communities in conducting/collaborating on assessments to identify unmet community health and health service needs and support CAHs and communities in developing projects/initiatives. |
|
Measure 5. Number of CAHs that report improvements in conditions addressed by their community health needs interventions at subsequent needs assessments. |
| Support CAHs and communities in conducting/collaborating on assessments to identify unmet community health and health service needs and support CAHs and communities in developing projects/initiatives. |
|
Measure 6. Number of community paramedicine programs identified as a potential intervention based on the community needs assessment. |
| Support CAHs and communities in conducting/collaborating on assessments to identify unmet community health and health service needs and support CAHs and communities in developing projects/initiatives. |
|
Measure 7. Number of communities that have begun piloting community paramedicine programs. |
| Objective 1 - Flex programs must assist hospitals in evaluating the effects of conversion to critical access status |
|
Measure 1. Number of new CAHs. |
| Objective 1 - Flex programs must assist hospitals in evaluating the effects of conversion to critical access status |
|
Measure 2. Number of hospitals eligible for CAH conversion. |
| Objective 1 - Flex programs must assist hospitals in evaluating the effects of conversion to critical access status |
|
Measure 3. Number of hospitals requested assistance in conversion to CAH status. |
| Objective 1 - Flex programs must assist hospitals in evaluating the effects of conversion to critical access status |
|
Measure 4. Number of hospitals helped in conversion to CAH status. |
| Objective 1 - Flex programs must assist hospitals in evaluating the effects of conversion to critical access status |
|
Measure 5. Number of hospitals unsuccessful in their attempt to convert to CAH status. |
| Objective 1 - Flex programs must assist hospitals in evaluating the effects of conversion to critical access status |
|
Measure 6. Number of CAHs de-designating. |
| Objective 1 - Flex programs must assist hospitals in evaluating the effects of conversion to critical access status |
|
Measure 7. Number of CAHs closed. |
|
| Title |
Description |
Comment |
|
|
| Remove QI Objective 1 Measure 10 |
Remove the following measure "10. 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." |
|
| Remove QI Objective 1 Measure 11 |
Remove the following measure "11. 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." |
|
| Remove QI Objective 1 Measure 12 |
Remove the following measure "12. Medical Record documentation indicates that there was nurse to nurse communication prior to the transfer of the patient from the ER to another facility." |
Measures 12-22 are under subsection ED Transfer. All the ED transfer measures are being removed. |
| Remove QI Objective 1 Measure 13 |
Remove the following measure "13. Medical Record documentation indicates that there was physician to physician communication prior to the transfer of the patient from the ER to another facility." |
|
| Remove QI Objective 1 Measure 14 |
Remove the following measure "14. Medical Record documentation indicates that patient information including name, address, age, gender was sent with the patient." |
|
| Remove QI Objective 1 Measure 15 |
Remove the following measure "15. Medical Record documentation indicates that contact information for significant other and/or family member was sent with the patient." |
|
| Remove QI Objective 1 Measure 16 |
Remove the following measure "16. Medical Record documentation indicates that insurance information was sent with the patient." |
|
| Remove QI Objective 1 Measure 17 |
Remove the following measure "17. Medical Record documentation indicates that vital signs taken and were sent with the patient." |
|
| Remove QI Objective 1 Measure 18 |
Remove the following measure "18. Medical Record documentation indicate that neuro assessments were done, as appropriate, and sent with the patient." |
|
| Remove QI Objective 1 Measure 19 |
Remove the following measure "19. Medical Record documentation indicate that the following nursing communications were sent with the patient." |
|
| Remove QI Objective 1 Measure 20 |
Remove the following measure "20. Medical Record documentation indicates that information was sent on the treatment provided in the originating hospital, Y/N/NA." |
|
| Remove QI Objective 1 Measure 21 |
Remove the following measure "21. Medical Record documentation indicates that information was sent on the tests and procedures that were done in the ER, Y/N/ NA." |
|
| Remove QI Objective 1 Measure 22 |
Remove the following measure "22. Medical Record documentation indicates that the results from completed tests and procedures were sent with the patient, Y/N/NA." |
|
|
| Remove QI Objective 3 Sub-Measure 3 |
Remove the following sub-measure "Sub-measure 3. Number of staff answering 9 or more out of 10 correctly post-training." |
|
| Remove QI Objective 3 Sub-Measure 4 |
Remove the following sub-measure "Sub-measure 4. Number of staff answering 9 or more out of 10 correctly post-training four months later." |
|
| Remove QI Objective 3 Sub-Measure 5 |
Remove the following sub-measure "Sub-measure 5. Total Number of staff contacted to complete post-test four months later." |
|
| Remove QI Objective 3 Sub-Measure 6 |
Remove the following sub-measure "Sub-measure 6. Total Number of staff that completed the post-test four months later." |
|
| Remove QI Objective 3 Sub-Measure 7 |
Remove the following sub-measure "Sub-measure 7. Number of other rural providers participating in the training." |
|
| Remove QI Objective 3 Sub-Measure 8 |
Remove the following sub-measure "Sub-measure 8: Number of other rural providers answering 9 or more post-test questions correctly post-training." |
|
| Remove QI Objective 3 Sub-Measure 9 |
Remove the following sub-measure "Sub-measure 9. Number of other rural providers answering 9 or more post-test questions correctly four months post-training." |
|
| Remove QI Objective 3 Sub-Measure 10 |
Remove the following sub-measure "Sub-measure 10. Total Number of Other Rural Providers contacted to fill out the post-test." |
|
| Remove QI Objective 3 Sub-Measure 11 |
Remove the following sub-measure "Sub-measure 11. Total Number of Other Rural Providers contacted to fill out the post-test four months later." |
|
|
| Remove QI Intervention 4 Subsection 1 |
Remove the following subsection "Medical Condition 1" |
|
| Remove QI Intervention 4 Subsection 2 |
Remove the following subsection "Medical Condition 2" |
|
| Remove QI Intervention 4 Subsection 3 |
Remove the following subsection "Medical Condition 3" |
|
| Remove QI Intervention 4 Subsection 4 |
Remove the following subsection "Medical Condition 4" |
|
| Remove QI Intervention 4 Subsection 5 |
Remove the following subsection "Medical Condition 5" |
|
|
| Remove QI Intervention 5 Measure 3 |
Remove the following measure "Measure 3. Change in readmissions for each CAH associated with the project." |
|
| Remove QI Intervention 5 Measure 3A |
Remove the following measure "(3A.)Current Year Readmission Rate." |
|
| Remove QI Intervention 5 Measure 3B |
Remove the following measure "(3B.)Baseline [Prior Year] Readmission Rate." |
|
|
| Remove QI Intervention 6 Measure 2 |
Remove the following measure "Measure 2. Number of survey responses." |
|
| Remove QI Intervention 6 Measure 3 |
Remove the following measure "Measure 3. Number CAHs continuing to use patient safety surveys at six(6) months." |
|
|
|
| Remove FOI Objective 1 Measure 7 |
Remove the following measure "Measure 7. Number of improvement activities based on meetings." |
|
| Remove FOI Objective 1 Measure 8 |
Remove the following measure "Measure 8. The number of CAHs with identified outcomes derived from the meetings." |
|
| Remove FOI Objective 1 Measure 11 |
Remove the following measure "Measure 11. Total number of CAHs still using the new processes 90 days after implementation." |
|
| Remove FOI Objective 1 Measure 12 |
Remove the following measure "Measure 12. Number of other rural providers still using the new processes 90 days after implementation." |
|
|
| Remove FOI Objective 2 Measure 3 Sub-Measure 4 |
Remove the following sub-measure "Sub-Measure 4. Number of staff and department heads showing 90% information retention four months after education on documenting charity care." |
|
|
| Remove FOI Intervention 1 |
Remove all measures for Intervention 1. |
|
|
| Remove FOI Intervention 2 |
Remove all measures for Intervention 2. |
|
|
| Remove FOI Intervention 3 |
Remove all measures for Intervention 3. |
|
|
| Remove FOI Intervention 4 Measure 2 |
Remove the following measure "Measure 2. Total ED wait time baseline." |
|
| Remove FOI Intervention 4 Measure 3 |
Remove the following measure "Measure 3. Total ED wait time current (after intervention)." |
|
| Remove FOI Intervention 4 Measure 4 |
Remove the following measure "Measure 4. Time it takes to get from ED to medical screening exam baseline." |
|
| Remove FOI Intervention 4 Measure 5 |
Remove the following measure "Measure 5. Time it takes to get from ED to medical screening exam current." |
|
| Remove FOI Intervention 4 Measure 6 |
Remove the following measure "Measure 6. ED education satisfaction scores." |
|
|
| Remove FOI Intervention 5 Measure 3 |
Remove the following measure "Measure 3. Total revenue at start of Lean Project in targeted area." |
|
| Remove FOI Intervention 5 Measure 4 |
Remove the following measure "Measure 4. Total number of dollars normally spent on activity targeted for Lean implementation." |
|
| Remove FOI Intervention 5 Measure 5 |
Remove the following measure "Measure 5. Total number of dollars spent after Lean implementation." |
|
| Remove FOI Intervention 5 Measure 6 |
Remove the following measure "Measure 6. Total amount of staff required for operations prior to Lean." |
|
| Remove FOI Intervention 5 Measure 7 |
Remove the following measure "Measure 7. Total amount of staff required for operations after Lean implemented." |
|
| Remove FOI Intervention 5 Measure 8 |
Remove the following measure "Measure 8. Average patient wait time prior to Lean implementation." |
|
| Remove FOI Intervention 5 Measure 9 |
Remove the following measure "Measure 9. Average patient wait time after Lean Implementation." |
|
| Remove FOI Intervention 5 Measure 13 |
Remove the following measure "Measure 13. CMA score." |
|
|
| Remove FOI Intervention 6 Measure 1 |
Remove the following measure "Measure 1. Number of coding errors prior to training." |
|
| Remove FOI Intervention 6 Measure 2 |
Remove the following measure "Measure 2. Number of coding errors after training." |
|
| Remove FOI Intervention 6 Measure 3 |
Remove the following measure "Measure 3. Number of Baseline claim denials." |
|
| Remove FOI Intervention 6 Measure 4 |
Remove the following measure "Measure 4. Number of Current claim denials." |
|
| Remove FOI Intervention 6 Measure 5 |
Remove the following measure "Measure 5. Baseline Gross AR." |
|
| Remove FOI Intervention 6 Measure 6 |
Remove the following measure "Measure 6. Current Gross AR." |
|
| Remove FOI Intervention 6 Measure 7 |
Remove the following measure "Measure 7. Number of CAHs in the state." |
|
| Remove FOI Intervention 6 Measure 9 |
Remove the following measure "Measure 9. Total Number of CAH staff participating in training." |
|
| Remove FOI Intervention 6 Measure 13 |
Remove the following measure "Measure 13. Average number of coding denials per month." |
|
| Remove FOI Intervention 6 Measure 14 |
Remove the following measure "Measure 14. Average number of billing denials per month." |
|
|
| Remove FOI Intervention 7 Measure 3 |
Remove the following measure "Measure 3. CAH Board members Pre-test scores." |
|
| Remove FOI Intervention 7 Measure 3A |
Remove the following measure "3A. Number Taking Pre-Test." |
|
| Remove FOI Intervention 7 Measure 3B |
Remove the following measure "3B. Aggregate Total of All Pre-Test Scores." |
|
| Remove FOI Intervention 7 Measure 4 |
Remove the following measure "Measure 4. CAH Leaders' Pre-test scores." |
|
| Remove FOI Intervention 7 Measure 4A |
Remove the following measure "4A. Number Taking Pre-Test." |
|
| Remove FOI Intervention 7 Measure 4B |
Remove the following measure "4B. Aggregate Total of All Pre-Test Scores." |
|
| Remove FOI Intervention 7 Measure 5 |
Remove the following measure "Measure 5. CAH Board members Post-test scores." |
|
| Remove FOI Intervention 7 Measure 5A |
Remove the following measure "5A. Taking Post-Test." |
|
| Remove FOI Intervention 7 Measure 5B |
Remove the following measure "5B. Aggregate Total of All Post-Test Scores." |
|
| Remove FOI Intervention 7 Measure 6 |
Remove the following measure "Measure 6. CAH Leaders' Post-test scores." |
|
| Remove FOI Intervention 7 Measure 6A |
Remove the following measure "6A. Taking Post-Test." |
|
| Remove FOI Intervention 7 Measure 6B |
Remove the following measure "6B. Aggregate Total of All Post-Test Scores." |
|
|
| Remove FOI Intervention 8 Measure 2 |
Remove the following measure "Measure 2. Number of contact hours (meeting hours times number of people attending)." |
|
| Remove FOI Intervention 8 Measure 3 |
Remove the following measure "Measure 3. Education Pre-test Outcome survey scores." |
|
| Remove FOI Intervention 8 Measure 3A |
Remove the following measure "3A. Number Taking Pre-Test." |
|
| Remove FOI Intervention 8 Measure 3B |
Remove the following measure "3B. Aggregate Total of All Pre-Test Outcome Survey Scores." |
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| Remove FOI Intervention 8 Measure 3C |
Remove the following measure "3C. Pre-Test Average Score:" |
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| Remove FOI Intervention 8 Measure 4 |
Remove the following measure "Measure 4. Education Post-test Outcome survey scores." |
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| Remove FOI Intervention 8 Measure 4A |
Remove the following measure "4A. Taking Post-test Outcome Survey." |
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| Remove FOI Intervention 8 Measure 4B |
Remove the following measure "4B. Aggregate Total of All Post-Test Outcome Survey Scores." |
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| Remove FOI Intervention 8 Measure 4C |
Remove the following measure "4C. Post-Test Average Score:" |
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| Remove FOI Intervention 8 Measure 5 |
Remove the following measure "Measure 5. Average Survey Score." |
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| Remove FOI Intervention 8 Measure 6 |
Remove the following measure "Measure 6. Education Satisfaction Pre-test Average score." |
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| Remove FOI Intervention 8 Measure 6A |
Remove the following measure "6A. Number Taking Education Satisfaction Pre-Test." |
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| Remove FOI Intervention 8 Measure 6B |
Remove the following measure "6B. Aggregate Total of All Education Satisfaction Pre-Test Scores." |
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| Remove FOI Intervention 8 Measure 6C |
Remove the following measure "6C. Post-Test Average Score:" |
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| Remove FOI Intervention 8 Measure 7 |
Remove the following measure "Measure 7. Education Satisfaction Post-test Average score." |
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| Remove FOI Intervention 8 Measure 7A |
Remove the following measure "7A. Number Taking Education Satisfaction Post-Test." |
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| Remove FOI Intervention 8 Measure 7B |
Remove the following measure "7B. Aggregate Total of All Education Satisfaction Post-Test Scores." |
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| Remove FOI Intervention 8 Measure 7C |
Remove the following measure "7C. Post-Test Average Score:" |
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| Remove FOI Intervention 8 Sub-Measure 2 |
Remove the following sub-measure "Sub-Measure 2. Total number of CAH staff participating." |
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| Remove FOI Intervention 8 Sub-Measure 3 |
Remove the following sub-measure "Sub-Measure 3. Number of staff answering 9 or more out of 10 correctly post-training." |
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| Remove FOI Intervention 8 Sub-Measure 4 |
Remove the following sub-measure "Sub-Measure 4. Number of staff answering 9 or more out of 10 correctly post-training four months later." |
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| Remove FOI Intervention 8 Sub-Measure 5 |
Remove the following sub-measure "Sub-Measure 5. Total Number of staff contacted to complete post-test four months later." |
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| Remove FOI Intervention 8 Sub-Measure 6 |
Remove the following sub-measure "Sub-Measure 6. Total Number of staff that completed the post-test four months later." |
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| Remove FOI Intervention 8 Sub-Measure 8 |
Remove the following sub-measure "Sub-Measure 8. Number of other rural providers answering 9 or more post-test questions correctly post-training." |
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| Remove FOI Intervention 8 Sub-Measure 9 |
Remove the following sub-measure "Sub-Measure 9. Number of other rural providers answering 9 or more post-test questions correctly four months post-training." |
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| Remove FOI Intervention 8 Sub-Measure 10 |
Remove the following sub-measure "Sub-Measure 10. Total number of other rural providers contacted to fill out the post-test." |
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| Remove FOI Intervention 8 Sub-Measure 11 |
Remove the following sub-measure "Sub-Measure 11. Total number of other rural providers contacted to fill out the post-test four months later." |
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| Remove HSD Objective 1 Measure 2 |
Remove the following measure "Measure 2. Number of STEMI patients in total." |
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| Remove HSD Objective 1 Measure 3 |
Remove the following measure "Measure 3. Number of STEMI patients receiving aspirin within 24-hours in total." |
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| Remove HSD Objective 1 Measure 4 |
Remove the following measure "Measure 4. Number of STEMI patients not receiving aspirin within 24 hours in total." |
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| Remove HSD Objective 1 Measure 5 |
Remove the following measure "Measure 5. Number of STEMI patients with a STEMI Referral Hospital door-to-balloon (first device used) time within 90 minutes upon transfer." |
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