North Dakota Critical Access Hospital Quality Network, Statewide - - PDF document

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North Dakota Critical Access Hospital Quality Network, Statewide - - PDF document

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4/16/2018 North Dakota Critical Access Hospital Quality Network, Statewide CAH Region Meeting Holiday Inn Riverside, Minot April 18, 2018 Center for Rural Health University of North Dakota School of Medicine & Health Sciences Agenda for

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

North Dakota Critical Access Hospital Quality Network, Statewide CAH Region Meeting

Holiday Inn Riverside, Minot April 18, 2018

Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

  • Network Annual Meeting
  • CAH Quality Network Update
  • MBQIP Data Portal (EDTC)
  • ND CAH Financial Analysis and Accountable Care

Organizations (ACO)

  • ND Trauma System Today
  • ND Society Healthcare Risk Management
  • Legal Issues Facing CAHs
  • NDHIN Functionality
  • Hospital HIIN teams will present success stories and

best practices

Agenda for Today

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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

“Network Annual Meeting” April 18, 2018

Network’s Mission: To support ongoing performance improvement of North Dakota’s Critical Access Hospitals. Network’s Mission: To support ongoing performance improvement of North Dakota’s Critical Access Hospitals.

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

ND CAH Quality Network Executive Members

President Marcie Schulz – Hazen VP Coleen Bomber – Northwood Jodi Atkinson – Bottineau Peggy Larson – Lisbon Candie Thompson – Harvey Camille Settelmeyer – Valley City Ben Bucher – Cando Lori Seim‐ Park River Doris Vigen – Mayville

Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

Annual Meeting

  • Incoming and Outgoing Network Executive

Committee Members

  • Thank you‐ Doris Vigen for serving 11 Years!
  • Meet every month by webinar to provide support

and direction for Network statewide activity

  • Strategic Planning August 2018 (7 objectives)
  • Develop and manage Network
  • Facilitate best practice sharing
  • Highlight workforce development initiatives & resources
  • Engage in rural advocacy
  • Enhance professional development
  • Optimize technology utilization

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

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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

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

Medicare Rural Hospital Flexibility 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

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

Flex Priority Focus Areas 2018‐2019

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

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

Flex Funded 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

Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

ND Flex Program Activity

  • Rural Community‐Based Palliative Care Project, 3

years‐ just started! (7 CAH/Rural Communities‐ Cavalier, Harvey, Hazen, Hettinger, McVille, Tioga & Watford City

  • National Electronic Clinical Quality Measures

(eCQM) Pilot (2 CAHs‐ Tioga & Wishek)

  • Strategies Targeting Reduction in Infections via

Engagement (STRIVE) (4 CAHs‐ Hettinger, Carrington, Valley City and Williston)

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

ND Flex Program Activity

  • Frontier Community Health Integration Project

(FCHIP) (3 ND CAHs‐Bowman, Elgin & Watford City)

  • Emergency Department Patient Experience

(EDCAHPS) Pilot with Illinois CAH Network (5 ND CAHs Bottineau, Harvey, Northwood, Cavalier & Grafton)

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

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

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

Medicare Beneficiary Quality Improvement Project (MBQIP) Focus

Quality Domains 1. Patient Safety 2. Patient Engagement 3. Care Transitions 4. Outpatient

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

MBQIP Activity 2018‐2019

Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

MBQIP Hospital Compare 2016

  • Nationally ND CAHs reported higher for

Inpatient measures (ND 94% CAHs vs Nationally 85%)

  • Outpatient measures (ND 69% of CAHs vs 60%

CAHs Nationally

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

New MBQIP Measure

Antibiotic Stewardship‐NHSN

  • Thank you for completing your annual facility survey!
  • 33 of 36 ND CAHs have completed
  • Next steps‐ CAHs work on elements and actions to

ensure optimal antibiotic prescribing and limit overuse and misuse of antibiotics

  • Future additions coming will be Healthcare Associated

Infection measures (CAUTI, MRSA and CDI)

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

New MBQIP Inpatient ED Measures

  • ED‐1 Median time from ED arrival to ED departure

for admitted patients

  • ED‐2 Admit decision time to ED departure time for

admitted patients

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

Retired MBQIP Measure after August 2018

Below Outpatient Measures (retired August 2018)

  • OP‐1 Median Time to Fibrinolysis
  • OP‐4 Aspirin at Arrival
  • OP‐20 Door to Diagnostic Evaluation by a

Qualified Medical Professional

  • OP‐21 Median Time to Pain Management for Long

Bone Fracture

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

Upcoming 2018 MBQIP Data Reporting Submission Deadlines

  • April 30‐ Emergency Department Transfer

Communication (EDTC) (REDCap)

  • May 1‐ Outpatient Measures
  • May 1‐ Population and sampling
  • May 15‐ Outpatient‐27 Influenza Vaccination HCP

(CDC NHSN)

  • May 15‐ Inpatient Measures

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

Population and Sampling‐ Why Important?

  • Enter data using secure portal of QualityNet.org
  • If you report a zero, on population and sampling

report‐ this meets a measures requirement and will show up on your MBQIP reports

  • If no cases and nothing entered on population and

sampling report, this says to CMS and Flex program you are not a participating CAH

  • Zero shows you would have reported if you had

cases that quarter

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

Population and Sampling

  • Submit via the QualityNet secure portal
  • Select Hospital Quality Reporting‐drop down box
  • Enter your facility CCN number
  • Select reporting period
  • Enter cases in the grids
  • *Fields for the required measures should not be left

blank! Enter zero where there are no cases.

  • Video

https://www.qualityreportingcenter.com/media/vide

  • s/iqr/popandsamp/index.html

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

National Rural Health Association (NRHA), “Rural Health Practitioner of the Year”

2018 Award Winner is Dr. Kent Hoerauf

  • Board certified internal and geriatric medicine

physician at West River Health Services in Hettinger

  • Important contributions to greater than 20,000

rural residents

  • Created 1st designated Alzheimer’s unit is SW ND

and West River’s level IV trauma system

  • Serves as clinical professor of internal medicine at

UND SMHS

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Center for Rural Health

University of North Dakota School of Medicine & Health Sciences

National Rural Health Day November 15, 2018, “Power of Rural”

  • Celebrate National Rural Health Day!
  • www.PowerofRural.org Ideas on how to

celebrate in your community

  • Templates, Ideas, Key Messages‐ toolkit online

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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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