SAFER Care for Critical Access Hospitals NRHA September 2016 · 2016-09-07 · SAFER Care for Critical Access Hospitals Marilyn Grafstrom, BSN, MPA, CPHRM Rural Health Liaison, Stratis

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

5

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

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

sheetLink 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

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13

SAFER Care Topic Resource

Sheet

• Lists each MBQIP and HEN topic and

provides links to resources

14

15

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

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

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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

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

26

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

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

35

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

37

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

39

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….

41

42

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.

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

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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

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

49

© 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 ?

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.