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Hospitals

Stratis Health works toward its mission to improve health care quality and safety in hospitals through initiatives funded by federal and state government contracts, and community and foundation grants, including representing Minnesota in the Lake Superior Quality Innovation Network serving Michigan, Minnesota, and Wisconsin, under the Centers for Medicare & Medicaid Services Quality Improvement Organization Program.

Our hospital work is focused on quality measure reporting, clinical improvement, value-based purchasing, and preventing avoidable readmissions, healthcare-associated infections, and adverse drug events. We support hospitals through strategic partnerships and learning and action networks, as well as focused training and technical assistance based on evidence and best practices. We assist with data analysis and improvement activities that achieve rapid, wide-scale improvement, resulting in safer, more effective patient care, better health for populations and communities, and lower health care costs. Current QIO work (3-page PDF)

Hospital Communication Distribution List. Stratis Health routinely communicates key information to Minnesota hospitals regarding CMS and Minnesota hospital quality measures. Please list your name and information below and check the topics you would like to receive information about. Please fax this completed form to Mary Montury, Stratis Health, 952-853-8503. (2-page PDF)

Hospital Leadership Distribution List. Stratis Health routinely communicates key information to Minnesota hospital leaders regarding CMS and state quality measures, including information on measure changes, rule changes, and the hospital value-based purchasing program. To ensure that your hospital leaders receive these important messages, print and fill in this form, and fax to Mary Montury, Stratis Health, 952-853-8503. (1-page PDF)

Quality Reporting

Inpatient quality program

The Hospital IQR program was developed as a result of the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003. Section 5001(a) of Pub. 109-171 of the Deficit Reduction Act (DRA) of 2005 provided new requirements for the Hospital IQR program, which built on the voluntary Hospital Quality Initiative. The Hospital IQR program is intended to equip consumers with quality of care information to make more informed decisions about healthcare options. It is also intended to encourage hospitals and clinicians to improve the quality of inpatient care provided to all patients. The hospital quality of care information gathered through the program is available to consumers on the Hospital Compare website. The Hospital IQR program requires "sub-section (d)" hospitals to submit data for specific quality measures for health conditions common among people with Medicare, and which typically result in hospitalization. Eligible hospitals that do not participate in the Hospital IQR program will receive an annual market basket update with a 2.0 percentage point reduction. Inpatient quality program

Outpatient quality program

The Hospital Outpatient Quality Reporting (OQR) Program is a quality data reporting program implemented by the Centers for Medicare & Medicaid Services (CMS) for outpatient hospital services. Under this program, hospitals report data using standardized measures of care to receive the full annual update to their Outpatient Prospective Payment System (OPPS) payment rate, effective for payments beginning in calendar year (CY) 2009. The Hospital OQR Program is modeled on the current quality data reporting program for inpatient services, the Hospital Inpatient Quality Reporting Program. To meet Hospital OQR requirements and receive the full Annual Payment Update (APU) under the OPPS, hospitals must meet administrative, data collection and submission, and data validation requirements. Outpatient quality program

Statewide Quality Reporting Measurement System (SQRMS)/State infection quality reporting

Minnesota's 2008 Health Reform Law requires the commissioner of Health to establish a standardized set of quality measures for health care providers across the state. The goal is to create a uniform approach to quality measurement in Minnesota to enhance market transparency and improve health care quality. To implement the collection and reporting of quality measurement data, the Minnesota Department of Health (MDH) has developed the Minnesota Statewide Quality Reporting and Measurement System (created through Minnesota Rules, Chapter 4654). Summary sheet of infection reporting requirements

Pay for Performance and Improvement Programs

Value-Based Purchasing Program

Starting in October 2012, Medicare began rewarding hospitals that provide high-quality care for their patients through the Hospital Value-Based Purchasing (VBP) Program. Hospitals paid under the Inpatient Prospective Payment System (IPPS) are paid for inpatient acute care services based on quality of care—not the volume of services they provide.

As the Medicare Quality Improvement Organization for Minnesota, Stratis Health offers technical assistance and support for Minnesota hospitals to be successful in a value-driven environment. Understanding Value-Based Purchasing (10-page PDF)

Hospital-Acquired Condition Reduction Program

Beginning in FY 2015, the Hospital-Acquired Condition (HAC) Reduction Program, mandated by the Affordable Care Act, requires the Centers for Medicare & Medicaid (CMS) to reduce hospital payments by 1 percent for hospitals that rank among the lowest-performing 25 percent with regard to HACs. Understanding the Hospital-Acquired Condition Reduction Program (5-page PDF)

Hospital Readmissions Reduction Program

The Hospital Readmissions Reduction Program, mandated by the Affordable Care Act, requires the Centers for Medicare & Medicaid (CMS) to reduce payments to IPPS hospitals with excess readmissions. The program is effective for discharges beginning October 1, 2012.

Unlike the Value-based Purchasing (VBP) program, this is a penalty program and a hospital cannot get additional monies, only lose money as result of their performance. What is similar to the VBP program is that the penalty for the Readmission Reductions Program affects the base DRG for discharges. Understanding the Hospital Readmissions Reduction Program (3-page PDF)

Stratis Health’s Improving Transitions of Care Program aims to improve care for Medicare beneficiaries who transition among care settings through a comprehensive community effort. These efforts aim to reduce readmissions following hospitalization by 20 percent over three years and to yield sustainable and replicable strategies to achieve high-value health care for sick and disabled Medicare beneficiaries. Coordination of care

In partnership with the Institute for Clinical Systems Improvement and the Minnesota Hospital Association, Stratis Health is leading a Minnesota campaign to reduce avoidable hospital readmissions. The RARE Campaign has engaged hospitals and care providers across the continuum of care to prevent avoidable hospital readmissions across Minnesota.

Key Quality Improvement Priorities

Adverse drug events

Along with multidisciplinary/multi-setting community teams, Stratis Health is participating in the national Patient Safety and Clinical Pharmacy Services Collaborative (PSPC), a patient-centered initiative to support health care organizations in reducing and preventing adverse drug events. The collaborative integrates evidence-based clinical pharmacy services into the care and management of high-risk, high-cost, complex patients. Its aim is to develop integrated care teams, with cost-effective clinical pharmacy services, to improve health outcomes and safety for high medication risk patient populations in alignment with national quality standards. Medication Management

Healthcare-associated infections

We work with Minnesota hospitals to reduce healthcare-acquired infections through the Collaborative Health­care Associated Infection Network (CHAIN), a partnership with the Association for Professionals in Infection Control and Epidemiology - Minnesota Chapter, Minnesota Department of Health, and Minnesota Hospital Association. CHAIN is currently focusing on the reduction of central line associated bloodstream infections (CLABSI), catheter associated urinary tract infections (CAUTI), surgical-site infections (SSI), and clostridium difficile infections (CDI). CHAIN

Readmission reduction program

The national Hospital Readmissions Reduction Program is a penalty-based program designed to reduce payments to IPPS hospitals with excess readmissions. The program is effective for discharges beginning October 1, 2012. In the FY 2013 IPPS final rule CMS determined which hospitals are subject to the penalties of the program; the methodology to calculate the readmission adjustment factor; what portion of the IPPS payment will be used to calculate the adjustment amount; and the process for hospitals to review their readmission information and submit corrections to the information before the readmission rates are made public. Hospital Readmissions Reduction Program

Stratis Health’s Improving Transitions of Care Program aims to improve care for Medicare beneficiaries who transition among care settings through a comprehensive community effort. These efforts aim to reduce readmissions following hospitalization by 20 percent over three years and to yield sustainable and replicable strategies to achieve high-value health care for sick and disabled Medicare beneficiaries. Coordination of care

Stratis Health, in partnership with the Institute for Clinical Systems Improvement and the Minnesota Hospital Association, is leading a Minnesota campaign to reduce avoidable hospital readmissions. The RARE Campaign has engaged hospitals and care providers across the continuum of care to prevent avoidable hospital readmissions across Minnesota.

Palliative care

We are working to establish or strengthen palliative care programs in rural communities. We’ve supported more than 25 rural communities, in Minnesota and nationally, to build community capacity to offer palliative care services. People in rural communities have less access to palliative care services. And, models of palliative care relevant to rural communities are not available to guide program development. Palliative care is a field new to many health care providers. This approach to managing serious and advanced illness centers on relieving suffering and improving quality of life for patients and their families. Practitioners of palliative care help patients and their families understand treatment options, and facilitate effective communication among health care professionals, patients, and family members—bringing together the support systems that patients need to determine how to plan for the best quality of life and care. Palliative care

Contacts

Contact Stratis Health for assistance with your quality improvement and patient safety needs. If your hospital has projects it would like to work on, contact us to discuss how we can work together to support new initiatives.

Abstraction

Robyn Carlson, data quality specialist

952-853-8587

Adverse Drug Events

Hospital-Acquired Infections

Kim McCoy, program manager

952-853-8563

Palliative Care

Transitions of Care

Janelle Shearer, program manager

952-853-8553

Rural Health

Karla Weng, program manager

952-853-8570

General Hospital Information

Mary Montury, program coordinator

952-853-8541

National Helpdesk Contact

7:00 a.m. - 7:00 p.m., CST, Monday - Friday

866-288-8912, Fax 888-329-7377, email