D.27 FY19 SES ADDENDUM VERSION 2.01.pdf

FY2019 Network Director and Medical Center Director Performance Plan Addendum

1 | P a g e Version 2.01

Element Baseline Data (BD), Performance Measures (PM), Supporting Indicators (SI), Resources (R) and Supporting Guidance (SG) (Revisions are noted with Dark Red Text)

1. Leading Change (20%)

1.a. Spread Innovation & Best Practices

R: Diffusion Marketplace (under development) R: Replication Tracker R: Diffusion of Excellence Pulse Space

1.b. Suicide Prevention SG: Suicide Prevention Initiative Field Implementation Guidance

1.c. Whole Health System

(WHS)

R: Self-Assessment Tool (In development, slated to be rolled out Dec/Jan) R: Field Implementation Program

2. Leading People (20%)

2.a. Employee Engagement

BD:

2018 AES - VHA AES

Use and Sharing by VISN.XLSX

PM: AES Dashboards R: Overview of Data Sharing/Use Sponsorship (from the Dashboard, includes several resources within it) R: 8-Step Project Plan (for data sharing/use) R: Communication Plan (this is the most important piece for the senior leader role) R: Fall FY18 Engagement Toolbox (the theme here was data sharing/use, specifically on pgs. 7-8)

2.b. Environment of Care

(EOC)

R: Performance Logic Data and Trends SI: (e5eoc2) % of times Senior Management Team (or designee) attends EOC rounds SI: (e5eoc5) % of times Facility Team Members attend EOC rounds SI: (psat9top) Cleanliness of Hospital Environment (IP) SI: (psat9adj) Cleanliness of Hospital Environment (IP) (Adj) The above are some examples of potential areas to target for EOC improvement.

2.c. High Reliability Organization (Network Only)

R: Website in development

SG: VA HRO Principles

20181210_HRO_Prin ciples VA Language_v4.pptx

3. Business Acumen (10%)

3.a. Focus Resources R: Efficiency Opportunity Grid

3.b. Telehealth Clinical Resource Sharing

SI: (tele1) Telehealth Modalities SI: (tele7) Telemental Health Unique Veterans

3.c. Clinical Documentation Improvement (CDI) SG: CDI SharePoint https://www.surveymonkey.com/r/DY9XXXP https://www.vapulse.net/community/under-secretary-for-health/diffusion-of-excellence https://vaww.portal2.va.gov/sites/PERC/PEC_Portal/SitePages/SPI_Recommendations.aspx?InitialTabId=Ribbon%2ERead&VisibilityContext=WSSTabPersistence&View=%7b35126fbf-260c-41be-8c9b-746b56478a94%7d&SortField=Intervention&SortDir=Asc https://vaww.va.gov/PATIENTCENTEREDCARE/Field_Implementation_Program.asp http://aes.vssc.med.va.gov/Pages/Default.aspx file://///v10.med.va.gov/cin/Service/AES%20Survey%20Results/AES_ActionPlanning_EL_OpeningArticle_FY18.pdf file://///v10.med.va.gov/cin/Service/AES%20Survey%20Results/AES_ActionPlanning_EL_8StepPlan_FY18.pptx file://///v10.med.va.gov/cin/Service/AES%20Survey%20Results/AES_ActionPlanning_EL_CommPlan_FY18.pptx http://aes.vssc.med.va.gov/OrganizationalHealth/OrganizationalHealthDocumentLibrary/The%20Q1%20Engagement%20Toolbox%20-%20Electronic%20Version.pptx https://eoc.va.gov/login/accept_prelogin_auth.html http://vaww.rs.rtp.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/Performance+Reports/Measure+Management/Measure&Measure=3154&Year=2019 http://vaww.rs.rtp.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/Performance+Reports/Measure+Management/Measure&Measure=3154&Year=2019 http://vaww.rs.rtp.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/Performance+Reports/Measure+Management/Measure&Measure=3254&Year=2019 http://vaww.rs.rtp.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/Performance+Reports/Measure+Management/Measure&Measure=3528&Year=2019 http://vaww.rs.rtp.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/Performance+Reports/Measure+Management/Measure&Measure=3183&Year=2019 https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/MgmtReports/OPES/OPES_EfficiencyOpGrid&rs:Command=Render http://vaww.rs.rtp.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/Performance+Reports/Measure+Management/Measure&Measure=115&Year=2019 http://vaww.rs.rtp.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/Performance+Reports/Measure+Management/Measure&Measure=2640&Year=2019 https://vaww.vha.vaco.portal.va.gov/sites/HDI/HIM/vaco_HIM/subsite5/subsite3/CDI%202/Forms/AllItems.aspx

2 | P a g e

Element Baseline Data (BD), Performance Measures (PM), Supporting Indicators (SI), Resources (R) and Supporting Guidance (SG) (Revisions are noted with Dark Red Text)

SG: Revised CDI Program Checklist

CDI Program

Checklist FY2019.xlsx

4. Building Coalitions (10%)

4.a. Coding Turnaround Time BD: Corrected FY18 Baseline Data

Coding TAT FY18

Baseline (revised).xlsx

PM: (otat1) HIM Outpatient Coding Turn Around Time (TAT)

4.b. Claims Suspended for Authorizations BD:

Occ1 Fy18 baseline data.xlsx

PM: (occ1) Claims Suspended for Authorizations

4.c. Community Care Consult Management

BD:

CommCare Consult

Management Baseline Data_10012018.xlsx

SI: Office of Community Care Top Metrics Dashboard SI: (cccon1) Community Care Consults in Pending Status lt or equal to 7 Days SI: (cccon2) Community Care Consults in Active Status lt or equal to 30 Days SI: (cccon3) Community Care Consults in Scheduled Status lt or equal to 90 Days

4.d. Excellence in Customer Experience (CX) (Moved from 5.e.)

SG: If the MCD or ND is unable to attend the symposium they may send a designee. The Patient Experience self-assessment will be rolled out at the Symposium in February and a link to it will be added on the Veteran Experience Pulse Page (per below).

PX Symposium.docx

R: Veteran Signals

VSIGNALS ONE

PAGER 25OCT2018.pdf

R: Veteran Experience Pulse Page SI: Veteran Signals (Medallia) SI: All Employee Survey (AES) (see element 2.a) SI: Survey of Health Experiences of Patients (SHEP)

5. Results Driven (40% overall) http://vaww.rs.rtp.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/Performance+Reports/Measure+Management/Measure&Measure=3458&Year=2019 http://vaww.rs.rtp.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/Performance+Reports/Measure+Management/Measure&Measure=3530&Year=2019 https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fWorkloadFee%2fCommunityCare%2fTop8Metrics%2fDashboard&rs:Command=Render http://vaww.rs.rtp.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/Performance+Reports/Measure+Management/Measure&Measure=3531&Year=2019 http://vaww.rs.rtp.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/Performance+Reports/Measure+Management/Measure&Measure=3533&Year=2019 http://vaww.rs.rtp.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/Performance+Reports/Measure+Management/Measure&Measure=3534&Year=2019 https://www.vapulse.net/groups/veterans-experience-office-official https://va.voice.medallia.com/sso/va/dashboard.do?v=bMvwWIR5zZG5h4Dm-UhpBKUcCL6j16.lUt2V6Tfv*skOOODsbJ-SKzgQbykuu*3CBP9l_b.3ZPe5Nt54Yo8_FpSlQ1V5Cbu.65GDrDb*tTfe0n0T_MZ7D4 https://vaww.car.rtp.med.va.gov/programs/shep/shepReporting.aspx

3 | P a g e

Element Baseline Data (BD), Performance Measures (PM), Supporting Indicators (SI), Resources (R) and Supporting Guidance (SG) (Revisions are noted with Dark Red Text)

5.a. SAIL (20%) PM: SAIL Portal SI: Symphony Action Triggers (SAT)

5.b. Environment of Care Deficiencies (5%)

PM: (e5eoc1) % deficiencies identified during EOC rounds that are closed timely

BD:

EOC Deficiency

FY18 Baseline.xlsx

5.c. Expand Telehealth into Home & Non-VA Settings (5%)

SG: VHA Notice 2018-25, Expansion of Telehealth Services into the Home and Other Non-VA Settings

VHA Notice

2018-25, Expansion of Telehealth Services into the Home and Other Non-VA Settings.pdf

SI: (tele11) % PACT Providers that completed an offsite CVT Visit SI: (tele12) % of MH Providers that completed an offsite CVT Visit SI: (tele9) Video Telehealth to Off Site Patients

5.d.1 CLC Compare (5%)

PM: CLC Compare R: “CLC Relative Performance vs. Absolute Improvement from 1 year ago” under “SAIL CLC (VA Internal Benchmarking)” R: “CLC Monthly SPC Charts” under “Miscellaneous Tools and Reports”

5.d.2. Growth/ Improvement in Community-based Long- Term Services and Support

(LTSS) (5%)

Only for Facilities without a CLC

BD: nicexp7 nicexp7 Baseline

Data.xlsx

PM: (nicexp7) % of LTSS Obligations for PCS Services SI: (nicexp8) % of LTSS Obligations for HCBS Services

R: nicexp8 FY18 Data nicexp8 FY18

Data.xlsx

5.e. CMS Hospital Compare & Ambulatory HEDIS Measures (Preliminary

DRAFT)

R: VHA CMS Hospital Compare Site R: Access to Care (Outpatient Compare) R: IPEC SharePoint

R: Hospital Compare SAIL Miniseries Presentation

HospitalComparePr eviewReports-Feb2019Release-v4 SAIL Miniseries.pptx https://sail.vssc.med.va.gov/ https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fMgmtReports%2fTriggerCube%2fSAT_FacilityDetails&rs:Command=Render http://vaww.rs.rtp.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/Performance+Reports/Measure+Management/Measure&Measure=3512&Year=2019 http://vaww.rs.rtp.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/Performance+Reports/Measure+Management/Measure&Measure=3532&Year=2019 http://vaww.rs.rtp.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/Performance+Reports/Measure+Management/Measure&Measure=3456&Year=2019 https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fCIA%2fCLC%2fCLC%20Analytics&rs:Command=Render http://vaww.rs.rtp.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/Performance+Reports/Measure+Management/Measure&Measure=3149&Year=2019 http://vaww.rs.rtp.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/Performance+Reports/Measure+Management/Measure&Measure=3150&Year=2019 http://ipec.vssc.med.va.gov/VHAExt/Pages/home.aspx https://www.accesstocare.va.gov/Healthcare/OutpatientCompareData http://ipec.vssc.med.va.gov/Pages/default.aspx