State Rural Hospital Quality Initiatives

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State Rural Hospital Quality Initiatives

• Flex Program Meeting
• August 19, 2003

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States with Established Initiatives

• Montana
• Pennsylvania
• Nevada
• Kansas
• Idaho

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Montana CAH Quality Improvement Network

• Formed February 2001
• 34 members voluntary
• Purpose Meet CoP requirements
• Quality Assurance/Improvement
• Medical Staff Credentialing
• Outside Peer Review
• Clinical Policies and Procedures
• Annual Program Review

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Montana CAH Quality Improvement Network

• Lessons Learned
• Future Plans
• Evolving to Rural Healthcare Performance
  Improvement Network
• Multi-state Benchmarking Project
• Balanced Scorecard Demonstration
• Expansion into non-CAH areas

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Pennsylvania State Office of Rural Health CAH
Performance Improvement Initiative

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PA CAHs

• Pennsylvania currently has six (6) Critical
  Access Hospitals
• Bucktail Medical Center
• Muncy Valley Hospital
• Jersey Shore Hospital
• Fulton County Medical Center
• Meyersdale Medical Center
• Troy Community Hospital

Context
Year 1 Project
Year 2 Project
Current Status
Susquehanna Valley Rural Health Network
Future Direction

• Members of multi-hospital Health Systems

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PA CAHs

• In many ways, Pennsylvania is ideal for
  developing a pilot collaborative model among its
  Critical Access Hospitals
• CAHs are geographically close (driving distance)
• Small number of facilities
• Relatively strong, stable management teams
• However, there are still challenges
• Two hospitals are members of health systems that
  mandate certain reporting structures, procedures
  and PI initiatives
• Each hospital has unique characteristics in terms
  of
• Patient volumes
• Levels of care
• Scope of services

Context
Year 1 Project
Year 2 Project
Current Status
Future Direction
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PA CAHs

• PAORH established the following goals for the
  initial Performance Improvement (PI) project
• Develop a collaborative PI model among the six PA
  Critical Access Hospitals
• Design a system for peer benchmarking using
  quality related performance indicators
• Conduct environmental assessment of existing
  Quality Assessment and Performance Improvement
  (PI) programs
• Efforts should be consistent with
• Joint Commission for Accreditation of Healthcare
  Organizations (JCAHO) accreditation
• Quality Insights (the states peer review
  organization) benchmarking, quality improvement
  and utilization management activities
• State/federal licensure requirements

Context
Year 1 Project
Year 2 Project
Current Status
Future Direction
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PA CAHs

• The Year 1 Performance Improvement (PI) project
  involved the following activities
• On site comprehensive Quality Program Assessments
• Comparison of strengths/weaknesses based on site
  visits
• Report identifying opportunities for improvement
  and common areas of interest for future
  collaboration
• Which identified several key themes
• 100 interest in developing and implementing a
  quality related set of performance benchmarks
• Widespread need for capacity building,
  particularly in the areas of data analysis,
  reporting, and implementing projects based on
  data
• Disparity among facilities in terms of
  infrastructure, training, capacity and systems
  for data analysis and reporting
• Eagerness to work as a consortium of hospitals
  that openly share knowledge and experience

Context
Year 1 Project
Year 2 Project
Current Status
Future Direction
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PA CAHs

• As a result of the findings from Year 1, PAORH
  established the following goals for the Year 2
  (PI) project
• Benchmarking Project. Design, build and
  implement the data collection and reporting
  infrastructure required to populate performance
  reports
• Additional CAH Trainings. Facilitate hands-on
  data analysis and reporting educational sessions,
  introducing the concept of Statistical Process
  Control for healthcare decision making
• Technical Assistance. Provide focused, on site
  technical assistance in areas that are identified
  by individual facilities
• Joint Quality Improvement Program. Using the
  results of the benchmarking project, identify and
  design an improvement project tailored to the
  specific needs of the 6 PA CAHs

Context
Year 1 Project
Year 2 Project
Current Status
Future Direction
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PA CAHs
Time Frame
Context

• Below is a proposed timeline and update of key
  data collection implementation components

Year 1 Project
Year 2 Project
Current Status
Future Direction
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PA CAHs

• Noteworthy Developments
• All 6 CAHs have elected to integrate the data
  collection process into a more focused
  Performance Improvement project using the
  Balanced Scorecard framework
• Administrators want to harvest the potential
  value of benchmarking by linking the process into
  their strategic planning and Performance
  Improvement efforts
• Project Managers (typically Quality Coordinators
  or DONs) have committed to using the Balanced
  Scorecard framework as a platform for measuring
  their Quality and Performance Improvement Plans
• All six Quality Coordinators have committed to
  developing a network of relationships that share
  information and approaches to PI at their
  respective facilities, using the Balanced
  Scorecard as the common language

Context
Year 1 Project
Year 2 Project
Current Status
Future Direction
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PA CAHs

• Noteworthy Developments
• Administrators reached the conclusion that
  Clinical Quality is only one aspect of
  Performance Improvement, and that there is a
  benefit to integrating
• Mission and Vision
• Finance
• Clinical quality
• Patient care and satisfaction
• Physician and Staff satisfaction
• into a single, unified strategy

Context
Year 1 Project
Year 2 Project
Current Status
Future Direction
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PA CAHs

• Opportunities to Build on Our Experience
• Use the results of the benchmarking project to
• Identify opportunities for joint PI projects
• Define best practices among participating
  hospitals
• Evaluate performance against like hospitals
• Encourage knowledge transfer and spirit of
  collaboration
• Link up with other state-wide benchmarking
  projects
• Use the Balanced Scorecard framework to
• Enhance Performance Improvement at all PA CAHs
• Bring clarity to PA CAH mission and vision
• Develop linkages between clinical quality and
  finance
• Nurture an understanding of inter-relatedness
  among different hospital functions
• Create a common language for PI in rural
  Pennsylvania

Context
Year 1 Project
Year 2 Project
Current Status
Future Direction
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Nevada Flex Program

• The Nevada FLEX Program has been at the forefront
  of quality assurance and quality improvement
  efforts in Nevada. In the focal area of quality
  assurance and quality improvement, the Nevada
  FLEX Program and its partners have
• Established a "Nevada FLEX QI Committee" or
  network that meets on a quarterly basis to
  design and implement FLEX-supported quality
  improvement projects and monitoring
• Developed and conducted periodic training and
  workshops for
• all QA/QI/Risk Managers in Nevada rural
  hospitals, including an annual two-day
  workshop, "Health Care Quality Improvement
  Nevada's Rural and Frontier Hospitals," developed
  in partnership
• with HealthInsights (QIO)

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Nevada Flex Program

• Developed a 15-indicator quality-of-care
  monitoring system that will allow FLEX program
  staff and individual hospitals to assess the
  impact of CAH designation on the quality of care
  (full implementation of this important project is
  pending the resolution of medical privilege and
  legal liability issues)
• The development and implementation of a QA and
  credentialing agreement (per the Nevada Rural
  Health Plan) in every certified CAH and
• 5. Developed an implemented an annual "QA/QI
  Self-Assessment" in CAHs and other interested
  rural hospitals - the findings of this assessment
  have been used by the aforementioned QI Committee
  and program staff to guide FLEX-supported
  quality improvement projects.

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Kansas Office of Local and Rural Health

• Kansas Critical Access Hospital QI Plan
• Rural Health Options Project Quality Committee
• Involvement of State QIO
• Workforce Issues
• Competitive Network grant Program

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Idaho Office of Rural Health
The Idaho Performance Improvement Goal is to
develop implement a comprehensive performance
improvement program specifically for Idaho CAHs

• Initiate a Performance Improvement Advisory
  Committee/Workgroup
• State Office of Rural Health
• Bureau of EMS
• Qualis Health QIO
• Idaho Hospital Association
• Mountain States Group, Inc.

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Idaho Office of Rural Health

• The Committee will oversee
• The initiative
• Identifying uniform indicators benchmarks
• Data collection mechanisms
• Systems for analysis
• Resources for assistance

• Performance Improvement Advisory subcommittees
  will be established in these areas
• financial/ business management
• clinical quality/patient safety
• staffing community/patient services

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Idaho Office of Rural Health

• Continue to support web-based clinical quality
  indicators
• Initiate planning and implementation of Quality
  Collaboration Model
• clinical quality/patient safety
• financial/business management
• community/patient services
• staffing
• Assistance will be provided to CAHs and partner
  health care providers during the adjustment period

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New State Initiatives

• Indiana
• Illinois
• South Dakota
• Michigan

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Plenty of Money Little Direction
Indiana Office of Rural Health

• PRO/QIO received an automatic grant to review
  current quality (50K award)
• The PRO would do an on-site survey, similar to
  Federal licensure survey
• Emphasis on patient records
• Duplicative, no help, a hassle, and no benefit

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Less Money More Input

• CAHs developed program to help measure and
  improve quality
• Proposal requests brought competition to project
  and decreased Flex program costs
• Indiana Rural Health Association received the
  grant
• Survey done of CEOs and quality personnel to
  evaluate needs
• Benchmarking system to allow CAH to CAH
  comparisons of administrative and clinical
  performance
• Will lead to comparison with other rural hospitals

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Illinois Center for Rural Health

• Quality Improvement user group - developed four
  clinical indicators for Illinois CAHs. Data
  collection began in August 2003
• CAH Nurse Leaders group - initiated a med/surg
  productivity study for CAHs in Sept 2002. The
  study identified a new measurement, activity
  adjusted hours per patient day (AAHPPD), to
  measure med/surg staffing levels. The study also
  demonstrated the problems of using the standard
  hours per patient day (HPPD) benchmark
• Business Office user group - have initiated a
  comparison benchmark for business office
  operations in a CAH
• Peer review user group - are completing a
  hospital model peer review program for small
  hospitals and a peer review network service for
  cases that can not be reviewed internally.

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South Dakota Office of Rural Health

• Quality Improvement Initiative in South Dakota
• Critical Access Hospital Quality Improvement
  Conference held on June 11, 2003
• Keynote Speaker Darlene Bainbridge
  MS,RNNHA,CPHRM,CPHQ
• Quality Improvement Steering Committee
• Purpose Develop a Strategic Plan for CAH Quality
  Improvement Initiative
• Mission Statement To provide leadership through
  collaboration for the South Dakota Critical
  Access Hospital Quality Improvement Initiative.

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South Dakota Office of Rural Health

• Four goal areas of plan
• 1. Human Capital
• 2. Quality Improvement
• 3. Organizational Operations
• 4. Leadership Development
• Steering Committee has formed four workgroups to
  address each goal area
• Steering Committee has met once and will meet an
  additional 3 times during the next year
• Steering Committee membership CAH
  Administrators, CAH Directors of Nursing, CAH
  Quality Improvement Coordinators, Hospital System
  Quality Improvement Directors, QIO, Depart. of
  Health Licensure and Certification, Hospital
  Association and FLEX Program Staff

FLEX funding will be utilized to carry out
activities of Plan
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Michigan Center for Rural Health

• 2 ongoing clinical measures
• Decided there was a need for expansion and
  formalization
• Strategic Planning to Formalize Group
• Assistance from Georgia State Rural Networking
  Technical Assistance Program (TAP)
• Integrating Network Development Grant from the
  Upper Peninsula