Massachusetts State Flex Profile

Top Flex Activities

Program Area: Support for Quality Improvement: 

Three top Massachusetts Flex FY 2016 activities for Quality Improvement are: 

  • Improving Emergency Department Transfer Communication (EDTC) measures
  • Improving employee and inpatient influenza immunization measures 
  • Reducing adverse drug events 

The Massachusetts Flex team is working on improving two Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) composite measures, improving outpatient measures OP-5, OP-18, OP-20 through OP-23 and providing an extensive onsite quality improvement (QI) assessment to two critical access hospitals (CAHs) during the three-year grant period. The structure for Massachusetts Flex QI effort is a long-standing Massachusetts Rural Hospital QI Network, which is a collaboration with the state's QIN-QIO which meets at least two times per year in person and at least two times per year via teleconference.  

For improvement in influenza immunizations, the state Flex Coordinator recruited all Massachusetts CAHs and rural PPS hospitals to attend and connect at an excellent statewide Department of Public Health Acute Care Hospital Healthcare Personnel Flu Summit in January 2016. Focus on influenza immunization continued at almost all subsequent in-person and teleconference QI Network meetings. Preliminary data reveals that Massachusetts recently met the state-recommended goal for all hospitals to achieve a 90% or greater total rate of employee flu immunizations. The Massachusetts Flex Program continues to work on improvement of patient influenza immunization rates to match employee rates.

Almost all Massachusetts CAHs and small rural hospitals now report to the statewide Massachusetts Immunization Information System (MIIS), which assists with tracking patient immunizations and can help improve patient influenza immunization efforts.

To prevent adverse drug events, the Massachusetts Flex Program coordinated a carry-over project with the Institute for Safe Medication Practices (ISMP) which involved a nurse practitioner and pharmacist team performing on-site assessments at each CAH to focus on high-risk medication handling and antibiotic stewardship. This project builds on previous on-site assessments done by ISMP a few years ago that focused on oncology services and sterile compounding. Reports with detailed recommendations will be available soon and the Massachusetts Flex Program will track the number of best practices instituted and positive behavior changes achieved at each facility as a result of these assessments. 

Please share a success story about reporting quality data or using quality data to help Critical Access Hospitals (CAHs) in your state improve patient care: 

All Massachusetts CAHs are reporting EDTC measures. All CAHs have significantly improved their composite scores between 2015 Quarter 4 and 2016 Quarter 3. 

Stratis Health provided a series of presentation on EDTCs to the in-person Massachusetts Rural Hospital QI Network meetings in September 2015, March 2016, and November 2016. Topics covered included MBQIP with a focus on Outpatient and EDTC measures. The Network consists of both CAHs and rural PPS hospitals. Massachusetts Flex fielded Q&A sessions on methodology and visited with two CAHs in person to review their identified actions and progress on all MBQIP activities, including EDTC measures. During Massachusetts Rural Hospital QI Network teleconferences, CAHs confirmed continued focus on improving EDTC measures 4 and 6 (medical and nurse information, respectively) as primary areas of concern.

During the November 2016 in-person meeting, one of the CAHs presented on their efforts to improve multiple measures, including EDTCs. Best practices to improve EDTCs, particularly EDTC measures 4 and 6 included: 

  • Meeting with nurses and providers to clarify the larger context of need for the measures
  • Updating content of the transfer checklist 
  • Moving the transfer checklist to a more prominent place on the patient record

Periodic check-ins and repetition with staff were found to be helpful in improving the frequency of clinicians providing complete transfer information. As a result, the state average for EDTC composite score went from 65% in 4Q15 to 92% in 3Q16. In 3Q16, all Massachusetts CAHs had a composite EDTC score of 90% or above, which was the original ideal goal for this project for the end of the 3-year grant period.    

Program Area: Support for Financial and Operational Improvement: 

The top three financial and operational (F&O) projects for the current Massachusetts Flex year (FY 2016) involve continuation of the long-standing Massachusetts Rural Hospital CEO/CFO Forum, a learning and action network which is a collaboration with the Massachusetts Hospital Association and has the expert support of and key facilitation by a financial consulting group. In addition to detailed federal, state and industry updates and guest presenters, the group is focused on:

  • Rapid Cycle Benchmarking on selected F&O measures
  • Demonstrating value of small rural hospital to larger health system and Improving physician alignment 
  • One onsite intensive strategic, financial and operational assessment at one Massachusetts CAH per year during the 3 year grant period

Hospital-specific value-based transformation assistance is also part of state Flex offerings. The CEO/CFO Forum brings in additional expertise as needed from state agencies and other resources. The group meets in-person for full day meetings three to four times per year and communicates by phone, teleconference and via email in between in-person meetings. In addition, the consulting firm has brought expertise on valuing swing beds, alternative payment arrangements, and physician practice management to this group of rural hospital leaders.

The Massachusetts Flex Program tracks measurement over time on the Flex Monitoring Team’s (FMT) key financial indicators using FMT data and additional data within our state, as available, via the Massachusetts Center for Health Information and Analysis (CHIA) and the Massachusetts Health Policy Commission.

Please provide information about any efforts to assist CAHs/communities and partner organizations in the transition to value-based care: 

Efforts to assist CAHs and small rural hospitals in their transition to value-based care are built into Massachusetts's two key Flex networks: the Massachusetts Rural Hospital CEO/CFO Forum and the Massachusetts Rural Hospital QI Network. In the CEO/CFO Forum, this includes special group emphasis on physician alignment and health system partnership strategies. The Massachusetts Flex Program also participates in the statewide Transformation Practice Initiative Task Force, a multifaceted group focused on value-based transition of primary and specialty care, and have had representatives attend the CEO/CFO Forum.

Please provide information about network activities in your state to support Flex Program activities (such as financial improvement networks, CAH quality networks, operational improvement with CEOs or EHR workgroups): 

Massachusetts Rural Hospital CEO/CFO Forum
This is a learning and action network consisting of CAHs and small rural hospitals, as well as a collaboration with the Massachusetts Hospital Association and it is facilitated (along with core presentations plus ongoing benchmarking activities) by a financial consulting firm. This group participates in group learning, shares best practices and identifies common challenges. It meets in person three times a year, with teleconferencing and emailing, as well as assessments at selected hospitals, in between sessions. Among other things, this group assists hospitals in their transformation to value-based care and in best practices in working with their larger health system, as applicable.  

Massachusetts Rural Hospital QI Network 
This group is also composed of CAHs and small rural hospitals and includes a collaboration with the state QIN-QIO. This group also meets in person two to three times per year with additional scheduled project-focused teleconferences and speakers. 

The state has had an ongoing Massachusetts Rural Hospital Pharmacy Network for many years, but it is now activated on an ad-hoc project basis, since Massachusetts has lost a long-standing collaborative partner, the Massachusetts College of Pharmacy, due to key leadership changes at their institution. The Massachusetts Flex Program has successfully collaborated on multiple projects with the Institute for Safe Medication Practices (ISMP) via the pharmacy network and highly recommends working with this group.

Please provide information about cross-state collaborations you may be working on related to the Flex Program: 

Massachusetts has a long-standing New England Rural Hospital Performance Improvement Network which is a collaboration between the New England Rural Health RoundTable and the Flex Programs in Maine, Massachusetts, New Hampshire and Vermont. Through this network, Massachusetts contracts with the Institute for Healthcare Improvement (IHI) and offer an array of quality improvement certifications in order to help build QI capacity at small and rural hospitals.

QI certification offerings include Certified Professional in Healthcare Quality (CPHQ), Certified Professional in Health Risk Management (CPHRM), Certified Professional in Patient Safety (CPPS), Certification in Infection Control (CIC) with the addition this year of Trauma Nurse Core Course (TNCC) and Pharmacy Antibiotic Stewardship certification. Massachusetts is also exploring adding Emergency Nursing Pediatric Course (ENPC) certification training and Healthstream programming focused on developing and retaining first year nurses. Massachusetts has also supported the offering of the Rural Trauma Team Development Course (RTTDC) designed by the Rural Trauma Committee of the American College of Surgeons Committee on Trauma via NEPI and otherwise.

From the last Flex Program year, please describe a best practice you would like to share with other states: 

This year, for the first time, the Massachusetts Flex Program was able to offer a rural hospital training to address protocols and best practices in improving patient care for those experiencing sexual and/or domestic violence. The Flex Coordinator piloted this program at a CAH located in a Massachusetts rural area with some of the highest sexual/domestic violence (S/DV) rates in the state. This program was a collaboration with the statewide Massachusetts DPH Rural Sexual and Domestic Violence Project, as well as with a local community-based advocacy organization, with input from an additional statewide advocacy organization. Analysis and planning led to a half-day training at the hospital featuring two Massachusetts-based expert and highly regarded domestic violence trainers. The training included S/DV background, best practice protocols for treating patients experiencing S/DV, assessment techniques, practice/role-playing and a Q & A with several area community-based organizations. 

More than two-thirds of participants rated the training at 5 (highest positive rating on 5-point scale). The hospital aims to capture before- and after-training DV referral rates and DV diagnosis coding data. Improvements for next attempts include offering CEUs and altering timeframe to increase numbers of nurses and doctors in attendance.

Program Statistics

What type of organization is your Flex office housed in?: 
State Government
What is the number of full time employees (FTE) in your Flex office?: 
How many CAHs are in your state?: 
Do you have any hospitals interested in converting to CAH status?: 

Additional Information

Flex Program Staff

Cathleen McElligott
State Office Director, Massachusetts
(508) 792-7880
Ronnie Rom
Flex Coordinator, Massachusetts
(413) 586-7525

This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB1RH24206, Information Services to Rural Hospital Flexibility Program Grantees, $1,100,000 (0% financed with nongovernmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.