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Some common acronyms…

Montana Rural Hospital Flexibility and Rural Healthcare Performance Improvement Network Orientation Program June 2010. 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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Some common acronyms…

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  1. Montana Rural Hospital Flexibilityand Rural Healthcare Performance Improvement Network Orientation ProgramJune 2010

  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

  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 April 2010 • 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 Objectives 2009-2010 • Continue collaboration with Mountain Pacific Quality Health-MT’s QIO • Support key CAH staff on quality and performance improvement issues • Maintain and enrich PIN data programs • Provide networking and education opportunities for key CAH staff • Sustainable leadership skills development program

  8. Flex Grant Objectives 2009-2010 • Advance development of health information technology systems in MT CAHs • Support MT DPHHS EMS Trauma Systems to encourage trauma designation • Partner with EMS and trauma stakeholders to support and assist rural EMS agencies • Provide Community Health Services Program in conjunction with MT Office Rural Health

  9. Flex QIO Collaboration Activities 2009-2010 • Promote Hospital Compare data submission • Support development of potential rural projects • Medication Reconciliation project-Round 2 • Networking, meetings, list serve

  10. Flex Networking/Ed Activities 2009-2010 • Joint QI Coordinators & DONs Regional Meetings • Region 1 Marcus Daly Memorial Hospital, Hamilton • Region 2 Marias Medical Center, Shelby • Region 3 Sidney Health Center, Sidney (north) • Region 3 Fallon Medical Center, Baker (south) • Region 4 Ruby Valley Hospital, Sheridan • Region 5 Livingston HealthCare, Livingston • Oct 2010; dates to be announced

  11. Flex Networking/Ed Activities 2009-2010 • CAH Administrators • Sept 22 & 23, MHA Fall Convention, Billings • Directors of Nursing (DON) Forum • March 16-18, 2011 • QI Coordinators Showcase • April 20-22, 2010 Fairmont Hot Springs

  12. Flex Networking/Ed Activities 2009-2010 Champions for Quality 2010 “Embracing Challenges and Changes” July 16-18, 2010 Great Northern Hotel Helena • Medical Education, CMEs • Symphony Under the Stars and Family Fun! • 100% say this conference is worth their time to attend!

  13. Flex Networking/Ed Activities 2009-2010 • Health Care Trustee Association of MT (HCTAM) • - televideo education for trustees • - 2 scholarships to attend Western Region Trustee Symposium • - funding to support Trustee track at the MHA convention • Coding Tele-video series • CFO Networking: new ListServe

  14. Sustainable Leadership 2009-2010 • Leadership Institute Series underway • LEAN Process Management

  15. Flex HIT Support Activities 2009-2010 • HIT Technical Assistance website • Collaboration with MHA HIT Task Force

  16. Flex EMS Support Activities 2009-2010 • Build regional ATLS training caches • Web-based trauma coordinator training • Encourage CAH reporting to State Trauma Registry • Support for Pre-hospital Trauma Life Support training • Group purchasing for the Western EMS Network

  17. Flex MORH Collaborative Activities 2009-2010 (MT Office of Rural Health) • Community Health Services Development (CHSD) • Year 4-Needs assessment and community health care planning; • 6 sites: McCone County-Circle, St. John’s-Libby, Teton Medical-Choteau, St. Joe’s-Polson, Frances Mahon-Glasgow, Wheatland Memorial-Harlowton • Lean Process Management in a CAH • Sites selected: Clark Fork Valley-Plains, Liberty County-Chester, Pioneer-Big Timber, Roosevelt-Culbertson, Prairie Community-Terry, Fallon Medical-Baker

  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 47 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, benchmarking • Education, training and PI resources • PIN Education Committee • Regulatory information and support (CMS) • Tag by tag review; last 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 • Currently under construction- watch for big changes!

  26. PIN Benchmarking Project • 9 years in the development • 13 indicators initially; 26 currently • 94% reporting rate in 1st quarter 2010 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 2010 • Patient Safety : Reduce Preventable Falls • Pediatric Emergency Care: launched April 2010 • Clinical Benchmarking Project • Pressure Ulcers, HF, CAP, Stroke, Inter-facility Transfer measures • Quality Awards: 2010 recipient criteria • Applications due August 1, 2010 • 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” • Cultural transformation is a slow, deliberate, strategic process

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

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