Quality Transparency Dashboard FAQ
Frequently Asked Questions

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Quality Transparency Dashboard Frequently Asked Questions
(FAQs): 

1. What is the Quality Transparency Dashboard? 

The Quality Transparency Dashboard is an Excel file consisting of a single presentation page and two supporting tabs. The presentation page is a succinct expression of five quantitative measures and three programs. The dashboard includes consumer-level explanations and limitations of each measure. Hospitals may complete their program status and they may add comments. Please review these webinars:

Quality Transparency Dashboard Quarterly Update: May 2018

Quality Transparency Dashboard Quarterly Q&A: May 2018

2. What should hospitals do with the Quality Transparency Dashboard Excel file?

Upon receipt of Excel file from Hospital Quality Institute (HQI), hospitals are asked to:

  • Review data for accuracy
  • Provide yes/no information about their evidence-based quality of care practices by filling in checkboxes
  • Provide optional comments about performance and initiatives
  • Post the information to the hospital’s public-facing website

Send the link for your posted dashboard to HQIanalytics@hqinstitute.org in order for HQI to count your participation

3. Which measures appear in the dashboard?

The quantitative measures include: 

  • CLABSI – Central line-Associated Blood Stream Infection
  • Colon SSI – Colon Surgical Site Infection
  • NTSV – Nulliparous, Term, Singleton, Vertex Cesarean Birth Rate
  • Sepsis Mortality
  • Hospital-wide All-Cause 30-day Unplanned Readmission Rate

The program areas include:

  • Maternity Safety Program
  • Sepsis Protocol 
  • Respiratory Monitoring Program

4. Why did HQI select these measures?

Subject matter experts, in conjunction with HQI and Patient Safety Movement Foundation representatives, selected these measures from available data that hospitals report to other government and non-government organizations. 

5. Where did these data originate? 

  • HQI extracted CLABSI and Colon SSI data from CMS Hospital Compare HAI files
  • NTSV C-section rates from CMQCC
  • Hospital-wide All-Cause 30-day Unplanned Readmission Rate from CMS Hospital Compare Unplanned Hospital Visits files
  • Sepsis Mortality rate calculated from Office of Statewide Health Planning and Development (OSHPD) inpatient discharge files  

6. Why is HQI involved?

HQI provides coordination and support for improvement and harmonizes measures for patient safety and quality improvement activities for California Hospital Association, Hospital Council of Northern and Central California, Hospital Association of Southern California, and Hospital Association of San Diego and Imperial County.  The organization builds reliable and sustainable measures to gauge California’s performance and identifies opportunities for focus and innovation.

7. Who will have access to my hospital’s quality transparency dashboard?

Any member of the public who can access a given hospital’s website will be able to access the quality transparency dashboard posted on that website.

8. How can my hospital improve these outcomes?

Improvement requires organization-wide commitment in conjunction with a coherent approach. There are numerous tools available at the HQI webpage for Clinical Harm Elimination.  

9. How can I share these measures on my hospital’s website?

Many hospitals have a web development team, while others may lack such resources. Each hospital may modify the format and appearance of the information in the dashboard to suit its needs. The simplest approach might be to capture the Excel presentation tab and post it as a graphic image. Other approaches may involve reformatting the information for display in a web browser.

10. How many hospitals will participate and have the dashboard available on their website?

HQI strongly encourages all acute care hospitals in California to voluntarily participate.  

11. When will hospitals post dashboard content?

Hospitals will be posting the dashboards on their websites over the next several months.  Our goal is for the dashboards to be available across the state by the end of 2018. Visit the Quality Transparency Scorecard page for a current picture of the number of participating hospitals in California.

12. How does HQI plan to inform the public about the availability of this dashboard?

HQI and the Patient Safety Movement Foundation regularly communicate about the availability of the dashboard through various channels. Each hospital may choose how to communicate the availability of this information to its community.

13. Will there be an expansion of the quality of care measures?

HQI, in conjunction with Patient Safety Movement Foundation and the hospital associations, may consider additional measures in the future.

14. How often will HQI update data?

HQI will perform updates based on data releases from identified sources. Some of these sources update quarterly, while others update annually.

15. Are the quality of care measures specific to the hospital?  

Data reported on the hospital quality dashboard are specific to each hospital.  Hospitals also have an opportunity to provide comments on the dashboard describing their continuous improvement to patient safety and quality of care.

16. Why does CLABSI and/or Colon SSI display as “not available” in some dashboards?

National Healthcare Safety Network (NHSN) calculates standardized infection ratios (SIR) only when the expected number of infections during the specified time interval is at least 1.0. Expected number of infections less than 1.0 yields not available. EXCEPTION: Based on stakeholder feedback, dashboards will display SIR of 0.0 when the number of observed infections was 0.0, regardless of the expected number of infections (effective May 2018-Q2 release).

17.  Can a hospital modify the dashboard?

Hospitals may modify the dashboard to meet local visual presentation and accessibility needs. HQI encourages hospitals to address the minimum data and content, with the local option of adding content such as other measures or more timely data.

18. Where can a hospital obtain further assistance?

Contact the HQI Analytics Team at HQIAnalytics@hqinstitute.org

19. Are there examples of the way that other hospitals have implemented the hospital quality transparency dashboard on their websites?

Contact the HQI Analytics Team at HQIAnalytics@hqinstitute.org for some examples.

20. Can a hospital display other measures in addition to those already included on the hospital quality transparency dashboard?

The five outcome measures and the three program measures are a minimum measure set. Hospitals are encouraged to display additional measures.

21. The hospital transparency dashboard shows “ABC Hospital” in the name, instead of my hospital name. Is this the correct file?

To show your hospital’s data, open the spreadsheet file and click “Enable editing” 

22. What is the easiest way to implement the hospital quality transparency dashboard on our website?

Check the program status boxes, add comments if needed, save as pdf, and post the pdf on your website.

23.  Can my hospital just add links to other websites that show quality data instead of posting the dashboard?

Some hospitals already present quality data or links to external quality data on their websites, which is consistent with the goal of improving hospital transparency about quality measures. The Quality Transparency Dashboard is intended to be an easy way for other hospitals to join the transparency evolution. HQI encourages hospitals to share data on their own websites as the preferred method, either using the provided dashboards or their own presentation, as this is much more convenient and transparent for the health consumer and community.

24. What needs to be in place for our hospital to respond ‘Yes’ to the questions that our hospital has programs in place for maternal safety, sepsis, and respiratory monitoring?

A program is a planned series of actions to accomplish a specified objective. Responding ‘yes’ to any of the three clinical program questions attests that minimum program components are in place:

  1. Implementation and use of evidence-based clinical protocols to guide care.
  2. A multidisciplinary group or champion leading, monitoring, and improving hospital performance on the topic.

Additionally, a hospital that responds “Yes” may have:

  1. Implementation and use of evidence-based clinical protocols to guide care.
  2. A multidisciplinary group or champion leading, monitoring, and improving hospital performance on the topic.
  3. Identified Physician and clinical champions who lead and role model adherence to best practice protocols in each department where care is delivered, often with a designated champion leader or coordinator.
  4. Access to ongoing clinical education for staff and support for clinical topic competencies.
  5. Electronic records triggers and workflows supporting clinical decision-making and practice guidelines or periodic chart review to confirm adherence.
  6. A commitment to transparency evidenced by sharing performance among staff.
  7. Active patient/family engagement.

For further questions, involving program components, please contact HQI, we are ready to support your work in this area. Lynn Forsey: lforsey@hqinstitute.org

25. What are the maternal safety evidence-based practice components involved in a ‘Yes’ response to the maternal safety program question?

  • Belong to California Maternal Quality Care Collaborative (CMQCC), Alliance for Innovation on Maternal Health (AIM) Program, or other similar organizations.
  • Post-partum hemorrhage bundles.
  • Preeclampsia bundles.
  • Efforts to reduce early elective deliveries.
  • Efforts to lower rate of nulliparous, term, single, vertex, (NTSV) – cesarean births.
  • Guidelines to prevent maternal venous thromboembolism.
  • Emergency response preparedness.

26. What are the respiratory monitoring evidence-based practice components involved in a ‘Yes’ response to the respiratory monitoring program question?

  • Respiratory monitoring is an integral component of care across patient care environments.
  • Assessment/evaluation of pre-surgical patient for risk of respiratory compromise and ASA assignment, and appropriate triage for surgery.
  • Assessment of patients for OSA using STOPBANG or other standardized tool.
  • Use of pulse oximetry or other monitor device for patients at risk for respiratory decline or compromise.
  • Safe opioid prescribing practices.
  • Rapid response team.

https://www.hqinstitute.org/post/reducing-harm-respiratory-depression-non-icu-patients-through-risk-mitigation-and-respiratory

In addition, the Patient Safety Movement Foundation (PSMF) addresses opioid safety related respiratory monitoring. Here is a link to the PSMF APSS:

https://patientsafetymovement.org/actionable-solutions/challenge-solutions/failure-to-rescue-monitoring-for-opioid-induced-respiratory-depression/

27. What are the sepsis care evidence-based practice components involved in a ‘Yes’ response to the sepsis program question?

What are the sepsis care evidence-based practice components involved in a ‘Yes’ response to the sepsis program question?

  • Use of sepsis clinical treatment protocols from a nationally or internationally recognized healthcare safety organization such as The Surviving Sepsis Campaign (http://survivingsepsis.org/Bundles/Pages/default.aspx).
  • Education for early identification of sepsis, including the emergency department workforce.
  • Rapid treatment and monitoring of patient with sepsis, using sepsis bundle or protocol.
  • Champion or coordinator monitoring time to diagnosis, treatment, and adherence to guidelines.

28. How does HQI calculate sepsis mortality?

Please visit the sepsis mortality calculation explanation:  http://www.hqinstitute.org/post/quality-transparency-dashboard-0

29. Why does one Quality Transparency Dashboard list multiple hospitals or locations? How are the data from separate locations treated when multiple locations appear on one dashboard?

HQI creates a single dashboard for all hospitals that share a CMS Certification Number (CCN), because CMS-sourced data (CLABSI, Colon SSI, and VTE) are only available from CMS Hospital Compare aggregated by CCN. In contrast, NTSV and Sepsis Mortality may be reported to CMQCC and OSHPD under separate OSHPD ID numbers. 

In cases where values for NTSV or Sepsis Mortality were available for only one hospital across several hospitals that share a CCN, the values were used to represent all the hospitals in the dashboard. In cases where multiple hospital location-specific values were available, each numerator and each denominator value from each location is combined to create a single measure used to represent all the hospitals appearing in that dashboard.

30. Why was VTE-6 removed from the dashboards?

In response to the Centers for Medicare & Medicaid Services (CMS) dropping VTE-6 (potentially preventable venous thromboembolism) from their Quality Improvement Program Measures for Acute Care Hospitals for fiscal year 2021, HQI replaced the VTE-6 measure with the Hospital-wide All-Cause 30-day Unplanned Readmission Rate starting 2020 Q3.