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Montana Rural Hospital Flexibility and Rural Healthcare Performance Improvement Network Orientation Program June 2011

Montana Rural Hospital Flexibility and Rural Healthcare Performance Improvement Network Orientation Program June 2011. Some common acronyms…. Flex = Rural Hospital Flexibility Program PIN = Performance Improvement Network DPHHS = MT Dept of Public Health and Human Services

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Montana Rural Hospital Flexibility and Rural Healthcare Performance Improvement Network Orientation Program June 2011

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  1. Montana Rural Hospital Flexibilityand Rural Healthcare Performance Improvement Network Orientation ProgramJune 2011

  2. 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

  3. Some common acronyms… CAH = Critical Access Hospital QI = Quality Improvement PI = Performance Improvement CMS = Centers for Medicare and Medicaid Services

  4. 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 responsibilities Flex grant year runs from September 1 thru August 31

  5. Flex Director Carol Bischoff 457-8016 carol@mtha.org Rural Hospital Quality Coordinator Kathy Wilcox 461-6186 kathy@mtha.org Flex/PIN Staff

  6. Montana Critical Access Hospital Program Status June 2011 • Blackfeet Comm. Hospital • Daniels Memorial Healthcare Center • Sheridan Memorial Hosp. • Northern Rockies Medical Center • Liberty Medical Center • North Valley Hospital • St. John’s Lutheran Hospital • Marias Medical Center • Fort Belknap Service Unit • Phillips County Hospital • Frances Mahon Deac. Hospital • Poplar Comm. Hospital • Pondera Medical Center • NE MT Health Services • Roosevelt Med. Center • Big Sandy Med. Center • St. Joseph Hospital • Teton Medical Center • Missouri River Med. Center • Sidney Health Center • St. Luke Comm. Hospital • Clark Fork Valley Hospital • McCone Co. Health Center • Garfield Co. Health Center • Central Montana Medical Center • Mineral Community Hospital • Glendive Medical Ctr • Prairie Community Hospital Granite Co. Medical Center • Powell Co. Medical Center • Mountainview Medical Center • Wheatland Memorial Healthcare • Roundup Memorial Healthcare • Holy Rosary Healthcare Marcus Daly Memorial Hospital Fallon Medical Complex • Broadwater Health Center • Community Hospital of Anaconda • Rosebud Health Care Center • Dahl Memorial Healthcare Assoc. • Pioneer Medical Center • Livingston Healthcare • Big Horn County Memorial Hospital • Stillwater Comm. Hospital • Ruby Valley Hospital • Crow/N. Cheyenne Indian Hospital • Barrett Memorial Hospital • Madison Valley Hospital • Beartooth Hosp. & Health Center • Critical Access Hospitals • Potential Critical Access Hospital

  7. Flex Grant Core Areas 2010-2011 • Quality Improvement • Operational and Financial Improvement • Health System Development and • Community Engagement

  8. Flex Grant Activity Sampler • Core activities • QA/QI/PI: CoP assistance and other quality based projects: benchmarking, clinical improvement & benchmarking, quality education & support network • Meetings: CEO x 2, DON Forum, QI Showcase, Champions for Quality, • Regional QIC/DON • Coding workshops • Other projects vary from year to year • CAH CFO networking options • HIT web-based resource book • Facility specific economic impact reports • Cost report review • Leadership Institute • Lean internships • PIN website • THE LIST IS ALMOST ENDLESS!

  9. Goal #1-Support efforts to improve and sustain quality of care • 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

  10. The Flex Medicare Beneficiary QI Project …aka MBQIP! Precursor to value-based purchasing for CAHs? Phase 1 Measures (one-year time frame 2011-2012) Pneumonia: Hospital Compare CMS Core Measures Congestive 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 Orders Outpatient Emergency Department Transfer Communication

  11. Goal #2- Support efforts to improve Montana CAH financial and operational performance • Meetings: Administrator, Nursing Directors • Coding workshops • CFO Networking • Medical necessity determination (RAC) • Explore capital funding options • Leadership Institute • Lean internships

  12. Goal #3- Support efforts to assist CAHs in developing systems of care, addressing community needs • GEMS-Geriatric Emergency Medical Services • CHSD-Community Health Services Development • Year 5-Needs assessment and community health care planning • Fallon 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

  13. Flex Networking/Ed Activities 2010-2011 Champions for Quality 2011 “Back to the Future” July 14-16, 2010 Great Northern Hotel Helena • Medical Education, CMEs, Nursing CE credits • 100% say this conference is worth their time to attend! Lunchtime Learning: another opportunity for provider education

  14. 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

  15. Flex Networking/Ed Activities 2010-2011 • Coding workshops: 5th year! • CFO Networking: ListServe; HFMA attendance • Credentialing: MTAMSS Conference June 2011

  16. Sustainable Leadership 2010-2011 • Leadership Institute • Lean Process Management North Valley Hospital, Whitefish Northern Rockies, Cut Bank Broadwater Health Center, Townsend McCone County Health Center, Circle Rosebud Health Care Center, Forsyth Fallon Medical Center, Baker

  17. 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

  18. Significant Flex resources support the Montana Rural Healthcare Performance Improvement Network (PIN)

  19. 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)

  20. Performance Improvement (PI) Program C-0191 Agreements with qualified entities C-0195 Agreements for Credentialing and Quality Assurance C-0271 Clinical policies and procedures

  21. 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

  22. 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)

  23. Performance Improvement (PI) Program • Provides support for in-house PI staff • Opportunities 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

  24. 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

  25. Facility Staff Support Resources • “Best Practice” tools, resources and education • PIN ListServ pin@astro.lyris.net • Quarterly PIN newsletter • PIN website www.mtpin.org

  26. PIN Benchmarking Project • 11 years in the development • 13 indicators initially; 25 currently • 94% reporting rate in 1st quarter 2011 Continually refining metrics & peer groups

  27. 5 Peer Groups Sample report 8 quarters

  28. Clinical ImprovementStudies 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

  29. 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!

  30. 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”

  31. Cultural transformation is a slow, deliberate, strategic process. QUESTIONS?

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