Assessing Participation Status

Quality Improvement Standards in the Annual Assessment

The Annual evaluation takes place in May. Determination of Participation Status is based on the following QI standards:

  • Complete and timely data submission for the data year (including > 90% valid responses in the mortality field) by February 28th of the following year
  • Successful correction of performance outliers identified on the prior data year’s Risk-Adjusted Clinical Dashboard
  • At least 90% valid responses on Level I and Level II measures. If a measure cannot be analyzed because less than 90% of procedures contain valid responses for that measure, it will appear as an outlier on the Annual Risk-Adjusted Dashboards. The Algorithm for creation of the Dashboards provides detailed information on the handling of missing data.

Quality Improvement Standards in the Mid-Year Assessment

The mid-year evaluation takes place in the fall. Determination of Participation Status is based on the following QI standards:

  • Hospital has submitted a QI plan to address outliers identified on the Annual Risk-Adjusted Clinical Dashboards
  • Data collection staff have met the standard on inter-rater reliability test(s)
  • Case counts for the most recent data year have been validated against CHARS or other external reference data

Participating in COAP, in Full Compliance with QI Standards

The site is a participant and has met ALL of the QI standards, i.e.

Complete data (requires > 90% valid responses in the mortality field) submitted as of February 28th.

AND

Invalid case counts from the prior data year have been resolved.

AND

Any Level I measures that were outliers in the prior data year or the prior three-year average do not persist as outliers into the current data year.

AND

Two or fewer of the Level II measures that were outliers in the prior data year or the prior three-year average persist as outliers into the current data year.

AND

None of the Level I indicators and two or fewer of the Level II indicators from the prior TWO three-year averages persist as outliers in the current three-year average (new criterion as of the 2004 data year – see definition below)

Definitions

Participating in COAP: contract signed, submitting payments when invoiced, and submitting data.

Level I Measures – CABG: mortality, post-operative stroke, new requirement for dialysis, use of arterial grafting

Level I Measures – PCI: mortality

Level II Measures – CABG: length of stay, early extubation rate (“early”: < 6 hours), RBC transfusion rates, return to OR

Level II Measures – PCI: post-procedure MI, ER to dilation time (STEMI), excellent lesion results, adverse post-procedure events, extended length of stay (primary PCI > 5days, non-primary PCI > 2 days). PCI Level II indicators were updated in 2004 – click here for more information.

Outlier: hospital performance for a quality measure differs unfavorably from the state average by more than two standard deviations.

Three-year average: hospital performance averaged over three years. Adopted as a new criterion for participation status in the data year 2004. This indicator provides a view of the pattern of performance over a longer period of time. (Click here for examples of how the criterion affects participation.)

Approved by COAP Management Committee: October 20, 2004