4/20/2017 ND Critical Access Hospital Quality Network “Statewide CAH Quality Network Meeting” April 20, 2017 Center for Rural Health University of North Dakota School of Medicine & Health Sciences Agenda for Today • Network Annual Meeting • CAH Quality Network Update • MBQIP Data Portal (EDTC) • Innovate ND HRET Hospital Improvement Innovative Network (HIIN) • NDHIN Overview • Changing the Opioid Conversation • Recruiting and Retaining Healthcare Workforce • ND Top Survey Deficiencies 1
4/20/2017 “Network Annual Meeting” April 20, 2017 Network’s Mission: To support ongoing performance improvement Network’s Mission: To support ongoing performance improvement of North Dakota’s Critical Access Hospitals. of North Dakota’s Critical Access Hospitals. Center for Rural Health University of North Dakota School of Medicine & Health Sciences ND CAH Quality Network Executive Members President Doris Vigen – Mayville VP Coleen Bomber – Northwood Jodi Atkinson – Bottineau Peggy Larson – Lisbon Candie Thompson – Harvey Marcie Schulz – Hazen Camille Settelmeyer – Valley City Ben Bucher – Cando Chris Wyatt – Langdon Center for Rural Health University of North Dakota School of Medicine & Health Sciences 2
4/20/2017 • Established in 1980, at The University of North Dakota (UND) School of Medicine and Health Sciences in Grand Forks, ND • One of the country’s most experienced state rural health offices • UND Center of Excellence in Research, Scholarship, and Creative Activity • Home to seven national programs • Recipient of the UND Award for Departmental Excellence in Research Focus on – Educating and Informing – Policy – Research and Evaluation – Working with Communities – American Indians – Health Workforce – Hospitals and Facilities ruralhealth.und.edu Medicare Rural Hospital Flexibility Program (Flex) Center for Rural Health University of North Dakota School of Medicine & Health Sciences 3
4/20/2017 The Flex Grant Program Supports ND CAHs • Provides resources to strengthen rural healthcare • Assists CAHs and their communities to have access to quality care • Assists CAHs to improve quality and performance Center for Rural Health University of North Dakota School of Medicine & Health Sciences Medicare Rural Hospital Flexibility (Flex) Team • Brad Gibbens, Deputy Director • Lynette Dickson, Associate Director • Jody Ward, Senior Project Coordinator • Kylie Nissen, Senior Project Coordinator • Angie Lockwood, Project Coordinator • Julie Frankl, Project Specialist • KayLynn Bergland, Administrative Assistant 4
4/20/2017 Flex Priority Focus Areas 2017‐2018 Population Health Financial Quality Management & Operational Improvement Emergency Medical Performance Services Integration ND CAH Quality Network Relationship Network Voice for ND Building Established 36 CAH Strong! CAHs Between CAHs 2007 and Tertiaries Participate with Support CMS Support CAH ED CAHPS and Participate with Conditions of Needs HCAHPS QHA and HAI Participation Collaborative Webpage Virtual www.ruralhealth. List Serve und.edu/projects/ Library cahquality Center for Rural Health University of North Dakota School of Medicine & Health Sciences 5
4/20/2017 Federal Office of Rural Health Policy (FORHP) Attention Toward Quality Improvement Medicare Beneficiary Quality Improvement Program (MBQIP) participation is required to be eligible to participate in Flex activities and receive funds i.e., • Technical Assistance • Education • Site visits • SHIP funds Medicare Beneficiary Quality Improvement Program (MBQIP) Focus Quality Domains 1. Patient Safety 2. Patient Engagement 3. Care Transitions 4. Outpatient Center for Rural Health University of North Dakota School of Medicine & Health Sciences 6
4/20/2017 Using Data to Improve Quality • Mapping your current process • Analyzing your data • Implementation plan • Report out • Share success Center for Rural Health University of North Dakota School of Medicine & Health Sciences Mapping Your Current Process Road Map • Select a Quality Improvement Project • Form a Team • AIM‐ What are we trying to accomplish? Center for Rural Health University of North Dakota School of Medicine & Health Sciences 7
4/20/2017 Analyze Data • Measures‐ How will we know that our changes are an improvement? • Ideas‐ What changes can we make that will result in an improvement? Center for Rural Health University of North Dakota School of Medicine & Health Sciences Types of measures Measures linked to your project aim and goals • Outcome ‐ The ultimate results you are trying to achieve (overall wait time for pain meds in long bone fracture) • Process ‐ what you do to achieve your outcome (# of forms completed) Center for Rural Health University of North Dakota School of Medicine & Health Sciences 8
4/20/2017 Measurement Plan to Display Data • Run Chart • Graphs • How often will you collect • Who will collect • How to summarize data Center for Rural Health University of North Dakota School of Medicine & Health Sciences Plan, Do, Study, Act (PDSA) • PDSA testing your ideas • Sustain and hardwire Center for Rural Health University of North Dakota School of Medicine & Health Sciences 9
4/20/2017 MBQIP Activity‐ handout at registration table Center for Rural Health University of North Dakota School of Medicine & Health Sciences Patient Safety OP‐27, Influenza Vaccine Influenza Vaccine coverage among healthcare personnel Reported to CDC National Healthcare Safety Network (NHSN) • Patients seen: October 1, 2016 to March 31, 2017 • CAH needs an NHSN account (Registration takes about 2‐3 weeks) • Data due May 15, 2017 (numerator and denominator for your facility) Center for Rural Health University of North Dakota School of Medicine & Health Sciences 10
4/20/2017 NHSN Influenza Vaccination Summary Center for Rural Health University of North Dakota School of Medicine & Health Sciences AMI Cardiac Care Outpatient Measurement MBQIP QI Measure ND Median Time 3 Q # ND CAHs National Median Time 2016 OP‐1 Median time to 22 Minutes 18 33 Minutes fibrinolysis OP‐2 Fibrinolytic 50% 18 50% therapy received within 30 minutes of ED arrival OP‐3b Median time to 120 Minutes 18 66 Minutes transfer to acute coronary intervention OP‐4 Aspirin on arrival 97% 21 95% OP‐5 Median time to 9 Minutes 21 8 Minutes ECG 11
4/20/2017 Outpatient (OP‐21) Median Time to Pain Management For Long Bone Fracture MBQIP QI Measure ND Median Time 3 Q 2016 National Median Time OP‐21Median time 37 Minutes based on 141 45 Minutes to Pain patients Management for Long Bone Fracture MBQIP Reporting Dates‐ handout at registration table 12
4/20/2017 Center for Rural Health University of North Dakota School of Medicine & Health Sciences Contact Jody Ward, MS, RN, APHN, Senior Project Coordinator UND Center for Rural Health School of Medicine and Health Sciences 1201 11 th Avenue SW Minot, ND 58701 Jody.ward@med.und.edu Phone: 701‐858‐6729 Webpage: ruralhealth.UND.edu Center for Rural Health University of North Dakota School of Medicine & Health Sciences 13
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