some common acronyms…
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
Montana Rural Hospital Flexibility
and Rural Healthcare Performance
Improvement Network
Orientation ProgramDecember 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 StaffFlex DirectorCarol Bischoff 457-8016 [email protected]
Rural Hospital Quality CoordinatorKathy 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
December 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 Activity Sampler
Core activitiesQA/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 yearCAH CFO networking optionsHIT web-based resource bookBalanced scorecard developmentFacility specific economic impact reportsCost report reviewLeadership InstituteLean internshipsPIN websiteTHE LIST IS ALMOST ENDLESS!
Flex Grant Core Area #1
• Quality Improvement
Medicare Beneficiary Quality Improvement ProjectPrecursor to value-based purchasing for CAHs?
Phase 1 Measures (HRSA collects data, Sept 2011 forward) Pneumonia: Hospital Compare CMS Core MeasuresCongestive 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 hrsOutpatient Interfacility Communication
Goal #1-Support efforts to improve and sustain quality of care
More later…
Goal #1-Support efforts to improve and sustain quality of care
Flex Grant Core Area #2
• Operational and Financial Improvement
• 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 MtgLivingstonFebruary 8-10, 2012
• DON ForumHelena March 21-23, 2012
• CAH Administrators Fall MtgBillings 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 ManagementApps 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
Goal #2- Support efforts to improve Montana CAH financial and operational performance
Flex Grant Core Area #3
• Health System Development and
Community Engagement
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
Goal #3- Support efforts to assist CAHs in developing systems of addressing community needs
Significant Flex resources supportthe 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 Boardo 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 staffo 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
oEngaging 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
• 11 years in development
• 13 indicators initially; 25 currently
• 98% reporting rate in 3rd 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- 2012• Patient Safety : Prevent MRSA Transmission
• Surviving Sepsis Campaign guidelines
• Clinical Benchmarking Projecto Pressure Ulcers, HF, CAP, Stroke, Inter-facility
Transfer measures, Reduce Preventable Falls adding HCAHPS, Feb 2012
• PIN Quality Awards: 2012 recipient criteriao MBQIP participation; improvement made; share learningo 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”
QUESTIONS?
Cultural transformation isa slow, deliberate, strategic
process.