Report for 2017-2018 Hospital Transformation Consortium Registration
85
Report for 2017-2018 Hospital Transformation Consortium Registration - Multistate Completion Rate: 40.5% Complete 15 Partial 22 Totals: 37 Response Counts 1. Hospital Name: 1
Transcript of Report for 2017-2018 Hospital Transformation Consortium Registration
Report for 2017-2018 HospitalTransformation Consortium Registration- Multistate
Complet ion Rat e: 40 .5%
Complete 15
Partial 22
T ot als: 37
Response Counts
1. Hospital Name:
1
2
Count Response
3 Madison County Memorial Hospital
3 SGMC Berrien Campus
2 BURKE MEDICAL CENT ER
2 Elbert Memorial Hospital
2 Flint River Hospital
2 Jefferson Hospital
2 Monroe County Hospital
2 Optim Medical Center - T attnall
2 Southwest Georgia Regional Medical Center
1 Appling Healthcare System
1 Bleckley Memorial Hospital
1 Burke County Hospital Authority d/b/a Burke Medical Center
1 Candler County Hospital
1 Crisp Regional hospital, Inc.
1 Elbert Memorial Hospital
1 Medical Center of Peach County
1 SGMC Lanier Campus
1 Stephens County Hospital
1 T AYLOR REGIONAL HOSPIT AL
3
Count Response
12 GA
10 Georgia
3 Ga
2 FL
2 ga
1 Florida
2. State:
3. Name of Primary Coordinator/Contact for HomeTown Health
4
5
Count Response
4 T ammy Stone
2 Becky Smith
2 DIANE HALL
2 Lynn Mitchell
2 Monica Cain
2 Pat Everson
2 Sandy Fletcher
2 T abitha Kent
1 Janet Jenkins
1 John Roland, RN, BSN, CNO, COO
1 Karen Clark
1 Keri Crosby
1 Laura Gentry
1 Michelle L. Murphy
1 Renee Bearden
1 SANDI BROWN
1 Sandy Fletcher, Financial Analyst, BOM
1 T ina DeBord
4. Phone Number for Primary Coordinator/Contact:
6
Count Response
2 229-209-1244
2 229-402-2047
2 229-433-8665
2 478-994-2521 xt 215
2 706 554 4435
2 8502531924
1 2292763146
1 478-472-3151
1 478-625-7000
1 478-625-7000, x268
1 478-654-2423
1 478-783-0243
1 478-934-6211
7
1 4784723100
1 706-213-2551
1 706-283-3151
1 706-437-2654
1 7062824256
1 850-253-1924
1 912-629-6934
1 912-685-1767
1 9123679841 ext 1450
Count Response
5. Email Address for Primary Coordinator/Contact:
8
Count Response
9
6. The g oal of the HomeTown Health Hospital Transformation Consortium isto build a g roup of hospitals and other stakeholders that work tog ether tosupport hospital collaboration and a community of shared best practices intransforming areas of Quality & Data Reporting , Financial Processes, &Technolog y in order to improve the value for the patient. The training willbeg in July, 2017 and run throug h May, 2018. 2017-2018 Deliverables:Prog ram education will be delivered throug h: ▪ Training Series in the Quality,to include: - A MIPS Roadmap (Provider Alternative Payment Models/MeritBased Incentive Prog ram) - Quality Transformation: HCAHPS Mini-Seriespresented by ICAHN and HCAHPS Best Practices & Manag ers Toolkits fromHomeTown Health - Quality Transformation: Rural Health Clinic ClinicalQuality Measures presented by ICAHN - Quality Transformation: QualityLeadership Recharg e Series ▪ Training Series in Financial Processes, toinclude: - Pricing Transparency: Focus on Charg emaster Series presented byHomeTown Health - Cost Report Mini-Series & Supplemental SupportCourses presented by Draffin & Tucker - Clinical Documentation Improvement(CDI) Series presented by HCCS , The Dunnick Group, LLC, & HTH, along witha Rural Coding Specialist Support Course prog ram - Quarterly Coding & ICD-10 Update Series presented by HCCS ▪ Training Series in Technolog y, toinclude: - Technolog y Transformation: Microsoft Office - LiveTraining Meeting in March, 2018 focused on "Technolog y’s Role in Value:Quality Care & Financial Processes ▪ Access to Foundational Support courseson HTHU.net plus new staff support courses developed throug hout theprog ram year ▪ Other resources, downloads, and toolkits for series of training▪ Access to trainers and industry expert support teamHospital may participatein various ways: 1. Hospitals who have previously selected the HospitalTransformation Consortium as the awardee for their SHIP Grant Funds(Georg ia) 2. Throug h individual hospital participation funded otherwise (Thiscould include hospital funded or hospitals who are receiving the Direct Awardof SHIP g rant funds and wish to apply it to Consortium participation in anystate.) Our hospital has selected to:
10
100% Participate in the HospitalTransformation Consortiumthrough the Georgia SHIP Grant,as previously submitted to theState Office of Rural Health
100% Participate in the HospitalTransformation Consortiumthrough the Georgia SHIP Grant,as previously submitted to theState Office of Rural Health
Value Percent Responses
Participate in the Hospital T ransformation Consortium
through the Georgia SHIP Grant, as previously submitted to
the State Office of Rural Health
100.0% 29
T ot als: 29
11
7. SHIP Consortium Ag reement: By sig nature below, our hospital is indicatingour commitment to participation in the Hospital Transformation Consortiumthroug h the 2017-18 Georg ia SHIP Grant prog ram. We are committed tocompletion of the Pre-Assessment and Post-Assessment, and will endeavor toparticipate in Online Courses, Webinar Attendance, and live meeting training .We will endeavor to apply the knowledg e provided to work toward theimprovement of our financial processes, quality of care, and use oftechnolog y with other consortium members.HomeTown Health'sCommitment as the SHIP Project Manag er: All reasonable steps are taken toassist a facility in the implementation and participation in the SHIP educationprog rams. Due to various external factors, HomeTown Health or its partnerscannot be held liable if the facility does not succeed due to factors such as, butare not limited to: poor cooperation by facility, lack of staff training , reg ulatoryor reimbursement matters, policy, etc.
27 Signatures
8. Prog ram Pricing : $9000 (Please Select Billing Option Below)
No d ata to d isp lay
12
Value Percent Responses
T ot als: 0
No dat a: No responses found for this question.
Count Response
9. Billing Information: Billing Contact (if different from above)
Count Response
10. Billing Email Address:
13
11. By sig nature below, our hospital is indicating our commitment toparticipation in the Hospital Transformation Consortium throug h the 2017-18prog ram. We are committed to completion of the Pre-Assessment and Post-Assessment, and will endeavor to participate in Online Courses, WebinarAttendance, and live meeting training . We will endeavor to apply theknowledg e provided to work toward the improvement of our financialprocesses, quality of care, and use of technolog y with other consortiummembers.HomeTown Health's Commitment as the Consortium Manag er: Allreasonable steps are taken to assist a facility in the implementation andparticipation in the SHIP education prog rams. Due to various external factors,HomeTown Health or its partners cannot be held liable if the facility does notsucceed due to factors such as, but are not limited to: poor cooperation byfacility, lack of staff training , reg ulatory or reimbursement matters, policy, etc.
0 Signatures
12. Who will be your hospital's contact for the CDI Mini-Series? (Werecommend desig nating a CDI Specialist or CDI Prog ram Leader, such as acoding manag er, physician/nurse champion, or other Financial Leader in yourhospital.) Name, Title:
14
Count Response
2 Cathy Hogan
1 Amanda Smith
1 Annette Everett, Case Mgmt
1 April Dukes, CNO
1 Callie Kervin
1 Candi Powers, Rev Cycle Director
1 Candice Powers, Director of Revenue Cycle
1 Case Manager/CDI
1 Elaine Pike
1 Irina Jocher, UR Coordinator
1 Joy Kicklighter
1 Lynn Mitchell
1 Pat Everson
1 SANDI BROWN
1 Sandi Brown, CCS
1 Stacy Smith, DON
1 T ina DeBord, QI Director
13. CDI Contact's Email Address:
15
Count Response
14. We have a Clinical Documentation Improvement (CDI) prog ram in place:
16
18% Yes18% Yes
12% Yes, but we are in the earlystages or just beginning12% Yes, but we are in the earlystages or just beginning
12% No, but we plan to or haveinterest in implementing one12% No, but we plan to or haveinterest in implementing one
35% No35% No
24% Unsure24% Unsure
Value Percent Responses
Yes 17.6% 3
Yes, but we are in the early stages or just beginning 11.8% 2
No, but we plan to or have interest in implementing one 11.8% 2
No 35.3% 6
Unsure 23.5% 4
T ot als: 17
15. In pursuit of a Clinical Documentation Improvement (CDI) prog ram, ourhospital has: (select all that apply)
17
Per
cent
Performed anAnalysis on
current clinicaldocumentation,
coding andrevenue cycleperformance
Assembled aCDI Team (CDI
Specialists,Physician
champions,cross-functional
team (nurse,scribe, etc.)
Invested orutilization of
electronic tools
Providedemployeetraining
programs (CDI,Coding,
Documentation,etc.)
CDI ProgramPerformance
Monitoring andReporting
None of theabove: but we
are interested ingetting started!
0
10
20
30
40
50
Value Percent Responses
Performed an Analysis on current clinical documentation,
coding and revenue cycle performance
25.0% 4
Assembled a CDI T eam (CDI Specialists, Physician champions,
cross-functional team (nurse, scribe, etc.)
6.3% 1
Invested or utilization of electronic tools 18.8% 3
Provided employee training programs (CDI, Coding,
Documentation, etc.)
31.3% 5
CDI Program Performance Monitoring and Reporting 6.3% 1
None of the above: but we are interested in getting started! 43.8% 7
16. Which of the following best describes the training /certification of yourcoding /CDI team?
18
53% We do not currently have adedicated CDI Team53% We do not currently have adedicated CDI Team
6% One full-time person withCDI Credentials6% One full-time person withCDI Credentials
6% One full time person withoutCDI Credentials6% One full time person withoutCDI Credentials
12% More than one person withCDI Credentials12% More than one person withCDI Credentials
24% Other - Write In (Required)24% Other - Write In (Required)
Value Percent Responses
We do not currently have a dedicated CDI T eam 52.9% 9
One full-time person with CDI Credentials 5.9% 1
One full time person without CDI Credentials 5.9% 1
More than one person with CDI Credentials 11.8% 2
Other - Write In (Required) 23.5% 4
T ot als: 17
19
Other - Write In (Required) Count
Certified Coding is Outsourced 1
I currently do it along with all of my other duties 1
No employee's are certified. 1
T wo CCS coders that review records 2 times per week on floors 1
T otals 4
17. What are your hospital's g reatest areas of need related to Coding orClinical Documentation Improvement? What specifically are you hoping to g etout of this prog ram?
20
ResponseID Response
10 Physician documentation
12 Improve documentation
15 Any and all related info. New learning curve for myself. Our coding is outsourced
and they do periodic reviews and discuss findings. Medical Necessity would be
number one denial. Not enough documentation.
16 Collaboration with outsource coders
21 Complete and accurate documentation without contradictions throughout the
entire record. Review by documenter prior to finalization to avoid computerized
"click" errors.
29 Improve documentation and case mix index
31 Physician and staff documentation relevant to why the patient is here. Present
on Arrival documentation/What is POA
32 Improvement in coding and charge capture.
33 Start a CDI program
18. Who will be the contact at your hospital for this Pricing Transparencyseries? (We recommend a Financial Leader.) Name, Title
21
22
Count Response
2 Richard Huth
1 Business Office Manager
1 Candice Powers, Director of Revenue Cycle
1 Celeste Dent, Accountant
1 Elaine Pike
1 John Graham
1 John Graham, CFO
1 Kathy Chancey/Robin Crosby
1 Lynn Mitchell, BOM
1 Renee Bearden
1 SANDI BROWN
1 Sandra Herndon, CFO
1 Sandy Fletcher, BOM
1 Sandy Fletcher, BOM, Financial Analyst
1 T ina DeBord, QI Director
19. Email for the Price Transparency/Charg emaster contact:
23
Count Response
20. Does your team proactively communicate price information, as well asinformation about your billing process, charity care and financial assistancepolicies, in a way that is easy to understand, to patients?
24
31% Yes - always31% Yes - always
31% Yes - Sometimes, but notconsistently31% Yes - Sometimes, but notconsistently
31% Yes, occasionally or rarely31% Yes, occasionally or rarely
6% No, never6% No, never
Value Percent Responses
Yes - always 31.3% 5
Yes - Sometimes, but not consistently 31.3% 5
Yes, occasionally or rarely 31.3% 5
No, never 6.3% 1
T ot als: 16
21. If yes: Our org anization’s price information easily accessible and presentedin a way that is understandable to and usable by the g eneral public, including : (mark all that apply)
25
8% Made available in thelanguages that are used mostoften in our community
8% Made available in thelanguages that are used mostoften in our community
42% Accessible via our websiteor immediately upon request42% Accessible via our websiteor immediately upon request
50% Other - Write In (Required)50% Other - Write In (Required)
Value Percent Responses
Made available in the languages that are used most often in our
community
8.3% 1
Accessible via our website or immediately upon request 41.7% 5
Other - Write In (Required) 50.0% 6
T ot als: 12
26
Other - Write In (Required) Count
Respond to calls regarding estimates 1
Verbally discussed in person with each client 1
available upon request 1
made avail in languages used most in community, financial counselor provides estimated
charges, handouts, etc as part of counseling and up front collection process
1
perfromed verbal 1
verbal only 1
T otals 6
22. Does your hospital have specially trained staff available to answer patientand family questions about estimated prices and provide additionalexplanations about how price may vary from estimates depending on thepatient’s care requirements?
27
81% Yes81% Yes
6% No6% No
13% Unsure13% Unsure
Value Percent Responses
Yes 81.3% 13
No 6.3% 1
Unsure 12.5% 2
T ot als: 16
Other - Write In (Required) Count
T otals 0
23. Do all staff involved in patient and family interactions (nurses,receptionists, as well as billing staff) receive g eneral training on your hospital’sprice information? (This mig ht include how to connect patients and familieswith specially trained hospital staff who are knowledg eable about hospitalcharg es, billing practices and financial assistance policies.)
28
63% Some of out staff, but notall63% Some of out staff, but notall
25% No, none of our staff receivetraining in this area25% No, none of our staff receivetraining in this area
6% Unsure6% Unsure
6% Other - Write In (Required)6% Other - Write In (Required)
Value Percent Responses
Some of out staff, but not all 62.5% 10
No, none of our staff receive training in this area 25.0% 4
Unsure 6.3% 1
Other - Write In (Required) 6.3% 1
T ot als: 16
Other - Write In (Required) Count
Not nursing 1
T otals 1
24. Which of the follow information does your hospital offer to patients as itrelates to potential prices? (Mark all that apply)
29
Per
cent
Estimatedprices specificto that patient’s
coverage
Out-of- pocketestimates(copays,
coinsurance,deductibles)
Out-of- networkprices, if
applicable
Averageprocedure
prices
Informationabout whether a
patient mayqualify forfinancial
assistance
Unsure0
20
40
60
80
Value Percent Responses
Estimated prices specific to that patient’s coverage 40.0% 6
Out-of- pocket estimates (copays, coinsurance, deductibles) 73.3% 11
Out-of- network prices, if applicable 40.0% 6
Average procedure prices 60.0% 9
Information about whether a patient may qualify for financial
assistance
66.7% 10
Unsure 6.7% 1
Other - Write In (Required) Count
T otals 0
30
25. What are your hospital's g reatest areas of need related to PricingTransparency and/or your Charg emaster? Do you have plans to expand currentpricing transparency efforts? What specifically are you hoping to g et out ofthis prog ram?
31
ResponseID Response
9 We are in need of a charge master review.
10 On going updates to charge master; specific goals; assignments; pricing
strategy; how often increases in CDM
12 Any information is helpful
15 No problems with OP. Mental Health collections from IP are not so good.
16 Marketing plan
25 Our hospital has a need to know that we are in line with other area hospitals in
regards to major outpatient procedures.
26 We would like to know if our hospital's pricing is inline with other hospital's on
high dollar procedures.
29 Developing pricing for employees to respond to our customers
32 We are currently undergoing a chargemaster review.
33 Expand assistance eligibility screening, POS collections and setting up payment
plans.
26. Who will be the prog ram leader for the Cost Report Mini-Series? (Werecommend CFOs, Controllers, Revenue Cycle Directors, Business OfficeManag ers, Financial Counseling leaders, COOs, or other cost/budg et staffroles.) Name, Title:
32
Count Response
2 John Graham, CFO
2 Patrick McGee, CFO
2 Richard Huth
1 Bryan Forlines
1 CFO
1 Celeste Dent, Accountant
1 Jeff Laird, Controller
1 Jessica Carter CFO
1 KAREN MCLEOD
1 Lynn Mitchell, BOM
1 Rhonda Durden, Chief Financial Officer
1 Robin Crosby/Pam Dean
1 Sandra Herndon, CFO
33
Count Response
27. Email for the prog ram leader for this mini-series:
28. Which of the following areas would be of particular interest/are atop need for your hospital team related to Cost Reports? (Select your top 5areas)
34
Per
cent
Ensur
ing th
at an
accu
rate
cost
repo
rt is
subm
itted
Manag
ing pr
oteste
d amou
nts/ap
peals
Sourc
e doc
umen
tation
main
tenan
ce
Basic
found
ation
educ
ation
for s
taff o
n "Cos
t Rep
ort 1
01"
Wor
kshe
et S-1
0/Unc
ompe
nsate
d Car
e
Proce
ss In
volve
ment fr
om C
linica
l and
othe
r Dep
artm
ent S
taff
Cost R
epor
t Pre
para
tion/T
ime M
anag
emen
t
Remain
ing up
-to-d
ate on
Hos
pital
oper
ation
s
Remain
ing up
-to-d
ate on
finan
cial a
ccou
nting
Medica
re La
ws and
Reg
ulatio
ns, th
e Prin
ciples
of M
edica
re R
eimbu
rsem
ent, a
nd
MCR Instr
uctio
ns
Other -
Write
In (R
equir
ed)
0
80
Value Percent Responses
Ensuring that an accurate cost report is submitted 53.3% 8
Managing protested amounts/appeals 26.7% 4
Source documentation maintenance 73.3% 11
Basic foundation education for staff on "Cost Report 101" 60.0% 9
Worksheet S-10/Uncompensated Care 80.0% 12
Process Involvement from Clinical and other Department Staff 46.7% 7
Cost Report Preparation/T ime Management 46.7% 7
Remaining up-to-date on Hospital operations 33.3% 5
Remaining up-to-date on financial accounting 40.0% 6
Medicare Laws and Regulations, the Principles of Medicare
Reimbursement, and MCR Instructions
66.7% 10
Other - Write In (Required) 6.7% 1
35
29. What are your hospital's g reatest areas of need related to the Cost Reportand/or the S-10 worksheet? What specifically are you hoping to g et out of thisprog ram?
36
ResponseID Response
9 Karen would need to answer this and she may want to assign another person to
be responsible.
10 Accurate complete documentation to support the information submitted and
accurate calculation of uncompensated care for reimbursement
11 Utilizing cost report for decision support (what if scenarios)
12 Any and all information you have to offer
15 I need all training related to Cost report areas as far as gathering the info
reported in the cost report. Knowledge of Cost report detail would be great.
16 CAH areas of opportunity.
25 Our hospital has a need for overall, general knowledge of cost report
preparation since our cost report preparer is an external CPA.
26 Our hospital has a need for overall, general knowledge of cost report
preparation.
29 Accuracy
32 see above
30. Who will be the prog ram contact for the HCAHPS Mini-Series? (Werecommend the individual responsible for manag ing and measuring the patientexperience in your hospital, your CNO, Quality Director, or similar. ) Name, Title:
37
38
Count Response
2 T ammy Stone
1 CNO
1 Carla Nelson CQO
1 Diane Quick, Joint Commission Coordinator
1 John Roland, RN,BSN,CNO,COO
1 Laura Gentry, CNO
1 Melissa Layfield
1 Monica Cain
1 PAT RICIA MAYO
1 Robin Crosby, Revenue Cycle
1 T ammy Rowland, Nurse
1 T ina DeBord, QI Director
1 T onya Beckum
1 Zach Nicholson
1 Zach Nicholson, Quality Manager
31. Email for the HCAHPS contact email address:
39
Count Response
32. Does your marketing department/team provide community educationreg arding HCAHPS scores?
40
56% No56% No
13% Unsure13% Unsure
31% We dont' have a dedicatedmarketing department/team31% We dont' have a dedicatedmarketing department/team
Value Percent Responses
No 56.3% 9
Unsure 12.5% 2
We dont' have a dedicated marketing department/team 31.3% 5
T ot als: 16
Other - Write In (Required) Count
T otals 0
33. Do you have internal media (such as TV monitors) that roll educationinformation on routine schedule?
41
13% Yes13% Yes
75% No75% No
6% Unsure6% Unsure
6% Other - Write In (Required)6% Other - Write In (Required)
Value Percent Responses
Yes 12.5% 2
No 75.0% 12
Unsure 6.3% 1
Other - Write In (Required) 6.3% 1
T ot als: 16
Other - Write In (Required) Count
Web ex via Internet 1
T otals 1
34. What other patient satisfaction surveys do you utilize at your hospital (orwithin your system)? Select all that apply.
42
Per
cent
EmergencyDepartment
Physicianpractices (CG
CAHPS)
Outpatient surveys Ambulatorysurgery
department
Other - Write In(Required)
0
10
20
30
40
50
Value Percent Responses
Emergency Department 33.3% 4
Physician practices (CG CAHPS) 8.3% 1
Outpatient surveys 50.0% 6
Ambulatory surgery department 16.7% 2
Other - Write In (Required) 33.3% 4
Ambulatory surgery department Count
will start January 2018 1
T otals 1
43
Other - Write In (Required) Count
Internal real data collected on Med/Surge unit 1
Our hospital only does Inpatient. 1
PAT RICIA WILL NEED T O ANSWER T HIS 1
Unofficial HCAHP survey for swingbed admissions 1
T otals 4
35. How are your patient satisfaction surveys implemented? (select all thatapply)
Per
cent
"Home grown" survey Vendor While in department only Other - Write In(Required)
0
20
40
60
80
100
44
Value Percent Responses
"Home grown" survey 12.5% 2
Vendor 87.5% 14
While in department only 6.3% 1
Other - Write In (Required) 12.5% 2
Other - Write In (Required) Count
Not sure 1
Vendor and real time data on med/surge unit 1
T otals 2
36. Do you provide up-dated HCAHPS scores to providers and ask for input?
45
69% Yes69% Yes
25% Unsure25% Unsure
6% Other - Write In (Required)6% Other - Write In (Required)
Value Percent Responses
Yes 68.8% 11
Unsure 25.0% 4
Other - Write In (Required) 6.3% 1
T ot als: 16
Other - Write In (Required) Count
Data is sent to the Quality Committee and follow a process to be reported to the next
level up, Quality Management Review Committee and to medical staff.
1
T otals 1
37. Do you have a physician champion for patient satisfaction or PI related topatient surveys?
46
50% Yes50% Yes
19% No19% No
25% Unsure25% Unsure
6% Other - Write In (Required)6% Other - Write In (Required)
Value Percent Responses
Yes 50.0% 8
No 18.8% 3
Unsure 25.0% 4
Other - Write In (Required) 6.3% 1
T ot als: 16
Other - Write In (Required) Count
Recently hired a Chief Medical Officer 1
T otals 1
38. What are your hospital's g reatest areas of need related to HCAHPS? Whatspecifically are you hoping to g et out of this prog ram?
47
ResponseID Response
9 GET WIT H PAT RICIA ON T HIS
10 Improvement in all scores
11 ways to improve HCAHPS scores in all areas that BMH currently monitors (Swing
beds, Inpatient).
15 T raining due to new staff inheritance of this task.
16 Use current NRC report
21 Ways to improve our scores
25 Patient education channels.
26 Education channels.
29 Education and customer service training
31 Increase patient satisfaction scores consistently and improve number of
completed surveys.
33 Implement CG in our clinics
48
39. Who will be the prog ram contact for this RHC CQM series? (Werecommend the person in charg e of overseeing the Clinic, Billers, MedicalStaff Liaison, etc.)
49
Count Response
2 T ammy Stone
1 ANN RYCROFT
1 Allison Clark, Administrator
1 Charlott Engram
1 Darla Busby, Clinical Coordinator
1 Debbie Shirley
1 Karen McLeod,
1 Kim Dozier
1 NO RHC/NA
1 Paul Parrish
1 Robin Crosby
1 T eresa Bryant
1 T ina DeBord
40. Email for the RHC CQM contact:
50
Count Response
41. Do you currently use any Lean or other methodolog y for identifying PI inthe clinic?
51
23% Yes- Other: Write In23% Yes- Other: Write In
39% No39% No
39% Unsure39% Unsure
Value Percent Responses
Yes- Other: Write In 23.1% 3
No 38.5% 5
Unsure 38.5% 5
T ot als: 13
Yes- Other: Write In Count
check lists 1
six sigma 1
T otals 2
42. Have you ever completed an internal or external clinic assessment?
52
7% Yes - internal7% Yes - internal
29% Yes- Both29% Yes- Both
29% No, neither29% No, neither
36% Unsure36% Unsure
Value Percent Responses
Yes - internal 7.1% 1
Yes- Both 28.6% 4
No, neither 28.6% 4
Unsure 35.7% 5
T ot als: 14
43. Does staff provide input for opportunities to improve in the clinic?
53
36% Yes (Provide method forinput collection)36% Yes (Provide method forinput collection)
29% No29% No
36% Unsure36% Unsure
Value Percent Responses
Yes (Provide method for input collection) 35.7% 5
No 28.6% 4
Unsure 35.7% 5
T ot als: 14
Yes (Provide method f or input collection) Count
During regular staff meetings that are held. 1
survey 1
verbal 1
verbal or written 1
T otals 4
54
44. Do you currently post quality outcomes for staff and providers in the clinic?
14% Yes14% Yes
57% No57% No
29% Unsure29% Unsure
Value Percent Responses
Yes 14.3% 2
No 57.1% 8
Unsure 28.6% 4
T ot als: 14
45. What are your hospital's g reatest areas of need related to Rural HealthClinic Clinical Quality Measures? What specifically are you hoping to g et outof this prog ram?
55
ResponseID Response
10 A home grown survey to utilize
11 NA
15 Physician documentation
16 Specifics related to benchmarking, coding, clinical and financial integration.
21 Improved compliance with quality initiatives
26 Our facility does not have a RHC.
29 Education and training
46. Who will be the prog ram contact for this series? (We recommend QualityLeaders or Up-and-Coming Quality Leaders) Name, Title:
56
57
Count Response
2 T ammy Stone
1 Carla nelson CQO
1 Cheryl T rice
1 Chief Quality Officer
1 Diane Quick, Joint Commission Coordinator
1 John Roland RN, BSN, CNO, COO
1 Lynn Mitchell, BOM
1 Michelle Murphy, Director of Quality
1 Monica Cain
1 Patricia Mayo
1 T ammy Rowland, Nurse
1 T ina DeBord, QI Director
1 T onya Beckum
1 Zach Nicholson
1 Zach Nicholson, Quality Manager
47. Email for the Quality Leadership Recharg e contact:
58
Count Response
48. Have you ever completed a quality department review /evaluation?
59
56% Yes56% Yes
6% No6% No
38% Unsure38% Unsure
Value Percent Responses
Yes 56.3% 9
No 6.3% 1
Unsure 37.5% 6
T ot als: 16
49. Do you have a physician champion for the quality department?
60
69% Yes69% Yes
13% No13% No
19% Unsure19% Unsure
Value Percent Responses
Yes 68.8% 11
No 12.5% 2
Unsure 18.8% 3
T ot als: 16
50. Does quality work with individual manag ers/staff to identify opportunitiesfor PI each year?
61
88% Yes88% Yes
6% No6% No
6% Unsure6% Unsure
Value Percent Responses
Yes 87.5% 14
No 6.3% 1
Unsure 6.3% 1
T ot als: 16
51. Are you currently using an accreditation org anization? Mark all that apply,below.
62
Per
cent
The Joint Commission (TJC) DNV Other - Write In (Required)0
10
20
30
40
50
Value Percent Responses
T he Joint Commission (T JC) 43.8% 7
DNV 43.8% 7
Other - Write In (Required) 25.0% 4
Other - Write In (Required) Count
AHCA 2
None 1
T JC-Lab only 1
T otals 4
63
ResponseID Response
10 Leadership buy in and accountability
11 Broad Education for entire staff as it relates to Quality/PI monitoring.
15 Physician and Employee training in the Quality Mgt and the importance of this.
16 Not a dedicated resource, balancing priorities
21 Analysis of quality data Reporting tools Closing DNV nonconformities from one
year to the next survey
29 Implementing ideas and time management
31 1. Up to date software to aid in document/contract control 2. Help with writing
reports electronically 3. Education/training to managers and staff on quality
processes
33 She is new.
52. What are your Quality Leaders g reatest needs, challeng es, or stressors atthis time? What specifically could this prog ram provide to help build up yourQuality Leadership and/or quality prog ram?
64
53. Who will be the prog ram contact for this MIPs series? (We recommendbilling leaders: If you hospital employs physicians, the individual who overseesthe physician practices, and if not, your Medical Staff Liaison) Name, Title:
65
Count Response
2 Callie Kervin, HIM
2 T ammy Stone
1 Charlott Engram
1 Debbie Shirley office manager
1 Diane Quick, Joint Commission Coordinator
1 Hollay Roland, Operations Director
1 Karen Mcloud, CFO, Practice Administrator
1 Kim Dozier
1 Paul Parrish
1 Robin Crosby, Revenue Cycle
1 T ina DeBord, QI Director
1 kathy keen
54. Email for MIPS prog ram contact:
66
Count Response
55. Our hospital is a part of an Accountable Care Org anization (ACO).
67
14% Yes14% Yes
64% No64% No
21% Unsure21% Unsure
Value Percent Responses
Yes 14.3% 2
No 64.3% 9
Unsure 21.4% 3
T ot als: 14
56. Does your hospital employ physicians?
68
71% Yes, less than 1571% Yes, less than 15
14% Yes, more than 1514% Yes, more than 15
7% No7% No
7% Unsure7% Unsure
Value Percent Responses
Yes, less than 15 71.4% 10
Yes, more than 15 14.3% 2
No 7.1% 1
Unsure 7.1% 1
T ot als: 14
57. Does your hospital manag e practices?
69
64% Yes64% Yes
36% No36% No
Value Percent Responses
Yes 64.3% 9
No 35.7% 5
T ot als: 14
58. What is your physician plan for the 2017 Merit Based Incentive Payment(MIPS) and Advanced Alternative Payment Model transition?
70
8% Submit something(Reporting only one Quality, ACIor IA measure earning enoughMIPS points to avoid a penalty.)
8% Submit something(Reporting only one Quality, ACIor IA measure earning enoughMIPS points to avoid a penalty.)
25% Submit a partial year(Submit 90 days of 2017 data toMedicare, earning a neutral orpositive payment adjustment.)
25% Submit a partial year(Submit 90 days of 2017 data toMedicare, earning a neutral orpositive payment adjustment.)
17% Submit a full year: (Submit afull year of 2017 data toMedicare, earning a positivepayment adjustment.)
17% Submit a full year: (Submit afull year of 2017 data toMedicare, earning a positivepayment adjustment.)
8% No participation: (Notsending in any 2017 data,resulting in a negative 4%payment adjustment.)
8% No participation: (Notsending in any 2017 data,resulting in a negative 4%payment adjustment.)
42% Unsure42% Unsure
Value Percent Responses
Submit something (Reporting only one Quality, ACI or IA
measure earning enough MIPS points to avoid a penalty.)
8.3% 1
Submit a partial year (Submit 90 days of 2017 data to Medicare,
earning a neutral or positive payment adjustment.)
25.0% 3
Submit a full year: (Submit a full year of 2017 data to Medicare,
earning a positive payment adjustment.)
16.7% 2
No participation: (Not sending in any 2017 data, resulting in a
negative 4% payment adjustment.)
8.3% 1
Unsure 41.7% 5
T ot als: 12
59. Is there a need for assistance in manag ing quality measures related tophysicians?
71
15% No, not at this time15% No, not at this time
54% Yes, we could use somerecommendations54% Yes, we could use somerecommendations
8% Yes, this is a strong need atour hospital8% Yes, this is a strong need atour hospital
23% Unsure23% Unsure
Value Percent Responses
No, not at this time 15.4% 2
Yes, we could use some recommendations 53.8% 7
Yes, this is a strong need at our hospital 7.7% 1
Unsure 23.1% 3
T ot als: 13
60. What are your specific areas of need for provider based alternativepayment models or MIPs? What specifically are you hoping to g et from thisprog ram/training ?
72
ResponseID Response
10 actual requirements for submission and who must participate
11 Our sister hospital T aylor Regional manages Physicians and Practices.
15 Any training.
16 Understanding of changes made in the program going forward
26 Our hospital needs a better understanding of the workflow process regarding
MIPS.
29 MIPS in regards to hospital based physicians, ER, pathology, radiology and
anesthesia
31 Gain knowledge and recommendations
33 Understanding RHC requirements for MIPS
61. Who will be the prog ram contact for the HIT Transformation series? (Werecommend both HIT/technolog y leaders/CIOs, administrators, or otherquality leaders, as this series is meant to improve quality improvement throug h
73
the use of technolog y.) Name, Title
74
Count Response
2 Shannon Webb, Clinical IT
1 Celeste Dent, Accountant
1 Christian Rekowski, IT Director
1 Gary Gower, IT Director
1 Jeff Laird, Controller
1 Lou Semrad
1 Lynn Mitchell, BOM
1 Mitch Hiers IT Director
1 Pat Everson
1 Pat Wells Clinical IT
1 SCOT T WYNNE
1 Scott Wynne, IT Director
1 T ammy Stone
1 T ony Harper
62. Email for the prog ram contract for the HIT series:
75
Count Response
63. Our hospital currently uses the following EHR Vendor:
76
47% Evident/CPSI47% Evident/CPSI
13% Healthland/CPSI13% Healthland/CPSI
20% Meditech20% Meditech
7% Epic7% Epic
13% Other - Write In (Required)13% Other - Write In (Required)
Value Percent Responses
Evident/CPSI 46.7% 7
Healthland/CPSI 13.3% 2
Meditech 20.0% 3
Epic 6.7% 1
Other - Write In (Required) 13.3% 2
T ot als: 15
Other - Write In (Required) Count
EPIC implementation in November 2017 1
McKesson/Paragon 1
T otals 2
77
64. Our hospital is current utilizing electronic clinical quality measures(eCQMs) to use data from our electronic health records (EHR) and/or healthinformation technolog y systems to measure health care quality.
71% Yes71% Yes
14% No14% No
14% Unsure14% Unsure
Value Percent Responses
Yes 71.4% 10
No 14.3% 2
Unsure 14.3% 2
T ot als: 14
65. Our hospital is current submitting data to computerized disease reg istries.
78
39% Yes39% Yes
8% No, but we hope to/haveinterest in beginning8% No, but we hope to/haveinterest in beginning
23% No23% No
31% Unsure31% Unsure
Value Percent Responses
Yes 38.5% 5
No, but we hope to/have interest in beginning 7.7% 1
No 23.1% 3
Unsure 30.8% 4
T ot als: 13
66. If yes, our hospital is effectively utilizing the disease reg istry to identify andmanag e patients with a particular condition across our reg ion.
79
60% Yes60% Yes20% Yes, but there is room forgreater or more effictive use ofthis data
20% Yes, but there is room forgreater or more effictive use ofthis data
20% No20% No
Value Percent Responses
Yes 60.0% 3
Yes, but there is room for greater or more effictive use of this
data
20.0% 1
No 20.0% 1
T ot als: 5
67. Our hospital is currently utilizing Computerized physician order entry(CPOE) to enter medication orders or other physician instructionselectronically.
80
86% Yes86% Yes
14% No14% No
Value Percent Responses
Yes 85.7% 12
No 14.3% 2
T ot als: 14
68. As it relates to Computerized physician order entry (CPOE), what are thechalleng es related to implementing or fully utilizing CPOE? Select yourhospital's top three:
81
7% The time related toinstalling/maintaining thesystem
7% The time related toinstalling/maintaining thesystem
7% The cost related toinstalling/maintaining thesystem
7% The cost related toinstalling/maintaining thesystem
36% Provider Resistance36% Provider Resistance
14% Cost or need for training14% Cost or need for training
36% Other - Write In (Required)36% Other - Write In (Required)
Value Percent Responses
T he time related to installing/maintaining the system 7.1% 1
T he cost related to installing/maintaining the system 7.1% 1
Provider Resistance 35.7% 5
Cost or need for training 14.3% 2
Other - Write In (Required) 35.7% 5
T ot als: 14
82
Other - Write In (Required) Count
EPIC implementation November2017 1
No challenges at this time 1
Provider resistance, cost or need for training, disruption to current care settings 1
implementation date November 2017 1
the time related to installing/maintaining the system, provider resistance, disruption to
current care settings
1
T otals 5
69. Our staff's technical skills in utilizing technolog y available to aid in qualityimprovement: 1- poor, 5- averag e, 10- exemplary
Per
cent
0 1 2 3 4 5 6 7 8 90
10
20
30
40
50
83
70. Our leadership/system administrator's technical skills or ability to utilizetechnolog y available to aid in quality improvement: 1- poor, 5- averag e, 10-exemplary
Per
cent
3 4 5 6 7 8 9 100
5
10
15
20
25
30
71. Please provide comments to expand on any questions above. What are yourhospitals challeng es or obstacles in utilizing technolog y? Are there specifictechnolog y needs or areas your hospital is exploring ? What specifically areyou hoping to g et from this prog ram/training ?
84
ResponseID Response
10 CPSI/Evident is limited in data collection and retrieval and not enough staff
trained in adhoc reports
15 More training
16 #64 would not allow me to select 3 answers so they were entered under
"Other"
21 Meditech upgrade Jan 2019 to assist in meeting meaningful use requirements.
Cost requirements
26 Our hospital does not have an IN-house IT person/Cost.
29 Adequate technology, education
31 Staff education and training
85
