Open the document that says final project part 1: Use the videos listed below to answer the questions in Activity 1
Videos: https://www.youtube.com/watch?v=okO8Z7ZPPuw&feature=youtu.be ,
For Activity 2: on the Final project document: Utilize the attached charts 1-5 to complete
For Activity 3: on the Final project document: Utilize the attached document that says Policy and Procedures
—— For Final Project 2 open up the attached document read the directions and answer all questions———
*****ALL QUESTIONS CAN BE ANSWERED ON A WORD DOCUMENT ATTACHED AND SENT BACK******
4508Final Quality Project
Part 1: Quality Improvement and the EHR
Overview
This activity focuses on Quality Improvement using EHRs. The activity uses online resources as well as
copies of actual medical records. For this assignment, you will perform an audit of the
documentation of consents in the chart for accuracy and quality. Afterwards, you will make
recommendations about the consent and audit process. This encompasses quality management,
performance improvement and initiatives within a healthcare system.
Quality Improvement (QI): Systematic and continuous actions that lead to measurable improvement
in health care services and the health status of targeted patient groups. (www.hrsa.gov)
Continuous Quality Improvement (CQI): Is a quality management process that encourages all health
care team members to continuously ask the questions, “How are we doing?” and “Can we do it
better?” (Edwards, 2008). To address these questions, a practice needs structured clinical and
administrative data. (www.healthit.gov)
Rapid-Cycle Quality Improvement: A QI methodology that was developed out of the need to see
improvement quicker. It reduces wasted activity and efforts for a quick turnaround on QI projects.
PDSA/PDCA: Plan, Do, Study/Check, Act. A commonly used QI strategy that is a four step rapid-cycle
quality improvement strategy.
• Plan: Identify an opportunity to improve and plan a change
• Do: Carry out the plan on a sample number of patients.
• Study/Check: Examine the results. Were your goals achieved?
• Act: Use your results to make a definitive decision. Incorporate the changes into your
workflow.
SMART Goals:
• Specific (simple, sensible, significant).
• Measurable (meaningful, motivating).
• Achievable (agreed, attainable).
• Relevant (reasonable, realistic and resourced, results-based).
• Time bound (time-based, time limited, time/cost limited, timely, time-sensitive).
http://www.hrsa.gov/
http://www.healthit.gov/
Activity 1
Watch video: Implementing EHRs to Improve Healthcare Quality: https://youtu.be/okO8Z7ZPPuw
Watch video: The Path to Interoperability: https://youtu.be/PaWcU7rqqyA
Answer questions 1-3.
1. Most physicians feel as if EHRs do not save them time. What is your response to this?
a. Were EHRs designed to “save time” in the healthcare documentation process?
b. If not, what was the EHR designed to do? Be thorough in your response.
2. When implementing organization wide QI initiatives, many employees and physicians take the
attitude of “that won’t work here.”
a. How should the organization respond?
b. What would be different ways of implementing an initiative that could combat this
response?
3. Do you feel quality improvement is an easier process now that many healthcare organizations
are utilizing an EHR? Why?
Activity 2
Use the chart forms linked in the assignment description on Canvas to complete this activity:
You are completing an internship in the Quality Department at General Hospital. As part of your
internship, the director of the department has asked you to complete a small quality improvement
project utilizing their EHR. The director would like you to determine if randomly selected five charts
meet the following criteria:
• The consent is detailed and addresses the following 8 items:
o Permission
o Unforseen Conditions
o Anesthesia
o Specimens
o Photographing, Videotaping, etc.
o Explanation of Procedure, Risks, Benefits, and Alternatives
o Blood Transfusion
o No Guarantees
• All signatures required are present
o Patient/Relative/Guardian
o Physician
o Witness
4-8. Record chart findings: (questions will be individual on quiz). All valid electronic signatures
are denoted by an /es/ with the name of the individual signing and the date/time of the
signature.
Question # Chart # Yes No
4. 1
5. 2
6. 3
7. 4
8. 5
9. Based on your findings from the 5 charts, what would be a goal for improvement (use the
SMART goal format)?
Analyze the process and come up with your QI process (keep it simple)
10. Plan:
11. Do:
12. Check/Study:
13. Act:
Activity 3
You are the director of the Health Information Management Department of Hospital XYZ. The
hospital has been using an EHR for 6 years and has been part of the Meaningful Use Incentive
Program for 3 years.
Part of your success has been the routine audits of medical records. The clinical staff is short-handed
and has admitted to not being able to document as they used to as evidenced by the results of
Activity 2. Your current staff of two are not able to meet the demands of auditing the charts and you
will be hiring a third person to work with you. Among your many duties as manager is keeping
policies and procedures up-to-date.
Your team has composed the step by step process for a policy about auditing but after you review it
you notice there are key elements missing that you as director must complete. The policy with the
highlighted areas needed is located on the Modules page under this assignment (Critical thinking is
required)
14. Title of policy
15. Purpose of auditing
16. Individuals responsible for documenting clinical information in the medical record
17. Individuals responsible for auditing the medical record to ensure documentation is complete
18. Definitions – do not define, just list the words from the policy that should be defined
1
A. Reviewed/Revised:
December 1, 2019
B. Purpose:
_(15) ________________________________________________________
_____________________________________________________________
_____________________________________________________________
C. Policy:
It is the policy of Hospital XYZ to maintain an auditing and monitoring program,
which will evaluate adherence to corporate compliance policies, meets one of
the seven elements as stated in the Office of the Inspector General (OIG)
Guidance on Compliance Programs for Hospitals, and the State Office of the
Medicaid Inspector General Compliance program requirements, Federal and
State regulations and other regulations as may be required.
D. Scope:
__(16)_________________ is responsible for documenting clinical information
in the medical record.
__(17) ________________ is responsible for auditing the medical record to
ensure documentation is complete.
E. Definitions:
(18) ______
__________
__________
__________
Hospital XYZ
Health Information Management Department
_(14)_____________ Policy and Procedure
2
F. Procedures:
Techniques for the auditing and monitoring process may include:
• On-site reviews
• Unannounced mock surveys, audits and investigations
• Interviews with staff.
• Check of personnel records to determine whether any individuals who
have been reprimanded for compliance issues in the past are among
those currently engaged in improper conduct.
• Interviews with personnel involved in management, operations, and
other related activities.
• Questionnaires developed to solicit impressions of a broad cross section
of the organization’s Representatives.
• Reviews of written materials and documentation prepared by various
Representatives .
• Trend analyses or longitudinal studies that seek deviations, positive or
negative in specific areas over a given period of time.
• Review of electronic records to determine appropriate or inappropriate
accesses.
• Review of departmental policies and procedures.
Audit File: All documentation regarding the audit will be maintained in the
appropriate audit file. Any corrective action required will be tracked and
confirmed.
Audit File Retention: A copy of the documentation supporting the findings will be
maintained in the designated audit file. This file will be maintained indefinitely.
Training Requirements: Individuals designated by the Health Information
Management Director to conduct audits shall participate in any training provided
by the Corporate Compliance Office. Auditors shall:
• Possess the qualifications and experience necessary to adequately
identify potential issues with the subject matter to be reviewed.
• Be objective and independent of line management.
• Have access to existing audit and health care resources, relevant
personnel, and all relevant areas of operation.
• Report any and all review results and deviations from “norms” to the
Director.
• Have the authority to request and review any related information.
3
Self-Assessment and Annual Compliance Work Plan
An annual risk assessment will be performed to evaluate the effectiveness of and
opportunities for improvement in the Compliance Program. Risk areas can
include any of the following:
• Regulatory/legal issues
• Funds Flow Process
• Environmental/health/safety issues
• HR issues
• IT/systems issues
• Reimbursement
The Compliance Staff will assist the Health Information Management Director in
determining the elements of the annual work plan, taking into consideration the
State Office of the Medicaid Inspector General (OMIG) compliance guidance,
yearly audit and monitoring results, risks identified through the annual risk
assessment and recommendations from the Compliance Committee. The HIM
Director will submit the written compliance work plan for approval by the
Executive Committee.
Reporting
Reviews should be reported to the Director.
The Director will maintain audit documentation and report findings on a regular
basis to the Compliance Committee and the Executive Committee.
_____________________________
Health Info Mgmt Director
_____________________________
Compliance Director
_____________________________
Chief Executive Officer, XYZ Hospital
Consents Apr 06,2016
INPATIENT UNIT
==========================================================================
*** WORK COPY ONLY *** Printed: Jul 25, 2017 06:35
LOCAL TITLE: CONSENTS
DATE OF NOTE: APR 06, 2016@09:15 ENTRY DATE: APR 06, 2016@09:15
AUTHOR: CLERK,EIGHT EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Consent for:
Consious sedation for colonoscopy, Esophagogastroduodenoscopy and
any possible biopsies.
Consent reviewed by patient:
Consent signed by patient: YES
Consent reviewed by physician: YES
Consent signed by physician: YES
Procedure(s) discussed with patient: YES
Physician(s) who spoke with patient:
Doctor One
Consent with patient chart: YES
/es/ EIGHT CLERK
FACULTY
Signed: 04/06/2016 09:15
————————————————————————–
End of report
SMITH, JON 555-55-5501 Dec 1, 1974 (42)
Consents Apr 06,2016
ORTHOPAEDIC
==========================================================================
*** WORK COPY ONLY *** Printed: Jul 25, 2017 06:34
LOCAL TITLE: CONSENTS
DATE OF NOTE: APR 06, 2016@08:45 ENTRY DATE: APR 06, 2016@08:45
AUTHOR: CLERK,NINE EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Consent for:
anesthesia and right total knee arthroplasty
Consent reviewed by patient: YES
Consent signed by patient: YES
Consent reviewed by physician: YES
Consent signed by physician: YES
Procedure(s) discussed with patient: YES
Physician(s) who spoke with patient:
surgeon and anesthesiologist
Consent with patient chart: YES
/es/ NINE CLERK
FACULTY
Signed: 04/06/2016 08:45
————————————————————————–
End of report
SMITH, JANE 555-55-5502 Jan 01, 1972 (45)
Consents Apr 24,2016
INPATIENT UNIT
==========================================================================
*** WORK COPY ONLY *** Printed: Jul 25, 2017 06:36
LOCAL TITLE: CONSENTS
DATE OF NOTE: APR 24, 2016@07:00 ENTRY DATE: APR 24, 2016@07:00
AUTHOR: DOCTOR,EIGHT EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Patient Consent Form for Operation or Special Procedure
1. Permission: I hereby authorize the doctor (and other such physician (s) at
the Hospital as he/she may designate) to perform upon the following
operation(s):
L4-L5 Laminectomy
2. Unforeseen Conditions: If any unforeseen condition arises in the course of
the operation or procedure for which other procedures, in addition to or
different from those above contemplated, are necessary or appropriate in the
judgment of the said physician or his designee(s), I further request and
authorize the carrying out of such operation or procedures.
3. Anesthesia: I consent to the administration of anesthesia under the direction
of the Department of Anesthesiology. I understand that certain risks and
complications (including damaged teeth) may result from the administration of
anesthesia.
4. Specimens: Any organs or tissue surgically removed may be examined and
retained by the Hospital for medical, scientific or educational purposes and
such tissues or parts may be disposed of in accordance with accustomed practice
and applicable State laws and regulations.
5. Photographing, Videotaping, etc: I consent to the photographing, videotaping,
televising or other observation of the operation or procedures to be performed
including appropriate portions of my body, for medical, scientific or
educational purposes, provided my identity is not revealed by the pictures or
descriptive texts accompanying them.
6. Explanation of Procedure, Risks, Benefits and Alternatives: The nature and
purpose of the operation/procedure, possible alternative methods of treatment,
the expected benefits and complications, attendant discomforts and the risks
involved have been fully explained to me. I have been given an opportunity to
ask questions and all my questions have been answered fully and satisfactorily.
7. I further consent to the administration of blood or blood products as may be
considered necessary. I recognize that there are always risks to health
associated to the administration of blood or blood products and such risks have
been fully explained to me.
8. No Guarantees: I acknowledge that no guarantee or assurance has been made to
me as to the results that may be obtained.
I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT TO OPERATION
THAT THE EXPLANATIONS THEREIN REFERRED TO WERE MADE AND THAT ALL THE BLANK
SPACES ABOVE HAVE BEEN COMPLETED PRIOR TO MY SIGNING.
Patient/Relative/Guardian:
Electronic Signature
Relationship, if other than patient signed:
Physician: Dr. Eight
Electronic Signature
Witness: Nurse, Five
Electronic Signature
————————————————————————–
Page 1
THOMAS, JON 555-55-5503 Feb 01, 1972 (45)
Jon Thomas
Jon Thomas
Consents Apr 24,2016
INPATIENT UNIT
==========================================================================
*** WORK COPY ONLY *** Printed: Jul 25, 2017 06:36
/es/ EIGHT DOCTOR
FACULTY
Signed: 04/24/2016 07:00
————————————————————————–
End of report
Consents Apr 04,2016
INPATIENT UNIT
==========================================================================
*** WORK COPY ONLY *** Printed: Jul 25, 2017 06:37
LOCAL TITLE: CONSENTS
DATE OF NOTE: APR 04, 2016@06:00 ENTRY DATE: APR 04, 2016@06:00
AUTHOR: NURSE,FOUR EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Patient Consent Form for Operation or Special Procedure
1. Permission: I hereby authorize the doctor (and other such physician (s) at
the Hospital as he/she may designate) to perform upon the
following operation(s):
Left Radical Mastectomy
2. Unforeseen Conditions: If any unforeseen condition arises in the course of
the operation or procedure for which other procedures, in addition to or
different from those above contemplated, are necessary or appropriate in the
judgment of the said physician or his designee(s), I further request and
authorize the carrying out of such operation or procedures.
3. Anesthesia: I consent to the administration of anesthesia under the direction
of the Department of Anesthesiology. I understand that certain risks and
complications (including damaged teeth) may result from the administration of
anesthesia.
4. Specimens: Any organs or tissue surgically removed may be examined and
retained by the Hospital for medical, scientific or educational purposes and
such tissues or parts may be disposed of in accordance with accustomed practice
and applicable State laws and regulations.
5. Photographing, Videotaping, etc: I consent to the photographing, videotaping,
televising or other observation of the operation or procedures to be performed
including appropriate portions of my body, for medical, scientific or
educational purposes, provided my identity is not revealed by the pictures or
descriptive texts accompanying them.
6. Explanation of Procedure, Risks, Benefits and Alternatives: The nature and
purpose of the operation/procedure, possible alternative methods of treatment,
the expected benefits and complications, attendant discomforts and the risks
involved have been fully explained to me. I have been given an opportunity to
ask questions and all my questions have been answered fully and satisfactorily.
7. I further consent to the administration of blood or blood products as may be
considered necessary. I recognize that there are always risks to health
associated to the administration of blood or blood products and such risks have
been fully explained to me.
8. No Guarantees: I acknowledge that no guarantee or assurance has been made to
me as to the results that may be obtained.
I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT TO OPERATION
THAT THE EXPLANATIONS THEREIN REFERRED TO WERE MADE AND THAT ALL THE BLANK
SPACES ABOVE HAVE BEEN COMPLETED PRIOR TO MY SIGNING.
Patient/Relative/Guardian:
Electronic Signature
Relationship, if other than patient signed:
/es/ FOUR NURSE
FACULTY
————————————————————————–
End of report
THOMAS, JANE 555-55-5504 Mar 01, 1972 (45)
Jane Thomas
Jane Thomas
Consents Apr 13,2016
MED-SURG
==========================================================================
*** WORK COPY ONLY *** Printed: Jul 25, 2017 06:35
LOCAL TITLE: CONSENTS
DATE OF NOTE: APR 13, 2016@06:00 ENTRY DATE: APR 13, 2016@06:00
AUTHOR: DOCTOR,EIGHT EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Patient Consent Form for Operation or Special Procedure
1. Permission: I hereby authorize the doctor (and other such physician (s) at
the Hospital as he/she may designate) to perform upon the
following operation(s):
Total Thyroidectomy
2. Unforeseen Conditions: If any unforeseen condition arises in the course of
the operation or procedure for which other procedures, in addition to or
different from those above contemplated, are necessary or appropriate in the
judgment of the said physician or his designee(s), I further request and
authorize the carrying out of such operation or procedures.
3. Anesthesia: I consent to the administration of anesthesia under the direction
of the Department of Anesthesiology. I understand that certain risks and
complications (including damaged teeth) may result from the administration of
anesthesia.
4. Specimens: Any organs or tissue surgically removed may be examined and
retained by the Hospital for medical, scientific or educational purposes and
such tissues or parts may be disposed of in accordance with accustomed practice
and applicable State laws and regulations.
5. Photographing, Videotaping, etc: I consent to the photographing, videotaping,
televising or other observation of the operation or procedures to be performed
including appropriate portions of my body, for medical, scientific or
educational purposes, provided my identity is not revealed by the pictures or
descriptive texts accompanying them.
6. Explanation of Procedure, Risks, Benefits and Alternatives: The nature and
purpose of the operation/procedure, possible alternative methods of treatment,
the expected benefits and complications, attendant discomforts and the risks
involved have been fully explained to me. I have been given an opportunity to
ask questions and all my questions have been answered fully and satisfactorily.
7. I further consent to the administration of blood or blood products as may be
considered necessary. I recognize that there are always risks to health
associated to the administration of blood or blood products and such risks have
been fully explained to me.
8. No Guarantees: I acknowledge that no guarantee or assurance has been made to
me as to the results that may be obtained.
I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT TO OPERATION
THAT THE EXPLANATIONS THEREIN REFERRED TO WERE MADE AND THAT ALL THE BLANK
SPACES ABOVE HAVE BEEN COMPLETED PRIOR TO MY SIGNING.
Patient/Relative/Guardian:
Electronic Signature
Electronic Signature
Relationship, if other than patient signed: Mother
————————————————————————–
Page 1
DOE, JON 555-55-5505 Apr 01, 1999 (17)
Jon Doe
Jon Doe
Jane Doe
Consents Apr 13,2016
MED-SURG
==========================================================================
*** WORK COPY ONLY *** Printed: Jul 25, 2017 06:35
/es/ EIGHT DOCTOR
FACULTY
Signed: 04/13/2016 06:00
————————————————————————–
End of report
4508
Final Quality Project
Part 2: Clinical Quality Measures for Hospitals
Overview
This activity focuses on Quality Measures for Hospitals. The activity uses online resources from
the CMS website. The Clinical Quality Measures for Hospitals activity focuses on the Hospital
Value Based Purchasing (VBP) Program
Background
The National Quality Strategy (NQS) was first published in March 2011 as the National Strategy
for Quality Improvement in Health Care, and is led by the Agency for Healthcare Research and
Quality on behalf of the U.S. Department of Health and Human Services (HHS). Today, the NQS
serves as a guide for identifying and prioritizing quality improvement efforts, sharing lessons
learned, and measuring the collective success of Federal, State, and public‐ and private‐sector
healthcare stakeholders across the country.
The Aims of the NQS are threefold:
Better Care: Improve the overall quality by making health care more patient‐centered,
reliable, accessible, and safe.
Healthy People/Healthy Communities: Improve the health of the U.S. population by
supporting proven interventions to address behavioral, social, and environmental
determinants of health in addition to delivering higher‐quality care.
Affordable Care: Reduce the cost of quality health care for individuals, families,
employers, and government.
To align with this, CMS has set goals for their Quality Strategy. These include:
• Make care safer by reducing harm caused in the delivery of care
– Improve support for a culture of safety
– Reduce inappropriate and unnecessary care
– Prevent or minimize harm in all settings
• Strengthen person and family engagement as partners in their care
• Promote effective communication and coordination of care
• Promote effective prevention and treatment of chronic disease
• Work with communities to promote best practices of healthy living
• Make care affordable
CMS’s vision states that if we can find better ways to pay providers, deliver care, and distribute
information than patients can receive better care, health dollars are spent more wisely, and
there are healthier communities, a healthier economy, and a healthier county. It is with this in
mind that they have created multiple quality payment programs.
In January 2015, the Department of Health and Human Services made an announcement that
set in place measurable goals and a timeline to move the Medicare program towards paying
providers based on the quality of care rather than the quantity. This was the first time in the
history of the program that explicit goals were set. They invited private sector payers to match
or exceed these goals as well. These goals included:
1. Alternative Payment Models
a. 30% of Medicare payments tied to quality or value through Alternative Payment
models by the end of 2016 and 50% by the end of 2018
2. Linking Fee‐For‐Service payments to Quality/Value
a. 85% of all Medicare fee‐for‐service payments tied to quality or value by 2016;
90% by the end of 2018
The Affordable Care Act was passed in 2010 and authorized the establishment of the Hospital
VBP Program, built on the quality reporting infrastructure of the Hospital Inpatient Quality
Reporting (Hospital IQR) Program. The programs intent was to promote better clinical
outcomes for hospital patients, improve the patient experience of care during hospital stays,
and encourage hospitals to improve the quality and safety of care that all patients receive by:
Eliminating or reducing the occurrence of adverse events,
Adopting evidence‐based care standards and protocols that result in the best outcomes
for the most patients, and
Re‐engineering hospital processes that improve patients’ experience of care.
There are several domains covered by the Hospital VBP program. The first year began with 2
domains and increased over time to the current 4 domains. These domains and the weights
assigned to them vary over the years. Below is a table of these domains and their weights by
year:
2013 2014 2015 2016
Clinical Process of Care 70% 45% 20% 10%
Patient Experience of Care 30% 30% 30% 25%
Outcome ‐ 25% 30% 40%
Efficiency ‐ ‐ 20% 25%
The following 2 years had changes to the language of the categories
2017 2018
Clinical Care 5% 25%
Patient and Caregiver Experience of Care/Care Coordination 25% 25%
Outcome 25% ‐
Efficiency (and “cost reduction” in 2018) 25% 25%
Safety 20% 25%
The following 2 years (2019 and 2020) are subject to the proposed updates:
Clinical Care – 25%
Person and Community Engagement – 25%
Safety – 25%
Efficiency and Cost Reduction – 25%
The Hospital VBP program adjusts hospitals’ payments based on their performance on the
domains that reflect hospital quality. Each data set includes the following:
An achievement score – scores awarded to hospitals that achieve certain levels of
performance compared to other hospitals; compare an individual hospital’s rates with
all other participating hospital’s rates from a baseline period
An improvement score – scores award to hospitals that improved over its own baseline
period performance; compare an individual hospital’s rates with all their own rates from
a baseline period
A measure/dimension score – represents higher of either the achievement or
improvement points
The total score for each hospital is out of 100. The program is budget neutral and uses the
funds saved by reducing payments for base operating diagnosis‐related group (DRG) payments
to fund value‐based incentive payments to hospitals for discharges in that fiscal year based on
their performance under the program.
The applicable percent reduction to participating hospitals’ base operating DRG payment
amounts increased by 0.25% each year, starting at a 1% reduction in the first year of the
Hospital VBP program until it reached 2%. The reductions by year are:
2013: 1%
2014: 1.25%
2015: 1.5%
2016: 1.75%
2017+: 2%
Incentive payments are applied to hospitals on a claim‐by‐claim basis and each hospital’s value‐
based incentive payment percentage that the hospital earns for the year is determined based
on that hospital’s Total Performance Score (TPS) on the Hospital VBP measures. The hospital’s
TPS is converted to a value‐based incentive payment adjustment factor, and that factor is then
multiplied by the base operating DRG payment amount for each Medicare fee‐for‐service
discharge in a year to calculate the adjusted payment amount that applies to the discharge for
that year.
In 2018, there was a 2% reduction in base DRG payments for the year which made $1.9 billion
available for Value‐Based Incentive payments.
Domains
Clinical Care Domain
Assesses estimates of deaths in the 30 days after entering the hospital for a specific condition
(reported as the “survival” rate; therefore, higher percentage rates are favorable). Patients who
received high‐quality care during their hospitalizations and their transition to the outpatient
setting will likely have improved outcomes, like survival rate. Includes:
Acute myocardial infarction (AMI) 30‐day mortality rate
Heart failure (HF) 30‐day mortality rate
Pneumonia (PN) 30‐day mortality rate
Person and Community Engagement Domain
Based on the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)
which is a national, standardized survey that asks adult patients about their experiences during
a recent hospital stay. The domain score encompasses 8 important dimensions of hospital
quality:
Communication with nurses
Communication with doctors
Responsiveness of hospital staff
Cleanliness and quietness of hospital environment
Communication about medicines
Discharge information
Care transition
Overall rating of hospital
Safety Domain
Assesses a broad set of healthcare activities that affect patients’ well‐being. Patients who
received high‐quality care during their hospitalizations will likely have improved outcomes, like
reduced risk of in‐hospital falls with hip fracture, bed sores, and other adverse events, reduced
risk of healthcare‐associated infections, and improved quality of life. Includes:
AHRQ (PSI‐90) patient safety for selected indicators
Central line‐associated bloodstream infection (CLABSI)
Catheter‐associated urinary tract infection (CAUTI)
Surgical site infection (SSI)
Methicillin‐resistant Staphylococcus Aureus (MRSA)
Clostridium difficile Infection (CDI)
Perinatal Care (PC)‐01
Efficiency and Cost Reduction Domain
Increases the transparency of care for consumers by recognizing hospitals that provide high
quality care at lower costs to Medicare. Is determined by the Medicare spending per
beneficiary (MSPB) measure.
Activity 1: Answer the following critical thinking questions:
1. The patient experience/engagement category has remained steady over the years,
ranging from 25‐30% of the total score. Why is it important for organizations to be
graded on this category? What affect does it have on the healthcare provided?
2. The category of efficiency/cost reduction was introduced in 2015. What is the
importance of measuring efficiency/cost reduction on the healthcare system as a
whole?
3. Do you think a 2% reduction in payments is sufficient to encourage behavioral changes
in the quality of care provided? Why or why not?
Activity 2:
You will review several facilities and their scores for the Hospital Value‐Based Purchasing
program. Scores are provided on the CMS website but have been extracted and combined to a
single excel file located on the modules page under this assignment. Each domain has a
separate tab in the excel file as well as a separate tab for Total Performance Score.
Open the HVBP Scores file
Use the Hospital Measures Definitions file to identify the measures in the HVBP Scores
file.
Search the corresponding tabs for the 3 local hospitals and their scores.
Hospital Provider Number
Orlando Health 100006
Florida Hospital 100007
Osceola Regional Medical Center 100110
4. Under the Clinical Care domain, what was the benchmark for the “Acute Myocardial
Infarction (AMI) 30‐day mortality rate”?
a. 0.8732
b. 0.8506
c. 0.90
d. 10 out of 10 points
5. Under the Clinical Care domain, which hospital had a performance rate lower than the
benchmark for “Acute Myocardial Infarction (AMI) 30‐day mortality rate”?
a. Orlando Health
b. Florida Hospital
c. Osceola Regional Medical Center
6. Under the Clinical Care domain, which hospital had a performance rate lower than their
baseline for “Heart Failure (HF) 30‐day mortality rate”?
a. Orlando Health
b. Florida Hospital
c. Osceola Regional Medical Center
7. Under the Patient Experience of Care domain, what was the achievement threshold for
“Responsiveness of hospital staff”?
a. 0.90
b. 32.72
c. 65.16
d. 80.15
8. Under the Patient Experience of Care domain, which hospital received improvement
points for “Communication with Doctors”?
a. Orlando Health
b. Florida Hospital
c. Osceola Regional Medical Center
9. Under the Patient Experience of Care domain, Florida Hospital received 5 points for
their “Care Transition” measure score. Were these points for achievement or
improvement?
a. Achievement
b. Improvement
10. Under the Safety domain, what was the benchmark for “Perinatal Care (PC)‐01” (This is
identified as (PC‐01))?
a. 0
b. 0.0204
c. 10 out of 10 points
11. Under the Efficiency domain, what was the achievement threshold for “Medicare
spending per beneficiary (MSPB)”?
a. 0
b. 0.9869
c. 0.8396
d. 10 out of 10 points
12. Under the Total Performance Score, which hospital had the highest TPS?
a. Orlando Health
b. Florida Hospital
c. Osceola Regional Medical Center