Each state was asked to respond to the following question:
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.
The following is a success story from one of Alabama’s CAHs located in Blount County, as reported by their Director of Nursing:
The greatest impact for St. Vincent’s Blount has been the MBQIP emergency department transfer communication (EDTC) measure. Prior to acknowledging and reporting EDTC, Blount treated skilled nursing facility (SNF) transfers like a discharge home. Since the beginning of reporting, Blount has greatly improved communication with the community's four nursing homes upon transfer of the patient. In addition to improving verbal communication, this improved awareness of returning imperative documentation to the SNF, such as medications received in the Emergency Department (ED). Thorough communication has improved the transition in care from the ED to the SNF.View Alabama's State Flex Profile >
The Alaska Flex Program has instituted bi-weekly calls between the State Division of Public Health, the QIO and Alaska State Hospital and Nursing Home Association to discuss the CAHs and their quality performance. Struggling CAHs are identified and resources are then best directed to help the CAH, allowing the CAHs to receive help in real time rather than waiting for a quarterly report to identify problems.View Alaska's State Flex Profile >
Emergency department transfer communication (EDTC) data is so current that when reports are run, data sharing is done immediately. One Arizona CAH Quality Director goes directly to the Emergency Department when the data is pulled to make sure they are doing all the best practices for the patients. Success is identified when the data is used to drive change and, in this case, it is used immediately.View Arizona's State Flex Profile >
The EDTC information reported has helped several of the Arkansas CAHs streamline their emergency transfer protocols by identifying trends. This has led to greater efficiencies within the hospital systems, ultimately improving patient care by improving the flow of patient care.View Arkansas's State Flex Profile >
CRHC has implemented Electronic Health Record (EHR) User Group conference calls once each quarter with each of the EHRs and the facilities utilizing that vendor’s product to discuss items from action plans/priority lists, EHR functionality and challenges related to data extraction and reporting, patient portals and disease registry modules. The biggest challenge continues to be the lack of functionality to pull data and generate reports out of the EHR in order to drive quality improvement and decision-making. The success is when a user willingly shares how they located and/or created a report to pull iCARE data and provide instructions on how the other facility using that vendor’s product can do the same.View Colorado's State Flex Profile >
All 30 Georgia CAHs have committed to reporting the full set of MBQIP measures.View Georgia's State Flex Profile >
The recent change in how the MBQIP data are presented showed where there might be some shortcomings in the actual reporting of the data for Hawaii's small volume hospitals. Problems with the processes involved with the reporting have led to additional training on how to use the different reporting tools and what is required in order to get proper credit for reporting quality measures.View Hawaii's State Flex Profile >
All Idaho CAHs are actively participating in MBQIP and all CAHs have received education on all required MBQIP measures. All 27 CAHs are reporting Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and emergency department transfer communication (EDTC). The Idaho Flex Program, Hospital Improvement and Innovation Network (HIIN) and the Quality Improvement Organization-Quality Improvement Network (QIO-QIN), Qualis Health, meet monthly to discuss initiatives, share ideas, avoid duplication and whenever possible explore opportunities for collaboration. A number of the MBQIP additional measures align with the HIIN. The Idaho Flex Program works to coordinate with the HIIN and the QIN-QIO to avoid a duplication of efforts around MBQIP additional measures.View Idaho's State Flex Profile >
The Illinois Flex program supports the 51 CAHs and four small rural facilities in reporting quality data and using quality data to improve patient care. This year three of the facilities were recognized by the National Rural Health Association (NRHA) as Top Performers for CAHs. Mason District Hospital in Havana, Illinois was in the Top 20 for Best Practice in Patient Satisfaction and Sparta Community Hospital in Sparta, Illinois and St. Joseph’s Hospital in Highland, Illinois both ranked in the Top 20 for Best Practice in Quality.
ICAHN uses best practices from the state's top ranking hospitals to identify best practices and resources to share in the network. Through these efforts with the Illinois Flex Program, ICAHN was able to provide immunization carts, an identified best practice, to 20 hospitals to assist in their efforts with employee immunizations to improve overall compliance. The Illinois Flex Program also supports the improvement of critical times for stroke and STEMI, as well as reporting of data. All 51 CAHs along with the two who have applied for CAH status have received the Illinois Stroke Center designation. Through the support of a Stroke and STEMI expert, Illinois CAHs are below the state goal of 60% of achievement of door-to-needle timeframes of 60 minutes.View Illinois's State Flex Profile >
Indiana's CAHs' commitment to improving patient care is evidenced by their reporting data. Compared to all other CAHs nationally, Indiana’s CAHs reported at a rate that was higher for inpatient measures (97.1 percent vs. 84.7 percent nationally) and outpatient measures (77.1 percent vs. 50.7 percent nationally). Indiana’s CAHs rank 13th for inpatient measure reporting and 7th for outpatient measure reporting among the 45 states participating in the Flex Program. Compared to scores for all other CAHs nationally, from Q2 2014 through Q1 2015, Indiana’s CAHs have significantly better scores on seven process of care measures, significantly worse scores on seven measures, no significant differences on 19 measures and insufficient data to compare 5 measures.View Indiana's State Flex Profile >
Floyd Valley Healthcare, part of Avera Health, was one of the hospitals recognized at the 2016 National Rural Health Association’s Critical Access Hospital Conference as a Top 20 CAH. The hospital, with an average daily census of about 10, is located in Le Mars, Iowa, which claims to be the Ice Cream Capital of the World and is northeast of Sioux City.
Quality and patient perspectives are only a portion of the measures considered in the CAH ranking methodology. Upon review of the Medicare Beneficiary Quality Improvement Project (MBQIP) data, these were likely strong contributors to Floyd Valley’s success. A Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) five star hospital, Floyd Valley Healthcare performs with excellence across every MBQIP domain and has also been a strong participant and performer in the Centers for Medicare & Medicaid Services (CMS) Partnership for Patients program.
When asked for the most powerful factors that drive Floyd Valley’s success, 18-year Administrator Mike Donlin described a healthy culture of teamwork and devotion to patients that impacts everything from the pristine appearance of the campus to excellence in billing and medical records. The culture is one where leaders respect and encourage staff and provide the resources needed to do their jobs well. Donlin stated, “For the whole management team, no one pushes back on investing in quality. We count it as a given and a part of the minimum of what our community expects of us.” He added that the work of quality is ongoing. “Nothing is sustainable without effort.”
Beyond embracing Avera’s proactive quality and patient safety stance, Dolin also points to the power of partnerships to extend the reach of excellence into every aspect of patient care. The hospital collaborates with its principal affiliate Avera Health as well as nearby UnityPoint Health on joint quality and patient safety projects. It is active in the Iowa Hospital Association’s Hospital Improvement and Innovation Network (HIIN) and participates in a Medicare Shared Savings Program Accountable Care Organization (ACO). “We seek participation in everything we can to prepare for what’s coming down the pike in terms of value-based purchasing. It is dangerous to rely on the present payment system,” Donlin stated.View Iowa's State Flex Profile >
The state has consistently been behind the national average as it relates to CAHs and quality data reporting, making the ability to strategically build targeted interventions towards the areas of highest need a challenge. In order to eliminate the reporting rate disparity in Kansas CAHs, the State Office of Primary Care and Rural Health (SOPC) has been actively involved with the KQIP’s efforts to promote voluntary reporting of quality data. To this end, the SOPC has worked to incentivize active participation by incorporating reporting expectations for any hospital participating in the Kansas Flex-supported initiative and/or to receive the Kansas Small Rural Hospital Improvement Grant Program (SHIP) funding. Additionally, the SOPC has supported KQIP in assuring accessible quality reporting education, training and technical support available to Kansas CAHs.
Through these collective efforts, the number of Kansas CAHs reporting quality measures have increased significantly:
- The percentage of Kansas CAHs reporting outpatient data to the Centers for Medicare & Medicaid Services (CMS) through one quarter increased from 25.3 percent in 2013 (Q2-Q1) to 89.3 percent in 2015 (Q1-Q4)
- The percentage of Kansas CAHs reporting four quarters of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data increased from 19.3 percent in FY2013 (Q2-2012 to Q1-2013) to 75.2 percent in FY2016 (Q2-2015 to Q1-2016)
Kentucky is averaging about 80% of CAHs reporting their emergency department transfer communication (EDTC) data. For Kentucky, this is hugely successful. Hospitals are reading and using these reports and asking questions relevant to them.View Kentucky's State Flex Profile >
Louisiana CAHs requested hands-on, step-by-step training on reporting data into electronic systems. Although the Louisiana Flex Program could find many training resources on utilizing data, the state Flex staff could not locate the specific training requested by the hospitals. Two of Louisiana's CAHs that had already been successful in data reporting agreed to design a training toolkit and provide peer-to-peer instruction classes to the other CAHs. The training toolkits are available on the state Flex Program's website for hospitals to access as needed: Louisiana MBQIP Peer Training ToolkitView Louisiana's State Flex Profile >
The State of Maine received two awards in 2016 from the Federal Office of Rural Health Policy:
- The MBQIP Certificate of Excellence was presented to the Maine Flex Program in recognition of Outstanding State Quality Performance
- The MBQIP Certificate of Excellence was presented to the Maine Flex Program in recognition of Quality Performance Improvement
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.View Massachusetts's State Flex Profile >
The MICAH QN continues to be a success in the state of Michigan. The group has consistently worked together to improve on a variety of measures. Currently, they have a workgroup analyzing the emergency department transfer communication (EDTC) data to determine what resources are needed to raise the bar with EDTC 4 and EDTC 5.View Michigan's State Flex Profile >
Using Flex funds to support quality improvement consultants in their work to make one-on-one contact through site visits with most of the 78 CAHs was well worth the time, effort and cost. Participating CAHs eagerly accepted the support, received personalized technical assistance and were able to tie their reporting efforts to planning for quality improvement initiatives.View Minnesota's State Flex Profile >
MS SORH received a national award from the Federal Office of Rural Health Policy for having all 32 (at the time) CAHs reporting the MBQIP transitions of care measure.View Mississippi's State Flex Profile >
In 2016, the Montana Flex Program received data for the first time about healthcare worker influenza immunization rates in Montana CAHs. Eighteen hospitals reported data and the data was shared with CAH quality staff at regional meetings across the state in the fall. Participants expressed concern about the rates and the potential impact on patient care, as well as a desire to improve these rates. Since sharing this data, 36 hospitals have registered to participate in a statewide quality improvement study in this area. The reporting, benchmarking and sharing of this data clearly demonstrated an opportunity for improvement and inspired participation in an improvement project.View Montana's State Flex Profile >
Nebraska subcontracts the Capture Falls Program, which includes a series of projects to improve the safety and quality of care in CAHs. The Capture Falls Program now includes a web-based reporting system where participating CAHs report and track fall incidents. Participating CAHs participate in developing action plans, regular learning conference calls with project managers, training webinars and site visits to establish their Capture Falls program. The web-based reporting system allows them to enter all incident data and pull real-time reports for their facility.View Nebraska's State Flex Profile >
For over a decade, Flex funding has been utilized to support a QI network that meets quarterly to develop hospital-level and network-based strategies to increase quality reporting and to utilize quality and patient safety data to improve the quality of care provided by Nevada's rural and frontier hospitals.View Nevada's State Flex Profile >
At one CAH, the staff who had submitted the MBQIP outpatient measures left out hospital employment. No one knew how to collect and report the measures. The Flex Program staff includes a Rural Health QI Coordinator; this staff person was able to provide on-site training to six CAH staff at their convenience. The training included:
- Specifications for the outpatient measures
- How to locate the patient information needed from electronic health record (EHR) reports they had on hand
- Step by step instructions for entering data into CART
- How to submit data files to QualityNet
The Flex staff member rewrote existing CART instructions to be a step by step, easy to follow process that the CAH staff were able to use and practice in CART on the spot. The CAH staff completed a Technical Assistance and Information evaluation tool with positive results.View New Hampshire's State Flex Profile >
New Mexico critical access hospitals (CAHs) are all using different systems and methods of reporting data and all have different methods of sharing data with staff. This year, OPCRH is subcontracting to bring together quality directors by providing technical assistance focused upon quality improvement (QI) around the Medicare Beneficiaries Quality Improvement Project (MBQIP) measures. The subcontractor will provide access to data that the OPCRH will use to assist New Mexico rural hospitals in identifying areas of quality improvement and use a network-based approach to facilitate best practice exchanges among the participating hospitals.
Each of the New Mexico CAHs will be supported in the development of a targeted Performance Improvement Plan. This will result in the implementation of a state-wide performance measurement and benchmarking system of financial and operational and quality measures consistent with MBQIP for New Mexico rural hospitals. Establishing quality benchmarks will enable the Flex Program to identify poor performing CAHs for education and support. Additionally, CAHs will receive access to market, quality, safety, patient satisfaction and financial performance data for comparative analysis. A representative from the subcontractor will attend at least one New Mexico rural health network Quality Improvement meeting to “kick-off” the New Mexico quality improvement and MBQIP benchmarking project.View New Mexico's State Flex Profile >
Through its contract with ORH, the North Carolina Quality Center (NCQC) held seven content and networking webinars featuring the following:
- A 3-month series on TeamSTEPPS providing key communication and leadership tools/strategies
- Improvement success stories using TeamSTEPPS and Lean from a CAH in Oregon
As a result of the webinars, site visits and Learning and Action Network (LAN) meetings conducted by NCQC, North Carolina CAHs increased quality reporting in outpatient measures (67 percent to 71 percent), Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures (71 percent to 81 percent), and emergency department transfer communication (EDTC) measures (81 percent to 86 percent).View North Carolina's State Flex Profile >
Some success stories regarding the Ohio CAHs reporting quality data and/or using quality data to improve patient care includes the following:
- CMS Quality Rating Ohio's UHHS Geneva was the only CAH nationally awarded a 5-star rating
- MBQIP Certificate of Excellence – Ohio State Quality Performance ranked in top 10 states on quality and performance
- Becker’s Hospital Review -2016 Edition, CAHs to Know – listed Ohio's H.B. Magruder Hospital and UHHS Geneva
Some success stories regarding the Ohio CAHs reporting financial data and/or using data to improve financial operations through financial assessments includes the following (breakdown of improvements noted by hospital for the INDICATOR assessment provided by iVantage Health Analytics, Inc.):
- Aultman Orrville - Although the overall cost excess for the facility has increased, significant improvements in cost excess have been noted in supplies ($20k reduction in cost excess), and clinical service lines ($7k reduction in cost excess). The labor excess alone was reduced by $70k, with the greatest cost reduction in overhead areas. Clinical areas remained at or above existing levels
- Fulton County - Although the overall cost excess for the facility has increased, significant improvements in cost excess have been noted in administration ($600k reduction in cost excess) and supplies ($400k reduction in cost excess)
- Henry County - The overall cost per adjusted admission has dropped by $400, from a high of $7,026 in 2013 to $6,543 in 2015. Significant gains in cost excess reduction can be seen in administration ($92k), supplies ($40k) and imaging ($140k)
- Highland - The overall cost excess has been reduced by roughly $1 million from 2015 through annualized 2016 data. Significant cost excess has been seen in support services ($178k), supplies ($280k) and selected ancillary services ($38k)
- Hocking Valley - The overall cost per adjusted admission has dropped by nearly $1k from a high of $5,991 in 2014 to $5,021 in 2016. Cost excess reduction can be seen in support services ($92k) and selected ancillaries ($400k). FTE excess has been reduced by 12 FTEs for a labor savings of $547k
- Morrow County - The overall cost per adjusted admission has dropped significantly from a high of $8,135 per admission in 2010 to $3,750 in 2015. $596k in cost excess has been reduced from 2014 to 2015, with significant reductions noted in administration ($227k), IT ($198k), supplies ($76k), imaging ($94k), rehabilitation services ($100k) and selected ancillaries ($190k). Labor excess has been reduced by $38k from 2014 to 2015
- Fostoria - Although the overall cost per adjusted admission has increased from 2014 to 2015, cost savings can be seen in support services ($182k), supplies ($236k), rehabilitation services ($47k), selected ancillaries ($515k) and nursing ($25k). The labor component of this excess reduction totaled $250k
- Defiance - Overall cost excess has been reduced by $1.2 million, with significant reductions noted in administration and ancillary services
The collection method of emergency department transfer communication (EDTC) data was updated in the previous grant year. CAHs in Oklahoma now submit their quarterly data via Survey Monkey.View Oklahoma's State Flex Profile >
One success that OORH had this past year was the development of the Critical Access Hospital (CAH) Quality Reporting Guide, created by an experienced CAH Quality Officer in a frontier hospital. In Oregon, turnover in CAH Quality Officers has been high and it is important to have a step-by-step resource for new quality staff to be able to immediately access (without having to wait for a training opportunity).View Oregon's State Flex Profile >
During the 2015-2016 budget year, the Pennsylvania CAHs completed a project improvement program with a subcontractor. The project included an initial meeting where a hospital project was identified, a mid-year check-in webinar and a summary meeting where the results were shared with the CAH Chief Executive Officer (CEO).View Pennsylvania's State Flex Profile >
The South Carolina Office of Rural Health (SCORH) Flex Program currently has two CAH workgroups; one that is focused on quality and the other that is focused on finance. The CAH quality workgroup is comprised of Chief Nursing Officers and Quality Directors and the CAH finance workgroup is comprised of Chief Executive Officers and Chief Financial Officers. During the last CAH quality meeting, the quality workgroup walked through each of the MBQIP measures in great detail. The detailed MBQIP measure walk through allowed for the group to discuss who, what and how each of the measures are currently being collected at the individual CAHs. This best practice sharing discussion sparked greater involvement of not only the quality staff at the CAHs but CEO and CFO leadership as well. To date, two of the lower MBQIP reporting CAHs have taken an active role in improving their quality data reporting. In addition to the CAH Quality workgroup, a greater emphasis has been placed on the CAHs' Star Ratings, or lack of Star Ratings, on Hospital Compare.View South Carolina's State Flex Profile >
As of the Quarter 3 2016 submission, 37 CAHs with signed memorandums of agreement (MOAs) submitted emergency department transfer communication (EDTC) data. As of November 2016, all 38 CAHs in the state now have signed MOAs.View South Dakota's State Flex Profile >
The in-person workshops, as well as the regular webinars, are two contributing factors to CAH personnel reporting quality data. Workshop attendees have reported experiencing peer to peer support at the in-person workshops which has been increased participant’s knowledge. The support attendees increased their knowledge by communicating their successes and/or issues they have experienced/are experiencing.
The topics for the webinars are formed based on current MBQIP core measures. All of the webinars have been very well attended and the contributing reasons are the following:
- Always offered in the morning and the afternoon on Tuesdays
- Information shared is relevant
- Plenty of time for questions
- Webinars are well organized
Another contributing factor to successful data reporting is the data guru that works on compiling and sharing the reported measures. This individual loves data and has the ability to explain everything in layman’s terms, while also being extremely accessible.View Texas's State Flex Profile >
The Utah Flex Coordinator has developed spreadsheets for each independent CAH with individual graphs for each 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.
By continuously providing feedback real-time on EDTC data received from all CAHs, all the rural independent CAHs have made significant improvement over time.View Utah's State Flex Profile >
Since 2015, six out of eight CAH hospitals have begun reporting on all Emergency Department Transfer Communication (EDTC) measures. In Quater 1 of 2016, four CAHs were reporting all EDTC measures and one was only reporting some measures. In Quarter 2, those five were reporting all EDTC measures and in Quarter 3 a total of six of eight CAHs were reporting all EDTC measures.View Vermont's State Flex Profile >
Virginia CAHs received the Federal Office of Rural Health Policy (FORHP) Medicare Beneficiary Quality Improvement Project (MBQIP) Certificate of Excellence for the second year in a row. Intensive quarterly trainings for data extraction, reporting and comparative data analysis continues to be facilitated by a contracted firm known nationally for its successful work with small rural hospitals. CAHs are measured against national benchmarks, state-level benchmarking and other Virginia CAHs.View Virginia's State Flex Profile >
Washington has contracted for the second year with a QI “hands-on” consultant whose background included working in a CAH extracting data and reporting measures. In the first year, the consultant designed a MBQIP workshop that was rolled out on each side of the state. As part of the workshop the consultant compiled a MBQIP Desk Manual, which included resources, explanations of accessing CART and tips to extracting data. The manual was so well-received that for FY2016 the consultant is updating the Manual and will be repeating the workshops for all new QI CAH staff and those that may have missed the first workshop. In addition, the consultant will be assessing the CAHs and their readiness to report to identify which CAHs will need more onsite technical assistance.View Washington's State Flex Profile >
Wisconsin Flex used MBQIP data to identify CAHs that struggle with achieving high Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, then issued a request for proposals, asking the identified CAHs to submit a proposal aimed at improving one or more of their HCAHPS scores. Wisconsin Flex was able to fund three CAHs and their proposed projects. They will be required to submit progress reports to Flex. Their HCAHPS scores will be monitored to determine if their efforts have resulted in improvement in their targeted HCAHPS scores.View Wisconsin's State Flex Profile >