SAFER Care for Critical Access Hospitals NRHA September 2016 · 2016-09-07 · SAFER Care for...
Transcript of SAFER Care for Critical Access Hospitals NRHA September 2016 · 2016-09-07 · SAFER Care for...
SAFER Care for Critical
Access Hospitals
Marilyn Grafstrom, BSN, MPA, CPHRM
Rural Health Liaison, Stratis Health
NRHA Critical Access Hospital Conference, Kansas City, MO
Sept. 21-23, 2016
Five Six Good Things
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Roseau, MN
Objectives
• Describe the SAFER Care for CAH approach to
streamlining hospital quality and patient safety
reporting and improvement
• Report an understanding of CAH patient safety and
quality improvement project prioritization
• Express increased readiness to develop or expand a
robust hospital quality and patient action plan
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Describe the SAFER Care for CAH approach to
streamlining hospital quality and patient safety
reporting and improvement
Critical access hospital (CAH) participation in federal
and state quality and patient safety programs improves
quality of care for rural populations. Stratis Health, the
Minnesota Hospital Association, and Minnesota’s
Medicare Rural Hospital Flexibility Program are helping
Minnesota CAH’s strengthen reporting and
improvement capacity by streamlining metrics and best
practices.
SAFER Care
MBQIP
HEN topics
Others
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SAFER Care for Critical
Access Hospitals• Quality Improvement
Specialist site visits to
MN CAH’s
• Continued phone
consultation
• SAFER Care webinars,
regional meetings
• CAH quality advisory
group
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SAFER Care Resources
• SAFER Care CAH Roadmap
• SAFER Care data inventory
– Measures, specifications
• SAFER Care topic resource
sheetLink to SAFER Care Roadmap, Data Inventory and
Topic Resources
• CAH Quality Improvement
Implementation Guide
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SAFER Care Roadmap
Safety Teams and Organizational Structure (who)
Access to Information (data)
Facility Expectations (culture)
Engagement of Patients and Families
Resiliency
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SAFER Care Roadmap Best
Practice Topics
• Falls
• Pressure ulcers
• ADE
• Perinatal safety
• Safe procedures
• Health care associated
infections
• Readmissions
• Controlled substance diversion
• Stroke
• VTE
• Delirium
• Sepsis
• ED throughput
• Time critical care
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SAFER Care Data Inventory
• Lists for all HEN and MBQIP measures:– Data element
– Mandatory reporting?
– Minnesota project leader
– NQF number
– Data submission method
– Frequency of data submission
– Data source
– Measure specification
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SAFER Care Topic Resource
Sheet
• Lists each MBQIP and HEN topic and
provides links to resources
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RQITA CAH Quality Improvement
Implementation Guide & Toolkit
• Help CAH staff structure and
support quality improvement
efforts, as well as identify
best practices and strategies
for improvement of MBQIP
measures
• Provide basic directions and
resources for conducting and
streamlining quality
improvement projects in rural
hospitals, with a particular
focus on MBQIP
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Not considered in SAFER
Care for CAH…
• PQRS
• MN Trauma registry
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Highest MN CAH Priorities
1. HCAHPS
2. Fall prevention
3. Medication safety (ADE, med recon, EHR)
4. Culture
Other Priorities• Workplace violence
• CAUTI
• Hand hygiene
• System priorities
• Sepsis
• PFE
• Readmissions
• Infection Prevention
• PQRS, MN Community Measures
• Triple Aim
• Delirium
• Stroke
• Quality reporting
• NPSG
• ED physician services
• Critical Test reporting
• EHR
• Employee satisfaction
• Employee resilience
• CDI
• Streamlining
• EDTC
• VTE
• Pressure ulcers
• EED
• Mental Health
• Bedside rounding
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Top MN CAH Successes
• HCAHPS
• EDTC
• Fall prevention
• Bedside shift report
• Increased quality reporting
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Top MN CAH Challenges
1. Too many measures– Confusing, hard to keep up, too many changes
– “It’s hard to be really good at any one thing with so many topics”
– “The tug of war of industry obligations and providing good care”
2. Not enough time
3. Culture
What We Are Learning
• There is a wide range in critical access
hospital patient volumes and resources
• Higher patient volume and resources do
not always predict better quality metrics
• Culture drives quality. Leaders drive
culture
• It goes better if everyone owns quality
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Some Structures Observed
• DON responsible for quality/patient safety
with secretarial/admin assistant
• DON responsible for quality with quality
coordinator
• Quality as a separate department reporting
to CEO
• Quality Director reporting to CNO
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Improvements Observed
• 100% of MN CAH’s have submitted
EDTC data as of Q1 ‘2016
• Around 90% MN CAH’s participating in
HCAHPS or have plan in place
• Increased attendance in SAFER Care
quarterly webinars and regional
meetings
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Next Steps
• Culture of Excellence Cohort– Mentor model
– CEO involvement rather than sign off
– Studer, Lee, Baird, Nance, TeamSTEPPS
• Continued SAFER Care calls
• Continued quarterly education
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Report an understanding of CAH
patient safety and quality
improvement project prioritization
Two lenses….
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Patient safetyHospital
safety
Quality Improvement Prioritization
Factors
Topic/
project
Low performance
based on data
Potential harm to patients (severity)
Alignment with national/state
priorities
Enthusiasm
Multiple/ broad priorities
The number of patients
impacted (frequency)
Value Based Purchasing
2018 (PPS hospitals)• Patient and Caregiver-Centered Experience
of Care/Care Coordination (25%)
• Safety (25%)
• Clinical Care (25%)
• Efficiency and Cost Reduction (25%)
– Medicare spending per beneficiary
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Patient and Caregiver-Centered
Experience of Care/Care Coordination
HCAHPS (25%)
1. Communication with Nurses
2. Communication with Doctors
3. Responsiveness of Hospital Staff
4. Pain Management (proposed rule to remove from VBP calculation 2018)
5. Communication about Medicines
6. Cleanliness and Quietness of Hospital Environment
7. Discharge Information
8. Care Transition (3 new questions starting in FY 2018)
9. Overall Rating of Hospital
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Safety (25%)
• AHRQ PSI-90 Composite
• Central Line-Associated Bloodstream Infections (CLABSI)
• Catheter-Associated Urinary Tract Infections (CAUTI)
• Surgical Site Infection (SSI): Colon
• SSI: Abdominal Hysterectomy
• Methicillin-resistant Staphylococcus aureus (MRSA)
• C. difficile Infections (CDI)
• PC-01 Elective Delivery Prior to 39 Completed Weeks of
Gestation
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Patient Safety Indicators 90
(PSI 90)• PSI 03 Pressure Ulcer Rate
• PSI 06 Iatrogenic Pneumothorax Rate
• PSI 07 Central Venous Catheter-Related Blood Stream Infection Rate
• PSI 08 Postoperative Hip Fracture Rate
• PSI 09 Perioperative Hemorrhage or Hematoma Rate
• PSI 10 Postoperative Physiologic and Metabolic Derangement Rate
• PSI 11 Postoperative Respiratory Failure Rate
• PSI 12 Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rat
• PSI 13 Postoperative Sepsis Rate
• PSI 14 Postoperative Wound Dehiscence Rate
• PSI 15 Accidental Puncture or Laceration Rate
http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V50/TechSpecs/PSI_90_Patient_Safety_for_Selected_Indicators.pdf
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Clinical Care Outcomes
(25%)
• 30-day mortality, acute myocardial
infarction (MORT-30-AMI)
• 30-day mortality, heart failure (MORT-
30-HF)
• 30-day mortality, pneumonia (MORT-
30-PN)
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Efficiency and Cost
Reduction (25%)
• MSPB-1 Medicare spending per
beneficiary
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VBP for CAH?
VBP Performance Periods
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Predictive Positioning
• MBQIP
– connection with Flex funded
activities and SHIP grants
• FY 2017 – reporting one
measure in two domains
– Medicare CAH Conditions of
Participation proposed
changes
• National reporting
– NHSN, Quality Net
• Patient safety topics with
NQF endorsement
– Fall prevention
– CAUTI
– Early elective deliveries
• Global measures
– IMM – 2
– OP -27 HCP influenza
immunizations
• Clinical care outcomes
– all cases, all payers
readmissions
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MBQIP
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ACO…
an alignment consideration?• Risk Standardized, All Condition Readmission
• Documentation of Current Medications in the Medical Record
• Falls: Screening for Future Fall Risk
• Preventive Care and Screening: Influenza Immunization
• Pneumonia Vaccination Status for Older Adults
• Preventive Care and Screening: Body Mass Index Screening and
Follow-Up
• Preventive Care and Screening: Tobacco Use: Screening and
Cessation Intervention
• Preventive Care and Screening: Screening for Clinical Depression and
Follow-up Plan
• Cancer screening (colorectal and breast)
• Preventive Care and Screening: Screening for High Blood Pressure
and Follow-Up Documented
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National Quality Forum Rural
Provider RecommendationsAfter discussion of many of the rural health
and setting-specific challenges related to
performance measurement of rural
providers, the Committee agreed that their
recommendations should, at minimum,
address four key issues:
• Low case volume
• Need for measures that are most meaningful
to rural providers and their patients and
families
• Alignment of measurement efforts
• Mandatory versus voluntary participation in
CMS quality improvement programs
http://www.qualityforum.org/Publications/2015/09/Rural_Health_Final_Report.aspx
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If you don’t like where we’re
going….
Speak up….
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Express increased readiness to
develop or expand a robust
hospital quality and patient
action plan
RQITA CAH Quality Improvement
Implementation Guide & Toolkit
• Help CAH staff structure and
support quality improvement
efforts, as well as identify
best practices and strategies
for improvement of MBQIP
measures.
• Provide basic directions and
resources for conducting and
streamlining quality
improvement projects in rural
hospitals, with a particular
focus on MBQIP.
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The guide includes:• Quality improvement implementation model focused on small, rural
hospital settings
• Suggestions and considerations to identify and prioritize areas for
improvement
• Table detailing key national quality initiatives that align with MBQIP
priorities, including web links for further information
• 10 steps to leading quality improvement topics
• Acronym list related to MBQIP measures
• Summaries of current MBQIP measures by domain, including best
practices for improvement
• Glossary of key words - in the guide, key words have hyperlinks to
glossary definitions
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The toolkit includes:
• Quality and Patient Safety Committee Meeting Agenda/Minute
Template
• Ten Step Quality Improvement Project Documentation Template
• Brainstorming Tool
• Project Action Plan Template
• Rapid Tests of Change Tool
• Internal Quality Monitoring Tool
• Quality and Patient Safety Prioritization Tool for CAH
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Hub and Spoke Quality
Improvement Model
Quality/
Patient
Safety
Committee
EDTC
ED/IT HCAHPS
EVS
IMM 2
Infection
Prevention
OP
1,2,3,5,21
ED
HCAHPS
Nursing
HCAHPS
Pharm
OP 20,22
Admin
HCP IMM
Pharm
Key Success Factors of Hub
and Spoke Model
• Flexible structure
• Leadership engagement
• Systematic process
• Expectations that prioritize QI
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Flexible Structure
• No perfect way to run a CAH quality
program
• Be creative in how you allocate the work
• Decide what makes the most sense in
your hospital
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Leadership Engagement
• Resource allocation
• Accountability
• Switch – great ideas
to get the attention
of leaders
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© 2015 Heath Brothers, Courtesy of
Chip Heath and Dan Heath
Systematic Process
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MBQIP Toolkit: Quality and Patient Safety Committee Meeting Agenda/Minute Template
Instructions for use: This template was designed to provide a thorough inventory of possible agenda items to cover during a standing Quality and Patient Safety Committee meetings. Every meeting may not include every agenda item. Some agenda items are intended to provide documentation of tracking or regulatory compliance and will be only short updates. You might rotate agenda items, remove agenda items that are not applicable, or hold less frequent and longer meetings to accommodate what you determine to be necessary.
Quality and Patient Safety Committee Meeting Agenda/Minute Template
Date: Attendees:
Agenda Item Data
Review (if applicable)
Discussion/conclusion Action Person Responsible
Target Date
Patient Story
Policy/Procedure Review
Patient Safety Culture (HSOPS, Just culture, TeamSTEPPS, etc.)
HCAHPS
Healthcare alerts (JC Sentinel event, etc.)
Proactive Risk Assessments
Root Cause Analyses
Falls reported
Expectations that Prioritize QI
• Staffing shortages
– Patient care comes first
– Too busy cutting wood to sharpen the axe
• “The day-to-day trials of running a rural
hospital can take precedence over
strategy.”https://www.ruralcenter.org/srht/resources/rural-provider-leadership-summit-finding
s
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Key Points of Hub and
Spoke Model
• Can be used to guide rural hospital quality improvement to
leverage advantages of smaller scales, easier access to key
people, and less cumbersome decision-making hierarchies
• Flow of information from quality and safety chair to each project
or topic leader is critical to success of hub and spoke model
• Be creative and flexible to accommodate rural hospital
schedules in project planning
• Documentation templates can be effective tools to organize and
propel multiple projects
• Resist temptation to repeatedly allow a shift in patient census to
trump quality improvement work
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Ten Steps to Leading Quality
Improvement Topics
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The Power of Leadership
• “Leadership has the strongest
relationship to organizational outcomes
and value…..excellent rural hospitals
invariably have excellent leadership.”
https://www.ruralcenter.org/sites/default/files/Creating%20a%20Blueprint%20for%20CAH%20Pe
rformance%20Excellence_0.pdf
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Other Resources
• Rural Hospital Toolkit
for Transitioning to
Value-Based Systems
• Link to the toolkit
• Rural Health
Innovations, National
Rural Health Resource
Center
• Rural Provider
Leadership Summit
Findings
• Link to the Rural
Provider Leadership
Summit Findings
• National Rural Health
Resource Center
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Parting deep thoughts…
• Has the prevailing and protective reluctance to include critical
access hospitals in quality reporting programs and value based
reimbursement models created potentially safe havens for
disruptive physicians, comfortably complacent leaders, and
minimally qualified healthcare professionals?
• “A truth must become not only plain, but also commonplace
before it will be seen by the people who go to their work very
early in the morning; and not to act upon it must involve great
and pinching inconveniences before these same people will
make up their minds to act upon it” - Woodrow Wilson, 1887
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Remember to complete
your survey before you
leave this session.
Thank you!
Questions ?
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Stratis Health is a nonprofit organization that leads collaboration and
innovation in health care quality and safety, and serves as a trusted
expert in facilitating improvement for people and communities.
Prepared by Stratis Health, with funding from Minnesota Department of Heath Office of Rural Health & Primary Care.