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 1
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 4
Describe the SAFER Care for CAH approach to streamlining hospital quality and patient safety reporting and improvement 5
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.
HEN topics Others MBQIP SAFER Care 7
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 8
SAFER Care Resources SAFER Care CAH Roadmap SAFER Care data inventory Measures, specifications SAFER Care topic resource sheet Link to SAFER Care Roadmap, Data Inventory and Topic Resources CAH Quality Improvement Implementation Guide 9
SAFER Care Roadmap Safety Teams and Organizational Structure (who) Access to Information (data) Facility Expectations (culture) Engagement of Patients and Families Resiliency 10
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 11
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 12
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SAFER Care Topic Resource Sheet Lists each MBQIP and HEN topic and provides links to resources 14
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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 16
Not considered in SAFER Care for CAH PQRS MN Trauma registry 17
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 19
Top MN CAH Successes HCAHPS EDTC Fall prevention Bedside shift report Increased quality reporting 20
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 22
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 23
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 24
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 25
Report an understanding of CAH patient safety and quality improvement project prioritization 26
Two lenses. Patient safety Hospital safety 27
Quality Improvement Prioritization Factors Low performance based on data The number of patients impacted (frequency) Potential harm to patients (severity) Topic/ project Multiple/ broad priorities Alignment with national/state priorities Enthusiasm
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 29
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 30
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 31
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 32
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) 33
Efficiency and Cost Reduction (25%) MSPB-1 Medicare spending per beneficiary 34
VBP for CAH? 35
VBP Performance Periods 36
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 37
MBQIP 38
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 39
National Quality Forum Rural Provider Recommendations After 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 40
If you don t like where we re going. Speak up. 41
Express increased readiness to develop or expand a robust hospital quality and patient action plan 42
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. 43
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 44
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 45
Hub and Spoke Quality Improvement Model HCAHPS Nursing IMM 2 Infection Prevention HCP IMM Pharm HCAHPS EVS Quality/ Patient Safety Committee EDTC ED/IT HCAHPS Pharm OP 20,22 Admin OP 1,2,3,5,21 ED
Key Success Factors of Hub and Spoke Model Flexible structure Leadership engagement Systematic process Expectations that prioritize QI 47
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 48
Leadership Engagement Resource allocation Accountability Switch great ideas to get the attention of leaders 2015 Heath Brothers, Courtesy of Chip Heath and Dan Heath 49
Systematic Process 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. Attendees: Quality and Patient Safety Committee Meeting Agenda/Minute Template Date: Agenda Item 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 Data Review (if applicable) Discussion/conclusion Action Person Responsible Target Date 50
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. s https://www.ruralcenter.org/srht/resources/rural-provider-leadership-summit-finding 51
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 52
Ten Steps to Leading Quality Improvement Topics 53
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 54
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 55
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 56
Remember to complete your survey before you leave this session. Thank you!
Questions? 59
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.