Illinois Hospital Association

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July 26, 2007

Quality Improvement and Public Reporting Updates

There are several IHA membership services that are being provided to assist hospitals in responding to quality improvement initiatives and public reporting, including:

  • Enhanced Quality Reports In Preparation for Public Reporting
    • New Report Features for COMPdata Agency for Healthcare Research and Quality (AHRQ) Patient Safety and Quality Measurements
    • NEW IHA Comparative Initiative Reports Coming With First Quarter 2007 Data – Focus on Illinois Hospital Report Card Comparative Statistics and Individual Hospital Trends
  • Intervention Strategies for Addressing Targeted IHI 5 Million Lives Campaign Initiatives
  • Upcoming Pilot Survey on Hospital Leadership Quality Assessment Tool
  • IHA Updated Quality Web Site

Enhanced Quality Reports In Preparation for Public Reporting
Enhanced Reports for COMPdata AHRQ Patient Safety and Quality Measurements
IHA recently updated the COMPdata AHRQ patient safety and quality measurement module to allow for greater drill down capabilities and enhanced usage by hospital administrators and clinicians. This module is available on the COMPdata on-line system and all hospital comparative or individual hospital reports are readily accessible through a point and click type of approach.

The updated module now features:

  • Major payer category analysis – helpful for providers reviewing commercially available reports by commercial companies or health plans that may have limited access to Medicare or commercial payer only data. Some of the commercial reports are utilized for hospital awards programs or by consumers for hospital care decisions.
  • Highlighting of hospital’s individual performance as it relates to the overall state performance – notations on above, below, or within average performance according to statistical significance
  • Ability to readily pinpoint the cases that fell into the numerator values - important for hospitals identifying the patient cases that drove outlier performance
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    NEW IHA Comparative Initiative Reports Coming With First Quarter 2007 Data – Focus on Illinois Hospital Report Card Comparative Statistics and Individual Hospital Trends
    IHA is providing a jump start on the hospital infection reporting for the Hospital Report Card Act (HRCA) for hospitals participating in the IHA Comparative Performance Initiative. In addition to the existing analytical performance reports that hospitals now receive, there will be additional reports available. Please remember that this is a membership service available at no charge.

    Starting with 1st Quarter 2007 discharges, hospitals submitting Surgical Care Improvement Program (SCIP) information to IHA will get additional reports that include the measurements that will be utilized in the HRCA public reporting. For hospitals that submit SCIP data to IHA for this time period, IHA will also provide a bundle score that identifies the percent of patients that received the appropriate care for each of the measurements required to be reported under HRCA. All of these reports will be broken down by each of the SCIP procedures as well as overall SCIP statistics and will include hospital comparisons.

    As the HRCA also required the reporting of hospital infections, IHA will include the before procedure and after procedure infections as reported and utilized in calculating the SCIP process measurements. This particular report will be hospital specific and for the first release will not include hospital comparisons – it is informational only.

    Participating hospitals in the IHA Comparative Performance Initiative will receive these new reports in mid-August after the participating hospital data has been received. As in the past, reports will be available electronically so that hospitals may provide greater access to the reports for clinical management and executive and governance discussions.

    Intervention Strategies for Addressing Targeted IHI 5 Million Lives Campaign Initiatives
    In a continuing effort to provide access to successful hospital intervention strategies and approaches on the IHI 5 Million Lives Campaign 12 initiatives, IHA will be providing additional educational opportunities starting this September targeted to Illinois hospitals.

    Starting in September, IHA will host a series of 12 conference calls with each call focused on one of the 12 strategic IHI areas for improvement. These calls will include an overview of the initiative and feature Illinois hospitals that have been identified by IHI as Mentor Hospitals. IHI designates hospitals as ‘mentor hospitals’ based upon criteria established by IHI in demonstrating sustainable improvement in one or more of the targeted areas. The Illinois Mentor Hospitals will be sharing their successful intervention strategies and responding to member questions in a 45 minute conference call accessible to members at no charge.

    Upcoming Pilot Survey on Hospital Leadership Quality Assessment Tool (HLQAT)
    As reported in earlier communications, IHA is an advisory group member of the HLQAT and hosted a dialogue session with interested IHA member hospitals on HLQAT in June. Several IHA member hospitals participated in advising CMS and University of Iowa researchers on the design and content of the survey instrument. For additional information on this initiative, one can visit the host web site of the Oklahoma Foundation for Medical Quality (click here).

    HLQAT is an initiative spearheaded by the Centers for Medicare and Medicaid Services (CMS), IHI, American Hospital Association (AHA), University of Iowa College of Public Health, and other organizations all focused on improving outcomes of care through hospital leadership and governance.

    During the next two months, Illinois hospitals will have the opportunity to participate in a pilot survey project with more details on participation to come shortly. As a result of participation, the researchers will provide hospital specific feedback to each participating hospital on their HLQAT survey results and the relationship to hospital performance on the CMS HQA measurements. Comparative results will be available at national, state, and peer group levels only – no hospital specific information will be shared outside of the individual hospital.

    IHA Updated Quality Web Site
    Given all of the developments and learning and sharing environments that are occurring for IHA member hospitals, IHA is updating the Quality section of the Issues section of the IHA web site. The updates will include focused information on:

  • National Reporting Requirements including CMS HQA, AHRQ, Leapfrog and others
  • State Public Reporting Requirements including Hospital Report Card Act and Consumer Guide – with specific information on administrative rules, administrative reporting requirements, nurse staff information, infection reporting, training and education, and FAQs
  • Interventions and Improvement Efforts including IHI Campaign, Illinois Success Stories, and Quality Encounter programs
  • Integration of Quality and Health Information Technology including position papers, IHA Board adopted RHIO principles, and other key areas
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    IHA will continue to keep you updated on quality and public accountability developments and to provide opportunities for IHA member hospitals to be positioned strategically for all of the changes occurring in our healthcare environment.

    Staff Contact: Pat Merryweather: (630) 276-5590