eCQM Quality Improvement

Short Demo for Quality Improvement on the DDSP (duration: 9:14 minutes) click the link or copy/paste the following text in your web browser:
https://attendee.gotowebinar.com/recording/1216788166928826880

Purpose:

When selecting 'eCQM Submission' from the menu, the 'Quality Improvement' page becomes available.

Click on the 'Quality Improvement' tab to:

Evaluate the Initial Population and Observed Rate/Observation Value for eCQMs associated to active patient (accepted QRDA I documents).
Review patient data (QRDA I document) to understand how they processed against the eCQM logic.

The page provides the ability to access the Source Viewer and eCQM Logic Explorer for all Active Documents.

This page is intended to be used by users with knowledge of the structure and format of the QRDA I documents as well as how the content was processed against the eCQM logic. Familiarity with the QRDA I technical documentation will assist users of this page in identifying the reason why QRDA I documents were rejected or warnings generated.

Tip - Results will appear after data is loaded and processed

The Upload Data page may show that individual QRDA I file or the zip files have been uploaded to the DDSP; however, this page may display the message "Results will appear after data is loaded and processed".

Confirm that the uploaded file did not generate any high-level platform errors by reviewing the ‘Data Details’ on the Upload Data page.
If no high-level errors were generated by the file, then your file is in the queue for processing against the Schematron, edits, and eCQM logic.
The processing turnaround time is dependent upon how many other files (including from other organizations) are waiting in the queue for processing.
If you continue to receive this message after 24 hours, please create a DDSP Support Ticket by clicking on the 'Need Help?' button in the upper right-hand corner of the page.

How to Use:

Browser Zoom

This page may best be viewed at a zoom percentage less than 100%. The best zoom for you will depend on your computer and monitor.

Right-Click to Export

Right-clicking on file in ‘Active Documents’ provides the ability to export the data of all files or selected files as Excel or as CSV. To export specific files, select the files you would like to export by left-clicking on them and then right-click to popup the menu and click on ‘Export as Excel’ or ‘Export as CSV’. To export all files, move the cursor over any file in ‘Active Documents’ and right-click then choose ‘Export as Excel’ or ‘Export as CSV’ on the popup.

Quality Improvement Counts

The ‘Quality Improvement’ section of the page contains counts concerning the measures and patients that have been accepted and are active on the DDSP.

Definitions for Quality Improvement Counts:

Measure: The measure selected in the ‘Select Measure’ control.
Active Patients: For the selected Measure and Quarter, count of all unique patients among the active QRDA I documents that are uploaded.
Episodes of Care: For the selected Measure and Quarter, count of all unique encounters that the Active Patients had during the calendar quarter.
A patient that is discharged one time during the calendar quarter will have a one-to-one relationship between “active patient” and “episode of care”.
A patient that is discharged three times during the calendar quarter, will have a one-to-three relationship such that there is one “active patient” related to the three “episode of care”.

For example:

If there are five (5) “Active Patients” in the eCQM for the calendar quarter with one (1) encounter each, the number of “Episodes of Care” equals five (5).
If there is one (1) “Active Patients” discharged five times during the calendar quarter, the number of “Episodes of Care” equals five (5).
If there are five (5) “Active Patients” during the calendar quarter where:
- Two (2) were discharged two (2) times and
- Three (3) were discharged one (1) time,
- The number of “Episodes of Care” equals seven (7).

Active Documents

The last accepted QRDA I document processed by the DDSP with the same Key information (Patient ID in the PatientRole element and Quarter in the effective date in the Reporting Parameters section) will become the Active Document within the Platform and be counted as the Active Patient on this page. Do not split a patient's data into multiple QRDA I documents (e.g., ED and Stroke data) as the last QRDA I document processed for the patient will be the Active Document/Patient, which will affect your hospital's measure rates.

Error and Warning Messages

The Data Accuracy page is about those QRDA I documents which generated an error or warning, the Quality Improvement page is about those QRDA I documents that received only warnings or no warning/error messages.

Results by Measure

The ‘Results by Measure’ section of the page provides the Initial Population count and Observed Rate or Observation value for the measures and episodes of care.

Definitions for Results by Measure:

Initial Population: Count of all episodes of care evaluated that meet the Initial Population of the eCQM.
Observed Rate / Observation:
- Proportion eCQMs: The Observed Rate is calculated as the [Numerator divided by the Denominator].
- Continuous Variable eCQMs: The Observation value is the result of the “measure observations” calculation defined within the eCQM specification to evaluate the care provided by the hospital.
  - For example, time (in minutes) from ED facility location arrival to ED facility location departure for patients admitted to the facility from the emergency department.

Display More Measures

If all measures are not being displayed, hover over the Initial Population and Observed Rate / Observation data contained within the table and a scroll bar will appear on the right-side of the table. This will allow you to scroll down to see the additional measures for which data has been uploaded.

Population Breakdown for the Selected Measure (Episodes of Care)

The ‘Population Breakdown for the Selected Measure (Episodes of Care)’ Waterfall Chart shows how each patient’s episode of care were processed against the selected eCQM, for the selected calendar quarter.

A QRDA I document contains data for all episodes of care for a single patient that are related to a calendar quarter.
Patients admitted in one quarter and discharged in another quarter, will be counted in the calendar quarter in which they were discharged.
See definition of the components of the Waterfall Chart below.

Select Measure (left-hand side of page):

The ‘Select Measure’ element contains a drop-down list of the eCQMs that were processed against the uploaded patient data that were Accepted.

Select Quarter (left-hand side of page):

The ‘Select Quarter’ element contains the list of calendar quarters, based on patient discharge date, for which patient data has been uploaded for the selected measure.

Note: If all quarters are not being displayed, hover on any of the quarters within the table and a scroll bar will appear on the right-side of the table, scroll down to see all quarters applicable for the measure being reviewed.

Clear Selection (right-hand side of page, above 'Active Documents')

The ‘Clear Selection’ button returns the page back to its original display.

Active Documents (right-hand side of page):

The ‘Active Documents’ section lists all active QRDA I documents which have been uploaded and were not rejected due to an error.

Patients (QRDA I documents) which have been replaced by being re-uploaded are not accessible. Only the last version of a given document is ‘active’ and may be reviewed. For example:
- The QRDA I document for Mary Jane (named ‘Mary Jane QRDA’) is uploaded on 4/1 in a zip file named ‘MJ’.
- The QRDA I document for Mary Jane (named ‘Mary Jane QRDA’) is re-uploaded on 4/2 in a zip file named ‘MJ-2’.
- Only the 4/2 version of the Mary Jane QRDA I document is ‘active’ and available to be reviewed on this page.
Clicking on the ‘Magnifying Glass’ icon next to an active QRDA I document launches the Source Viewer and eCQM Logic Explorer which provides:
- A review of the patient data and how the active QRDA I document was processed against the eCQM logic, and if necessary
- The list of Schematron and Edit warnings that the file generated along with the ability to view the specific XML file structure of where the warnings occurred.

Review Patient Results (right-hand side of page, below 'Active Documents'):

Clicking this button will take you to a new page that will display how each patient's episode of care processed against the measure.

image-20240702-152706.png This picture shows the Quality Improvement page with notes next to useful information and selection boxes, where you can select measure, quarter, HCO and patient QRDA file name.

Definitions for the Waterfall Chart Population Breakdown for the Selected Measure:

Page Element	eCQM processed against
Episodes of Care	Count of all Active episodes of care evaluated by the eCQM. Note: QRDA I documents are evaluated by an eCQM if the Measure Section within the document states that the measure should be processed. In this manner, hospitals can add or remove measures from those they wish to evaluate or submit.
Not in Initial Population	Count of episodes of care which did not pass the Initial Population logic. The Not in Initial Population is calculated as the [Episodes of Care - Initial Population]
Initial Population	Count of episodes of care evaluated which meet the Initial Population as documented in the specification
Does Not Meet	Count of episodes of care in the Initial Population that does not meet the measure population criteria for the measure
Measure Population	Count of episodes of care that meet the population criteria for the measure Depending on the measure, it can be the same count as the Initial Population or a subset of the Initial Population if the measure further constrains the Initial Population (e.g., Ischemic and Hemorrhagic stroke patients) The Measure Population is calculated as the [Initial Population minus Does Not Meet]
Exclusions	Count of episodes of care that are removed from the Measure Population because they meet specific criteria that made it clinically unnecessary for the patient to receive the numerator clinical action. In proportion measures, these episodes of care are removed before determining if the Numerator criteria are met In continuous variable measures, these episodes of care are removed before calculating the measure’s Observation value
Exceptions	Proportion measures: Count of episodes of care removed from the Measure Population because the Numerator criteria were not met Exceptions are generally provider or patient determined reasons for refusing certain clinical actions Continuous Variable measures: not applicable
Denominator / Population	"Denominator" for Proportion eCQMs: Count of episodes of care for which the measure applies after removing those episodes of care that were either excluded or had exceptions The Denominator value is used when calculating the Observed Rate Denominator = [Measure Population minus (Exclusions plus Exceptions)] "Population" for Continuous Variable eCQMs: Count of episodes of care used to calculate the Observation Value Population = [Measure Population minus Exclusions]
Cases Failing the Measure	Proportion measures: Count of Denominator episodes of care which do not meet the Numerator criteria Continuous Variable measures: not applicable
Numerator	Proportion measures: Count of episodes of care which meet the processes or outcomes evaluated by the measure Numerator = [Denominator minus Cases Failing the Measure] Continuous Variable measures: not applicable

How each element of the page affects the other page elements:

Counts at top of page

The counts at the top of the page adjust as the elements on the page are modified. Clearing these selections returns the counts back to their original state.

Page Elements	User Action	Population Breakdown for the Selected Measure	Select Measure	Select Quarter	Documents
Population Breakdown for the Selected Measure	Clicking a measure result (population bar) within the Waterfall Chart	Highlights population bar for that measure result	No change	Displays quarter(s) for which patient data exists with that measure result	Displays the patient’s active QRDA I document(s) which received the measure result
Select Measure	Clicking a specific measure	Displays measure result breakdown for selected measure	Displays selected Measure in drop-down box	Displays quarter(s) for which patient data exists for the selected measure	Displays each patient’s active QRDA I document in the Initial Population of selected measure
Select Quarter	Clicking a specific quarter to further filter the measure data	Displays measure result breakdown for selected measure and quarter	No Change	Highlights selected Quarter	Displays each patient’s active QRDA I document in the Initial Population of selected measure and quarter
Active Documents	Clicking a specific patient’s QRDA I document	Displays measure result for the selected patient	No Change	Displays quarter associated for the selected QRDA I	Highlights selected patient’s QRDA I document
Clear Selection	Clicking ‘Clear Selection’ button	Returns the entire page back to its original state

Important Information for Using the Quality Improvement page

Joint Commission DDSP User Documentation

The Joint Commission