Welcome to Lesson 2 of ACC's Heart Failure Version 4 Accreditation ACD and Calculated Measures course. This learning activity was developed by myself. I am Liza St. Clair and I will also be narrating this presentation. Our objectives for this module is to demonstrate how to review the Calculated Measures functionalities while using the ACD and also highlight the useful resources that will be available to you to help you better analyze your data. This specific module will review the Calculated Measures functionalities on the online Heart Failure Accreditation Tool. You can easily access Calculated Measures by selecting on the left navigation menu Calculated Measures below the Essential Components selection. Please note that to comply with Clinical Quality Essential Components, facilities are required to review a minimal set of heart failure performance metrics to achieve heart failure accreditation. These metrics include measures that are already collected and monitored by CMS. These include your admission rate, 30-day readmission, and mortality rate. These specific facility performance measures are not collected in the ACD or included in the Calculated Measures function. Therefore, to comply with these measures, all sites will need to demonstrate compliance with these performance metrics by submitting supporting documentation from other data sources. This can be easily done by selecting the Supporting Documents tab and linking an existing supporting document or uploading a new supporting document associated with the essential component. Calculated Measures are reporting measures, which are automatically calculated from the ACD data. Compliance with the measures is provided in a monthly report with a convenient drill-down feature. It is formatted to match all items within the Clinical Quality EC-8, which supports measure process improvement line items within the tool. For EC-8-M1 to EC-8-M5, completing patient episodes of care within the ACD ensures mandatory items within EC-8 are satisfied. If the full ACD is completed, the recommended Calculated Measures will populate as well. To access the Calculated Measures function, select it on the left navigation bar of the Heart Failure Accreditation homepage. This will open up the Calculated Measures homepage. Within the Calculated Measures function, the user can easily access the ACD as well, if needed. On this homepage, the Mandatory Calculated Measures are listed. Below the Mandatory Measures, the Recommended Calculated Measures are listed as well. Similar to the function of the Essential Components, to access more detailed information regarding the Calculated Measures, click on the black caret to the left of the Calculated Measure Identifier. This will allow access to the measure definition and the different components related to the measure. The measure definition references the linked essential component requirements, inclusion and exclusion criteria, and how the measure was computed. To review the facility monthly Calculated Measures report, click on the Measures Year to Date Report hyperlink on the Calculated Measures homepage. During the accreditation process, the Measure Year to Date Report will likely be referenced often to validate the data entry. If the data reflects erroneous information, such as negative numbers or results well outside the range, changes can be made to the patient record as needed. The changes will then be updated and reflected in the report by the next day. This is a sample of the Measure Year to Date Report. The initial screen reflects the monthly data per calculated measure. On the right-hand side of the report, the date and time of when the report was last updated will be displayed. To drill down on the patient episodes of care that qualified for the measure, click on Details under the Calculated Measure Identifier. A table will then display with detailed information. Users may now analyze and validate the cases that were included in the measure and determine how the calculated measure value was computed. If the user would like to review the patient record of any outliers or make any changes to a patient record, then the user simply needs to click on the View hyperlink on the right-hand column to view the patient's ACD record. We began our Heart Failure Version 4 Accreditation Workshop modules with reviewing the current state of heart failure and this graphic. Matthew Edwards Deming is renowned as the father of quality and was quoted to say, you can't manage what you don't measure. By utilizing the ACD or other data sources, the data obtained should serve as a fuel to review compliance with quality and process metrics to drive improvement initiatives. We look forward to our partnership and journey together of achieving Heart Failure Version 4 Accreditation to be the vehicle towards attaining our shared strategic goal of delivering excellent patient care to the community and the heart failure population that you serve. This now concludes Lesson 2 of 2. You have now completed all lessons. Thank you for your participation.

ACC's Heart Failure Version 4 Accreditation ACD

Calculated Measures

Liza St. Clair

data analysis resources

heart failure performance metrics