Each state was asked to respond to the following question:
In each of the following program areas, please list up to three top Flex activities in your state for FY2016, and include information on how you measure this/these activities. Also, if applicable, please include information on past work for this/these activities if your current work is building upon it.
The following responses relate to Program Area: Support for Quality Improvement.
Alabama’s Rural Quality Network (RQN)
The Flex grant provides funding and logistics for hospitals to receive professional training, information, best practices and networking. Core Measure scores are captured, benchmarked and used to identify best practices to be shared. Quality projects are determined annually by the group, with this year’s focus to continue benchmarking the selected core measures of benchmarking and improving Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores. All hospitals are required to share quality data in order to participate in the RQN. The RQN is the favorite Flex activity, and the networking further facilitates sharing in many areas, promoting growth and improvement by participating hospitals.
During 2015-2016, RQN participants attributed the following results to participation in the network:
- Better understanding of Core Measures and why they are important
- Improved transition of care from the critical access hospitals (CAHs) to other health care settings to improve patient outcomes
- Improved patient safety in hospitals and communities by ensuring all health care providers and eligible patient populations received their influenza vaccination
- Improved HCAHPS scores through utilization of teach back
- Better understanding of the effects of sepsis through education
Medicare Beneficiary Quality Improvement Project (MBQIP)
The CAHs meet prior to the RQN for MBQIP networking, where unblinded data is shared and training is provided by consultants to promote quality improvements in targeted areas.View Alabama's State Flex Profile >
The three top quality improvement (QI) activities for the Alaska Flex Program are:
- Provide technical assistance to critical access hospitals (CAHs) through collaboration with the quality improvement organization (QIO) to improve consistency of Medicare Beneficiary Quality Improvement Project (MBQIP) participation and facilitate reporting, including zero cases
- Work through the hospital association to involve CAHs in a multi-hospital QI collaborative that facilitates face-to-face meetings, site visits, monthly webinars, teleconferences and newsletters to promote peer networking, best practices and data collection
- Support mentoring programs to match more experienced quality professionals at larger hospitals with less experienced quality staff at CAHs to receive peer support, establish relationships to combine resources and build knowledge and skill through shared experiences
- MBQIP: The Flex Coordinator encourages all CAHs to report MBQIP measures. MBQIP reports are monitored to look for missed opportunities and further analyzed for overall trends. A standard report is sent to each CAH with a separate summary report from the Flex Coordinator. The separate report is a more detailed analysis of the hospital's progress. All improvements are congratulated, and the QI staff person is asked to what they attribute their success. Missed opportunities and downward trends are noted, and the QI staff person is asked about any planned activities that might address those issues
- Collaborative: All CAHs are encouraged to participate in the QI collaborative, participation is monitored. CAHs within the collaborative set targets and then participate in activities to achieve their target. The number of CAHs setting targets and their progress toward meeting that target is reported and analyzed quarterly
- Mentoring: Pairs participate in activities to learn QI skills. At the conclusion of the training, the pairs choose projects of interest they will work on over the next few months. At the conclusion of the project, pairs are encouraged to do a poster presentation on their QI activity discussing their challenges and whether they met their goals
The Arizona Rural Hospital Flexibility Program (AzFlex) provides training and education to Arizona’s critical access hospitals (CAHs) on the Medicare Beneficiary Quality Improvement Project (MBQIP) by monitoring and evaluating data, creating and disseminating reports to CAH leadership and reviewing best practices so that Arizona CAHs can reach and sustain 100 percent MBQIP reporting.
- Monthly webinars with CAH Quality Network
- Onsite technical assistance site visits conducted to educate and assist CAHs in MBQIP
- Monthly MBQIP reminders and tips
- Customized reports with hospital scorecards on the MBQIP domains
The Arkansas Flex Program subcontracts to support critical access hospital (CAH) performance improvement strategies to aid in the overall improvement of the quality of care. The subcontractor provides the following to the CAHs:
- Technical assistance through onsite visits, emails and video teleconferences
- Regional and statewide collaborative educational meetings and workshops, with updates on quality improvement strategies
- Current data reporting tools for abstraction, submission and reporting of quality data
Additionally, the subcontractor will collect emergency department transfer communication (EDTC) measures data via electronic means from the Arkansas CAHs quarterly. They will provide technical assistance as needed to collect and submit this data.View Arkansas's State Flex Profile >
The Colorado Rural Health Center (CRHC) continues to build on previous work in the area of quality improvement with the Critical Access Hospital (CAH) Quality Network, Regional Quality Improvement (QI) Workshops and Improving Communications and Readmission program (iCARE) among other efforts. To measure the benefit of these projects, CRHC utilizes Medicare Beneficiary Quality Improvement Project (MBQIP) data, benchmarking system reports and Flex Monitoring Team (FMT) reports, as well as additional data and information gathered from programs such as iCARE.View Colorado's State Flex Profile >
Florida has consultants providing one-on-one site visits and webinars to educate the critical access hospitals (CAHs) on reporting techniques and best practices.View Florida's State Flex Profile >
Medicare Beneficiary Quality Improvement Project (MBQIP) activities are focused on the four different quality domains. Building and maintaining the participation of all critical access hospitals (CAHs) in MBQIP through these sets of quality measurement and reporting activities are required.
The program utilizes a subcontractor to implement the MBQIP program. The program additionally provides education and training to assist CAH Quality Improvement (QI) staff in their QI program development and continuous quality improvement methods and tools. Starting with the basics, this course is designed to provide a foundation for the QI leader to develop an effective improvement team within their CAH.
The program provides access to performance measurement system software that helps hospitals collect, report and analyze clinical quality data. Real-time reporting provides immediate feedback on performance for hospital quality improvement opportunities. The CAHs have access to ongoing technical assistance for data collection and reporting to the Centers for Medicare & Medicaid Services (CMS) Hospital Compare website. The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Culture Survey tool is provided via web-based survey as well as additional online resources such as survey guidance, tips, and standard and customizable marketing templates. Post-survey technical assistance is provided via dashboards, graphics, prioritized questions and dimensions as well as next steps.View Georgia's State Flex Profile >
Medicare Beneficiary Quality Improvement Project (MBQIP) Participation and Training
Hawaii brings the critical access hospitals (CAHs) together quarterly for updates on the MBQIP, to provide training on quality improvement and to evaluate measures used in MBQIP. This is a full day activity and includes the CAHs that have shown improvement in their measures as trainers on what changes they have implemented.
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey Training
All of Hawaii’s CAHs participate in HCAHPS. The Hawaii Office of Primary Care and Rural Health (OPCRH) provides training to the CAHs on what HCAHPS is, what it measures and how to put processes in place to ensure that they receive high HCAHPS survey scores. Quarterly, the Hawaii Flex Program reviews the CAHs HCAHPS scores and identifies areas for improvement with each of the CAHs.View Hawaii's State Flex Profile >
The Idaho Flex Program is implementing “Moving the Needle,” an Idaho peer learning collaborative series which provides an opportunity for all 27 Idaho critical access hospitals (CAHs) to participate in quality improvement educational opportunities focused on all required Medicare Beneficiary Quality Improvement Project (MBQIP) measures. The series focuses on providing CAHs with population and sampling criteria, data collection best practices and sharing evidence-based tools and strategies to improve outcomes. It also allows Idaho CAHs to benchmark against their baselines for all required MBQIP measures. Activities include:
- In-person full-day annual educational workshops in November and May facilitated by a consulting firm
- Two webinars annually focused on benchmarking facilitated by a consulting firm
- Onsite technical assistance site visits conducted annually to all 27 CAHs by the Flex Coordinator
The Illinois Flex Program will continue efforts to encourage critical access hospitals (CAHs) to improve scores in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), as currently all CAHs have contracts with an approved HCAHPS vendor or are collecting independently. The CAHs are reporting in the Medicare Beneficiary Quality Improvement Project (MBQIP).
The Illinois Critical Access Hospital Network (ICAHN) is assisting hospitals in expanding their HCAHPS programs, increasing reporting and improving overall scores to include stroke and ST-Elevated Myocardial Infarction (STEMI) response times, emergency department transfer communication measures and vaccination compliance, with a goal of 90 percent participation. A best practice identified by the CAHs for improved vaccination rates from top performing hospitals included enforced policies and immunization carts with necessary forms and equipment. ICAHN will work with CAHs to increase participation in HCAHPS and develop customer service strategies to improve scores with a focus on response rates, teach back methods, strategies to improve quietness, and scripting with discharge. ICAHN is also working with the CAHs to improve participation in Get with the Guidelines program and assist the CAHs in efforts to maintain Emergent Stroke Center designation.
As of 2016, all of the CAHs in Illinois are designated. Education and training will focus efforts on managing swing bed programs and gathering quality measures. The Illinois Rural Community Care Organization (IRCCO) will be focusing on improving transitions of care from the CAH to other healthcare settings in order to improve patient outcomes.View Illinois's State Flex Profile >
Indiana's Medicare Beneficiary Quality Improvement Project (MBQIP):
- Aids critical access hospitals (CAHs) in publicly reporting specific inpatient and outpatient measures to Hospital Compare as well as reporting on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient assessment of care survey measures and emergency department transfer communication (EDTC) measures. This allows for improvements to health care service, processes and administration
- Provides technical assistance to CAHs to implement quality improvement (QI) initiatives to improve patient safety scores, HCAHPS scores, EDTC scores and outpatient scores
Indiana also provides CAH Quality Education Programs focused on quality improvement and leadership development.View Indiana's State Flex Profile >
Iowa's goals are to improve patient safety in critical access hospitals (CAHs) and the community by:
- Ensuring all health care providers and eligible patient populations receive their influenza vaccinations
- Provide technical assistance (TA) workshops and consultation site visits to improve hospital staff and patient vaccination rates and provide on-line vaccination data reporting system reports (in addition to other data reports)
These goals will be measured by the percentage of CAH staff vaccinated, the percentage of eligible patient population vaccinated and the percentage of CAHs reporting on influenza vaccination rates.View Iowa's State Flex Profile >
Grant resources are focused on carrying out the required Activities 1.01 through 1.04 as outlined in the funding opportunity announcement (FOA). Work plan activities are accomplished with the Kansas Flex Program’s involvement in the Kansas Quality Improvement Partnership (KQIP). In 2012, KQIP came together to maximize resources dedicated to improving quality and to eliminate or reduce duplication of efforts by Kansas providers. The KQIP is a group of leading health care organizations that strive to coordinate quality improvement and patient safety initiatives for health care providers. KQIP includes the Kansas Healthcare Collaborative (KHC), Kansas Hospital Association (KHA), Kansas Foundation for Medical Care (KFMC), Kansas Medical Society (KMS) and Kansas Department of Health and Environment (KDHE), including the Primary Care and Rural Health Program and the Healthcare-Associated Infections Advisory and Planning Committee. This group provides the collective expertise and voice for quality and patient safety in Kansas.View Kansas's State Flex Profile >
In the Patient Safety Organization, within The Kentucky Institute for Patient Safety and Quality (KIPSQ) project, hospitals receive an electronic patient safety event reporting system and participate in one "deep dive" for small rural hospital quality improvement unintended events. Kentucky will provide best practice guidelines in areas identified in the "deep dive" and train hospitals on the utilization of Patient Safety Organization (PSO) for peer review activities, as well as review patient safety and patient error data using the Agency for Healthcare Research and Quality (AHRQ) common formats. This will be measured by the number of hospitals participating in KIPSQ, attending KIPSQ webinars and submitting data in the "deep dive." The Flex Program will survey hospitals to determine implementation of education and best practice guidelines distributed by the PSO.
In the effort of stroke care improvement, Kentucky will use a developed Stroke Care Improvement program in partnership with the American Heart and Stroke Association for small rural hospitals and critical access hospitals (CAHs) to provide a comprehensive training program and best practices guide through a certified primary stroke center. Three stroke care improvement workshops will be held in the state, with three hospitals attending the first and two attending the second. All sessions will have post-training assessments.
This year, the Kentucky Flex Progam is implementing a new quality improvement (QI) director training. This training will cover the basics of what a new CAH QI director needs to know regarding the Medicare Beneficiary Quality Improvement Project (MBQIP), the Kentucky Hospital Engagement Network (KHEN) and other quality initiatives. Most importantly, Kentucky is focusing on improvement around MBQIP measures with training specific to each subset of measures.View Kentucky's State Flex Profile >
The Louisiana Flex Program’s focus in the Quality Improvement program area is to support all Louisiana critical access hospitals (CAHs) to fully participate in Medicare Beneficiary Quality Improvement Project (MBQIP). Louisiana has taken several different approaches in previous years to increase the number of CAHs that have signed the memorandum of understanding to 26 out of the 27 Louisiana CAHs. These activities included meeting directly with hospital CEOs to explain the MBQIP program and benefits as well as implementing peer-to-peer training sessions for hospitals presented by quality improvement (QI) team members at two hospitals already participating in MBQIP.
In FY 2016, activities began shifting to more fully support CAHs participating in MBQIP. Activities included how to use data reports to make changes, identify opportunities for cost savings, expansion of services, etc. and were delivered through a combination of training webinars and 1:1 hospital team meetings provided by a subcontractor. Reporting rates have improved in each MBQIP domain:
- Reporting on immunization measures (patient safety) improved from 8 to 11 hospitals
- Reporting on HCAHPS results improved from 8 to 15 hospitals
- Reporting on Outpatient measures improved from 6 to 13 hospitals
- Reporting on EDTC measures improved from 1 to 14 hospitals
Maine’s Flex Program brings together networks of critical access hospital (CAH) staff from all 16 CAHs in the state and measures activities through the Medicare Beneficiary Quality Improvement Project (MBQIP) and other publicly available quality data, as well as through survey instruments.
- The Maine CAH Chief Executive Officer (CEO) Network provides overall strategic direction to the Flex Program
- The Maine CAH Chief Nursing Officer (CNO) Network serves as a workgroup to share best practices and learning opportunities as well as provide strategic direction to the Maine CAH Nurse Managers
- The Maine CAH Quality Improvement (QI) Directors Network meets quarterly
All 16 hospitals participate in a benchmarking project to identify MBQIP measures, particularly Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, that network members agree to address at their individual facilities, work as a group to identify best practices to impact and report back to the group on successes and challenges. In 2014, the Maine Flex Program began bringing together the Maine CAH Chief Financial Officers (CFOs). In collaboration with the Maine Hospital Association, the agendas have primarily focused on cost reports and charge master review. This collaboration meets twice per year.
Through participation in the New England Performance Improvement (NEPI) Network, a collaboration of Flex Programs in Maine, New Hampshire, Vermont and Massachusetts, Maine CAH staff have free access to various offerings from the Institute for Healthcare Improvement (IHI), including IHI Open School and Expeditions. Also through NEPI, Maine CAH staff are able, on a limited basis, to pursue free certification programs to become either a Certified Professional in Patient Safety (CPPS) or Certified Professional in Healthcare Risk Management (CPHRM).View Maine's State Flex Profile >
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.View Massachusetts's State Flex Profile >
In this program area, Michigan will:
- Support the Michigan Critical Access Hospital (MICAH) Quality Network (QN) activities
- Support member quarterly meetings, provide follow-up activities and support a listserv
- Support data benchmarking of MICAH QN core measures
- Support the Medicare Beneficiary Quality Improvement Project (MBQIP)
The bulk of quality improvement activity is subcontracted to a quality improvement organization with assistance from the Minnesota Hospital Association (MHA). The subcontractor provides the following services under their Minnesota Flex contract:
- During year one of this three-year grant cycle, quality improvement consultants make site visits to nearly all critical access hospitals (CAHs) to help CAH staff understand quality data reports and connect them to relevant tools and resources
- Hold quarterly meetings by phone to support quality improvement and patient safety
- Provide a single point of contact to respond to questions and assist CAHs in navigating reporting processes for the Medicare Beneficiary Quality Improvement Project (MBQIP) and the Minnesota State Quality Reporting Measure System (SQRMS)
- Provide individual outreach to CAHs as needed, with a priority on those not consistently reporting required MBQIP measures
- Convene and facilitate reporting updates and networking sessions
- Provide educational webinars
- Establish and convene the Minnesota CAH Quality Advisory Group, which includes representation from the Minnesota Department of Health, the University of Minnesota School of Public Health, the American Heart Association, Minnesota Hospital Association, Minnesota Alliance for Patient Safety, several CAHs, one tertiary hospital and the National Rural Health Resource Center
- During year two of the three-year grant period, convene meetings of cohorts of hospitals with a focus on Time Critical Care Diagnoses and Culture of Excellence
The Flex Program Coordinator offers mock survey assistance to CAHs upon request. The Flex Coordinator has developed a good understanding of the Conditions of Participation (CoP) for CAHs, and fields many questions by email and phone. To strengthen that resource, the Flex Coordinator has nurtured a positive relationship with Minnesota State Survey staff, who willingly serve as a consultant. About once a year (depending on the workload of the survey staff), the Flex team arranges a statewide phone call where CAH staff can hear from the State Survey Staff about the most common findings on CAH surveys for that year, receive CMS CoP updates and pose their questions directly to the survey staff.View Minnesota's State Flex Profile >
The Mississippi State Office of Rural Health (MS SORH) has contracted with a consulting group to provide technical assistance on the Medicare Beneficiary Quality Improvement Project (MBQIP) to all 31 critical access hospitals (CAHs). This technical assistance includes hospital site visits if required, and hospital staff education on MBQIP measures and reporting requirements. MBQIP technical assistance is measured by the number of CAHs participating in the activity and improvements in outcomes.View Mississippi's State Flex Profile >
In order to achieve the objectives in this area, the Flex Program has contracted with the Missouri Hospital Association (MHA) to offer technical assistance. MHA offers technical assistance for the Medicare Beneficiary Quality Improvement Project (MBQIP) utilizing webinars, conference calls, in person trainings, regional trainings and one statewide training annually. MHA has built a dashboard for critical access hospitals (CAHs) that will promote MBQIP and utilize the data for quality improvement activities. Each hospital now has the ability to look at aggregate performance, and most current average performance as a state as well as nationally on the dashboard. It also provides information about rates and how each hospital ranks by state for the most current quarter, last four and eight quarters. Lastly, the dashboard provides charts for the rate of each measure against the rate of other hospitals in the state and nationally. The new report will now also begin including whether or not the change in the measure was statistically significant.View Missouri's State Flex Profile >
Montana encourages public quality reporting through a weekly Monday Medicare Beneficiary Quality Improvement Project (MBQIP) Message, a comprehensive MBQIP manual with updates, quarterly MBQIP calls and MBQIP Report Cards for hospital administrators and quality improvement staff.
The state also conducts Statewide Quality Improvement Studies (QIS) that are designed to be high-level improvement projects. Critical access hospitals (CAHs) throughout the Montana Performance Improvement Network (PIN) are asked to commit to providing baseline and remeasurement data. Ideally, this data is available to the Montana Flex Program through existing MBQIP reporting. The Montana Flex Program develops improvement tools and resources specific to the project measure in a toolkit format for the PIN to use as appropriate in their facilities. The Montana Flex Program has developed a QIS for Healthcare Worker Immunizations and Emergency Department Transfer Communications. Quality Improvement Coordinators from the PIN were asked for input in targeting specific project improvement measures.
MBQIP To Outcomes (M2O) has been designed as a rapid improvement project and integrates quality coordinator education, Lean coaching and project management with a targeted performance improvement project. Improvement is measured with existing MBQIP data. Projects for FY 2016 will be an outpatient and HCAHPS measures, chosen by Quality Improvement Coordinators based on opportunity for improvement in measures with higher volumes.View Montana's State Flex Profile >
The Nebraska Flex Program uses the Baldrige framework for improving quality and the overall performance of critical access hospitals (CAHs). This model is used because it emphasizes the importance of leadership in changing the culture of the organization and improving communication at all levels. There is also a strong focus on customer satisfaction and measuring results. The key activities under quality improvement are:
- Support CAHs participating in the Medicare Beneficiary Quality Improvement Project (MBQIP)
- Continue to support the training and implementation of Capture Falls within the CAHs
- Conduct mock surveys
- Support participation of CAHs in an annual quality conference in Nebraska
In order to improve MBQIP scores, Nebraska staff are working with the Nebraska Hospital Association, the University of Nebraska Medical Center, the quality improvement organization (QIO) and the CAH networks to identify best practices and share these practices in all of the CAHs.View Nebraska's State Flex Profile >
In this area, Nevada will:
- Develop statewide strategies for quality improvement (QI) via quarterly meetings of a Flex-supported Nevada Rural Hospital Quality Improvement Network comprised of CAH QI and Risk Managers during each year of the project period
- Assist Nevada CAHs with the ongoing development of non-Medicare Beneficiary Quality Improvement Project (MBQIP) quality benchmarking capacity and utilization of non-MBQIP benchmarking data for QI and risk management projects
- Support Nevada critical access hospital (CAH) participation in ongoing infection control programs and surveillance via quarterly meetings of a Flex-supported Infection Control (IC) Workgroup during each year of the project period
In FY 2016 the New Hampshire Flex Program's focus is on providing technical assistance and information to critical access hospital (CAH) quality improvement (QI) staff on collecting and reporting Medicare Beneficiary Quality Improvement Project (MBQIP) outpatient measures. As of the close of FY 2015, 100 percent of CAHs were reporting patient safety, patient engagement and care transition measures. A staff member is dedicated to assisting the CAHs to report MBQIP measures and to identify and act on opportunities for improvement. The Flex Program also directly trains new CAH staff on data collection, using the Centers for Medicare & Medicaid Services (CMS) Abstraction and Reporting Tool (CART), the Emergency Department Transfer Communication (EDTC) Data Collection Tool and accessing the National Healthcare Safety Network (NHSN).
The Flex Program provides quarterly MBQIP benchmarking charts to the CAH Chief Executive Officers (CEO)/Presidents showing each CAH's data compared to each of the other New Hampshire CAHs. In order to facilitate CAH process improvements, the Flex Program provides quarterly MBQIP reports including run charts of each measure with comments identifying trends and shifts in the data over time, and potential opportunities for improvement. The usefulness of this report will be evaluated using a CAH staff feedback tool, as well as monitoring the MBQIP measures' performance over time.View New Hampshire's State Flex Profile >
The New Mexico Office of Primary Care and Rural Health (OPCRH) will contract with the New Mexico Hospital Association (NMHA) to support hospitals in their continued shared accountability of patient safety by offering hospital staff, senior leaders and physicians on-site education regarding their roles in quality, patient safety and process improvement through plan-do-study-act (PDSA), high reliability organizations and team training. Hospital staff will be able to understand their role in creating a strong patient safety culture and improving quality of care. In the area of Quality Improvement, New Mexico will:
- Foster a learning organization environment by improving support for hospital quality directors including data and analytics, performance improvement, regulatory and accreditation, population health, quality review and accountability and patient safety
- Provide ongoing quality improvement support to the quality improvement leads through email, phone calls, site visits or training and education opportunities
- Host quarterly virtual meetings and one in-person opportunity per year for all the Quality Directors representing the 13 participating hospitals to network and share learnings. Quality improvement leads will be able to be able to identify and demonstrate the full set of quality improvement competencies needed to support their hospital’s quality improvement program
- Improve patient safety on select, nationally accepted Flex-related indicators by providing webinars on specific clinical topics
- Promote and support hospital participation in patient safety trainings and other educational meetings provided by NMHA. Hospital staff will implement evidence-based practices and professionally-designed and accepted processes to reduce harm and improve patient outcomes
The North Carolina Office of Rural Health (ORH) has subcontracted the following activities:
- Identify the best source of data within three months of the start of Year 1
- Have critical access hospitals (CAHs) submit data for baselines within six months of Year 1
- Establish individual baselines and report back to each CAH by end of Year 1
- Follow-up with each CAH and identify opportunities for improvement within three months of start of Year 2
- Have CAHs submit data within six months of Year 3
- Assess effectiveness of improvements by end of Year 3
The ORH Flex Program Manager will monitor the contract to meet the proposed timelines.View North Carolina's State Flex Profile >
North Dakota's focus areas include:
- Encourage public quality reporting
- Maintain critical access hospital (CAH) participation in the Medicare Beneficiary Quality Improvement Project (MBQIP)
- Identify specific quality benchmarking and quality improvement activities through the North Dakota CAH Quality Network
- Collaborate with other quality improvement related initiatives involving North Dakota CAHs and emergency medical services (EMS)
The Ohio Flex Program is focused on several quality improvement projects. Three specific projects include:
- Improving patient safety in critical access hospitals (CAHs) in Ohio and the community by ensuring all health care providers and eligible patient populations receive their influenza vaccinations in collaboration with the Health Services Advisory Group, Inc. (the quality improvement organization (QIO) for Ohio) to increase the number of CAHs reporting HCP/OP-27 data to 33 (100 percent). The impact is that all CAHs will be trained on entering HCP/OP-27 data, running and utilizing reports
- Improving the transitions of care with emergency department transfer communication (EDTC) from the CAHs to other health care settings in order to improve patient outcomes to increase the percentage of CAHs reporting EDTC measures
- To continue, maintain and support the Flex Quality, Financial and Operational Improvement Network (Flex QI Network) with the use of a consultant for quality improvement services and training for CAHs. The Flex QI Network has existed since 2004 and is supported by subcontractor in benchmarking, web-based reporting and quality measures improvement technical assistance and training
The Oklahoma Flex Program has a great relationship with their former quality improvement organization (QIO). Through this relationship, they have coordinated and hosted workshops throughout the state that focused on health information technology (HIT) privacy and security and meaningful use (MU). These workshops are open to hospital and clinic staff with really good turnouts. Surveys were utilized at these workshops to measure effectiveness and learn about other topics that are of interest to the attendees. Most recently, the focus has been on offering quality webinars and peer review services for CAHs.
The Oklahoma Flex Program has been working with a national quality consultant for many years and will continue that work into the next grant year. Utilizing resources from this consultant, the Flex Program is able to help hospitals start an online calendar system to streamline quality assurance activities into one master list. This allows hospitals to maintain a survey-ready culture within their facilities. Currently, the Oklahoma Flex Program is measuring the effectiveness of this program by the number of deficiencies participating facilities receive on the most recent Medicare survey at the hospitals. The Oklahoma Flex Program also has a great relationship with the Oklahoma Hospital Association.
CAHs in Oklahoma benefit from the quality webinars that are made available. During the previous grant year, the Oklahoma Flex Program has partnered with the Oklahoma State University (OSU) Simulation Lab to provide hands-on training in the emergency department (ED). The training consists of airway instruction and hands-on training with the tools. Hospital personnel are able to run codes on the simulation mannequin allowing staff to take a team approach to refreshing skills. There are plans to expand this training to offer more trauma-related skills and tailor programming to the needs of each specific hospital.View Oklahoma's State Flex Profile >
During FY 2016, the Oregon Office of Rural Health (OORH) has prioritized improving Medicare Beneficiary Quality Improvement Project (MBQIP) reporting and linking reporting to quality improvement programming. This includes:
- Increasing training and peer learning opportunities
- Making MBQIP data more meaningful by providing customizable benchmarking reports in Tableau
- Recognizing top reporters through a formal recognition program that includes conference scholarships and a small grant to implement a quality project at their hospital
The Pennsylvania Office of Rural Health (PORH) hired a full-time Quality Improvement (QI) Coordinator this budget year that will work directly with the Pennsylvania critical access hospitals (CAHs) to assist the hospitals in their improvement efforts in the Medicare Rural Hospital Beneficiary Project (MBQIP). The QI Coordinator will visit each CAH and review the hospital's MBQIP reports and identify a specific improvement project for focus during the current budget year. Baseline data will be identified and subsequent improvement recorded.View Pennsylvania's State Flex Profile >
In this area, South Carolina plans to support and assist critical access hospitals (CAHs) in implementing quality improvement activities to improve patient outcomes which include:
- Improving patient and community safety, ensuring that health care providers and eligible patient populations receive influenza vaccinations
- Supporting the improvement of patient experience of care through the use of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
- Supporting the improvement of transitions of care from the CAH to other health care settings in order to improve patient outcomes
- Supporting the improvement of the care provided in CAH outpatient settings in order to improve patient outcomes by determining baseline measures for OP-1, OP-2, OP-3 and OP-4 using Medicare Beneficiary Quality Improvement Project (MBQIP) data
- Supporting the improvement of the care provided in CAH outpatient and emergency department (ED) settings through addition measures
- Promote and improve the reporting of quality of care data by CAHs to assist all CAHs in the state to consistently publicly report data on all required measures by monitoring public reporting of required measures for all CAHs, providing technical assistance with reporting, outreaching to any CAHs who are not publically reporting and determining barriers and providing resources and support to overcome barriers, root cause analysis to determine barriers to reporting outpatient care measures
Successes are measured by CAH participation in CAH quality meetings, publicly available data, technical assistance requests, quality improvement activities and shared best practices, along with completion of site visits, coaching calls, root cause analysis and action plans.View South Carolina's State Flex Profile >
In this area, South Dakota will:
- Continue to assist critical access hospitals (CAHs) with building capacity and reporting the Medicare Beneficiary Quality Improvement Project (MBQIP) measures in all four quality domains
- Conduct the Agency for Healthcare Research and Quality’s (AHRQ) Hospital Survey on Patient Safety Culture
- Support collaborative projects to assist CAHs with improving MBQIP and AHRQ measures
The MBQIP Reports and AHRQ Survey scores will be the primary tools used to measure improvements in this program area.View South Dakota's State Flex Profile >
A critical access hospital quality improvement (CAHQI) initiative is continuing this year. The initiative is designed to bring together critical access hospital (CAH) staff and provide quality education programs through onsite workshops, webinars and conference calls. CAHs from across the state have been organized into four teams and each focus on one of the Medicare Beneficiary Quality Improvement Project (MBQIP) quality domains. Each team has been working to develop a process that will be made available for implementation by other CAHs in the state. The teams meet monthly and share:
- Targeted technical assistance to increase the number of reporting sites through assistance collecting and analyzing data
- Education and training on process improvement techniques that will be provided to CAHs, both in-person and virtually as well as coaching calls and webinar
Last year, the vendor that was subcontracted for the quality improvement project created a dashboard which allowed CAHs in Texas to report emergency department transfer communication (EDTC) measures. This year, more measures have been added to the dashboard and will continue to be added. The great thing about the dashboard is that Quality Directors are able to see their progress in real time. Viewing the data in real time makes it easier to make changes since it is easier to remember what was done two months ago versus nine months ago. Another positive is that the dashboard is user-friendly.View Texas's State Flex Profile >
The Utah Flex Program supports the rural independent hospitals by canvassing the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) vendor market and summarizing options. The decision was made to collectively contract with one HCAHPS vendor with a discount on pricing. Participating hospitals gave permission to the Flex Coordinator to access real-time HCAHPS data from this vendor. The Flex Coordinator summarizes the data on a monthly basis and distributes to participating CAHs. Trends are monitored and best practices shared in areas of decline or deficiency. Discussion of HCAHPS best practices is also part of regular rural independent hospital nurse manager group meetings.
The Flex Coordinator has developed spreadsheets for each independent CAH with individual graphs for each emergency department transfer communication (EDTC) measure. As data is submitted on a monthly basis, the Flex Coordinator updates these graphs and distributes to CAHs in real time, with observations about trends. CAHs are asked to provide feedback on causes of trends. Processes and procedures that have been effective in improving EDTC measures are shared with all CAHs.
The Flex Program continues to support the nurse managers of the rural independent hospitals in the state. This group is meeting three times a year, taking turns meeting at their respective hospitals. The nurse managers are engaged and enthused about these meetings, which last two days and cover a myriad of topics. They have the opportunity to network and share best practices.
One quality improvement program that developed from this group is hands-on training at the University of Utah Hospital, which is a teaching and tertiary care hospital. Nurses from the rural hospitals spend several days at the University hospital shadowing and obtaining hands-on training in Labor & Delivery, Surgical Services, Peripherally Inserted Central Catheter (PICC), Emergency Department (ED) and Intensive Care Unit (ICU). This program has been highly successful in providing training for rural nurses that lack experience given lower patient volumes in their rural hospitals.
Utah Flex has initiated the organization of a quality coordinator group of the rural independent hospitals. The first meeting was held on August 30, 2016. All hospitals were represented, and there was much enthusiasm for organization of the group and working together collaboratively moving forward. A follow-up meeting was held on September 22, 2016 and plans were made to hold the next meeting in the spring of 2017.View Utah's State Flex Profile >
Vermont Flex continues to work with the Vermont Program for Quality in Health Care (VPQHC) as a subcontractor to manage a network of quality directors and staff from the state's eight critical access hospitals (CAHs) and one additional Small Rural Hospital Improvement Grant Program (SHIP)-eligible hospital. This Quality Network collaborates to increase reporting, processes and clinical outcomes in all four Medicare Beneficiary Quality Improvement Project (MBQIP) domains.View Vermont's State Flex Profile >
The Virginia State Office of Rural Health (SORH) partners with the Virginia Hospital and Healthcare Association (VHHA) to implement the Virginia Rural Hospital Coaching Collaborative (Collaborative) in an effort to support quality and operational improvement for all Virginia Small Rural Hospital Improvement Grant Projects (SHIP) eligible hospitals. This group was previously called the Virginia Rural Hospital Studer Group Coaching Collaborative. The hospital association brings in speakers for the quarterly Leadership Development Institutes from expert organizations that further the “hardwiring excellence” Studer Group concepts. Dashboards are used to measure quarterly improvements in quality (and operations). An ancillary improvement in financial outcomes has been experienced by some participating hospitals.View Virginia's State Flex Profile >
Support in this area includes:
- Quality improvement (QI) leadership, training and technical assistance guided by critical access hospitals (CAH)
- QI Directors Advisory Committee, in partnership with the Washington State Hospital Association (WSHA) and Qualis
- QI training: basics for new directors, Medicare Beneficiary Quality Improvement Project (MBQIP) information, how to use the data being collected to identify what is important and what to do about it
- Certified Professional in Healthcare Quality (CPHQ) study materials and exams for quality improvement staff at CAHs in conjunction with Quality Improvement Leadership forums put on in collaboration with WSHA
- Supporting CAH participation in reporting MBQIP and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures to QualityNet and the Centers for Medicare & Medicaid Services (CMS) Abstraction and Reporting Tool (CART) through virtual and in-person technical assistance
- Education and training webinars for Antibiotic Stewardship requirements through collaboration with the Healthcare Associated Infections Program at the Washington State Department of Health
The West Virginia State Office of Rural health (SORH)/Flex and the West Virginia Hospital Association (WVHA) Critical Access Hospitals (CAH) Network plans to continue education efforts to increase participation in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPHS) initiatives through technical assistance as well as the implementation and continued reporting HCAHPS Measures. West Virginia Flex will continue to promote reporting to Hospital Compare by CAHs using Cart and other approved tools.
The WV SORH/Flex and WVHA CAH Network plans to continue education efforts to increase participation in Medicare Beneficiary Quality Improvement Project (MBQIP) initiatives through technical assistance, implementation and continued reporting of Out Patient Measures and Influenza Immunization Measures, and continue to promote reporting to Hospital Compare by WV CAHs using the Centers for Medicare & Medicaid Services (CMS) Abstraction and Reporting Tool (CART) and other approved tools.
The West Virginia SORH/Flex and WVHA CAH Network will collaborate to improve participation and provision of technical assistance for the WVHA CAH Network Executive Director and possible West Virginia CAH staff representatives for contract administration and to attend training and educational networking opportunities to discuss best practices.
The WV CAH Network will also maintain and direct a Performance Improvement Listserv.
The WVHA CAH Network provided technical assistance and collaboration to support development of hospital quality benchmarking and quality improvement education/training activities at the 2015 West Virginia Rural Health Conference and 2016 Association for Professionals in Infection Control and Epidemiology (APIC) Conference. This initiative provided scholarships for participating CAHs to attend at no cost for registration.View West Virginia's State Flex Profile >
Twenty-four critical access hospitals (CAHs) participate in a web-based event reporting project. The project is a patient safety initiative focusing on reducing inpatient falls and medication errors. Participating hospitals subscribe to a web-based patient safety event management system that allows hospitals to collect and analyze data, facilitate internal communication, manage follow-up and foster learning to support risk-quality-safety initiatives. Secondly, Wisconsin Flex is in the process of recruiting 35 CAHs to participate in an emergency department transfer communication (EDTC) collaborative project. For part of this project, each hospital that has struggled with EDTC measures will be matched with a mentor hospital that has proven to be strong with EDTC. Participant hospitals will take part in quality improvement initiatives to improve their communications.View Wisconsin's State Flex Profile >
Support for quality improvement (QI) activities includes the annual state planning meeting with stakeholders scheduled for March 2017. This planning meeting will incorporate ideas, lessons learned and best practices as shared by administration and staff of Wyoming's critical access hospitals (CAH), emergency medical services (EMS), subcontractors, Wyoming Hospital Association (WHA), State of Wyoming Behavioral Health and Office of Health Equity. A survey will be conducted after the meeting to determine areas of improvement and success.
The utilization of QI Roundtable calls will continue. These monthly calls provide an opportunity for CAH administration and staff to share lessons learned, best practices and areas of concern. A survey will be conducted after the roundtable and attendance will be measured.
For the Medicare Beneficiary Quality Improvement Project (MBQIP), Wyoming will provide continued education on submitting data, interpretation, discussion of improvement plans, implementation and communication analysis of results. Wyoming will track the number of CAHs submitting data, implementation of improvements and improvement results.View Wyoming's State Flex Profile >