# Presentation: 574022

## AHRQ Quality Indicators Learning Institute 

- Introduction to the AHRQ QI Learning Institute
- July 30, 2008

**Notes:**
Irene- Welcome and Context
This presentation will provide an overview of the Quality Indicators Learning Institute.  Quality Indicators, also known as QIs, were developed for the AHRQ, which is a federal agency in the Department of Health and Human Services.  The QIs contribute to AHRQ’s mission which is “to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.

## Agenda

- Welcome and Context
- Overview of the Learning Institute
- NQF Endorsement and CMS Use of AHRQ QIs
- Relevance of the Learning Institute
- Questions & Feedback
- Next Steps

## Background of QIs

- Developed through contract with UCSF-Stanford Evidence-based Practice Center
- Use existing hospital discharge data, based on readily available data elements
- Incorporate severity adjustment methods (APR-DRGs,comorbidity groupings) in IQIs
- Original goal: Use for national tracking, quality improvement
- Growing use for reporting and P4P
- For more information, please go to the QI web site: _[http://](http://www.qualityindicators.ahrq.gov/)__[www.qualityindicators.ahrq.gov](http://www.qualityindicators.ahrq.gov/)__[/](http://www.qualityindicators.ahrq.gov/)_

**Notes:**
How were the measures derived?????- Dale Bratzler asked.

## AHRQ Quality Indicators

**Inpatient QIs**
**Mortality**
**Utilization**
**Volume**

**AHRQ Quality Indicators**

**Prevention QIs**
**(Area Level)**
**Avoidable **
**Hospitalizations/**
**Other Avoidable **
**Conditions**

**Patient Safety **
**QIs**
**Complications**
**Failure-to-rescue**
**Unexpected death**

- Neonatal QIs

**Notes:**
These were the 3 original modules of AHRQ Quality Indicators just added a 4th.  

## Motivation for QI Learning Institute  

- 2005 QI User Meeting
- Attended by hospitals, hospital associations, State depts. of health etc.
- Focus on how organizations were using the AHRQ QIs
- Quality improvement
- Public Reporting
- Strong desire for networking and education around use of AHRQ QIs for public reporting

**Notes:**
We want to help the users.  Users requested a learning institute. 
Also 25 were recently endorsed by the National Quality Forum for public reporting, AHRQ would like to provide support to QI users and those considering using through the Learning Institute. 

## 12 States Use QIs for Public Hospital Reporting

**Notes:**
Currently 12 States are using the QIs to publicly report hospital performance.  

## Purpose of the QI Learning Institute

- 	To provide a forum for discussing and facilitating the use of the AHRQ Quality Indicators (QIs) in statewide and regional programs that report hospital quality measures to the public.

**Notes:**
Mamatha
Disclaimer and Constraints: The intent of the AHRQ Quality Indicators Learning Institute is to promote open discussions and interactions among program leaders, policymakers, researchers, and other experts involved in developing public reporting systems. Participants may not sell or solicit commercial products or services during these AHRQ-sponsored learning sessions.

## Target Audience

- 	Leaders from organizations involved in developing public reporting programs and interested in using the AHRQ Quality Indicators to assess hospital quality including...
- State Agencies/ Taskforces
- State Hospital Associations
- Coalitions

## Planning Committee 

- Dale Bratzler, DO - Oklahoma Foundation for Medical Quality
- Denise Love, MBA - National Association of Health Data Organizations
- Kim Streit, MBA, MHA - Florida Hospital Association
- Shoshanna Sofaer, MPH, DrPH - Baruch College, The City University of New York
- Jeff Geppert, JD - Battelle Memorial Institute

**Notes:**
A Planning Committee has been convened to advice AHRQ staff about the Learning Institute.  They are users and developers of the QIs and also leaders in public reporting and quality measurement so they are involved everyday with the issues that arise.  

Dale Bratzler- OK Foundation for Medical Quality, Medical Director for the National Hospital QIO Support Center 
Denise Love- Executive Director National Association of Health Data Organizations 
Kim Streit (FL)- Vice President of Health Care Research and Information for the Florida Hospital Association 
Shoshanna Sofaer- Endowed Professor of Health Policy at the School of Public Affairs, Baruch College, City University of New York- Reporting template developer
Jeff Geppert- J.D., Co-Director, Battelle Memorial Institute – QI technical assistance

## Staff

- AHRQ Center for Delivery, Organization, and Markets
- Irene Fraser, PhD, Director
- Mamatha Pancholi, MS, Program Officer, Quality Indicators Team Project
- Marybeth Farquhar, PhD, MSN, RN, Senior Advisor, Quality Indicators Team Project
- AHRQ Office of Communications and Knowledge Transfer
- Marjorie Shofer, MBA, Senior Program Analyst
- Margaret K. Rutherford, Editor
- AcademyHealth (Contractor)
- Katherine Griffith, Associate

## Activities

- 	A year-long series of activities focusing on measure selection, reporting formats, and the organizational infrastructure needed to conduct an effective public reporting program.
- Webinars
- In-person Meetings
- Online Discussions
- Live Chats
- Online Document Archive and Web Links

**Notes:**
The Learning Institute is a Forum for discussion about the QIs. 
-There will be Webinars on specific topics that are of interest to the participants.
-There will also be a website for online discussion (blog) on specific topics about QIs. 
-Could have LIVE chat sessions with “experts”
-One in-person meeting next winter
Events will be attended by AHRQ staff and experts in the field to provide feedback and technical support.  
If site is up maybe we can show it now???
The application Webex WebOffice is fairly straight forward, but we will have training sessions.  As you can see there is a calendar function, discussions folders for people to talk about certain topics with each other, a chat function to talk live with others- we hope to have set time when experts will be “chatting.” and more.  It provides an on-demand collaboration suite including a document manager, group calendar, database manager, task manager and several other collaborative business tools. 
The site is interactive with chat and discussion functions for members to ask questions and discuss issues related to publicly reporting QIs with each other and experts.  We have asked the planning committee and AHRQ staff to check it periodically and respond to inquiries and comments, plus we have an administrator check it daily to answer questions or find someone who can answer questions.  This site is a resource for participants. 

## AHRQ QI Model Reports 

- 	Model Reports are designed specifically to report comparative information on hospital performance based on the AHRQ Quality Indicators
- Hospital Quality Model Report: Health Topics - takes all the IQIs, PSIs, and PedQIs and puts them into health topics
- Hospital Quality Model Report: Composites - builds on four composite measures created by AHRQ using multivariate statistical analysis

## Possible Topics 

- Selecting Measures
- Sample size
- Validation
- Risk Adjustment
- Securing a Data Source and Checking Correctness
- Updating and Refreshing the Data
- Dry Runs and Sharing Data with Providers
- Designing a Communication Vehicle/ Selecting a Medium/ Reporting Format- Using the new Model Reports
- Integrating ratings from the QIs with other hospital data/ Correlation Between QIs and other measures
- Marketing and Promoting the reports (e.g. Preparing for Media and Press Releases)
- Evaluation of Public Reports

**Notes:**
Starting at this time, participants will be asked by Webex (through the webinar program) to pick 3 from above that they would like to learn more about through the Learning Institute. POLLING STARTS HERE!
Write mini-descriptions, and then explain. 
Selecting Measures 
Securing a Data Source and Checking Correctness 
Designing a Communication Vehicle/ Selecting a Medium/ Reporting Format- Using the new Model Reports (Have one for individual QIs and Composites)
Shoshanna’s notes on the Model Reports: THERE IS GENERAL LANGUAGE IN BOTH MODEL REPORTS ON HOW TO USE THE MEASURES; BUT THIS LANGUAGE SPEAKS TO THE REPORT AS A WHOLE, RATHER THAN ON HOW TO USE SPECIFIC MEASURES.  ON THE OTHER HAND, THERE IS ALSO LANGUAGE FOR EACH MEASURE AND COMPOSITE, IN PLAIN ENGLISH, ON WHAT THE MEASURE MEANS.  ONE OF THE TWO MODEL REPORTS IS BASED ON THE NEW QI COMPOSITE MEASURES, SO THOSE COMPOSITES WILL CERTAINLY BE COVERED, IN TERMS OF HOW THEY WERE GENERATED AND SCORED, ETC.  ALSO HOW TO EXPLAIN COMPOSITES TO PEOPLE.  THE BROADER TOPIC OF COMPOSITES WOULD TAKE A LOT MORE TIME TO COVER.  NQF HAS A TAP ON COMPOSITES RIGHT NOW.  
Sample size 
Validation
Risk Adjustment 
Unintendend Consequences of Reporting these Measures
Integrating ratings from the QIs with other kinds of hospital data/ Correlation Between QIs and other measures
Dry Runs and Sharing Data with Providers
Sharing the data with providers prior to going live is a critical step in the public reporting process.  Find out why it is important to share the data prior to the public release, how much lead time is needed, how to manage the leaks to the press, and how to get buy in from the providers. Setting ground rules about data can be used by individual hospitals.  
Preparing for Media and Press Releases
Marketing and Promoting the reports – Also PROMOTION BEYOND THE TIME OF THE ROLL OUT, INCLUDING THE USE OF "INFORMATION INTERMEDIARIES" AND CONTINUED PRESS OUTREACH.
Evaluation of Public Reports  
Updating and Refreshing the Data 

## Poll

- 	If you are a member of the target audience, please select your top three (3) choices of the topics listed that you would like the Learning Institute to address.  In the second question, please add any additional topics of interest to you.

## National Quality Forum (NQF)

- Standards of Hospital Care: Additional Priorities 2007- Submitted 2006
- Select Individual QIs (34)
- Composite Measures (4)
- Template/ Model Report(2)
- Other Submissions-ongoing

**Notes:**
Marybeth
Individual QIs have been reviewed and some endorsed already.  The consensus process at NQF has just begum to review the composite measures and reporting template.
Select Individual QIs (34)- 25 endorsed
Composite Measures (4)- Will be reviewed by the end of the year and hopefully endorsed at the beginning of 09. Framework for evaluation of composite measures is out for comment now. 
Template/ Model Report(1)- Going out for vote soon!

Hospital Additional  Priorities 2005-06, Pneumonia Mortality Supplement
IQI #20 – Inpatient Pneumonia Mortality

Additional QIs submitted 
Perinatal Project (3)
Perioperative Project (3)

## NQF Technical Advisory Panels

- Anesthesia & Surgery (16 measures)
- Patient Safety (14 measures)
- Pediatric (4 measures)
- Composite Measures (4 measures)
- Public Reporting & Implementation

**Notes:**
Standards of Hospital Care: Additional Priorities 2007 
Surgery & Anesthesia advanced 11 of the 16 measures;
Patient Safety advanced 13 of the 14 measures;
Pediatric advanced 3 of the 4 measures;
Composite SC is finalizing a framework for both ambulatory and hospital composites, which should be out shortly.  Then they will evaluate the composites based on the developed framework.  
The PR TAP is finalizing their guidance document which should be out for public comment shortly.
The total number of measures recommended for advancement to CSAC (Consensus Standards Approval Committee) was 26 QIs.

## NQF Endorsed QIs:Standards of Hospital Care: Additional Priorities 2007

- 	Patient Safety, Adult
**Accidental puncture or laceration **
**Death in low mortality DRGs **
**Iatrogenic pneumothorax **
**Death among surgical inpatients with serious, treatable complications**
**Bilateral cardiac catheterization rate **
**Congestive heart failure mortality **
**Hip fracture mortality rate **
**Transfusion reaction, age 18 years and older**
**Blood cultures performed within 24 hours prior to or 24 hours after hospital arrival for patients who were transferred or admitted to ICU within 24 hours of hospital arrival**
**Not QIs**

- Surgery and Anesthesia
**Abdominal aortic aneurysm volume**
**Abdominal aortic aneurysm repair mortality rate**
**Esophageal resection mortality rate**
**Esophageal resection volume**
**Incidental appendectomy in the elderly rate**
**Pancreatic resection mortality rate**
**Pancreatic resection volume**
**Postoperative wound dehiscence, age under 18 years**
**Postoperative wound dehiscence, 18 years and older**
**Foreign body left after procedure, age under 18 years**
**Foreign body left in during procedure, 18 years and older**
**Failure to rescue In-hospital Mortality**
**Failure to rescue 30-day mortality**

**Notes:**
White are QIs. Black are not. 

## NQF Endorsed QIs- Pediatric Standards of Hospital Care: Additional Priorities 2007

- Patient Safety, Pediatrics
- Accidental puncture or laceration
- Decubitus ulcer
- Iatrogenic pneumothorax in nonneonates
- Transfusion reaction, age under 18 years
- Pediatrics
- Pediatric heart surgery mortality
- Pediatric heart surgery volume
- PICU severity-adjusted length of stay
- PICU unplanned readmission rate
- Review of unplanned PICU readmissions
- Home management plan of care document given to patient/caregiver
- PICU pain assessment on admission
- PICU periodic pain assessment
- PICU standardized mortality ratio

## NQF Endorsed Measures- OtherStandards of Hospital Care: Additional Priorities 2007

**	**Length of Stay/Readmission
** ****Risk-adjusted average length of inpatient hospital stay**
**Overall inpatient hospital average length of stay (ALOS) and ALOS by DRG service category**
**All-cause readmission index**
**30-day all-cause risk standardized readmission rate following heart failure hospitalization**
**Severity-standardized average length of stay-routine care**
**Severity-standardized average length of stay-special care**
**Severity-standardized average length of stay-deliveries**
**	**Venous Thromboembolism
**VTE prophylaxis**
**Intensive Care Unit (ICU) VTE prophylaxis**
**VTE patients with anticoagulation overlap therapy**
**VTE patients unfractionated heparin (UFH) Dosages/platelet count monitoring by protocol (or Nomogram)**
**VTE discharge instructions**
**Incidence of potentially preventable VTE**

## Composite Measures

- Inpatient Quality Indicators
- Mortality for Selected Procedures
- Mortality for Selected Conditions
- Patient Safety Indicators
- Overall Safety
- Pediatric Quality Indicators
- Overall Safety

**Notes:**
NQF just finished developing a framework for evaluation of composite measures. It is currently out for comment. Once it is endorsed, they will review 4 AHRQ composite measures.  Many QI users expressed interest in the development of composite measures.  The goal of the effort was to develop a composite measure that might be used to monitor performance over time or across areas and populations using a methodology that could be applied at the national, regional, state or provider/area level.

## NQF Guidance Document
AHRQ Public Reporting Guidance Document
Tiering of QIs
Reporting Templates

- AHRQ Public Reporting Guidance Document
- Tiering of QIs
- Reporting Templates

**Guidelines for Consumer-focused Public Reporting**** **

**Notes:**
Currently NQF is developing “Guidelines for Consumer-focused Public Reporting.” This report has just gone out for comment at NQF and will be sent out soon for vote and NQF-endorsement.  
Based on extensive research (literature reviews, interviews w/ experts, two focus groups of medical officers and/or quality managers, four focus groups with the public who had recently experienced a hospital admission; and two rounds of cognitive interviews (19 interviews) to test draft versions of report template.
Form of dissemination:  Assumes website dissemination of hospital quality data but can be adapted to a printed report.
Indicators included: Includes all of the current IQIs and PSIs.  Four of the indicators are included but not labeled as “quality indicators”, and include four utilization rates for Caesarean sections and VBACs due to the controversy over the evidence and clarity about what is the “right” utilization rate for these procedures and directionality of the indicator.  Is more or less better?
Framing materials: A few easy to read materials that introduce key concepts such as elements of health care quality, how to use the report, what are the quality indicators, etc.
Organized by topic: Organized into nine topic areas.  The template permits users to select areas of interest to them as well as the indicators that they want to look at.  They can look at only one topic at a time, but are able to choose as many hospitals to include in the report as they would like.
Comparison chart across indicators: Users can select certain indicators of interest for inclusion of the comparison chart.  This chart is based on extensively tested in recent lab studies conducted as part of the CHAPS project.  Their research demonstrated that this kind of presentation of comparative data is far superior to other approaches—specifically people are much more likely to be able to identify high and low performances accurately and much more likely to use the information in making a decision.
Individual indicator graphs: The comparison chart is constructed so that once a selection is made, it takes the user to a horizontal bar graph which shows the absolute scores for each of the hospital's selected on a given indicator.  Special features include—the hospitals are ordered by performance, graphs covering volume and mortality for the same procedure are paired; the bar graph was designed to maximize comprehension of the bar showing the state or other average; graphs are structured to ensure that the numbers were always at least a whole integer
Technical details & resources:  This provides links to existing pages of the AHRQ QI website and has been included because testing indicates that even if people do not look at this kind of material, they want to know that it is there because it indicates that the sponsor is willing to be “transparent” about their methods.

## CMS Use of QIs 

- 	CMS recently decided to use 9 QIs for Public Reporting in Hospital Compare
- 1. Death among surgical patients with treatable serious complications
- 2. Iatrogenic pneumothorax. adult
- 3. Postoperative wound dehiscence
- 4. Accidental puncture or laceration
- 5. Abdominal aortic aneurysm (AAA) mortality (w and w/o volume)
- 6. Hip fracture mortality
- 7. Mortality for selected medical conditions (composite)
- 8. Mortality for selected surgical procedures (composite)
- 9. Complications/patient safety for selected conditions (composite)

## Relevance of the Learning Institute 

- Comments from:
- 	Kim Streit, MBA, MHA, Vice President, Health Care Research and Information, Florida Hospital Association
- 	Sylvia Cook, Team Leader, Texas** **Health Care Information Collection Center for Health Statistics, Texas Department of State Health Services

**Notes:**
Kim Streit, MBA, MHA,  Vice President of Health Care Research and Information, Florida Hospital Association
Sylvia Cook, Team Leader, Texas Health Care Information Collection Center for Health Statistics, Texas Department of State Health Services

## Poll

- 	At this time three polling questions will pop up to the right of your screen regarding your State’s public reporting requirements.

## Questions?

- What questions do you have about the AHRQ QI Learning Institute?
- How might you benefit from participating in the Institute?
- What particular issues would you like to see addressed?

## Stay Connected to the Learning Institute!

- If you represent a state agency/ taskforce, hospital association, or coalition and have not already done so, go to _[http://www.ahrq.gov/qilearninginstitute/](http://www.ahrq.gov/qilearninginstitute/)__ and sign up for QI Learning Institute E-mail Updates._
- AHRQ will send out an e-mail update with instructions about how to register for the Learning Institute.
- Sign up by September 30, 2008.

**Notes:**

Will we send it Wednesday?
The website is the one we described earlier and IS necessary to join to be part of the Institute.  
The site is password protected. It is Webex WebOffice.  There will be training to help 

## Upcoming Events 

- AHRQ Quality Indicators 101 (Webinar) - August 21, 2008, 2:00-3:30 pm ET
- AHRQ Annual Meeting- September 7-10, 2008, Bethesda, MD
- _[http://www.ahrq.gov/about/ahrqconf08.htm](http://www.ahrq.gov/about/ahrqconf08.htm)_
- QILI Networking Lunch - September 9, 2008, 12:00-1:00 pm ET
- QI User Meeting- September 10, 2008, 8:00-1:00 pm ET

**Notes:**

These Dates need to be confirmed.
Quality Indicators: Building blocks for Public Reporting 
Monday, August 18th: 3-5 pm EDT 
Wednesday, August 20th: 2-6 pm EDT 
Thursday, August 21st: 1-5 PM EDT 
Friday, August 22nd: 12-6 pm EDT 
Training Sessions for Learning Institute Website- TBD
AHRQ annual meeting- September 7-10, 2008, Bethesda, MD
QILI Networking Lunch - September 10, 2008, Bethesda, MD- Confirm

## Feedback 

- 	Please take a minute to complete a feedback form, that will pop up after you sign off, about your experience with this Webinar and suggestions for the Learning Institute.

## For More Information 

- QI Learning Institute Web site:
- 	_[http://www.ahrq.gov/qilearninginstitute/](http://www.ahrq.gov/qilearninginstitute/)_
- E-mail: _[QualityIndicatorsLearning@ahrq.hhs.gov](mailto:QualityIndicatorsLearning@ahrq.hhs.gov)_
- QI Web site:
- 	_[http://www.qualityindicators.ahrq.gov/](http://www.qualityindicators.ahrq.gov/)_