montana rural hospital flexibility and rural healthcare performance improvement network orientation...
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Montana Rural Hospital Flexibility
and Rural Healthcare Performance
Improvement Network
Orientation ProgramJune 2011
Some common acronyms…
Flex = Rural Hospital Flexibility Program
PIN = Performance Improvement Network
DPHHS = MT Dept of Public Health and Human Services
MHREF = MT Health Research and Education Foundation, the not-for-profit arm of
MHA
MHA = MT Hospital Association
Some common acronyms…
CAH = Critical Access Hospital
QI = Quality Improvement
PI = Performance Improvement
CMS = Centers for Medicare and Medicaid Services
Montana’s Flex Program MT Grantee = DPHHS Quality Assurance Division
Jeff Buska, Administrator Kathy Lubke, Program Officer
DPHHS contracts with MHREF to administer Flex funded activities
DPHHS retains program evaluation and fiscal management responsibilitiesFlex grant year runs from September 1 thru August 31
Flex/PIN StaffFlex Director
Carol Bischoff 457-8016 [email protected]
Rural Hospital Quality Coordinator
Kathy Wilcox 461-6186 [email protected]
St. John’s Lutheran Hospital
Clark Fork Valley Hospital
Mineral Community Hospital
Marias Medical Center
Liberty Medical Center
Pondera Medical Center
Teton Medical Center
Missouri River Med. Center
Big Sandy Med. Center
Powell Co. Medical Center
Granite Co. Medical Center
Ruby Valley Hospital
Barrett Memorial Hospital
Mountainview Medical Center
Livingston Healthcare
Pioneer Medical Center
Stillwater Comm. Hospital
Beartooth Hosp. & Health Center
Rosebud Health Care Center
Dahl Memorial Healthcare Assoc.
Fallon Medical Complex
Prairie Community Hospital
Garfield Co. Health Center
McCone Co. Health Center
Roosevelt Med. Center
Poplar Comm. Hospital
Sheridan Memorial Hosp.
Frances Mahon Deac. Hospital
Phillips County Hospital
Wheatland Memorial Healthcare
Montana Critical Access Hospital Program Status
June 2011
Critical Access Hospitals
Potential Critical Access Hospital
Broadwater Health Center
Madison Valley Hospital
St. Luke Comm. Hospital
Glendive Medical Ctr
Big Horn County Memorial Hospital
St. Joseph Hospital
Community Hospital of Anaconda
Marcus DalyMemorial Hospital
North Valley Hospital
Northern Rockies Medical Center
Daniels Memorial Healthcare Center
•NE MT Health Services
Fort Belknap Service Unit
Crow/N. Cheyenne Indian Hospital
Roundup Memorial Healthcare
Sidney Health Center
Blackfeet Comm. Hospital
Central Montana Medical Center
Holy Rosary Healthcare
Flex Grant Core Areas 2010-2011
• Quality Improvement
• Operational and Financial Improvement
• Health System Development and
Community Engagement
Flex Grant Activity Sampler
Core activitiesQA/QI/PI: CoP assistance and other quality based projects: benchmarking,
clinical improvement & benchmarking, quality education & support networkMeetings: CEO x 2, DON Forum, QI Showcase, Champions for Quality,
Regional QIC/DONCoding workshops
Other projects vary from year to yearCAH CFO networking optionsHIT web-based resource bookFacility specific economic impact reportsCost report reviewLeadership InstituteLean internshipsPIN websiteTHE LIST IS ALMOST ENDLESS!
• Continue Clinical Improvement Studies (CIS) • CIS Lunchtime Learning• CAH Peer review• Credentialing education • Benchmarking/Clinical benchmarking • Networking Meetings • PIN website • PI/QA/QI Education and resources• Prevent Transmission of MRSA collaborative w/ QIO, DPHHS• Maintain HIT website• HIT Training
Goal #1-Support efforts to improve and sustain quality of care
Precursor to value-based purchasing for CAHs?
Phase 1 Measures (one-year time frame 2011-2012) Pneumonia: Hospital Compare CMS Core MeasuresCongestive Heart Failure: Hospital Compare CMS Core Measures Phase 2 Measures (one-year time frame 2012-2013)Outpatient 1-7 as specified in Hospital Compare (AMI-ED, SCIP)Hospital Consumer Assessment of Healthcare Providers and Systems
Phase 3 Measures (one-year time frame 2013-2014)Pharmacist Review of OrdersOutpatient Emergency Department Transfer Communication
The Flex Medicare Beneficiary QI Project
…aka MBQIP!
• Meetings: Administrator, Nursing Directors• Coding workshops• CFO Networking• Medical necessity determination (RAC)• Explore capital funding options• Leadership Institute• Lean internships
Goal #2- Support efforts to improve Montana CAH financial and operational performance
• GEMS-Geriatric Emergency Medical Services
• CHSD-Community Health Services Development
Year 5-Needs assessment and community health care planningFallon Medical Center in Baker, Madison Valley Hospital in Ennis, Holy Rosary in Miles City, Dahl Memorial in Ekalaka, Rosebud Health Care Center in Forsyth, Prairie Community in Terry and Clark Fork Valley Hospital in Plains
• MT Rural Health Plan
Goal #3- Support efforts to assist CAHs in developing systems of care, addressing community needs
Flex Networking/Ed Activities 2010-2011
Champions for Quality 2011
“Back to the Future”
July 14-16, 2010
Great Northern Hotel HelenaMedical Education, CMEs, Nursing CE credits
100% say this conference is worth their time to attend!
Lunchtime Learning:another opportunity for provider education
Flex Networking/Ed Activities 2011
• CAH Administrators Billings Sept 21, 2011
• Joint QI Coordinators & DONs Regional Meetings
Oct 2011; dates & locations to be announced
• CAH Administrators Jan 2012
• DON Forum March 2012
• QI Showcase, Fairmont April 2012
Flex Networking/Ed Activities 2010-2011
• Coding workshops: 5th year!
• CFO Networking: ListServe; HFMA attendance
• Credentialing: MTAMSS Conference June 2011
Sustainable Leadership 2010-2011
• Leadership Institute
• Lean Process ManagementNorth Valley Hospital, WhitefishNorthern Rockies, Cut BankBroadwater Health Center, TownsendMcCone County Health Center, CircleRosebud Health Care Center, ForsythFallon Medical Center, Baker
Flex HIT Support Activities 2010-2011
• HIT Technical Assistance website
www.mtpin.org HIT Resource Guide
Username MT CAH48
Password HIT Resource
• HIT Education Programs
HIT Certification Program- MT Tech, Butte
IT/HIT Literacy- Helena College Of Technology
Significant Flex resources support
the Montana Rural Healthcare
Performance Improvement Network (PIN)
Performance Improvement Network• Formed at request of CAH CEOs in 2001
• All 48 MT CAHs are members
• Governance provided by PIN Advisory Board
up to 10 members: CEOs, DONs, QI/PI
• Clinical oversight provided by the Clinical
Improvement Panel (CIP)
Performance Improvement (PI) Program
C-0191 Agreements with qualified entities
C-0195 Agreements for Credentialing and Quality Assurance
C-0271 Clinical policies and procedures
Performance Improvement (PI) Program
C-0330 “Periodic Evaluation”, ie, the Annual CAH Program
Evaluation
C-0336 “An effective QA program”:the expectation of measurable
improvement
C-0337 All patient care and other services affecting patient health and safety are evaluated
Performance Improvement (PI) Program
C-0338 Includes nosocomial infections and medication therapy
C-0339 Includes quality and appropriateness of diagnosis
and treatment (ie, “peer review”)
C-0341 Considers findings and recommendations from
the QIO and takes corrective action
C-0342 Takes appropriate remedial action to address deficiencies found through the QA program (ie, CAH survey deficiencies)
Performance Improvement (PI) Program
•Provides support for in-house PI staffOpportunities for improving performance• Clinical improvement studies, clinical
benchmarking
Education, training and PI resources• PIN Education Committee
Regulatory information and support (CMS)• Tag by tag review; fourth Wed each month, 2 pm
Performance Improvement (PI) Program
Support for in-house staff, cont.
Consultation• onsite as requested
– Networking opportunities• sponsored meetings
Engaging administration and medical staff• Administrator meetings; Champions for Quality;
clinical improvement panel and studies
Facility Staff Support Resources
• “Best Practice” tools, resources and education
• PIN ListServ [email protected]
• Quarterly PIN newsletter
• PIN website www.mtpin.org
• 11 years in the development
• 13 indicators initially; 25 currently
• 94% reporting rate in 1st quarter 2011
Continually refining metrics & peer groups
PIN Benchmarking Project
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
XYZ Hospital 57.4 61.0 61.5 69.3 62.2 59.8 57.0 67.7
Peer group Max 83.6 84.3 91.1 76.4 84.0 92.0 90.7 84.0
Peer group Avg 68.5 69.5 71.6 70.4 70.5 71.1 72.2 70.8
Peer group Min 57.4 52.0 56.8 64.7 56.2 50.7 57.0 62.4
Average of 2003-Qtr 3
Average of 2003-Qtr 4
Average of 2004-Qtr 1
Average of 2004-Qtr 2
Average of 2004-Qtr 3
Average of 2004-Qtr 4
Average of 2005-Qtr 1
Average of 2005-Qtr 2
LOS (hours)
Peer Group 1
Sample report
8 quarters5 Peer Groups
Clinical ImprovementStudies Program
• Clinical Improvement Studies (CIS)2 studies underway at all times
• Clinical Improvement Panel (CIP)8 PIN Physician volunteers2 PIN mid-level volunteers
• CIS Development Committee (CIS-DC)DON and QI/PI Coordinator volunteers
CIS Program 2011
• Patient Safety : Prevent MRSA Transmission
• Pediatric Emergency Care: completed May 2011
• Clinical Benchmarking Project Pressure Ulcers, HF, CAP, Stroke, Inter-facility Transfer measures, Reduce Preventable Falls
• Quality Awards: 2011 recipient criteria Applications due August 1, 2011 You MUST apply to receive an award!
PIN Lessons Learned
• Leadership commitment is essential
• Involve more than CEOs
• Clarifying program responsibility and accountabilities in the facility are essential (not just the coordinator)
• Frequent communication
• “What gets measured gets managed”
QUESTIONS?
Cultural transformation isa slow, deliberate, strategic
process.