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Organizational Assessment Tool (OAT). Faizah Muheb VP, Analytical Services June 2013. OAT Description. A comprehensive evidenced-based tool Developed for the Hospital Engagement Networks (HENs) to: Help identify areas for quality improvement

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organizational assessment tool oat

Organizational Assessment Tool (OAT)

Faizah Muheb

VP, Analytical Services

June 2013


OAT Description

  • A comprehensive evidenced-based tool
  • Developed for the Hospital Engagement Networks (HENs) to:
    • Help identify areas for quality improvement
    • Support efforts to expand the use of models shown to improve care
    • Help achieve Partnership for Patients (PfP) goals
      • 40% Reduction of HAC’s
      • 20% Reduction of Readmissions

OAT Description

  • Safety culture
  • Leadership
  • Measurement
  • Medication
  • Purchasing practice
  • Procedural
  • Risk management
  • Nursing practice
  • Communication
  • Infection control
  • The OAT contains 139 questions organized by Areas of Focus
  • Markers for HACs and readmissions are included in the Areas of Focus

OAT Description

  • Background Questions
    • Hospital type
    • Average daily census
    • Annual rate of hospital admissions
    • HEN the hospital is associated with
    • Electronic Health Record (EHR) system


  • Reviewed evidence-based best practices
  • Developed markers to capture the highest standard of care known to mitigate patient harm
  • Conducted successive revisions of markers
    • CMS feedback
    • Clinical, patient safety, risk management, and quality improvement experts
  • Pilot tested the OAT with seven PfP hospitals
how will the oat be used
How will the OAT be used?
  • Assess Current Practices and Capabilities within GHA HEN
  • Prioritize efforts based on HEN results
  • Help identify hospitals with leading edge practices
oat release 2 0
OAT Release 2.0
  • OAT v2.0.0 replaces OAT v1.3.7, which hospitals completed in 2012
  • With the exception of some minor edits, the content of OAT v2.0.0 is the same
    • This is critical in providing hospitals with a way to compare their results from Year 1 to Year 2
    • Ensures ease of use – items and organization of items already familiar to users
  • Scoring has been revised to account for “Not applicable” responses
    • OAT v2.0.0 bases individual hospital scores on only those items that are applicable to them

Completing the OAT

  • A single OAT is completed per hospital
  • Recommend responsibility be assigned to the VP-Quality, VP - Medical Affairs, PSO or equivalent
  • Individual responsible for OAT contacts appropriate staff to gather information, as necessary
  • Pilot test found the OAT required ½-6 hours to complete
  • Pilot test hospitals reported the act of completing the OAT was beneficial

OAT Scoring

  • Points assigned to markers vary depending on the type of response set:
    • Dichotomous responses (5= Yes, 0=No)
    • Check all that apply (1 point for each checked item)
    • Likert Scale: Number of points = scale response
    • Others
      • Counts
      • Yes/ Yes but/No

Access to OAT Data

  • The OAT is for the HENs and hospitals
  • Only the HENs will be able to identify its hospital partners
  • HENs will provide CMS and the NCD the de-identified OAT data
    • National trends
    • Norms

OAT Resources-Update

  • An online version of the OAT will be available via SNAP Survey WebHost (FISMA Compliant)
  • GHA will work with NCD to create an online account for each hospital to complete the OAT
  • SNAP software includes an array of powerful analytical tools and real-time reporting
  • An electronic offline solution (excel version OAT) will be available for hospitals that may not be able to complete the web-based OAT
  • GA HEN Hospitals have until July 31, 2013 to complete the OAT
  • OAT is a resource for the HENs to achieve the goals of the PfP
  • The OAT consists of 139 evidenced-based best practices
  • OAT useful for identifying their hospital’s strengths and weaknesses
  • The NCD will establish a SNAP WebHost account for each HEN to securely administer and collect OAT data