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

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 Today • 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 Center for Rural Health University of North Dakota 2 School of Medicine & Health Sciences 1

4/16/2018 • 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 “Network Annual Meeting” April 18, 2018 Network’s Mission: To support ongoing performance Network’s Mission: To support ongoing performance improvement of North Dakota’s Critical Access Hospitals. improvement of North Dakota’s Critical Access Hospitals. Center for Rural Health University of North Dakota School of Medicine & Health Sciences 2

4/16/2018 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 Center for Rural Health University of North Dakota School of Medicine & Health Sciences 6 3

4/16/2018 Center for Rural Health University of North Dakota School of Medicine & Health Sciences 7 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 8 4

4/16/2018 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 Center for Rural Health University of North Dakota School of Medicine & Health Sciences 9 Flex Priority Focus Areas 2018‐2019 Population Health Financial Management & Quality Operational Improvement Emergency Medical Performance Services Integration Center for Rural Health University of North Dakota School of Medicine & Health Sciences 10 5

4/16/2018 Flex Funded ND CAH Quality Network Network Relationship 36 CAH Voice for ND Building Established 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 Center for Rural Health University of North Dakota School of Medicine & Health Sciences 12 6

4/16/2018 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) Center for Rural Health University of North Dakota School of Medicine & Health Sciences 13 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) Center for Rural Health University of North Dakota School of Medicine & Health Sciences 14 7

4/16/2018 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 Center for Rural Health University of North Dakota School of Medicine & Health Sciences 15 Medicare Beneficiary Quality Improvement Project (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 8

4/16/2018 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 Center for Rural Health University of North Dakota School of Medicine & Health Sciences 18 9

4/16/2018 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) Center for Rural Health University of North Dakota School of Medicine & Health Sciences 19 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 Center for Rural Health University of North Dakota School of Medicine & Health Sciences 20 10

4/16/2018 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 Center for Rural Health University of North Dakota School of Medicine & Health Sciences 21 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 Center for Rural Health University of North Dakota School of Medicine & Health Sciences 22 11

4/16/2018 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 Center for Rural Health University of North Dakota School of Medicine & Health Sciences 23 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 os/iqr/popandsamp/index.html Center for Rural Health University of North Dakota School of Medicine & Health Sciences 24 12