Quality Measures in Healthcare: Maine Quality Forum Initiatives
Maine Quality Forum (MQF) collaborates with various healthcare stakeholders to provide comparative health care quality information to consumers, purchasers, providers, insurers, and policy makers. The forum focuses on reporting provider-specific quality measures, aligning with the Institute of Medicine Framework for Measuring Health Care Quality, and utilizing different types of quality measures such as structural, process, outcome, and patient experience measures.
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Maine Quality Forum Identifying Quality Measures for Public Reporting MHDO/MQF CONSUMER ADVISORY GROUP NOVEMBER 17, 2017-WORKING DRAFT 1 MAINE QUALITY FORUM
Maine Quality Forum (MQF)-Title 24-A. Chapter 87, Section 6951 MQF shall work collaboratively with the Maine Health Data Organization, health care providers, health insurance carriers and others to report in useable formats comparative health care quality information to consumers, purchasers, providers, insurers and policy makers. The forum shall make provider-specific information regarding quality of services available on its publicly accessible website. 2 MAINE QUALITY FORUM
Institute of Medicine Framework for Measuring Health Care Quality Safe - Avoiding harm to patients from the care that is intended to help them. Effective - Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively). Patient-centered - Providing care that is respectful of and responsive to individual patient preferences, needs, and values. Timely - Reducing waits and harmful delays Efficient - Avoiding waste, including waste of equipment, supplies, ideas, and energy. Equitable - Providing care that does not vary in quality because of personal characteristics (e.g. gender, ethnicity, socioeconomic status) Source: Agency for Healthcare Research and Quality, https://www.ahrq.gov/professionals/quality-patient- safety/talkingquality/create/sixdomains.html 3 MAINE QUALITY FORUM
Types of Quality Measures Structural provider s capacity, systems, and processes to provide high- quality care (e.g. uses EHRs, accredited, # of board certified physicians) Process - what a provider does to maintain or improve health typically based on generally accepted recommendations for clinical practice (e.g. % of people receiving preventive screenings) Outcome - the impact of the health care service or intervention on the health status of patients (e.g. surgical mortality, complications, or HAIs). Patient Experience measures patient perspective about the care they received such as getting timely appointments, easy access to information, and good communication with health care providers. Source: Agency for Healthcare Research and Quality, https://www.ahrq.gov/professionals/quality-patient- safety/quality-resources/tools/perfmeasguide/perfmeaspt4a.html 4 MAINE QUALITY FORUM
Quality Measures Currently Reported on CompareMaine HCAHPS Patient Experience Summary Star data are downloaded from CMS Hospital Compare, https://www.medicare.gov/hospitalcompare/Data/Data- Updated.html#. PCMH/CG CAHPS Overall Provider Rating, data are downloaded from Patient Experience Matters http://www.mainepatientexperiencematters.org/about-the-data.php; CAHPS Database (Westat). Serious Complications data are downloaded from CMS Hospital Compare, https://www.medicare.gov/hospitalcompare/Data/Data- Updated.html#. Standard Infection Ratios (SIRs) for C.difficile and MRSA data are downloaded from CMS Hospital Compare 5 MAINE QUALITY FORUM
Websites that Report the Cost and Quality of Healthcare in Maine on CompareMaine Leapfrog Group A national nonprofit organization that publicly reports hospital performance reported through the voluntary Leapfrog Hospital Survey. -Includes some hospital performance data for all 33 Maine acute care facilities -Leapfrog also assigns a Leapfrog Hospital Safety Grade to each participating facility and a state overall safety grade (excluding Critical access hospitals). View a list of Leapfrog s current process and outcome safety measures as they appear on an individual hospital report: http://www.hospitalsafetygrade.org/table-details/eastern-maine- medical-center?findBy=state&state_prov=ME&rPos=391&rSort=distance 6 MAINE QUALITY FORUM
Websites that Report the Cost and Quality of Healthcare in Maine on CompareMaine (cont.) HospitalCompare Supported by the Centers for Medicare and Medicaid Services, this website includes quality performance data for 33 acute care hospitals in Maine and 1 VA hospital. Measure domains include: Overall rating, Timely and Effective Care, Patient Experience (HCAHPS), Complications, deaths and hospital returns (including HAIs) use of imaging, payment and value. For a full list of HospitalCompare quality measures : https://www.medicare.gov/hospitalcompare/Data/Data-Updated.html# 7 MAINE QUALITY FORUM
Key Challenge How do we balance adding content to the site with the ease of use? 8 MAINE QUALITY FORUM
Ideas on How to Improve the Quality Information Currently Presented on CompareMaine Improve the website s description of the Standard Infection Ratio (SIR) for C.difficile and MRSA Revise the display to give equal prominence to MRSA and C.difficile Better position the link to other health care quality sites like Leapfrog or Hospital Compare Display the number of times the procedure is performed as reported on CompareMaine (number of procedures or patient days) 9 MAINE QUALITY FORUM
Guidelines and Process for Prioritizing Quality Measure Selection: Nationally endorsed measure: Measure is endorsed by the National Quality Forum or required by a federal agency for public reporting. National benchmark: A national benchmark is available so performance can be compared to a national standard. Data availability: The data is available nationally (HospitalCompare, MONAHRQ), The measure can be calculated from available MHDO data (i.e. claims, hospital discharge, Chapter 270 data). Board of Directors authorizes new quality measures 10 MAINE QUALITY FORUM
Proposed Additions to CompareMaine Proposed Quality Measure Publically Reported Hospital readmissions within 30 days Hospital Compare Falls with Injury (NSPC-3) Leapfrog (as part of a broader injury measure) Central-line catheter bundle compliance in intensive care or mixed acuity units (HAI-3) MQF HAI Annual Report Bundle compliance for central-line catheters place placed before, during or after surgery (HAI-4) MQF HAI Annual Report Ventilator bundle compliance in intensive care or mixed acuity units (HAI-5) MQF HAI Annual Report Pressure ulcers (stage II-or-greater) (NSPC-1) Leapfrog 11 MAINE QUALITY FORUM
Continued Proposed Quality Measure Publically Reported Birth trauma Injury to neonate (PSI-17) MONAHRQ Complication rate following elective primary total hip arthroplasty and total knee arthroplasty Hospital Compare Comprehensive Diabetes Care or Preventive Screening Measures MONAHRQ Hip and Knee replacement Surgical Site Infection (SSI) 12 MAINE QUALITY FORUM
