Our Journey To Quality Excellence

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Our Journey To Quality Excellence

• Indiana Critical Access Hospital Benchmarking
  Program
• April 27, 2006
• InAHQ Spring Conference

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Overview of the CAH Program

• History
• Fee for Service
• 25 Beds
• LOS Avg. 96 Hours
• Sunset Provision

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Indiana CAHs (36)
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Putting Indiana CAHs in Perspective (1236)
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Indiana Critical Access Hospital Performance
Improvement Network
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Collaborative Partners
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State and National Collaborative Partners
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2005 2006 CAH Quality Initiatives

• Benchmarking Program
• Medical Error Reporting/Safety Culture
• Balanced Scorecard in the Rural Setting
• Heart Failure Pilot Program
• Public Reporting
• New CMS CAH Core Measures
• Network Development

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IRHA Heart Failure Pilot Project

• Aug 2005 AHA and IRHA Initial Strategic
  Planning
• Assess Need Based on Current Data Results
• Assess Funding Options
• Identify Stakeholders/Contibutors
• Identify Program Goal To Improve Patient
  Outcomes for HF Patients

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IRHA Heart Failure Pilot Project

• Sept 2005
• Initial Organizational Stakeholders Meeting in
  Indy
• (IRHA, HCE, ISDH, InSORH)
• CAH Interest Letter Developed/Distributed
• Interested CAH Initial Meeitng
• GWTG-HF Presentation
• Outline Program
• October 2005
• Review interest, Stakeholders accept CAHs in
  Program
• Develop Program Criteria
• Organize CAHs
• Next Steps

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Stakeholders Identified
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HF Program Goals

• Improved patient outcomes for heart failure
  patients
• Sharing information and networking
• Create preliminary pilot data to pursue
  additional funding
• Be proactive in preparing for public reporting
  and Pay 4 Performance (P4P)

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Perceived Barriers

• Participant motivation and involved in this
  initiative
• Sustained commitment and keeping momentum moving
  forward
• Identification of a committed data collector

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The Groundwork is Laid

• CAH Invites HF Contact Identified
• Memorandum of Understanding
• Conference Calls Projected
• Identify HF Team and Physician Champion
• Nine CAHs Accepted
• IRHA Distributed Funds Equally
• Administrative Costs
• 1 Year Lease for GWTG - HF
• CAH Training with Outcome Sciences

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Memorandum of Understanding

• Identifies Stakeholders
• Outlines Terms and Funding Amounts
• Outlines Commitment for a Successful Program
• Data Collection Individual/Back Up Support
• Concurrent Reviews
• HF Team
• Physician Champion

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The Work Begins Dec 2005

• HF Team and MD Champion Training
• Staff Training
• Begin Baseline Record Reviews (30)
• Identify review period
• Hardcopy data abstraction
• 1 ½ hours to 10 minutes/record
• Data Entry PMT
• Increase Conference Calls to Weekly
• Dunn Memorial Offers Support
• IRHA, HCE, AHA Provides Technical Support and
  Guidance

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All CAHs Work at Different Paces
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Conference Calls

• Critical to Monitor Progress and Identify Needs
• Forum for Sharing
• Provides Peer Support
• Sets the Pace to Meet Timelines
• Facilitates Networking Among CAHs

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HF Meetings Content

• Monitor Attendance
• Program Updates Next Steps
• Abstraction QA from Outcome
• Individual CAH Updates/Identify Needs
• Implementation and Promotional Tips/Tools/Resource
  s
• Set up Next Call

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January - March 2006

• Full Implementation All CAHs by January 1, 2006
• Data Abstraction and Data Entry (PMT) Continues
• Staff/Physician Training Continues
• Development of Tools (Hardcopy/E-Copy)
• Policy and Procedure
• Critical Pathways
• Standing Physician Orders for HF
• Discharge Instructions
• Chart Stickers
• Concurrent Reviews Begin for Jan 1, 2006 HF

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Contracts

• Ensure Access to CAH CMS Data
• CAH Release of Information Forms (HCE)
• Ensure Access to GWTG-HF Data
• Contract with OS to Receive GWTG-HF Data Reports
• Individual CAH Release of Information (MOU)

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Next Steps

• Promotional Aides (GWTG Stick Pins)
• QA with Abstraction Questions Develops
• AHA Onsite Visits
• AHA Monitors Usage Reports
• AHA Participation Awards
• Looking for Additional Funding to Support CAH
  Efforts

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The Journey Continues

• Decrease Conference Calls to Bi-Weekly
• Educational Program Presentation Slides
• Lobby Displays
• Educate staff, visitors and the community
• Maintain program momentum
• Develop Templates
• Shout it out!!!!!

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Data Results

• March 31, 3006 - Timeline to complete data entry
  of 30 baseline record reviews
• April 2006
• Aggregate Data Reported to CAHs
• Benchmarking with other CAHs
• Initial Quarterly Reports for Funding Source
• Keep Funding Sources and Stakeholders Informed

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Where Do We Go From Here??

• Data Entry Continues
• Continue to Assess Needs
• Evaluate Data Results
• Provide Education as necessary
• Quarterly Reports
• Re-evaluate Program
• Early 2007 Executive Summary of Program

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Share Your Successes!!!

• Presentations
• National Stakeholders Conference Call
• (AHA, QIO, National/State Orgs)
• State Level Presentations (InAHQ, IONE)
• National Level Presentations (Annual NRHA CAH
  Conference)
• Newsletters
• Enjoy Your Results!!!

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Indiana Rural Health Association

• Shawna Girgis, Cindy Large, Tina Elliott,
• Angie Hamilton, Paula Johnson
• Not Picture Dana Stidham, Glenda Parks

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Contact Information

• Cindy Large, RN, BSN
• CAH Benchmarking Coordinator
• Indiana Rural Health Association
• 812-478-3919 extension 229
• clargeirha_at_bizma.rr.com

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IRHA 9th Annual ConferenceJune 7 9, 2006

• Programs for all Healthcare Providers
• CAH Forum

www.indianaruralhealth.org