Quality health indicators
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Quality Health Indicators. Brought to you by…. Main Menu. About QHi The PiHQ Portal Defining your facility Selecting Measures Entering Data Dashboards Reports How we use the data. Select any menu item above to go directly to a topic or click to continue through the presentation.

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Quality Health Indicators

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Quality Health Indicators

Brought to you by…

Left click mouse or use down arrow to proceed through this presentation

Main Menu

  • About QHi

  • The PiHQ Portal

  • Defining your facility

  • Selecting Measures

  • Entering Data

  • Dashboards

  • Reports

  • How we use the data

Select any menu item above to go directly to a topic


click to continue through the presentation.

Quality Health Indicators

  • The Quality Health Indicator (QHi) web site was developed through the Kansas Hospital Association, KHA, and KRHOP the Kansas Rural Health Options Project to facilitate a benchmarking project for rural Kansas hospitals.

  • The goal of QHi is to provide hospitals an economical instrument to evaluate internal processes of care and to seek ways to improve practices by comparing specific measures of quality with like hospitals.

  • Using QHi as a tool, regional networks of hospitals and individual facilities can select from a library of indicators to determine which measures meet their unique needs.

Quality Health Indicators

  • More than 700 users in over 200 Critical Access and other small rural hospitals in Alaska, Arizona, California, Colorado, Kansas, Louisiana, Michigan, Minnesota, Missouri, Nebraska, New Mexico, Oklahoma and Wyoming use QHi as a data collection and benchmarking tool.

  • As a user-driven multi-state project, QHi is well-positioned to serve as a significant repository of information on quality of care and performance in rural hospitals nationwide.

Quality Health Indicators

Four Pillars Of Measurement









QHi Core Measures Set

All participating hospitals are asked to collect and report the 8 QHi Core Measures:

  • Clinical Quality

  • Hospital Associated Infections per 100 inpatient days

  • Unassisted Patient Falls per 1000 inpatient days

  • Inpatients Receiving Pneumonia Immunization (CMS PN-2)

  • Pneumonia Patients Given Antibiotics within 6 hours of admission (CMS PN-5c)

  • Employee Contribution

  • Benefits as a Percentage of Salary

  • Staff Turnover

  • Financial Operational

  • Days Cash on Hand

  • Gross Days in AR

Additionally, facilities can select from over 90 measures

in the QHi library of indicators:

  • Clinical Quality Measures

  • Inpatients Screened for Pneumonia (not a CMS measure)

  • Medication Omissions Resulting in Medication Error

  • Medication Errors Resulting from Transcription Errors

  • ER Provider Response Times

  • Return ER Visits within 72 hours with same/similar diagnosis

  • Readmits Within 30 Days with Same or Similar Diagnosis

  • Hospital Associated Infections per 100 inpatient days*

  • Unassisted Patient Falls per 1000 inpatient days*

  • CMS Pneumonia Measures

  • Inpatients Receiving O2 Assessment within 24 hours of admission - CMS Pn-1 (retired)

  • Inpatients Receiving Pneumonia Immunization - CMS PN-2*

  • Pneumonia Patients Given Antibiotics within 6 hours of admission - CMS PN-5c *

  • CMS OP Transfer Measures

  • Percentage of eligible patients who received thrombolytic therapy - CMS OP-1 and OP-2

  • Median Time from Emergency Dept Arrival to Time of Transfer to another Facility for Acute Coronary Intervention - CMS OP-3

  • Number of AMI patients without aspirin contraindications who received aspirin within 24 hours - CMS OP-4

  • Percentage of AMI or Chest Pain patients receiving ECG within 10 minutes of arrival (prior to transfer) - CMS OP-5 *Part of the 8 Core Measure Set

Clinical Quality Measures (continued)

HF Measures

  • Discharge Instructions provided to HF patients – CMS HF-1

  • Evaluation of LVS Function – CMS HF-2

  • ACEI or ARB for LVSD – CMS HF-3

  • Adult Smoking Cessation Advice/Counseling – CMS HF-4

    SCIP Measures

  • Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision – CMS SCIP-Inf-1a

  • Prophylactic Antibiotic Selection for Surgical Patients – CMS SCIP-Inf-2a

  • Prophylactic Antibiotics Discontinued Within 24 Hours after Surgery End Time – CMS SCIP-Inf-3a

  • Surgery Patients with Appropriate Hair Removal – CMS SCIP-Inf-6

  • Urinary Catheter Removed on Postop Day 1 or Postop Day 2 with Day of Surgery being Day 0 – CMS SCIP-Inf-9

  • Surgery Patients with Periop Temperature Management – CMS SCIP-Inf-10

  • Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Periop Period – CMS SCIP-Card-2

  • Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered – CMS SCIP-VTE-1

  • Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery – CMS SCIP-VTE-2

  • Patient Satisfaction Measures

  • How well staff worked together to care for the patient (QHi1)

  • The extent to which the patient felt ready for discharge (QHi2)

In addition to these original QHi patient satisfaction measures, 22 HCAHPS measures are now in the library of indicators.

  • Employee Contribution Measures

  • Non-Nursing Staff Turnover

  • Average Time to Hire (All Staff)

  • Nursing Staff Turnover

  • Average Time to Hire (Nursing)

  • Average Time to Hire (Non-Nursing)

  • Salary to Operating Expenses Comparison

  • Benefits as a Percentage of Salary*

  • Staff Turnover*

  • Hospital Characteristic Measures

  • Average Inpatient Days

  • Monthly Inpatient Census

  • Multi-State ALOS (in hours) Comparison

  • ALOS (in hours) Comparison

*Part of the 8 Core Measure Set

Financial & Operational Measures

  • Financial

  • Bad Debt Expense

  • Charity Care

  • Cost per Patient Day

  • Labor Hours per Patient Day

  • Operating Profit Margin

  • Current Ratio

  • Net Patient Revenue per Patient Days

  • Payer Mix – Commercial

  • Payer Mix – Medicaid

  • Payer Mix – Medicare

  • Payer Mix – Other

  • Payer Mix – Other Government

  • Payer Mix – Self/Private Pay

  • Days Cash on Hand *

  • Gross Days in AR *

  • Operational

  • Physical Therapy Labor Hours per Unit of Service

  • Laboratory Labor Hours per Unit of Service

  • X-ray Labor Hours per Unit of Service

  • Mammogram Labor Hours per Unit of Service

  • Ultrasound Labor Hours per Unit of Service

  • CT Labor Hours per Unit of Service

  • MRI Labor Hours per Unit of Service

  • Pharmacy Labor Hours per Unit of Service

  • Nursing Hours per Patient Day

  • Rural Health Clinic Encounters per FTE

  • Long Term Care Hours per LTC Patient Day

  • Laboratory Hours per Billed Service

*Part of the 8 Core Measure Set

Quality Health Indicators

Web Site Access

An email address and password are required to enter this secure web site.

The level of access is determined by the User type:

System Administrator – maintains the site – KHA/KHERF

State Administrator –provides support to Hospital Contacts in their State

Network Administrator – maintains Network profiles & provides support

Hospital Contact– maintains Hospital profiles , adds users & enters data

Hospital User – enters data and runs reports

View Only – views data and runs reports

Report Recipient – no access to QHi, only receives reports

The PiHQ Portal

Return to Main Menu

Users navigate through the suite of resources in the PiHQ Portal by using blue links across the top.

Hover text provides a brief description of each resource.

All QHi, HSI and SQSS users have access to the PiHQ search engine.

Or on any page throughout the portal here

Users type in search topic here

Results are pulled from all Portal resources.

Future enhancements will allow users to pull from resources outside of PiHQ as well.

The Resource Library holds all resource materials developed for PiHQ.

All users have access to the Resource Library

Results are pulled from all Portal resources.

Icons identify the source of the information.

All users have access to the Calendar

The Calendar provides registration information for upcoming Quality Training Sessions

Users with access to the application are directed to the home pate, without additional log in.

All HCAHPS measures can be automatically pulled from HSI and uploaded directly into QHi, eliminating duplicate entry.

Future enhancements will allow any HSI measure to be uploaded into QHi.

This Calendar system, developed by Darlene Bainbridge, is now in live beta-testing.

Users with access to the application are directed to their customized home page, without additional log in.

Partners in Healthcare Quality are working with 2 notable Risk Management vendors to pull aggregate data directly into QHi, further reducing data entry, and enhancing comparative analysis and benchmarking opportunities.




Return to Main Menu

Users navigate through QHi by clicking the main menu and sub-menu options

Click Administration to view

Hospital Profile page

Hospital Contacts are responsible for completing and maintaining the Hospital Profile page for their facility.

Allfields with a redasterisk*


Hospital Characteristics

define each facility for

creation of peer groups

when running reports

Question marks ? provide pop-up definitions throughout the QHi site

Click drop-down to select Level of Measurement . This applies only to Financial/Operational measures



Return to Main Menu

Click here to go to Measures Selection page

In Collected Measure Sets, users can select the default measures predetermined by their state or network

Additional Measure sets are available here

The QHi Core Measure Set is pre-selected as it is required for all hospitals

Collected Measures lists the measures within the measure sets currently collected by the hospital

Individual measures are selected and displayed under Additional Measures.

  • Additional Measures lists

  • Individual measures currently collected and

  • (2) other measures that are available to collect

Click the negative -icon to remove measure from

Currently Collecting

Indicates the number

of hospitals in QHi

collecting the


Click the plus + icon to

measure to

Currently Collecting

Click question mark icon ?to display the calculation for each measure

Click show elements

to display the elements

required to calculate

the measure



Return to Main Menu

Click Data Submissions to open the Data Submission page

Data elements populate the data entry screen based on measures selected in the Hospital Profile.

Click Go to: drop-down to select prior months’ data submissions

Select correct month and year from Month to add drop-down

IMPORTANT: User must check Activate data for reporting box in order for the data entered this month to be displayed on dashboards or in reports

Click Save to save data entered

If data for the month is entered and saved but not activated, this message will appear to remind the user to activate data for reporting

The prior month’s data is displayed for easy reference

Data elements automatically populate this screen based on the measures selected by the user in the Measures Selection page

Click to automatically calculate

measures and immediately

display results



Return to Main Menu

The Core Measures Dashboard provides comparison data for the eight QHi Core Measures

The Dashboard can be viewed as a table

Roll mouse over any dashboard graph to view the calculation

The Dashboard can also be viewed as combined graph and table

table View

Graph and table View

Dashboard data is calculated using a consecutive three-month summing average

Dashboard data is calculated

using a consecutive three month

summing average

State Avg values reflect data from hospitals in the same state as My Hospital and reported in the same time interval

QHi Avg values reflect data from all hospitals in QHi reporting the same measure in the same time interval

Financial measures on the Dashboard default to peer groups based on the hospital’s level of reporting (Hospital Only or Entire Enterprise)

A hospital must have activated data for at least one of the three months in the Date Range in order for the measure to be displayed on the Dashboard

My Hospital data for some clinical measures will not display on the Dashboard if the hospital had no occurrences during the Date Range period

The three months in the Date Range can be changed by clicking the drop-down to select the start month for the desired three-month period

Click here to view the

Dashboard as a PDF

PDF view

The PDF format allows the user to save, print or email the Dashboard in graph, table or graph/table views

Users can email the Dashboard in PDF to themselves by clicking To Myself

…or choose another recipient

User selects from a list of existing registered users

…or choose to add a new recipient

Enter the name and Email address of the new recipient

…and click Add New

…Enter the Name and Email address of the new recipient

…and click Add New


Click Create Schedule to establish a pre-determined schedule for emailing Dashboard reports to selected recipients

  • Select run date (Click on calendar icon)

  • Select frequency (click drop-down)

  • Select recipients

  • Click Save Schedule

  • Select a run date

  • Select the frequency

  • Select Recipients

  • Save Schedule

  • Report is sent through email as a PDF attachment.

Dashboard is sent through

Email (as scheduled) as a

PDF attachment


Click View My Dashboard

to create a customized


Click drop-down to select a measure to display on Dashboard

Only those measures being collected by the hospital will be available in the list

Selected measures are retained and are user specific

Notes section available to add comments or additional information


Return to Main Menu

Click Reports to view measures and create reports

There are 6 categories

of reports:

Clinical Quality


Financial Operational

Hospital Characteristics

Patient Satisfaction


The measures being

collected by the

hospital are listed in

each category

Click on a measure

to create a report

A hospital can view reports only for the measures and data elements it is collecting

Pick peer groups

Select date criteria

Pick optional hospital


Multiple criteria selected will more narrowly define the peer group

Available values are listed for the criteria chosen in Step 3

The report can be displayed

in four formats

Displays and holds

the criteria selected

Line Graph View

Bar Graph View

table View

The user’s facility

is identified as


Click to export

report data to


Click to export

report data

to Excel

Text Detail Measure View

Note that peer hospitals

are not identified by name

From the Excel report

users can create

customized graphs

to meet their needs

Text Detail Measure View

Click on the envelope icon to contact a peer hospital for benchmarking information

The Hospital Contact at the

selected peer hospital will

receive the Email message

Training and educational

materials are available

for download on the

Help page

How we use the data

Return to Main Menu

Quality Health Indicators

What do we do with the data?

A few comments from our hospitals…

  • I print a copy of the graphs and take it to the board for discussion. They appreciate seeing in color how we compare to other CAHs in KS as well as others in the USA.

  • On a quarterly basis I am giving a copy of the bar graphs to our Board Members at their meeting.

  • I give the Quality Committee a copy of the quality reports on a quarterly basis.

  • We track and present our indicators monthly and are usually above the norm. On the occasions when we fall below, it prompts us to review processes to seek improvements.

  • If we fall below expectations, we look for ways to improve and then report back to the board in the next quarter.

  • We like the Days in AR report. This is our only source for comparative information on this measure.

Quality Health Indicators

Thank you for viewing this demonstration.

If you have any questions or would like additional information on the QHi project, please contact:

Sally Perkins, QHi System Administrator

[email protected]



Stuart Moore, QHi Coordinator

[email protected]



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