Transcript Slide 1
Montana Rural Hospital Flexibility
and
Rural Healthcare Performance
Improvement Network
Orientation Program
December 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, fiscal
management responsibilities and some activities
Flex grant year runs from September 1 thru August 31
Flex/PIN Staff
Flex Director
Carol Bischoff
457-8016
[email protected]
Rural Hospital Quality Coordinator
Kathy Wilcox
461-6186
[email protected]
Montana Critical Access Hospital Program Status
December 2011
Blackfeet
Comm. Hospital
St. John’s
Lutheran Hospital
North Valley Hospital
Northern Rockies
Medical Center
Liberty Medical Center
Marias Medical
Fort Belknap
Center
Pondera Medical
Center
St. Joseph
Hospital
St. Luke
Clark Fork Comm.
Hospital
Valley
Hospital
Mineral
Community Hospital
Teton
Medical
Center
Service Unit
Big Sandy
Med. Center
Phillips
County
Hospital
Daniels
Sheridan
Memorial
Healthcare
Center
Memorial Hosp.
Frances
Poplar
Mahon Deac. •NE MT Comm. Roosevelt
Health
Hospital
Hospital Med. Center
Services
Missouri River
Sidney
Med. Center
Health
Center
Central Montana
Garfield Co.
Medical Center
Health Center
McCone Co.
Health Center
Glendive
Medical Ctr
Granite Co.
Medical
Center
Marcus Daly
Memorial
Hospital
Prairie
Community
Powell Co.
Mountainview
Hospital
Medical Center
Medical Center Wheatland
Roundup
Holy Rosary
Memorial
Memorial Healthcare
Healthcare
Fallon
Broadwater
Healthcare
Medical
Community
Health Center
Rosebud Health
Complex
Hospital of
Care Center
Anaconda
Dahl
Pioneer Medical Center
Memorial
Livingston
Big Horn County
Healthcare
Stillwater Comm.
Healthcare
Memorial Hospital
Assoc.
Ruby Valley
Hospital
Hospital
Crow/N. Cheyenne
Indian Hospital
Barrett
Madison
Beartooth Hosp. &
Memorial
Valley Hospital
Health Center
Hospital
Critical Access Hospitals
Potential Critical Access Hospital
Flex Grant Activity Sampler
Core activities
QA/QI/PI: support for meeting Conditions of Participation and performance
improvement projects: benchmarking, clinical improvement &
benchmarking, quality education & support network, PIN ListServ
Meetings: CEOs twice each year; DON Forum; QI Showcase; Champions for
Quality regional meetings; Regional joint QIC/DON
Coding workshops
Other projects vary from year to year
CAH CFO networking options
HIT web-based resource book
Balanced scorecard development
Facility specific economic impact reports
Cost report review
Leadership Institute
Lean internships
PIN website
THE LIST IS ALMOST ENDLESS!
Flex Grant Core Area #1
• Quality Improvement
Goal #1-Support efforts to improve and sustain
quality of care
Medicare Beneficiary Quality Improvement Project
Precursor to value-based purchasing for CAHs?
Phase 1 Measures (HRSA collects data, Sept 2011 forward)
Pneumonia: Hospital Compare CMS Core Measures
Congestive Heart Failure: Hospital Compare CMS Core Measures
Phase 2 Measures (HRSA begins data collection Sept 2012)
Outpatient 1-7 as specified in Hospital Compare (AMI-ED, SCIP)
Hospital Consumer Assessment of Healthcare Providers and Systems
Phase 3 Measures (HRSA plans to begin data collection Sept 2013)
Pharmacist Review of Medication Orders within 24 hrs
Outpatient Interfacility Communication
Goal #1-Support efforts to improve and sustain
quality of care
More later…
Flex Grant Core Area #2
• Operational and Financial Improvement
Goal #2- Support efforts to improve Montana CAH
financial and operational performance
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Meetings
Coding workshops
CFO Networking
Leadership Institute
Lean internships
HIT Training
Goal #2- Support efforts to improve Montana CAH
financial and operational performance
• CAH Administrators Winter Mtg
Livingston February 8-10, 2012
• DON Forum
Helena
March 21-23, 2012
• CAH Administrators Fall Mtg
Billings
Sept 19, 2012
Goal #2- Support efforts to improve Montana CAH
financial and operational performance
• Coding workshops: 7th year!
Integumentary system-May 23-June 20
ICD 10 and PCS training-July 12 and 26
• CFO Networking: ListServe; HFMA scholarships
Spring 2012
• Leadership Institute
Billings and Helena-Apps available Jan 2012
Goal #2- Support efforts to improve Montana CAH
financial and operational performance
• Lean Process Management
Apps available February 2012
• HIT Education Programs
-HIT Certification Program- MT Tech, Butte
Apps available April 2012
-IT/HIT Literacy- Helena College Of Technology
-HIMSS scholarships
Flex Grant Core Area #3
• Health System Development and
Community Engagement
Goal #3- Support efforts to assist CAHs in
developing systems of addressing community
needs
CHSD-Community Health Services Development
Year 6-Needs assessment and community health care
planning
Applications available by 12/31/2011
Explore development of local systems of care
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
o
up to 10 members: CEOs, DONs, QI/PI, CFO
• 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 staff
o Opportunities for improving performance
Clinical improvement studies, clinical benchmarking
Scholarships for attending MTAMSS, June, Bozeman
New!! PIN Peer Review program- enroll Feb 2012
o Education, training and PI resources
PIN Education Committee: CAH sample policies
o Regulatory information and support (CMS)
Admin Rules of MT webinar; Jan 19, 2:00 pm
Performance Improvement (PI) Program
Support for in-house staff, cont.
o Peer Networking
QI Showcase April 17-19
Joint QI Coord and DON regional meetings,Oct 2012
o Consultation
onsite as requested
o Engaging administration and medical staff
Administrator meetings; clinical improvement panel
and studies; Champions and Lunchtime Learning
Engaging Medical Staff
Champions for Quality 2012
• Medical Education, CMEs, Nursing CE credits
• 100% say this conference is worth their time to
attend!
• New approach under development for 2012
Facility Staff Support Resources
• “Best Practice” tools, resources and education
• PIN ListServ [email protected]
• Quarterly PIN newsletter
• PIN website www.mtpin.org
PIN Benchmarking Project
• 11 years in development
• 13 indicators initially; 25 currently
• 98% reporting rate in 3rd quarter 2011
Continually refining metrics & peer groups
Sample report
Peer
Group 1
100.0
90.0
80.0
LOS
(hours)
70.0
60.0
50.0
40.0
30.0
5 Peer
Groups
20.0
8 quarters
10.0
0.0
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
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
Clinical Improvement
Studies Program
• Clinical Improvement Studies (CIS)
2 studies underway at all times
• Clinical Improvement Panel (CIP)
8 PIN Physician volunteers
2 PIN mid-level volunteers
• CIS Development Committee (CIS-DC)
DON and QI/PI Coordinator volunteers
CIS Program 2011- 2012
• Patient Safety: Prevent MRSA Transmission
• Surviving Sepsis Campaign guidelines
• Clinical Benchmarking Project
o Pressure Ulcers, HF, CAP, Stroke, Inter-facility
Transfer measures, Reduce Preventable Falls
adding HCAHPS, Feb 2012
• PIN Quality Awards: 2012 recipient criteria
o MBQIP participation; improvement made; share learning
o You MUST apply to receive an award by Aug 1, 2012!
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”
Cultural transformation is
a slow, deliberate, strategic process.
QUESTIONS?