Fillable AIM3 Data Collection Reporting Month Year Facility Name (HealthInsight)

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AIM3 Data Collection Reporting Month Year Facility Name (HealthInsight)

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AIM3 Data Collection
Discharge Planning
Reporting Month
Submitter Name
Facility Name
Year
Contact Phone
Submitter Title
Contact Email
How many discharged patients have documented evidence in the chart that
they were sent home with a discharge plan?
1
1
• Complete the form and send to Ardis Cochrane at acochrane@healthinsight.org using PDF encryption and your IHS
Secure File Transfer login at https://securedata.ihs.gov/bds/Login.do
• Due by the second Friday of the month through January 10, 2020.
• Find an empty copy of this form at this location https://healthinsight.org/path-lan-2019 June materials.
• If you need help with this form, please contact Ardis Cochrane at acochrane@healthinsight.org.
How many of these patients have a documented attempt of phone contact
within 2 business days following discharge?
Discharge Plans
How many inpatient discharges did your service unit have this reporting month
(excluding hospital-hospital transfers)?
Do you collect this measure?
Did you use a chart sample for this measure?
(Minimum Sample Size: 10 for CAH, 25 for PPS)
Yes No
Yes No
1
2
Documented Phone Contact
Do you collect this measure?
Did you use a chart sample for this measure?
(Minimum Sample Size: 10 for CAH, 25 for PPS)
How many charts that were reviewed for this measure?
Yes No
Yes No
Percentage of inpaents who have a post discharge contact within 2 business days
Percentage of inpatients who are discharged with a post discharge plan
How many charts that were reviewed for this measure?
How many patients had an accurate ESI upon chart review?
1
5
Did your service unit complete a review of sample charts for appropriate tri-
age this reporting month?
Was the data regarding appropriate triage presented to the QAPI committee?
Triage, ESI Accuracy
1
4
Yes No
Did you use a chart sample for this measure?
(Minimum Sample Size: 10 for CAH, 25 for PPS)
Yes No
Yes No
How many of these patients have a documented attempt of phone contact
within 2 business days following discharge?
1
3
Emergency Department Patient Follow Up
Do you collect this measure?
Did you use a chart sample for this measure?
(Minimum Sample Size: 10 for CAH, 25 for PPS)
Yes No
Yes No
For paents who were discharged with provider follow up required, what percent-
age have a post-discharge contact within 2 days?
How many charts were reviewed for this measure?
How many charts were found to have a documented requirement for provider
followup?
Indicate the method of data submission for LWBS rate:
Left Without Being Seen
ED Dashboard raw, de-identied data submitted to HealthInsight using IHS Secure File Transfer. Please submit to
acochrane@healthinsight.org.
How many “Left Without Being Seen” (LWBS) patients (or charts reviewed) had a
documented attempt of phone contact within 2 business days of the visit?
1
6
1
7
ED Dashboard aggregated internally, indicate numerator and denominator here (Please do not enter the rate):
Numerator Denominator
Data collected manually, indicate numerator and denominator here (Please do not enter the rate):
Numerator Denominator
Do not currently collect this data
LWBS Patient Follow Up
Do you collect this measure?
Did you use a chart sample for this measure?
Yes No
Yes No
For ED paents who le prior to being seen by a provider, what percentage have a
post-discharge contact within 2 business days?
How many charts were reviewed for this measure, where the patient presented
to the ED and left prior to being seen by a provider for this reporting month?
LWBS Rate
Numerator: paents who le prior to being seen by a provider
Denominator: paents who presented to the ED this month
ED Throughput Median Times
Indicate the method of data submission for ED Throughput measures:
1
8
This measure refers only to ED patients with the following discharge codes: 1, 2, 3, 4b, 4c, or 5
1 - Home
2 - Hospice, Home
3 - Hospice, Health Care Facility
4b - Acute Care Facility - Critical Access Hospital
4c - Acute Care Facility - Cancer Hospital or Children’s Hospital
5 - Other Health Care Facility
ED Dashboard raw, de-identied data submitted to HealthInsight using IHS Secure File Transfer. Please submit to
acochrane@healthinsight.org.
ED Dashboard aggregated internally (by the service unit or Area), indicate the following including only the
discharge codes above:
Data collected chart review/manually:
Do not currently collect this data
What is the median time in minutes from arrival to triage?
What is the median time in minutes from arrival to MSE?
What is the median time in minutes from arrival to discharge (discharge
codes above)?
What is the median time in minutes from arrival to triage?
What is the median time in minutes from arrival to MSE?
What is the median time in minutes from arrival to discharge (discharge
codes above)?
What is the sample size?
DISCLAIMER: This material was prepared by Comagine Health, the Medicare Quality Innovation Network -Quality Improvement Organization for Nevada, New
Mexico, Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human
Services. The contents presented do not necessarily reect CMS policy. 11SOW-AIAN-19-115
• Thank you for completing this form
• Please send to Ardis Cochrane at acochrane@ healthinsight.org using PDF encryption and your IHS Secure File Transfer
login at https://securedata.ihs.gov/bds/Login.do
• Due by the second Friday of the month through January 10, 2020.
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AIM3 Data Collection Reporting Month Year Facility Name (HealthInsight)

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Completed 8 February 2021

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