Agenda for Today Network Annual Meeting CAH Quality Network - - PDF document

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

ND Critical Access Hospital Quality Network “Statewide CAH Quality Network Meeting” April 20, 2017

• 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

Agenda for Today

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

“Network Annual Meeting” April 20, 2017

Network’s Mission: To support ongoing performance improvement

• f North Dakota’s Critical Access Hospitals.

Network’s Mission: To support ongoing performance improvement

• f North Dakota’s Critical Access Hospitals.

Center for Rural Health

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

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• 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

Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

Medicare Rural Hospital Flexibility Program (Flex)

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

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

• 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

Medicare Rural Hospital Flexibility (Flex) Team

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Flex Priority Focus Areas 2017‐2018

Quality Improvement Financial Operational Performance Population Health Management & Emergency Medical Services Integration

Center for Rural Health

ND CAH Quality Network

Network Established 2007

36 CAH Strong! Voice for ND CAHs Relationship Building Between CAHs and Tertiaries Support CMS Conditions of Participation Support CAH Needs

Participate with ED CAHPS and HCAHPS Collaborative Participate with QHA and HAI

Webpage www.ruralhealth. und.edu/projects/ cahquality

List Serve Virtual Library

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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

Federal Office of Rural Health Policy (FORHP) Attention Toward Quality Improvement

Center for Rural Health

Medicare Beneficiary Quality Improvement Program

(MBQIP) Focus Quality Domains

• 1. Patient Safety
• 2. Patient Engagement
• 3. Care Transitions
• 4. Outpatient

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Center for Rural Health

Using Data to Improve Quality

• Mapping your current process
• Analyzing your data
• Implementation plan
• Report out
• Share success

Center for Rural Health

Mapping Your Current Process

Road Map

• Select a Quality

Improvement Project

• Form a Team
• AIM‐ What are we trying

to accomplish?

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Center for Rural Health

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

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
• utcome (# of forms completed)

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Center for Rural Health

Measurement Plan to Display Data

• Run Chart
• Graphs
• How often will you collect
• Who will collect
• How to summarize data

Center for Rural Health

Plan, Do, Study, Act (PDSA)

• PDSA testing your ideas
• Sustain and hardwire

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Center for Rural Health

MBQIP Activity‐ handout at registration table

Center for Rural Health

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)

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Center for Rural Health

NHSN Influenza Vaccination Summary

AMI Cardiac Care

Outpatient Measurement

MBQIP QI Measure ND Median Time 3 Q 2016 # ND CAHs National Median Time OP‐1 Median time to fibrinolysis 22 Minutes 18 33 Minutes OP‐2 Fibrinolytic therapy received within 30 minutes of ED arrival 50% 18 50% OP‐3b Median time to transfer to acute coronary intervention 120 Minutes 18 66 Minutes OP‐4 Aspirin on arrival 97% 21 95% OP‐5 Median time to ECG 9 Minutes 21 8 Minutes

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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 to Pain Management for Long Bone Fracture 37 Minutes based on 141 patients 45 Minutes

MBQIP Reporting Dates‐ handout at

registration table

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Center for Rural Health

Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

Jody Ward, MS, RN, APHN, Senior Project Coordinator UND Center for Rural Health School of Medicine and Health Sciences 1201 11th Avenue SW Minot, ND 58701 Jody.ward@med.und.edu Phone: 701‐858‐6729 Webpage: ruralhealth.UND.edu

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