Quality Corner: SDAHO and SD DOH Recognized for Quality Reporting

The South Dakota Association of Healthcare Organizations (SDAHO) along with the South Dakota Department of Health (DOH) were recognized for our Critical Access Hospitals (CAHs) progress in Quality Reporting. The recognition took place at the Reverse Site Visit (RSV) in Washington D.C, the week of July 15,2024. Becky Heisinger, SDAHO’s Director of Quality and Integration alongside Michelle Hoffman, Rural Hospital Programs Coordinator with the South Dakota DOH attended the event, which is specifically designed for state Flex Program Staff who are dedicated to enhancing healthcare access and outcomes in rural communities. Each year at the Reverse Site Visit the Federal Office of Rural Health Policy (FORHP) team acknowledges Flex states in several categories, one being MBQIP improvement, and this year South Dakota was recognized for progress in reporting of quality measures.

Hospitals are required by the (FORHP) to submit a minimum requirement of Medicare Beneficiary Quality Improvement Program (MBQIP) data to be eligible to participate in Medicare Rural Hospital Flexibility (Flex) Program funded activities. However not all SD hospitals report all MBQIP Measures, but this year there was an increase in the number of CAH’s who reported. Heisinger says, “Over the past year the SD Quality program went from having 8 CAH’s report all MBQIP measures to 20 CAHs report all MBQIP measures. That is wonderful progress.”  This success is due in part to the SD Flex Program Coordinator along with SDAHO’s Director of Quality Integration’s vision and technical assistance provided by SDAHO Clinical Improvement Consultants, Loretta Bryan and Michelle Hofer.

The Flex Monitoring Team (FMT) analyzed the data to identify high-performing Flex States on Quality Reporting and Performance. FORHP asked the FMT rank states on CAH quality performance using inpatient, outpatient, HCAHPS, and EDTC reporting and performance. Data and definitions used to determine high-performing Flex States included:

Analysis is based on data reported by CAHs with signed Memorandums of Understanding (MOUs) in the MBQIP program.

• Rankings were calculated with data used to create the FMT 2022 MBQIP Quality Measures Annual Reports (released in October 2023). Inpatient, outpatient, HCAHPS, and EDTC data are from Q1 2022 through Q4 2022.
• Measures used for calculating reporting and performance included: 1) two MBQIP Core inpatient measures (HCP/IMM-3 and Antibiotic Stewardship); 2) four MBQIP Core outpatient measures (OP-2, OP-3b, OP-18b, OP-22); 3) ten HCAHPS measures; and 4) eight EDTC measures.
• Reporting was defined as reporting data on at least one measure with a denominator value for inpatient and outpatient; reporting data with at least one completed survey for HCAHPS; and reporting data on at least one case for EDTC. For all four categories, reporting is calculated out of all CAHs in a state (not just those with signed MOUs).
• The number of CAHs by state is from the FMT CAH database and is based on certification status as of December 31, 2022.
• Of note, beginning in 2022, FMT received and included data for CAHs who were reporting data, but had volumes too low to be displayed. These CAHs are now considered to be “reporting” where previously they were not due to a lack of data indicating their low volume. This may have impacted reporting values for some states.

Methods that were used for each state include.

1. For each state, the below was calculated:

• An inpatient reporting percentage (the percent of CAHs in the state reporting data on at least one core inpatient measure)
• An outpatient reporting percentage (the percent of CAHs in the state reporting data on at least one core outpatient measure)
• An HCAHPS reporting percentage (the percent of CAHs in the state reporting HCAHPS data for at least one completed HCAHPS survey)
• An EDTC reporting percentage (the percent of CAHs in the state reporting EDTC data for at least one patient)
• An inpatient better performance measure (the number of inpatient measures on which CAHs in the state performed significantly better than CAHs in all other states)
• An outpatient better performance measure score (the number of outpatient measures on which CAHs in the state performed significantly better than CAHs in all other states)
• An HCAHPS better performance measure score (the number of HCAHPS measures on which CAHs in each state performed significantly better than CAHs in all other states)
• An EDTC better performance measure score (the number of EDTC sub-measures on which CAHs in each state performed significantly better than CAHs in all other states)

2. We then ranked the 45 Flex states on each of the eight measures above to create four reporting ranks (inpatient, outpatient, HCAHPS, and EDTC) and four performance ranks (inpatient, outpatient, HCAHPS, and EDTC). When multiple states had the same score, they each received the same rank (e.g., several states had 100% of their CAHs reporting inpatient measures and each received a rank of one).

3. Each state’s four reporting ranks were summed, and states were re-ranked to create a total reporting rank for each state. Similarly, each state’s four performance ranks were summed, and states were re-ranked to create a total performance rank for each state.

4. Each state’s total reporting rank and total performance rank were then summed, and states were ranked one last time on this combined reporting and performance sum. This method gives equal weight to reporting and performance across the four types of measures (inpatient, outpatient, HCAHPS, and EDTC).

Comparing this year’s results with last year’s, in the top ten there are six new states (Pennsylvania, Virginia, Alabama, Hawaii, South Dakota, Idaho). Six states that were ranked last year dropped out of the rankings (New Hampshire, New York, Nebraska, South Carolina, Michigan, Utah).

Results:

Using the data and methods described above, the top ten ranked states on quality reporting and performance were:

1. Pennsylvania
2. Virginia
3. Nevada
4. West Virginia
5. Alabama
6. Arkansas
7. Hawaii
8. South Dakota
9. Illinois
10. Idaho

Congratulations to all South Dakota’s CAHs for participating and assisting with this year’s recognition.