BROWARD HEALTH ENTERPRISE HOSPITALIST SERVICES RFP

Transcription

BROWARD HEALTH ENTERPRISE HOSPITALIST SERVICES RFP
FORMAL REQUEST FOR PROPOSAL
ADDENDUM NUMBER: (1)
April 20, 2016
THIS ADDENDUM IS ISSUED PRIOR TO THE ACCEPTANCE OF THE FORMAL RFQS. THE FOLLOWING
CLARIFICATIONS, AMENDMENTS, ADDITIONS, DELETIONS, REVISIONS, AND MODIFICATION FORM A
PART OF THE CONTRACT DOCUMENTS ONLY IN THE MANNER AND TO THE EXTENT STATED.
Revised Summary of Key Dates:
Bids Due: Thursday, April 28, 2016 before 3:00 P.M.
Bid Opening: Friday, April 29, 2016 10:30 A.M. - Broward Health Spectrum Office 1800 NW 49 Street,
Ft. Lauderdale, FL 33309, Conference Room 1040.
Q&A - (Questions submitted prior to inquiry deadline.)
•
Can you provide us with the Annual Number of Admissions to the Hospital Medicine
Programs at BHIP and BHCS? *NOTE: the Hospitalist cases that we have detail on and shared
here is predominantly FY 15. A few months were overwritten, and pertain to FY 16.
BHIP = 3,183 BHCS =3,740
•
Can you provide us with the Average Length of Stay (ALOS) in Hospital Medicine
Programs at BHIP and BHCS? BHIP = 4.08 BHCS =3.88
•
Can you provide us with the Annual Number of Observations to the Hospital Medicine
Program at BHIP and BHCS? BHIP =1,084 BHCS=2,305
•
Can you provide us with the Average Length of Stay (ALOS) for Observations in Hospital
Medicine Programs at BHIP and BHCS? We do not break that out. The hospital wide ALOS for
Observation for FY 15 was: BHIP = 1.26 BHCS = 1.22 BHN = 1.44
•
Can you provide us with the Annual Number of Billable Encounters or the Average
Number of Daily Billable Encounters (ADE) in the Hospital Medicine Programs at BHIP and BHCS?
We do not have that data.
•
Can you provide us with the anticipated Annual Number of Admissions to the Hospital
Medicine Program at BHN? No.
•
Can you provide us with the anticipated Average Length of Stay (ALOS) in Hospital
Medicine Programs at BHN? No.
•
Can you provide us with the anticipated Annual Number of Observations to the Hospital
Medicine Program at BHN and BHN? No.
•
Can you provide us with the anticipated Average Length of Stay (ALOS) for Observations
in Hospital Medicine Programs at BHN? BHN current LOS for observation is 1.44.
•
Can you provide us with the anticipated Annual Number of Billable Encounters or the
Average Number of Daily Billable Encounters (ADE) in the Hospital Medicine Programs at BHN?
We do not have that data.
•
Can you provide us with a breakdown (by percentage) of the top Commercial Managed
Care Programs? The following data was pulled from our Decision Support system. All Inpatients
were selected. Excluded Psych, Surgical patients (those who received a surgery charge), Rehab,
Peds, OB and all patients aged 0-18. The first chart is the top ten plans by facility where only
Commercial and Managed Care Commercial plans were selected and the second chart expanded to
include Medicare HMO.
Broward Health Inpatients: excludes Psych, Surgical, Rehab, Peds and OB
Managed Care Commercial /Commerical
BHIP
BHCS
64 CPCO-BCPP
Blue Cross Pref Pt Care Comm
115
212
36 CHCO-HUMA
Humana Commercial
58
184
62 CPCO-TRAV
United PPO
43
158
164 CPCO-NET
Blue Cross Network Health Exchange
52
134
65 CPCO-ARM
Armor Correctional
0
0
135 CHCO-AET
Aetna- Commercial
28
91
35 CHCO-HIP
Coventry HMO Commercial
39
78
57 CPCO-CIGN
Cigna Commercial
29
67
49 CPCO-CHOI
Best Choice - Broward Health
26
70
187 NCCO-VA
Non contracted Veterens
37
11
29 CHCO-AVME
Avmed Commercial
13
46
40 CHCO-CAC
United HMO
27
42
805
2
1,611
BHN
180
121
81
65
65
61
58
51
49
48
24
20
1,449
Managed Care Commercial /Medicare and Commercial
BHIP
BHCS
19 CHMC-HUMA Humana Medicare
531
665
64 CPCO-BCPP Blue Cross Pref Pt Care Comm
115
212
15 CHMC-AVME Avmed Medicare
90
148
23 CHMC-SUM Summit Medicare
88
81
114 CHMC-PHC Positive Healthcare Medicare
86
196
36 CHCO-HUMA Humana Commercial
58
184
164 CPCO-NET Blue Cross Network Health Exchange
52
134
124 CPMC-UNI United Medicare
48
51
62 CPCO-TRAV United PPO
43
158
125 CPMC-HUM Humana PPO Commercial
43
67
35 CHCO-HIP
Coventry HMO Commercial
39
78
24 CHMC-PCP
Preferred Care Partners Medicare
36
68
135 CHCO-AET Aetna- Commercial
28
91
65 CPCO-ARM Armor Correctional
1,992
3,220
BHN
970
180
112
100
159
121
65
70
81
60
58
76
61
65
3,286
•
Will the Hospital Medicine Programs at BHIP, BHCS and BHN be performing consults for
other physicians at their respective sites? If so what is the anticipated annual number of consults
facility? The hospitalist will be performing consults for Psych patients and surgical patients when
needed. We cannot determine the quantity of consults from data we have at the hospital.
•
What is a PSN as it relates to the Financial Service Class? PSN- rolls to Medicaid HMO for
us. Predominantly it is our South Florida Healthcare Network that we are partnering with the
Memorial Health System.
•
Will the hospitalist be managing the patients in the ICU? Open ICU- hospitalist manages
critical care with consult for subspecialties as needed – i.e. vent patients consulted with pulmonary,
dialysis managed with nephron, etc.

The statistical data provided appears to be the "hospital payor mix" and the "unassigned
payor mix". Can we please be provided the payor mix of the hospitalist program? For
BHIP and BHCS please see hospitalist mix below:
3
BHIP- Inpatient Cases
Hospitalist Cases- By Payor Mix
Tax Funded (Uninsured)
Self Pay (Uninsured)
Medicaid: Straight, PSN, HMO
Medicare: Straight
Managed Care (HMO/PPO)
212
1,151
333
905
582
3,183
7%
36%
10%
28%
18%
100%
56
340
72
313
303
1,084
5%
31%
7%
29%
28%
100%
227
978
273
905
1,357
3,740
6%
26%
7%
24%
36%
100%
166
597
141
276
1,125
2,305
7%
26%
6%
12%
49%
100%
BHIP- Observation
Medicare: Straight
BHCS- Inpatient Cases
Medicare: Straight
BHCS- Observation
Medicare: Straight
4

Top 5 Commercial plans for each facility: Please see previous chart.

Also, will the entire hospital census be seen by the hospitalist program at each location
or will there also be PCP's rounding on their own patients? PCPs round as well.

If so, what is the expected volume of the hospitalist patients only at each. Please see
above for the data we have for BHCS and BHIP.

Current ALOS for each location – Please see above.

Are the Observation Days on page 28 included in “Total Patient Days”, or are “Total
Patient Days” only for inpatients? Just Inpatients.

Staffing model – does evening shift mean nocturnist? Yes.

Are we to assume the current Chief Hospitalist will remain in this capacity, working with
us, if we are selected? That may be an option, but it is not definite. We are not sure how
current contracts with individual physicians are set up.

Are we free to suggest alternatives to the current staffing model if we feel appropriate?
Yes.

Physician Credentialing Preference/Requirements: Are physicians board certified in
family medicine also accepted? Yes.

We note that you provided data for newborns at Coral Springs. Do the hospitalists have
any OB responsibilities currently at that location? No.

Are there any providers you wish to retain at the BHCS or BHIP location? If so, do they
have any restrictive covenants related to future employment in those facilities? That may
be an option, but it is not definite. We are not sure about how current contracts with
individual physicians are set up.

Will the hospitalists be responsible for performing procedures? No.

Have you reported PQRS data for the prior year at each location? PQRS data has been
submitted for the District – Outpatient metrics, it is not an inpatient measurement.

Which patient satisfaction program is used at each location? We use Avatar.

30 day readmission rate of 5% or lower – Is this all cause admission rate or patients
discharged and admitted back to Hospitalist service? What is the baseline readmission
rate? BHIP – Crimson is used to monitor and measure readmissions.
Hospitalist all-cause admitted back to system facilities current rate 15.42%- national rate
13.67%
Hospitalist same cause admitted back to system is 3.47% national rate 2.61%
BHCS - Readmission rates are as follows:
AMI (all payors) = 0%
Heart Failure (all payors) = 11.11%
5
Pneumonia (all payors) = 2.2%
COPD (all payors) =2.8%
BHN - For CY 15 BHN rate in Crimson for all physicians is 12.35, all hospitals comparison
group in Crimson is 10.69.
 What is the Board Certification requirement? BC IM and FM or BC IM only? IM or FM – must be
board certified per the bylaws.
 Core measures at 100% - What is the current performance for core measures?
BHIP – see chart below:
CY
14
Rate
Top
10%
Jan15
Feb15
Mar15
Apr15
Q1
May15
Jun15
Jul15
Q2
Aug15
Sep15
Oct15
Q3
Nov15
Dec15
Q
4
Y
T
D
1
0
0
.
0
0
%
1
6
1
0
0
.
0
0
%
3
9
1
0
0
.
0
0
%
1
7
1
7
1
0
0
.
0
0
%
3
8
3
8
Stroke Indicators
S
T
K
1
VTE
Prophylaxi
s
100
%
100
%
100.
00%
3
numerator
denomina
tor
S
T
K
2
3
Discharge
d on
Antithrom
botics
100
%
2
100
%
numerator
denominat
or
S
T
K
3
S
T
K
4
S
T
K
5
S
T
K
6
Anticoagul
ation Tx
for A-fib
100.
00%
100
%
100
%
100.
00%
2
1
100.
00%
1
6
100.
00%
6
2
100.
00%
2
4
100.
00%
4
2
100.
00%
2
8
100.
00%
8
3
100.
00%
3
3
100.
00%
3
3
100.
00%
3
9
100.
00%
9
6
100.
00%
6
5
100.
00%
5
5
5
16
39
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
3
1
1
5
3
2
1
6
4
3
3
10
6
6
5
3
1
1
5
3
2
1
6
4
3
3
10
6
6
5
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
numerator
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
denominat
or
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
-
-
-
-
-
100.
00%
-
-
100.
00%
-
-
-
-
0
1
0
0
.
0
0
%
numerator
0
0
0
0
0
0
0
0
1
0
0
1
0
0
0
0
2
denominat
or
0
0
0
0
0
0
0
0
1
0
0
1
0
0
0
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
75.0
0%
100.
00%
88.8
9%
100.
00%
100.
00%
100.
00%
100.
00%
75.0
0%
80.0
0%
100.
00%
numerator
3
1
1
5
3
3
2
8
1
3
3
7
3
4
5
0
8
5
.
7
1
%
1
2
2
9
1
.
4
3
%
3
2
denominat
or
3
1
1
5
3
4
2
9
1
3
3
7
4
5
5
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
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00%
100.
00%
100.
00%
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00%
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00%
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00%
100.
00%
100.
00%
1
4
1
0
0
.
0
0
%
3
5
1
0
0
.
0
0
%
numerator
3
1
1
5
3
1
1
5
3
3
3
9
6
6
5
1
7
3
6
denominat
or
3
1
1
5
3
1
1
5
3
3
3
9
6
6
5
50.0
0%
100.
00%
-
66.6
7%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
80.0
0%
100.
00%
1
1
0
2
3
2
1
6
2
3
1
6
3
4
5
1
7
9
2
.
3
1
%
1
2
3
6
9
2
.
8
6
%
2
6
2
1
0
3
3
2
1
6
2
3
1
6
3
5
5
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
75.0
0%
100.
00%
100.
00%
90.0
0%
100.
00%
100.
00%
100.
00%
1
3
1
0
0
2
8
9
7
.
t-PA
administer
ed
Antithrom
botic by
end of day
#2
Discharge
d on
Statin
S
T
K
8
Stroke
Education
S
T
K
denominat
or
Assessed
for
Rehabilitat
100
%
100
%
100
%
100
%
100
%
100
%
97%
100
%
numerator
100
%
100
%
6
1
0
3
7
%
5
.
0
0
%
1
7
3
8
ion
3
numerator
denominat
or
Top
10%
Sepsis Indicators
Early
Managem
S
ent
E
Bundle,
P
Severe
Sepsis/Se
1
ptic Shock
new
CY
14
Rate
new
1
1
5
3
2
1
6
3
3
3
9
CY
14
Rate
6
3
7
3
1
1
5
3
2
1
6
4
3
3
10
6
6
5
1
7
Jan15
Feb15
Mar15
Q1
Apr15
May15
Jun15
Q2
Jul15
Aug15
Sep15
Q3
Oct15
Nov15
Dec15
Q
4
Y
T
D
36.3
6%
3
1
.
8
2
%
3
1
.
8
2
%
-
-
-
-
-
-
-
-
-
-
-
-
numerator
denominat
or
Top
10%
6
Jan15
Feb15
Mar15
Q1
Apr15
May15
Jun15
Q2
Jul15
Aug15
Sep15
Q3
20.0
0%
33.3
3%
1
2
4
7
7
5
6
11
2
2
2
2
Oct15
Nov15
Dec15
Q
4
Y
T
D
Venous Thromboembolism (VTE)
V
T
E
1
96.0
0%
100.
00%
92.3
1%
96.3
9%
96.3
0%
97.1
4%
100.
00%
97.7
8%
100.
00%
100.
00%
96.7
7%
98.9
2%
96.8
8%
100.
00%
94.8
7%
9
6
.
8
8
%
numerator
24
32
24
80
26
34
28
88
26
36
30
92
31
25
37
9
3
denominat
or
25
32
26
83
27
35
28
90
26
36
31
93
32
25
39
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
8
8
8
24
2
7
4
13
4
3
2
9
2
5
8
8
8
24
2
7
4
13
4
3
2
9
2
5
Venous
Thromboe
mbolism
Prophylaxi
s
V
T
E
2
ICU
Venous
Thromboe
mbolism
Prophylaxi
s
V
T
E
3
denominat
or
Venous
Thromboe
mbolism
Patients
with
Anticoagul
ation
Overlap
Therapy
V
T
E
4
denominat
or
Venous
Thromboe
mbolism
Patients
Receiving
Unfraction
ated
Heparin
with
Dosages/
Platelet
Count
Monitoring
by
Protocol
new
new
new
new
numerator
new
new
numerator
7
9
6
1
0
0
.
0
0
%
1
4
9
7
.
5
1
%
3
5
3
3
6
2
1
0
0
.
0
0
%
6
0
7
1
4
6
0
100.
00%
66.6
7%
100.
00%
81.8
2%
80.0
0%
100.
00%
100.
00%
91.6
7%
0.00
%
100.
00%
75.0
0%
78.5
7%
-
100.
00%
100.
00%
1
0
0
.
0
0
%
2
4
3
9
4
3
4
11
0
5
6
11
0
3
2
5
8
5
.
7
1
%
3
6
2
6
3
11
5
3
4
12
1
5
8
14
0
3
2
5
4
2
-
100.
00%
-
100.
00%
-
-
-
-
100.
00%
-
100.
00%
100.
00%
-
-
-
-
1
0
0
.
0
0
%
numerator
0
2
0
2
0
0
0
0
1
0
1
2
0
0
0
0
4
denominat
or
0
2
0
2
0
0
0
0
1
0
1
2
0
0
0
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
-
100.
00%
100.
00%
100.
00%
-
100.
00%
100.
00%
0
1
0
0
.
0
0
%
4
1
0
0
.
0
0
%
1
2
2
5
5
1
2
8
0
5
4
9
0
2
3
5
1
2
2
5
5
1
2
8
0
5
4
9
0
2
3
5
2
7
2
7
0
.
0
0
%
0
V
T
E
5
Venous
Thromboe
mbolism
Discharge
Instruction
s
V
T
E
6
numerator
denominat
or
Incidence
of
Potentially
Preventab
le Venous
Thromboe
mbolism
numerator
new
new
new
new
new
new
-
0.00
%
0.00
%
0.00
%
-
0.00
%
-
0.00
%
0.00
%
0.00
%
-
0.00
%
0.00
%
-
-
0
.
0
0
%
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
7
denominat
or
Top
10%
HBIPS
H
B
I
P
Admission
S
Risk
Assessme
1
nt
H
B
I
P
S
2
H
B
I
P
S
3
CY1
4
Rate
1
2
0
3
0
3
1
2
0
3
1
0
0
1
9
Jan15
Feb15
Mar15
Q1
Apr15
May15
Jun15
Q2
Jul15
Aug15
Sep15
Q3
Oct15
Nov15
Dec15
Q
4
Y
T
D
100
%
66.6
7%
93%
89.2
9%
94%
96%
98%
96%
94%
100
%
93%
96%
100
%
97%
92%
9
7
%
numerator
34
23
43
100
48
46
41
135
33
39
28
100
33
38
23
9
4
denominat
or
34
32
46
112
51
48
42
141
35
39
30
104
33
39
25
9
7
0.10
0
.
1
7
0
.
7
5
0.00
0
.
0
0
0
.
0
0
Hours of
Physical
Restraint
Use: rate
per 1000
hrs,
H
B
I
P
S
4
H
B
I
P
S
5
denominat
or
Patients
Discharge
d on
Multiple
Antipsych
otic
Medicatio
ns with
Appropriat
e
Justificatio
n
new
new
0.15
0.01
11.1
4%
numerator
15.1
5%
numerator
denominat
or
Post
Discharge
Continuin
g Care
Plan
Created
98.3
5%
numerator
H
B
I
P
S
7
1
9
4
.
4
9
%
4
2
9
4
5
4
Hours of
Seclusion
Use: rate
per 1000
hours
Patients
Discharge
d on
Multiple
Antipsych
otic
Medicatio
ns
H
B
I
P
S
6
0
denominat
or
Post
Discharge
Continuin
g Care
Plan
Transmitte
d to Next
Level of
Care
Provider
Upon
Discharge
0.00
0.13
0.00
0.06
0.00
0.20
0.00
0.31
0.00
0.02
0.01
0.00
0.00
0.34
0.00
0.00
0.00
0.00
0.00
0.03
0.00
0.03
0.00
0.07
0.00
0.00
0.00
12.9
0%
0.00
%
2.04
%
4.35
%
1.96
%
4.00
%
0.00
%
2.29
%
0.00
%
0.00
%
3.03
%
0.94
%
8.33
%
3.33
%
9.52
%
6
.
9
0
%
4
0
1
5
1
2
0
3
0
0
1
1
3
1
2
6
31
35
49
115
51
50
30
131
36
37
33
106
36
30
21
8
7
3
.
4
2
%
1
5
4
3
9
5
3
.
8
5
%
7
1
3
66.6
7%
-
100.
00%
75.0
0%
0.00
%
0.00
%
-
0.00
%
-
-
100.
00%
100.
00%
33.3
3%
100.
00%
50.0
0%
5
0
.
0
0
%
2
0
1
3
0
0
0
0
0
0
1
1
1
1
1
3
3
0
1
4
1
1
0
2
0
0
1
1
3
1
2
6
7
4
.
1
1
%
100.
00%
95.4
5%
90.4
8%
94.7
7%
93.2
2%
88.1
4%
90.5
7%
90.6
4%
87.2
3%
91.3
0%
76.9
2%
85.6
1%
72.0
9%
71.4
3%
81.4
8%
46
42
57
145
55
52
48
155
41
42
30
113
31
30
22
46
44
63
153
59
59
53
171
47
46
39
132
43
42
27
8
3
1
1
2
7
4
.
1
1
%
93.4
8%
95.4
5%
90.4
8%
92.8
1%
93.2
2%
83.0
5%
88.6
8%
88.3
0%
87.2
3%
87.2
3%
76.9
2%
84.2
1%
72.0
9%
71.4
3%
81.4
8%
numerator
43
42
57
142
55
49
47
151
41
41
30
112
31
30
22
denominat
or
46
44
63
153
59
59
53
171
47
47
39
133
43
42
27
P
S
Y
S
U
B
1
Alcohol
Abuse
Screening
P
S
Y
95.2
6%
0.01
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
100.
00%
numerator
37
35
36
108
41
39
41
121
36
42
34
112
35
48
42
denominat
or
Tobacco
Use
Screening
37
35
36
108
41
39
41
121
36
42
34
112
35
48
42
100.
00%
97.1
4%
97.1
4%
98.1
3%
100.
00%
97.3
7%
100.
00%
99.1
7%
97.2
2%
100.
00%
97.0
6%
98.2
1%
97.1
4%
97.9
2%
100.
00%
new
new
8
8
7
.
3
2
%
4
9
6
5
6
8
8
3
1
1
2
8
5
.
7
6
%
4
8
8
5
6
9
1
0
0
.
0
0
%
1
2
5
1
2
5
9
8
.
1
0
0
.
0
0
%
4
6
6
4
6
6
9
8
.
T
O
B
1
P
S
Y
T
O
B
2
P
S
Y
I
M
M
2
4
0
%
4
9
%
4
5
7
4
6
4
numerator
37
34
34
105
41
37
41
119
35
42
33
110
34
47
42
denominat
or
37
35
35
107
41
38
41
120
36
42
34
112
35
48
42
1
2
3
1
2
5
6.25
%
0.00
%
12.0
0%
6.90
%
25.0
0%
52.1
7%
50.0
0%
41.7
9%
43.7
5%
39.1
3%
26.6
7%
37.0
4%
62.5
0%
77.7
8%
70.0
0%
7
0
.
4
2
%
numerator
1
0
3
4
6
12
10
28
7
9
4
20
15
21
14
5
0
denominat
or
16
17
25
58
24
23
20
67
16
23
15
54
24
27
20
7
1
4
0
.
8
0
%
1
0
2
2
5
0
1
0
0
.
0
0
%
2
9
7
2
9
7
Tobacco
Use
Treatment
Provided
or Offered
new
Influenza
Immunizat
ion
100.
00%
100.
00%
100.
00%
100.
00%
-
numerator
47
50
49
146
0
denominat
or
47
50
49
146
0
Jan15
Feb15
Mar15
Q1
Apr15
new
-
-
-
100.
00%
100.
00%
100.
00%
0
0
50
53
48
0
0
50
53
48
1
0
0
.
0
0
%
1
5
1
1
5
1
Q3
Oct15
Nov15
Dec15
Q
4
Y
T
D
9
9
.
3
2
%
5
8
0
5
8
4
-
-
-
-
GLOBAL MEASURES
Top
10%
CY1
4
Rate
May15
Jun15
Q2
Jul15
Aug15
Sep15
Immunizations
I
M
M
2
Influenza
Immunizat
ion
-
100.
00%
97.9
6%
98.9
7%
0
0
93
96
96
0
0
93
98
97
9
8
.
9
6
%
2
8
5
2
8
8
267
277
284
266
259
8
0
9
4
2
5
103
107
136
105
116
3
5
7
1
8
5
100.
00%
98.9
4%
100.
00%
99.6
6%
numerator
102
93
100
295
denominat
or
102
94
100
296
342
297
336
325
308
258
301
289
291
274
140
142
145
142
137
114
145
132
115
104
ED IP Report
Median
time from
ED arrival
to ED
departure
for
E
admitted
D
ED
patients.
1
Overall
a
rate
Median
admit
decision
time to ED
departure
E
for
D
admitted
patients.
2
Overall
a
Rate
new
~
-
-
-
-
-
-
-
BHCS - 100% for all currently being measured on PMR: AMI, Stroke & VTE (retired in January 2016).
Now monitoring influenza screening which is at 100%.
BHN – see chart below:
9
Performance Measurement Report
Core Measures CY 15
Department: Quality Management
INDICATOR
Denise Mansfield
CY14
Nat Avg
Top 10%
Year:
CY15
CY15
YTD
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
0
0
N/P
0
0
N/P
0
0
N/P
0
0
N/P
0
0
NP
0
0
NP
0
0
NP
0
0
NP
0
0
NP
0
0
NP
0
0
NP
0
0
NP
0
0
NP
275
177
367.00
326.00
385.00
367.00
351.00
315.50
320.00
287.50
270.50
251.50
300.00
254.00
316.25
98
42
107.00
93.00
117.00
111.50
114.00
86.50
113.00
98.00
73.50
121.50
78.00
81.50
99.54
Acute Myocardial Infarction (AMI)
Fibrinolytic agent received within
AMI-7a 30 minutes of hospital arrival
(CMS only)
Emergency Department (ED)
Median Time from ED Arrival
ED-1 to ED Departure for Admitted
ED Patients (in minutes)
Admit Decision Time to ED
ED-2 departure Time for Admitted
Patients (in minutes)
Immunization
IMM-2
Immunization FLU
58%
100%
90.0%
99.0%
95
95
100.0%
98
94
98
94
100.0% 100.0%
96
93
94
96
93
94
100.0% 100.0% 100.0%
570
570
100.0%
-
-
-
-
-
-
45
45
100.0%
7
7
100.0%
9
9
100.0%
4
4
100.0%
6
6
100.0%
0
2
0.0%
42
42
100.0%
9
9
100.0%
6
6
100.0%
2
2
100.0%
4
4
100.0%
0
1
0.0%
33
33
100.0%
12
12
100.0%
9
9
100.0%
0
0
N/P
7
7
100.0%
0
2
0.0%
34
34
100.0%
9
9
100.0%
7
7
100.0%
2
2
100.0%
6
6
100.0%
0
0
NP
45
45
100.0%
6
6
100.0%
11
11
100.0%
4
4
100.0%
9
9
100.0%
0
2
0.0%
37
37
100.0%
6
6
100.0%
9
9
100.0%
1
1
100.0%
6
6
100.0%
0
2
0.0%
36
36
100.0%
16
16
100.0%
8
8
100.0%
0
0
N/P
5
5
100.0%
0
4
0.0%
38
38
100.0%
10
10
100.0%
6
6
100.0%
0
0
N/P
6
6
100.0%
0
2
0.0%
34
34
100.0%
9
9
100.0%
5
5
100.0%
1
1
100.0%
6
6
100.0%
0
2
0.0%
35
35
100.0%
8
8
100.0%
5
5
100.0%
0
0
N/P
5
5
100.0%
0
1
0.0%
35
35
100.0%
10
10
100.0%
5
5
100.0%
0
0
N/P
4
4
100.0%
0
0
N/P
32
32
100.0%
10
10
100.0%
5
5
100.0%
0
0
N/P
5
5
100.0%
0
0
N/P
446
446
100.0%
112
112
100.0%
85
85
100.0%
14
14
100.0%
69
69
100.0%
0
18
0.0%
28
28
100.0%
24
24
100.0%
9
9
100.0%
3
3
100.0%
18
18
100.0%
22
22
100.0%
13
13
100.0%
27
27
100.0%
32
32
100.0%
26
26
100.0%
8
8
100.0%
2
2
100.0%
24
24
100.0%
21
21
100.0%
14
14
100.0%
28
28
100.0%
28
28
100.0%
21
21
100.0%
1
1
100.0%
5
5
100.0%
16
16
100.0%
13
13
100.0%
12
12
100.0%
24
24
100.0%
25
25
100.0%
14
14
100.0%
5
5
100.0%
4
4
100.0%
13
13
100.0%
12
12
100.0%
9
9
100.0%
23
23
100.0%
20
20
100.0%
13
13
100.0%
3
3
100.0%
2
2
100.0%
9
9
100.0%
10
10
100.0%
10
10
100.0%
21
21
100.0%
27
27
100.0%
21
21
100.0%
2
2
100.0%
1
1
100.0%
18
18
100.0%
18
18
100.0%
14
14
100.0%
26
26
100.0%
29
29
100.0%
20
20
100.0%
4
4
100.0%
4
4
100.0%
17
17
100.0%
17
17
100.0%
18
18
100.0%
26
26
100.0%
35
35
100.0%
23
23
100.0%
3
3
100.0%
4
4
100.0%
21
21
100.0%
15
15
100.0%
17
17
100.0%
31
31
100.0%
25
25
100.0%
17
17
100.0%
3
3
100.0%
1
1
100.0%
15
15
100.0%
13
13
100.0%
9
9
100.0%
20
20
100.0%
19
19
100.0%
17
17
100.0%
0
0
NP
1
1
100.0%
14
14
100.0%
16
16
100.0%
13
13
100.0%
18
18
100.0%
22
22
100.0%
12
12
100.0%
0
0
NP
2
2
100.0%
11
11
100.0%
12
12
100.0%
12
12
100.0%
16
16
100.0%
35
35
100.0%
22
22
100.0%
2
2
100.0%
3
3
100.0%
19
19
100.0%
21
21
100.0%
16
16
100.0%
28
28
100.0%
325
325
100.0%
230
230
100.0%
40
40
100.0%
32
32
100.0%
195
195
100.0%
190
190
100.0%
157
157
100.0%
288
288
100.0%
49
49
100.0%
2
8
25.0%
0
8
0.0%
48
47
42
52
48
45
43
47
45
41
46
48
47
42
52
48
45
43
47
45
41
46
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
4
6
4
8
7
5
8
13
12
7
12
9
8
9
8
7
5
8
13
12
7
12
44.4% 75.0% 44.4% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
1
1
1
4
3
2
4
4
8
6
5
8
7
9
5
6
4
7
13
9
6
5
12.5% 14.3% 11.1% 80.0% 50.0% 50.0% 57.1% 30.8% 88.9% 100.0% 100.0%
553
553
100.0%
88
106
83.0%
39
87
44.8%
Venous Thromboembolism
VTE-1
VTE Prophylaxis
83.0%
98.0%
VTE-2
ICU VTE Prophylaxis
91.0%
100%
VTE-3
VTE-4
VTE Patients with
Anticoagulation Overlap
Therapy
VTE Patients Receiving
Unfractionated Heparin
Platelet Monitoring
VTE-5
VTE Discharge Instructions
VTE-6
Incidence of Potentially
Preventable VTE
92.0%
100%
96.0%
100%
73.0%
100%
0.0%
0%
Stroke
92.0%
100.0%
STK-1
VTE
Stroke VTE Prophylaxis by
end of Day 2
STK-2
Discharged on Antithrombics
STK-3
Anticoag Therapy for Atrial
Fib/Flutter prescribed at
discharge
STK-4
Thrombolytic Therapy
STK-5
Antithrombics Started by End
of Day 2
STK-6
Statin Prescribed at
Discharge
STK-8
Stroke Education
87.0%
100%
STK-10 Assessed for Rehab SVCS
97.0%
100%
99.0%
100%
95.0%
100%
63.0%
100%
98.0%
100%
94.0%
100%
Tobacco
TOB-1
Tobacco Use Assmt
TOB-2
Tobacco Use Treatment
TOB-3
Tobacco Use D/C Treatment
Sepsis
-
-
-
-
-
-
-
-
-
0
1
0.0%
3
14
21.4%
2
14
14.3%
5
29
17.2%
N/P
0
0
N/P
N/P
0
0
N/P
N/P
0
0
N/P
N/P
0
0
N/P
NP
0
0
NP
NP
0
0
NP
NP
0
0
NP
NP
0
0
NP
NP
0
0
NP
NP
0
0
NP
NP
0
0
NP
NP
0
0
NP
NP
0
0
NP
N/P
0
0
N/P
N/P
0
0
N/P
N/P
0
0
N/P
N/P
0
0
N/P
NP
1
1
100.0%
NP
0
0
N/P
NP
0
0
N/P
NP
1
1
100.0%
NP
0
0
N/P
NP
0
0
N/P
NP
0
0
N/P
NP
0
0
NP
NP
2
2
100.0%
SEP-1
Outpatient (OP)
Median Time to Fibrinolysis (in
OP-1
minutes)
OP-2
Fibrinolytic Therapy Received
Within 30 minutes of ED arrival
OP-3
Median Time to Transfer to
Another Facility for Acute
Coronary Intervention (in min)
OP-4
Aspirin at Arrival Prior to Transfer
OP-5
Median Time to ECG within 10
mins of arrival (in minutes)
OP-18
Median Time from ED Arrival to
ED Departure for Discharged ED
Patients (in minutes)
OP-20
Door to Diagnosis Evaluation by
a Qualified Medical Personnel
OP-21
Median Time to Pain
Management for Long Bone
Fracture
OP-23
Head CT or MRI Scan Results for Acute
Ischemic Stroke or Hemorrhagoc
Stroke Patients w ho Received Head CT
or MRI Scan Interpretation w ithin 45
minutes of ED arrival
Endoscopy / Polyp Survellience for
28
18
58%
100%
60
37
96%
100%
7.00
3.00
134.00
92.00
N/P
N/P
N/P
N/P
11.0
N/P
N/P
2.0
N/P
N/P
N/P
N/P
4.0
122.00
179.00
162.50
166.00
144.50
124.50
156.50
129.00
140.50
113.00
130.00
173.00
145.04
26.00
13.00
17.50
28.00
25.50
15.50
9.50
12.00
15.00
9.00
9.50
14.50
12.00
17.00
15.42
10
57.00
36.00
51.00
53.00
33.50
39.00
82.00
57.00
56.00
56.00
36.00
55.00
47.00
43.00
50.71
57%
0
0
0
0
0
0
0
0
0
0
1
1
2
100%
0
N/P
7
0
N/P
6
0
N/P
7
0
N/P
2
0
NP
3
0
NP
5
0
N/P
3
0
N/P
9
0
N/P
2
0
N/P
3
1
1
100.0% 100.0%
1
1
2
100.0%
49
Patient Safety Indicators and Inpatient Quality Indicators at 100% - What are these indicators and
what is the current baseline performance?
BHIP – see chart below:
Stat
e
Obs
Rat
e
CY1
4
Rate
Q1
Apr15
May15
Jun15
Q2
Jul15
Aug15
Sep15
Q3
Oct15
Nov15
Dec15
Q4
YTD
0.04
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
-
0.00
%
0.00
%
0.00
%
0.00
%
Patient Safety Indicators
(PSI)
PSI
3
PSI
6
Pressure Ulcers
numerator
0
0
0
0
0
0
0
0
0
0
0
0
0
denominator
671
219
222
240
681
220
197
219
636
112
87
199
2187
0.05
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.16
%
0.05
%
0.00
%
0.00
%
0.00
%
0.03
%
1
0
0
0
0
0
0
1
1
0
0
0
2
253
232
485
6514
0.00
%
0.00
%
0.00
%
0.00
%
Iatrogenic
Pneumothorax
0.04
%
0.00
%
numerator
denominator
PSI
7
Selected Infections
Due to Med Care
0.13
%
0.00
%
numerator
PSI
12
PSI
13
PSI
14
PSI
15
2085
691
662
685
2038
642
637
627
190
6
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0
0
0
0
0
0
0
0
0
0
0
0
0
177
173
350
4385
0.00
%
0.00
%
0.00
%
0.00
%
-
1046
519
484
530
1533
505
481
470
145
6
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
numerator
0
0
0
0
0
0
0
0
0
0
0
0
0
denominator
197
75
85
62
222
84
71
63
218
70
58
128
765
0.33
%
0.00
%
1.60
%
0.00
%
0.56
%
0.76
%
0.00
%
0.00
%
0.29
%
0.00
%
0.00
%
0.00
%
0.33
%
numerator
1
0
2
0
2
1
0
0
1
0
0
0
4
denominator
306
120
125
109
354
132
114
93
339
110
89
199
1198
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
numerator
0
0
0
0
0
0
0
0
0
0
0
0
0
denominator
22
11
14
11
36
19
4
7
30
11
7
18
106
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
numerator
0
0
0
0
0
0
0
0
0
0
0
0
0
denominator
61
26
34
27
87
28
27
25
80
34
20
54
282
0.00
%
0.00
%
0.00
%
0.14
%
0.05
%
0.00
%
0.15
%
0.00
%
0.05
%
0.37
%
0.00
%
0.19
%
0.04
%
0
0
0
1
1
0
1
0
1
1
0
1
3
270
250
520
6779
denominator
PSI
8
-
Postop Hip Fracture
Postop PE or DVT
Postop Sepsis
Postop Wound
Dehiscence
Accidental
Puncture/Laceration
0.01
%
0.76
%
1.36
%
0.76
%
1.36
%
0.00
%
0.23
%
0.90
%
0.00
%
0.05
%
numerator
denominator
2166
712
689
710
2111
671
662
649
198
2
-
-
-
-
-
Stat
e
Obs
Rat
e
CY1
4
Rate
Q1
Apr15
May15
Jun15
Q2
Jul15
Aug15
Sep15
Q3
Oct15
Nov15
Dec15
Q4
YTD
5.95
%
12.5
0%
33.3
3%
0.00
%
33.3
3%
50.0
0%
33.3
3%
0.00
%
0.00
%
0.00
%
0.00
%
-
-
-
-
27.7
8%
numerator
3
0
1
1
2
0
0
0
0
0
5
denominator
9
1
3
2
6
2
0
1
3
0
18
4.17
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
5.88
%
2.50
%
0.00
%
0.00
%
0.00
%
1.99
%
numerator
2
0
0
0
0
0
0
1
1
0
0
0
3
denominator
48
21
14
15
50
10
13
17
40
9
4
13
151
Inpatient Quality Indicators
(IQI)
IQI1
5
IQI1
6
AMI Mortality Rate
CHF Mortality Rate
2.87
%
2.58
%
11
-
IQI1
7
IQI1
8
IQI1
9
20.0
0%
0.00
%
0.00
%
50.0
0%
11.1
1%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
numerator
1
0
0
1
1
0
0
0
0
denominator
5
3
4
2
9
3
3
3
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
Acute Stroke Mortality
Rate
GI Hemorrhage
Mortality Rate
8.06
%
2.20
%
2.04
%
0.00
%
7.41
%
0
0
0
2
9
3
1
4
27
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
-
numerator
0
0
0
0
0
0
0
0
0
0
0
0
0
33
12
12
12
36
11
13
10
34
11
9
20
123
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0
0
0
0
0
0
0
0
0
0
0
0
0
Hip Fracture Mortality
Rate
2.30
%
5.88
%
-
14
2
8
5
15
7
5
7
19
5
6
11
59
4.94
%
0.00
%
0.00
%
10.5
3%
3.51
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
0.00
%
2.97
%
numerator
4
0
0
2
2
0
0
0
0
0
0
0
0
6
denominator
81
22
16
19
57
17
17
13
47
5
6
6
17
202
33.3
3%
0.00
%
33.3
3%
50.0
0%
33.3
3%
0.00
%
0.00
%
0.00
%
0.00
%
-
-
-
-
27.7
8%
numerator
3
0
1
1
2
0
0
0
0
0
5
denominator
9
1
3
2
6
2
0
1
3
0
18
denominator
IQI3
2
0.00
%
denominator
numerator
IQI2
0
0.00
%
-
Pneumonia Mortality
Rate
AMI without Transfers
Mortality Rate
3.43
%
6.06
%
2.34
%
5.88
%
BHN - see chart below
12
CY 15
AHCA
Esophageal Resection
IQI8 Mortality Rate (Removal
of the Throat)
Pancreatic Resection
IQI9 Mortality Rate (Removal
of the Pancreas)
Adbominal Aortic
CMS2010 IQI11 Aneurysm Repair
Mortality Rate
Craniotomy Mortality
IQI13 Rate (Surgical opening of
the skull)
Hip Replacement
CMS2010 IQI14
Mortality Rate
Acute Myocardial
IQI Comp IQI15 Infarction Mortality Rate
(Heart Attack)
Congestive Heart Failure
IQI Comp IQI16
(CHF) Mortality Rate
Acute Stroke Mortality
IQI Comp IQI17
Rate
Gastrointestinal (GI)
IQI Comp IQI18 Hemorrhage Mortality
Rate
Hip Fracture Mortality
IQI Comp IQI19
Rate
Pneumonia Mortality
IQI Comp IQI20
Rate
IQI30 PCTA Mortality Rate
Carotid Endarectomy
IQI31
Mortality Rate
Acute Myocardial
IQI32 Infarction Mortality Rate,
w/o Transfer Cases
CY14
1
1
100%
0
1
0.00%
0
16
0.00%
7
105
6.67%
0
546
0.00%
6
180
3.33%
5
465
1.08%
26
371
7.01%
1
292
0.34%
2
153
1.31%
3
271
1.11%
3
143
2.10%
6
173
3
2979
0.10%
0
Death in Low Mortality
812
DRGs
0.00%
13
Decubitus Ulcer
3572
0.36%
6
Death among Surgical
inpatients w serious
37
treatable cc
16.22%
0
Foreign Body Left in
0
During Procedure
5
Iatrogenic Pneumothorax 11381
0.04%
7
Central Venous Catheter 8427
BSI
0.08%
0
Postoperative Hip
1538
Fracture
0.00%
Complications of
EXP1
Anesthesia
PSI2
PSI Comp PSI3
CMS2010 PSI4
PSI5
CMS2010 PSI6
PSI Comp PSI7
PSI Comp PSI8
Perioperative hemorrhage
PSI9
or hematoma
Operative physiologic
PSI10 and metabolic
derangements
CMS2012 PSI11
Postoperative respiratory
failure
Postoperative Pulmonary
CMS2012 PSI12 Embolism or Deep Vein
Thrombosis
PSI Comp PSI13 Postoperative Sepsis
Postop wound
CMS2010 PSI14 dehiscsence in
abdominopelvic surg pts
Accidental Puncture or
CMS2010 PSI15
Laceration
5
3548
0.14%
2
1487
0.13%
30
2368
1.27%
12
3589
0.33%
0
262
0.00%
0
305
0.00%
18
12865
0.14%
PSI16 Tranfusion Reaction
-
O
b
s
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
0
0
0
0
0
0
1
11
9.09%
0
47
0.00%
3
21
14.29%
1
48
2.08%
2
41
4.88%
0
21
0.00%
0
13
0.00%
0
40
0.00%
0
14
0.00%
0
2
0.00%
3
17
17.65%
0
0
0
0
0
1
0.00%
2
8
25.00%
0
48
0.00%
1
19
5.26%
0
42
0.00%
2
33
6.06%
0
25
0.00%
1
21
4.76%
0
15
0.00%
0
12
0.00%
0
1
0.00%
1
19
5.26%
0
0
.
0
1
0.00%
0
2
0.00%
1
13
7.69%
0
33
0.00%
1
18
5.56%
1
27
3.70%
0
31
0.00%
0
25
0.00%
0
8
0.00%
0
21
0.00%
1
12
8.33%
0
2
0.00%
1
18
5.56%
0
0
0
0
0
3
0.00%
0
13
0.00%
0
47
0.00%
0
12
0.00%
0
34
0.00%
1
35
2.86%
0
18
0.00%
0
8
0.00%
0
29
0.00%
0
7
0.00%
0
3
0.00%
0
12
0.00%
0
0
0
0
0
0
0
7
0.00%
0
37
0.00%
1
12
8.33%
1
35
2.86%
4
41
9.76%
1
21
4.76%
0
15
0.00%
1
21
4.76%
0
6
0.00%
0
4
0.00%
1
11
9.09%
0
0
0
0
0
2
0.00%
0
10
0.00%
0
36
0.00%
0
14
0.00%
1
46
2.17%
1
29
3.45%
0
22
0.00%
0
11
0.00%
0
16
0.00%
1
7
14.29%
0
3
0.00%
0
13
0.00%
0
66
0.00%
0
276
0.00%
0
3
0.00%
0
0
0
1030
0.00%
0
666
0.00%
0
137
0.00%
0
0
0
0
0
2
0.00%
0
9
0.00%
0
57
0.00%
0
13
0.00%
0
41
0.00%
3
29
10.34%
0
25
0.00%
1
15
6.67%
0
33
0.00%
0
11
0.00%
0
2
0.00%
0
12
0.00%
1
324
0.31%
0
69
0.00%
2
327
0.61%
0
3
0.00%
0
0
0
1101
0.00%
0
474
0.00%
0
140
0.00%
0
0
0
0
0
1
0.00%
0
15
0.00%
0
39
0.00%
0
9
0.00%
2
58
3.45%
1
33
3.03%
0
16
0.00%
0
9
0.00%
2
30
6.67%
0
16
0.00%
0
2
0.00%
0
9
0.00%
0
75
0.00%
1
312
0.32%
1
3
33.33%
0
0
0
1089
0.00%
0
747
0.00%
0
129
0.00%
0
0
0
0
0
2
0.00%
1
9
11.11%
0
43
0.00%
1
13
7.69%
0
46
0.00%
3
30
10.00%
1
21
4.76%
0
19
0.00%
0
39
0.00%
1
16
6.25%
0
1
0.00%
1
13
7.69%
0
333
0.00%
0
77
0.00%
0
325
0.00%
0
3
0.00%
0
0
0
1159
0.00%
1
774
0.13%
0
158
0.00%
0
85
0.00%
2
318
0.63%
0
5
0.00%
0
0
0
1098
0.00%
0
755
0.00%
0
160
0.00%
0
81
0.00%
5
307
1.63%
2
4
50.00%
0
0
0
1022
0.00%
1
704
0.14%
0
147
0.00%
0
76
0.00%
4
300
1.33%
0
3
0.00%
0
0
0
1047
0.00%
0
741
0.00%
0
149
0.00%
0
76
0.00%
0
263
0.00%
0
2
0.00%
0
0
1
1008
0.10%
0
690
0.00%
0
132
0.00%
0
66
0.00%
0
255
0.00%
0
0
0
0
0
920
0.00%
0
620
0.00%
0
123
0.00%
1
129
0.78%
0
112
0.00%
3
105
2.86%
3
310
0.97%
0
16
0.00%
0
27
0.00%
0
1126
0.00%
0
0
-
1
294
0.34%
0
115
0.00%
4
109
3.67%
0
302
0.00%
0
22
0.00%
0
24
0.00%
0
1053
0.00%
0
0
-
0
332
0.00%
0
119
0.00%
1
109
0.92%
1
332
0.30%
0
28
0.00%
0
21
0.00%
0
1202
0.00%
0
0
-
0
323
0.00%
1
144
0.69%
6
127
4.72%
0
322
0.00%
0
23
0.00%
0
32
0.00%
0
1147
0.00%
0
0
-
0
279
0.00%
0
135
0.00%
2
122
1.64%
1
313
0.32%
0
27
0.00%
0
23
0.00%
0
1142
0.00%
0
0
-
0
284
0.00%
0
133
0.00%
3
127
2.36%
1
318
0.31%
0
18
0.00%
0
31
0.00%
0
1047
0.00%
0
0
-
2
308
0.65%
0
135
0.00%
1
124
0.81%
3
338
0.89%
0
20
0.00%
0
29
0.00%
0
1077
0.00%
0
0
-
1
247
0.40%
0
113
0.00%
0
105
0.00%
0
281
0.00%
0
16
0.00%
0
20
0.00%
1
1039
0.10%
0
0
-
1
232
0.43%
0
108
0.00%
1
103
0.97%
2
362
0.55%
0
21
0.00%
0
29
0.00%
0
943
0.00%
0
0
-
13
Oct
Nov
Dec
-
-
.
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
YTD
0
0
0
1
0.00%
0
13
0.00%
5
95
5.26%
0
387
0.00%
7
131
5.34%
6
377
1.59%
17
302
5.63%
2
194
1.03%
2
119
1.68%
3
244
1.23%
3
101
2.97%
0
20
0.00%
7
124
5.65%
1
657
0.15%
0
671
0.00%
14
2683
0.52%
3
26
11.54%
0
0
1
9474
0.01%
2
6171
0.03%
0
1275
0.00%
6
2428
0.25%
1
1114
0.09%
21
1031
2.04%
11
2878
0.38%
0
191
0.00%
0
236
0.00%
1
9776
0.01%
0
0
-

Communications with Doctors scoring from HCAPHS is in the CMS 75th percentile during first
contracted year; CMS 80th percentile during second contracted year; CMS 85th percentile during
third contracted year. - What is the current performance level?
HCAHPS Communication with MD to be at the 50th percentile need 81.50 and 85.50 is 75th –
BHIP: CY 2015 was 78.32 or 13th percentile. March it is 84.44.
BHCS: CY 2015 was 74.25 or 5th percentile; CYTD = 76.45 or 11th percentile.
BHN: CY2015 was 54th percentile. Scores by month shown below.
HCAHPS Composites
*included in Value Based Purchasing
3 Communication with Doctors*
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Cal Yr
78%
77%
78%
80%
81%
84%
81%
78%
82%
79%
78%
80%
80%
75th
%ile
86%
89%

55% of the discharge orders are in by 10:30am (orders cannot include pending consult discharge
order or test(s). What is the baseline performance level?
BHIP: 65% of the discharge orders are by noon.
BHCS: 35% are written by 10AM and 66% are written by noon.
BHN: 30%

Consultants to be utilized below the national benchmark. How does patient acuity level factor
into this? It does not. We base it on national average. What is the current national benchmark?
1.48

The Admits, Observation cases, and Patient Days are listed as Hospital Volume. Do these
numbers indicate all patient volume or is this specific to Hospitalist volume? Can you please
confirm this? The volumes provided in the RFP were for the entire hospital. Additional detail has
been provided in this addendum.

If this is all Hospital volume, can we get Hospitalist-specific info relative to at least these
3 data sets? Charts within this addendum show volume and payor mix for the hospitalist
cases we tracked monthly.

The RFP states that Broward Health North would like to add a Hospitalist program. Is there
currently a Hospitalist service in place? No.

If so, how many Hospitalist physicians are on staff? None. Care for the unassigned is done by oncall physicians. How many work days/nights? N/A.

For each of the three facilities, please explain the ICU involvement for the Hospitalist team. Are
the hospitalists required to perform procedures and what procedural experience is necessary?
All three facilities: Open ICU- hospitalist manages critical care with consult for subspecialties as
needed –i.e. vent patients consulted with pulmonary, dialysis managed with nephron, etc.

Do any of the hospitals have an Intensivist program? No.
14
90th
%ile

Top 5 DRG’s for each facility (also excludes all patient age 0-18):
All Payors
BHIP
BHCS
DRG 191 CHRONIC OBSTRUCTIVE PULMONARY D
81
114
DRG 192 CHRONIC OBSTRUCTIVE PULMONARY D
76
118
DRG 194 SIMPLE PNEUMONIA & PLEURISY W C
100
83
DRG 291 HEART FAILURE & SHOCK W MCC
48
103
DRG 292 HEART FAILURE & SHOCK W CC
100
90
DRG 312 SYNCOPE & COLLAPSE
48
83
DRG 313 CHEST PAIN
61
73
DRG 392 ESOPHAGITIS, GASTROENT & MISC D
305
501
DRG 552 MEDICAL BACK PROBLEMS W/O MCC
25
64
DRG 603 CELLULITIS W/O MCC
325
315
DRG 641 MISC DISORDERS OF NUTRITION,MET
88
45
DRG 683 RENAL FAILURE W CC
192
142
DRG 690 KIDNEY & URINARY TRACT INFECTIO
117
153
DRG 812 RED BLOOD CELL DISORDERS W/O MC
73
322
DRG 871 SEPTICEMIA OR SEVERE SEPSIS W/O
65
204
38
142
DRG 897 ALCOHOL/DRUG ABUSE OR DEPENDENC
131
29
DRG 918 POISONING & TOXIC EFFECTS OF DR
92
21
4,833
15
6,702
BHN
120
111
93
105
200
175
213
377
144
370
66
100
131
134
114
40
131
90
8,215
Top 10 Discharged DRG's by facility
no exclusions (except normal newborns)
DRG 194 SIMPLE PNEUMONIA & PLEURISY W C
DRG 203 BRONCHITIS & ASTHMA W/O CC/MCC
DRG 292 HEART FAILURE & SHOCK W CC
DRG 312 SYNCOPE & COLLAPSE
DRG 313 CHEST PAIN
DRG 392 ESOPHAGITIS, GASTROENT & MISC D
DRG 470 MAJOR JOINT REPLACEMENT OR REAT
DRG 603 CELLULITIS W/O MCC
DRG 683 RENAL FAILURE W CC
DRG 690 KIDNEY & URINARY TRACT INFECTIO
DRG 765 CESAREAN SECTION W CC/MCC
DRG 766 CESAREAN SECTION W/O CC/MCC
DRG 775 VAGINAL DELIVERY W/O COMPLICATI
DRG 794 NEONATE W OTHER SIGNIFICANT PRO
DRG 812 RED BLOOD CELL DISORDERS W/O MC
DRG 881 DEPRESSIVE NEUROSES
DRG 885 PSYCHOSES
DRG 897 ALCOHOL/DRUG ABUSE OR DEPENDENC
DRG 945 REHABILITATION W CC/MCC
DRG 946 REHABILITATION W/O CC/MCC
16
BHIP
100
44
102
49
61
305
159
342
199
121
74
71
140
2,026
146
-
BHCS
170
221
92
83
74
545
164
409
148
208
313
619
1,137
411
332
218
9
29
-
BHN
121
58
224
199
233
444
751
473
151
177
185
162
5
30
168
362
189
8,406
12,614
13,993

BROWARD HEALTH ENTERPRISE HOSPITALIST SERVICES RFP

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