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Some common acronyms…

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

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Some common acronyms…

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  1. Montana Rural Hospital Flexibilityand Rural Healthcare Performance Improvement Network Orientation ProgramDecember 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, fiscal management responsibilities and some activities 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 December 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 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!

  8. Flex Grant Core Area #1 • Quality Improvement

  9. 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

  10. Goal #1-Support efforts to improve and sustain quality of care More later…

  11. Flex Grant Core Area #2 • Operational and Financial Improvement

  12. Goal #2- Support efforts to improve Montana CAH financial and operational performance • Meetings • Coding workshops • CFO Networking • Leadership Institute • Lean internships • HIT Training

  13. 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

  14. 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

  15. 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

  16. Flex Grant Core Area #3 • Health System Development and • Community Engagement

  17. 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

  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, CFO • 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 • Scholarships for attending MTAMSS, June, Bozeman • New!! PIN Peer Review program- enroll Feb 2012 • Education, training and PI resources • PIN Education Committee: CAH sample policies • Regulatory information and support (CMS) • Admin Rules of MT webinar; Jan 19, 2:00 pm

  24. Performance Improvement (PI) Program Support for in-house staff, cont. • Peer Networking • QI Showcase April 17-19 • Joint QI Coord and DON regional meetings,Oct 2012 • Consultation • onsite as requested • Engaging administration and medical staff • Administrator meetings; clinical improvement panel and studies; Champions and Lunchtime Learning

  25. 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

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

  27. PIN Benchmarking Project • 11 years in development • 13 indicators initially; 25 currently • 98% reporting rate in 3rd quarter 2011 Continually refining metrics & peer groups

  28. 5 Peer Groups Sample report 8 quarters

  29. 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

  30. CIS Program 2011- 2012 • Patient Safety : Prevent MRSA Transmission • Surviving Sepsis Campaign guidelines • Clinical Benchmarking Project • Pressure Ulcers, HF, CAP, Stroke, Inter-facility Transfer measures, Reduce Preventable Falls • adding HCAHPS, Feb 2012 • PIN Quality Awards: 2012 recipient criteria • MBQIP participation; improvement made; share learning • You MUST apply to receive an award by Aug 1, 2012!

  31. 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”

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

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