Attachment_J-10_Revised_05122011

Attachment J-10 – Amendment # 2 as of May 12, 2011 Evaluation for the 10th SoW for Quality Improvement Organizations

The 10th SoW presents new opportunities for the QIO to improve the quality and efficiency of services rendered to Medicare Beneficiaries through learning activities associated with review and exchange of Medicare data, case review, input from providers, beneficiaries and experts in the field, dissemination and spread of best practices, and employing proven quality improvement techniques.

The bold and innovative approach to change outlined in the 10th SoW does not lend itself well to the traditional forms of contract evaluation which are more suited for assessing minimal performance by the QIO alone rather than engagement in collaborative partnerships to strive for maximal, sustainable improvement. Evaluation remains nonetheless important as such high expectations require quantitative and qualitative measures of accountability to ensure forward progress and prudent use of limited resources.

The following categories will serve as the basis for evaluating performance of the Learning Network and Technical Assistance Drivers as specified in Table 1 of Section J 10:

· Rapid Cycle Improvement in Quality Improvement Activities and Outputs

· Customer Focus and Value of the Quality Improvement Activities to Beneficiaries, Participants and CMS

· Ability to Prepare the Field to Sustain the Improvements

· Value innovation

· Commit to boundarilessness

· Unconditional teamwork

· Commitments Secured/Participants Engaged/ Results in Achievement of Contract Aims and Goals will be measured as specified in Table 3 in Section J 10 and according to the measure details specified in Table 2 of Section J 10.

Using lean and rapid techniques, QIOs will be monitored and measured for improvement on an ongoing basis using self-assessment and Contracting Officer Technical Representative (COTR) review. The COTR will complete assessment and review of qualitative and quantitative contract evaluation objectives. The qualitative evaluation will be comprised of rapid assessment of elements specified in Table 1in Section J10. The quantitative evaluation will be based on assessment of the QIO’s performance in each AIM as specified in Table 3 in Section J 10 and according to the measure details specified in Table 2 of Section J 10.

As noted in Section C.5, there will be two periods of evaluation under this SOW. The first (intermediate) evaluation will occur at the end of the 18th month of the contract. The second (final) evaluation will occur at the end of the 27th month of the contract. The evaluations will be based on the most recent data available to CMS. The performance results of the evaluation at both time periods (that is 18 months and 27 months) will be used, in addition to ongoing monitoring activities, to determine the performance on the overall contract.

Table 1. – Qualitative and Quantitative Evaluation Metrics (A template and/or reporting mechanism will be provided to the QIOs)

1. Rapid Cycle Improvement in Quality Improvement Activities and Outputs

The QIO must constantly assess the value of the Learning Networks, technical assistance, and case review using the best method as determined by the QIO. The QIO must make midcourse adjustments based on the feedback it receives from its participants and CMS as well as from its own performance monitoring towards achieving contractual bold goals. This will include how well the QIO builds a system for monitoring performance and how well it uses rapid cycle improvement to adjust to achieve ever higher performance and remove defects ,

2. Customer Focus and Value of the Quality Improvement Activities.

The QIO must constantly seek to meet the needs of the customers, involving Beneficiaries and other stakeholders in all aspects of quality improvement activities. Customer input should help to shape the design and ongoing operations of activities. Beneficiaries representing the diversity of the population served should be actively engaged in activities. The QIO must constantly assess the value of the Learning Networks and technical assistance for the participants using the best method as determined by the QIO. The QIO must make midcourse adjustments based on the feedback it receives from its participants. The solicitation of feedback may focus on questions such as how relevant were the topics to the work of the participants? How well did it meet the needs of the beneficiaries, participants, and CMS? What was the perceived quality of the activities as reported by the beneficiaries, participants, and CMS? What are suggested areas of improvement?

3. Ability to Prepare the Field to Sustain the Improvements

Early on in the project the QIO should begin establishing a plan that will help to increase the probability that the quality improvements attained, through the QIO’s work during the course of the 10th SoW, are maintained or improved when the QIO has completed its formal work with the participants. The QIO is expected to work with the participants on how to sustain improvement in the absence of the QIO.

4. Valuing Innovation

The QIO is expected to demonstrate solicitation and/or creation of new ideas that maximize improvement for the participants. This includes designing a mechanism by which all entities the QIOs work with and/or have contact with are able to contribute ideas that may be of value to the QIO’s improvement work. It may also include leading to a new product, service, or feature for the benefit of the participants.

5. Commitment to “Boundarilessness”

CMS will assess the QIOs ability to identify and engage multiple entities to impact improvement for patients and/or providers. This includes but is not limited to entities outside of CMS such as state, local, and national health care organizations, patient advocacy groups, professional associations, and others.

6. Unconditional Teamwork

The QIO should demonstrate its ability to work with other QIOs and stakeholders to spread improvement activities that are working. The QIO should demonstrate sharing of best practices with other QIOs as well as the entities that they identified and engaged outside CMS.

*Items 1, 2, and 3 (Quality improvements and activities, Customer Focus and Value to beneficiaries and participants, and Sustainability) will be assessed for each of the 4 Aims. Items 4, 5, and 6 will be assessed across the organization as a whole. Item 7 will be assessed for each Aim as noted in the Table 2 and 3.

Items will be scored by the COTR at least quarterly and will be summed over the course of the contract. Summed scores will be considered along with other performance scores at the time of the 18th month and 27th month evaluations.

Table 2 – Measure Detail Table

Beneficiary and Family Centered Care

Denominator: Total number of sampled cases Inclusion: reviews selected for beneficiary complaints, referrals to CMS and identified during other case review, BIPA, Grijalva, Weichardt, HWDRG Exclusion: EMTALA and technical denials.

Cases selected for IRR in one time period cannot be selected for IRR again.

CRMIS

Reliability

Timeliness of Beneficiary Complaints and Other Quality of Care Reviews

Numerator: Total number of quality of care reviews completed in established timeframes Denominator: Total number of completed quality of care reviews in CRMIS. Inclusion: Quality of care reviews conducted based on beneficiary complaints, referred to QIOs and identified during other case review types.

Exclusions: EMTALA, HWDRG, Appeals cases

CRMIS

Data lag is 2 days after the end of each quarter.

Timeliness of Discharge/Service Termination Reviews

Numerator: Total number of discharge/service termination reviews completed in established timeframes.

Denominator: Total number discharge/service termination reviews in CRMIS. Inclusions: BIPA, Grijalva and Weichardt reviews. Exclusions: Quality of Care, EMTALA, and HWDRG reviews.

CRMIS

Data lag is 2 days after the end of each quarter.

Timeliness of Other Reviews Types

Numerator: Total number of EMTALA and HWDRG reviews completed in established timeframes Denominator: Total number of EMTALA and HWDRG reviews completed in CRMIS.

CRMIS

Data lag is 2 days after the end of each quarter.

Denominator: Number of completed surveys for beneficiary complaints and discharge/services termination reviews. Inclusions: Total number of surveys conducted for beneficiary complaints, BIPA, Grijalva, and Weichardt reviews.

Exclusions: EMTALA, HWDRG, Referred Quality of Care reviews, and QIO initiated quality of care reviews.

Report from Survey contractor submitted on last day of time period.

Improve Health for Populations and Communities

Number of Eligible Professionals that the Offices Represent (Whole numbers – No numerators & denominators)

Number of Eligible Professionals assisted in using the EHR to report directly to 2012 PQRS (by 11/30/12)

(Whole numbers – No numeratosr & denominators)

Denominator : Number of Eligible Professionals that the QIO assisted that reporting to 2012 PQRS directly via their EHR

(Data expected in time for 27th month) N/A

At least 90% of the EPs assisted by the QIO successfully met PQRS Reporting requirements for 2012

(Whole number – No numerator & denominator)

(Data expected in time for 27th month) 2010 PQRI participation (by direct EHR-reporting)

Increase to at least 1.25* state specific number (as noted in J-18) of eligible professionals participating in PQRS via EHR-Reporting (in 2012, compared with 2010 baseline)

Denominator : Number of REC-recruited, installed offices

Denominator : Number of REC-recruited, installed offices invited to participate in the Learning and Action Network

At least 75% of the REC-recruited, installed offices will participate in a Learning and Action Network by September 30, 2013.

General Task Evaluation – Flu Immunizations

(Data expected in time for 27th month) 2010 PQRI measure #110 as reported by claims

6% relative improvement from baseline

General Task Evaluation – Pneumococcal Vaccination

(Data expected in time for 27th month) 2010 PQRI measure #111 as reported by claims

6% relative improvement from baseline

(Data expected in time for 27th month) 2010 PQRI measure #204 as reported by claims

6% relative improvement from baseline

(Data expected in time for 27th month) 2010 PQRI measure #201 as reported by claims

6% relative improvement from baseline

6% relative improvement from baseline

General Task Evaluation – Tobacco Cessation

(Data expected in time for 27th month) 2010 PQRI measure #115 as reported by claims

6% relative improvement from baseline

(Data expected in time for 27th month) 2010 PQRI measure #113 as reported by claims

6% relative improvement from baseline

(Data expected in time for 27th month) 2010 PQRI measure #112 as reported by claims

6% relative improvement from baseline

Improve Individual Patient Care: Quality Reporting and Improvement

% of Annual Payment Update - OQR Providers

% of eligible Hospitals receiving a non-zero CMS QIO Hospital Inpatient Quality and Experience of Care Performance Score (CQIHIQECPS)

Percentage of eligible Hospitals receiving non-zero CMS QIO Hospital Inpatient Quality and Experience of Care Performance Score (CQIHIQECPS)

% of eligible Hospitals receiving a non-zero CMS QIO Hospital Inpatient Quality and Experience of Care Performance Score (CQIHIQECPS) (FY 2014 Only)

Percentage of eligible Hospitals improving CMS QIO Hospital Inpatient Quality and Experience of Care Performance Score (CQIHIQECPS) (FY 2014 only)

% of eligible Hospitals meeting CMS QIO Hospital Inpatient Quality and Experience of Care Performance Score (CQIHIQECPS) thresholds

Percentage of hospitals meeting all CMS QIO Hospital Inpatient Quality and Experience of Care Performance Score (CQIHIQECPS) achievement thresholds.

Improve Individual Patient Care: Adverse Drug Events

local clinical pharmacy representation, clinicians from the multiple settings utilized by QIO’s targeted patient groups (e.g. hospitals, nursing homes, primary care clinics, specialty clinics, federally funded clinics, etc) Clinic and/or hospital senior leadership, patient and/or patient advocacy representation.

The QIO is free to partner with existing teams working on ADEs as long as those partners/teams are not already receiving Federal funding.

Adverse Drug Event (ADE):

An event resulting in injury or harm to a patient due to medication use Numerator: Total number of ADEs detected in the PoF per month.

Denominator: Total number of beneficiaries screened for ADE in PoF monthly.

Collab Tool

Potential Adverse Drug Event (pADE):

An event that was identified and avoided with appropriate interventions before affecting the patient.

Numerator: Total number of pADE identified and prevented in the PoF per month.

Denominator: Total number of pADE identified, prevented, and/or avoided in the PoF before affecting the patient.

Monthly INR for beneficiaries on Warfarin

Numerator: Total number of beneficiaries with monthly INR tests performed.

Denominator: Total number of beneficiaries in the PoF who are on anticoagulation therapy Collab Tool

INR in controlled range

Numerator: Total # of beneficiaries with the last INR within therapeutic range.

Denominator: Total # of beneficiaries who are on anticoagulation therapy in the POF

POF=Percentage of adults treated with anticoagulants with INR within a controlled range, as defined by their provider, for patients who are on chronic Warfarin Collab Tool

Diabetes Number of patients whose HgA1c levels move from “out-of-control (hgA1c >9%) to “under-control” in their diabetic population of focus

Numerator:

Total # of beneficiaries with A1C>9%

Denominator:

Total # of beneficiaries within the PoF with diabetes

Collab Tool

Demonstration of continuous improvement and participant engagement with a goal working toward 50% of their diabetic patients going from HgA1c of >9% to HgA1c of <9%

Diagnosis DSM IV Criteria

Reduction in the number of beneficiaries who are taking long or short acting antipsychotic medication and are prescribed a potentially inappropriate medication (PIM) Numerator:

Total # of benes prescribed PIM

Denominator:

Total # of benes taking short and/or long acting antipsychotics medication within PoF Collab Tool

Improve Individual Patient Care: HAIs, CLABSI, and CAUTI

*One of the following three CLABSI evaluation targets must be met.

CLABSI Relative Improvement Rate*

CLABSI Standardized Infection Ratio*

Less than or equal to 1.0

CLABSI Incident Rate*

Central line Insertion Practices (CLIP) adherence rate

Number of central line insertions during which recommended practices were followed as compared to number of central lines inserted Exclusions: Central line procedures in which recommended infection control practices were not indicated. Facility wards that do not insert central lines.

Greater than or equal to 25%

(36 month target in Table 3 for CDI RIR)

SSI reduction

Improve Individual Patient Care: PrU, PR and Systemic Change

High-Risk Nursing Home Pressure Ulcer

Percent of High Risk Residents with Pressure Sores (Stages 2, 3 and 4) (Long Stay).

Recruitment: Either MDS 2.0 or Available MDS 3.0 Data Tracking/ Evaluation MDS 3.0

Nursing homes recruited have an aggregate average PrU actual rate at or below 6% OR attained a minimum RIR of 20%

Tracking/ Evaluation MDS 3.0

Data Tracker

85%

Data Tracker

60%

Integrate Care for Populations and Communities

Percentage of proposed communities recruited that have signed community coalition charters and within 3 months.

Percentage of proposed communities recruited that have signed community coalition charters and within 3 months.

Numerator: Number of signed community coalition charters. Denominator: Number of communities recruited

75%

Percentage of eligible communities recruited that submit applications to a Care Transitions Program

Percentage of eligible communities recruited that submit applications to a Care Transitions Program Numerator: Number of communities that have submitted an application to a Care Transition Program. Denominator: Number of communities eligible for a Care Transitions Program

50%

Percentage of eligible communities recruited that are accepted into a Care Transitions Program

Percentage of eligible communities recruited that are accepted into a Care Transitions Program Numerator: Number of communities accepted into a Care Transitions Program. Denominator: The number of communities eligible for a Care Transitions Program

25%

Percentage of communities that can demonstrate 4 time series graphs showing positive trending data (to meet the intervention improvement objective) for 4 unique interventions over four quarters.

Percentage of communities that can demonstrate 4 time series graphs showing positive trending data by intervention over four quarters.

Numerator: Number of communities that can demonstrate 4 time series graphs showing positive trending data by intervention over four quarters.

Denominator: The number of communities participating in the Care Transitions learning collaborative

The percentage decrease in the rate of re-hospitalizations within 30 days of discharge from an acute care hospital per 1,000 eligible FFS beneficiaries from the specified geographic area for those communities participating in the Learning Collaborative.

The percentage decrease in the rate of re-hospitalizations within 30 days of discharge from an acute care hospital per 1,000 eligible FFS beneficiaries from the specified geographic area for those communities participating in the Learning Collaborative.

Numerator: Number of hospital readmissions to an acute care hospital within 30 days of an acute care hospital discharge. Denominator: The number of Medicare FFS beneficiaries living in the specified community(ies) that have been recruited by the end of Quarter 4. .

7% relative improvement from baseline

The percentage decrease in the rate of acute care hospitalizations per 1,000 eligible FFS beneficiaries from the specified geographic area for those communities participating in the Learning Network.

The percentage decrease in the rate of acute care hospitalizations per 1,000 eligible FFS beneficiaries from the specified geographic area for those communities participating in the Learning Network.

Numerator: Number of hospital admissions Denominator: The number of Medicare FFS beneficiaries living in the specified community (ies) that have been recruited by the end of Quarter 4. .

5% relative improvement from baseline

Percentage of state wide readmissions per 1,000 Medicare beneficiaries

Percentage of state wide readmissions per 1,000 Medicare beneficiaries

Numerator: Number of state-wide hospital readmissions to an acute care hospital within 30 days of an acute care hospital discharge. Denominator: The number of Medicare FFS beneficiaries living in the state x 1000.

2% relative improvement from baseline

Percentage of state wide admissions per 1,000 Medicare beneficiaries

Percentage of state wide admissions per 1,000 Medicare Beneficiaries

Numerator: Number of state-wide admissions to an acute care hospital.

Denominator: Number of Medicare FFS beneficiaries living in the state x 1000

2% relative improvement from baseline

Total costs for those Medicare FFS beneficiaries living in communities participating in the Learning Network who have been recruited by the end of Quarter 4.

2% relative improvement from baseline

Table 3 – Monitoring, 18th Month and 27 Month Minimum Performance Criteria Beneficiary and Family Centered Care

January 31, 2013 Intermediate Target (18th month)

October 31, 2013 Final Target (27th month)

Improve Health for Populations and Communities

Baseline

October 31, 2012

January 31, 2013 Intermediate Target (18th month)

Documentation that QIO assisted the offices=at least the state specific number (as noted in J-18) of eligible professionals (Deadline 11/30/12)

April 30, 2013

July 31, 2013

October 31, 2013

(27th month)

At least 90% of the EPs assisted by the QIO successfully met PQRS Reporting requirements for 2012

Increase to at least 1.25* state specific number (as noted in J-18) of eligible professionals participating in PQRS via EHR-Reporting (in 2012, compared with 2010 baseline)

January 31, 2014

April 30, 2014

Sustain progress

Improve Health for Populations and Communities

Baseline

January 31, 2013 Intermediate Target (18th month)

October 31, 2013

(27th month)

Flu immunizations (measure 110) Pneumococcal vaccinations (measure 111) Low-dose aspirin therapy among patients with ischemic vascular disease (measure 204) Blood pressure control among patients with hypertension (measure 201) LDL-C control among patients with ischemic vascular disease (measure 203) Tobacco cessation intervention (measure 226) Colorectal cancer screening (measure 113) Breast cancer screening (measure 112)

Improve Individual Patient Care: Quality Reporting and Improvement

% of Annual Payment Update - IQR Providers

% of Annual Payment Update - OQR Providers

Baseline

October 31, 2013 Final Target (27th month)

Improve Individual Patient Care: Quality Reporting and Improvement

Baseline

January 31, 2013 Intermediate Target (18th month)

October 31, 2013 Final Target (27th month)

Improve Individual Patient Care: HAIs, CLBSI, and CAUTI

*One of the above three CLABSI evaluation targets must be met.

Baseline

100% of participating facilities continuously tracking and reporting the urinary catheter measure using the NHSN

As above

January 31, 2013 Intermediate Target (18th month)

October 31, 2013 Final Target (27th month)

Baseline

10% or greater participants agreeing to participate in SSI reduction projects

15% or greater participants agreeing to participate in SSI reduction projects

20% or greater participants agreeing to participate in SSI reduction projects

January 31, 2013 Intermediate Target

January 31, 2014

July 31, 2014 (36th month)

Improve Individual Patient Care: Pressure Ulcer, Physical Restraints and Systemic Improvement