wyoming medicare rural hospital flexibility (flex) program · webinar and login information will be...
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WYOMING MEDICARE RURAL HOSPITAL FLEXIBILITY (FLEX)
PROGRAM
WY Quality Improvement RoundtableNovember 21, 2019Facilitated By: Rochelle Schultz Spinarski,Rural Health Solutions
Happy Rural Health
Day!
AGENDA
MBQIP Updates
HCAHPS Best Practices - RQITA
MBQIP
EDTC Changes and Training:
Measures have changed
National training for all CAHs. Please have staff participate in one of the training opportunities: December 12, 2p-3p CST December 18, 11a-12p CST January 8, 3p-4p CST Webinar and login information will be sent in the next few weeks so save the dates on your
calendar
QHi – For those using QHi, updated tools will also be available for 1Q2020 reporting.
Patient Experience: Best Practices of High Performing CAHs
Sarah Brinkman, MBA, MA, CPHQ
November 21, 2019Wyoming QI Round Table
Happy Rural Health Day!
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Stratis Health• Independent, nonprofit, Minnesota-based organization
founded in 1971– Lead collaboration and innovation in health care
quality and safety, and serve as a trusted expert in facilitating improvement for people and communities
• Work at intersection of research, policy, and practice • Long history of working with rural providers, CAHs, and
the Flex Program• Rural Quality Improvement Technical Assistance
(RQITA) is a FORHP funded program of Stratis Health
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Rural Quality Improvement Technical Assistance Center (RQITA)• Cooperative agreement awarded to Stratis Health
starting September 2015 from the Health Resources and Services Administration Federal Office of Rural Health Policy (HRSA FORHP).
• Improve quality and health outcomes in rural communities through TA for FORHP quality initiatives– Flex/MBQIP– Small Health Care Provider Quality Improvement Grantees
(SCHPQI)• Focus on quality reporting and improvement
Overview• Strategies to maximize HCAHPS response
rates• Best practices to improve HCAHPS
performance on individual metrics• Identify strategies connected to improvement
across HCAHPS • Review resources to help with HCAHPS
improvement
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HCAHPS Overview• Survey instrument developed by AHRQ (Agency for Healthcare
Research and Quality) to measure patient perceptions of care • Results publicly reported on Hospital Compare since 2008 • Standardized, 29 question survey compiled into 10 metrics• Required by CMS (Centers for Medicare and Medicaid Services)
for all Prospective Payment System (PPS) hospitals since 2007• MBQIP Core Measure for Critical Access Hospitals (CAHs)
– Over 87% of CAHs participate in HCAHPS – It is not uncommon for CAHs to outperform PPS hospitals
• CMS rolled out HCAHPS star rating in 2015 for hospitals with more than 100 completed surveys in rolling four quarters
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HCAHPS Metrics• Overall Rating of Hospital• Willingness to Recommend this Hospital• Communication with Nurses• Communication with Doctors• Responsiveness of Hospital Staff• Communication About Pain• Communication about Medicines• Cleanliness of Hospital Environment• Quietness of Hospital Environment• Discharge Information• Care Transition
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High Performing CAH Focus Groups
• Goal: Capture and share best practices of high performing critical access hospitals.
• Definition of high performing: – 5 Star HCAHPS rating from CMS (higher volume)– Approximation of comparable rating (lower volume)– Pilot test of process with MN CAHs, remainder
sampled nationally
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Participating Hospitals• Abbeville Area Medical Center, Abbeville, SC • Alliance Health Madill, Madill, OK• Appleton Area Health Services, Appleton, MN • Avera Holy Family Hospital, Estherville, IA • Beartooth Billings Clinic, Red Lodge, MT• Bigfork Valley Hospital, Bigfork, MN• Bronson LakeView Hospital, Paw Paw, MI• CentraCare Health Melrose, Melrose, MN• Central Valley Medical Center, Nephi, UT• Charles A. Dean Memorial Hospital,
Greenville Junction, ME • Community Memorial Hospital, Hamilton, NY• CrossRidge Community Hospital, Wynne, AR• Glacial Ridge Health System, Glenwood, MN • Grant Regional Health Center, Lancaster, WI• Gunnison Valley Hospital, Gunnison, UT• H.B. Magruder Hospital, Port Clinton, OH• Sanford Westbrook Medical Center, Westbrook, MN• Horn Memorial Hospital, Ida Grove, IA • Johnson Memorial Health Services, Dawson, MN
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• LakeWood Health System, Staples, MN• Marshall County Hospital, Benton, KY• Mayo Clinic Health System St. James,
St. James, MN• Meeker Memorial Hospital, Litchfield, MN• Mercy Hospital Waldron, Waldron, AR• Munising Memorial Hospital, Munising, MI• North Shore Hospital, Grand Marais, MN• Perry County Memorial Hospital, Tell City, IN• Power County Hospital District, American Falls, ID • Renville County Hospital & Clinics, Olivia, MN• River's Edge Hospital and Clinic, St. Peter, MN• Riverwood Healthcare Center, Aitkin, MN • Sanford Wheaton Medical Center, Wheaton, MN• Sheridan Memorial Hospital, Sheridan, WY• Shoshone Medical Center, Kellogg, ID• Sleepy Eye Medical Center, Sleepy Eye, MN• Spectrum Health Kelsey Hospital, Lakeview, MI • UHHS Conneaut Medical Center, Conneaut, OH• Yoakum Community Hospital, Yoakum, TX
Focus Group Performance Comparison
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HCAHPS Topic or Composite(Q3 2015 – Q2 2016)
Focus Group Average Difference National
AverageResponse Rate 38% 9% 29%
Overall Rating of Hospital 82% 10% 72%Willingness to Recommend this
Hospital81% 9% 72%
Communication with Nurses 88% 8% 80%
Communication with Doctors 88% 6% 82%
Responsiveness of Hospital Staff 82% 13% 69%
Pain Management 88% 17% 71%
Communication about Medicines 72% 7% 65%
Cleanliness of Hospital Environment 84% 10% 74%
Quietness of Hospital Environment 72% 9% 63%
Discharge Information 89% 2% 87%Care Transition 61% 9% 52%
HCAHPS Response Rates
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HCAHPS Implementation ModesHCAHPS surveys can be administered in four ways, or modes:
1. Mixed (mail followed by telephone)2. Mail only 3. Telephone only 4. Interactive voice response (IVR)
Source: http://www.hcahpsonline.org
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HCAHPS Response RatesAt the time of the study:• National HCAHPS response rate average
was 29%• Study hospitals: average response rate
was 38%– 68% mailed surveys only (60% national)– 18% telephone (40% national)
National data source: http://www.hcahpsonline.org
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HCAHPS Response Rate Strategies• Tell patients about the survey
– During discharge planning– Flyer or brochure– Posters, the hospital website, or announcements on waiting
room television screens– Remind during discharge phone calls
• Leader rounding – assess patient satisfaction during stay and/or remind of survey
• Weekly or biweekly patient lists to vendors
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Improvement Strategies
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Patient Experience Best Practices
• Key Strategies – Frequently mentioned in multiple sessions by multiple hospitals
• Additional Strategies – Strategies identified more sporadically, but that CAHs called out as impacting their success in certain areas
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Global Improvement: Key Strategies
Leader Behaviors
Culture
Data
• Leader visibility• Leadership development• Leader rounding with staff
• Standards of behavior• Teamwork• Accountability
• Share the data with staff and providers often
• Opportunities for discussion and suggestions
• Friendly competition and momentum
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Global Improvement: Additional Strategies
• Staff engagement• Evaluations or pay for performance• Hire to fit• Dedicated staff or committee• Staffing ratios
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Nursing Communication: Key Strategies
Whiteboards
Bedside Shift Report
Daily Huddles
• communication tool• must be used faithfully• users design
• template/checklist• natural leaders • observational auditing
• multidisciplinary• leaders involved• in care units• different structures
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Nursing Communication: Additional Strategies• Data feedback & discussion • Hourly rounding • Nurse leader rounding with patients • Nurse engagement/ownership • Mandatory scrub colors
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Physician Communication Strategies
• Data feedback, friendly competition• Nurses accompany physicians on rounds• Sit down during patient visits• Note pads and pens at bedside• Engaged physician leaders• Hospitalist programs
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Responsiveness of Hospital Staff:Key Strategies
Hourly Rounding
No Pass Zone
Technological Devices
• May alternate RNs with CNAs
• Four Ps• ↓ call light use
• Everyone answers call lights • Non-clinical support can be
provided by anyone• May decrease traffic in
patient care areas
• Call light systems• Two way speakers• Nurse communication
devices
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Responsiveness of Hospital Staff: Additional Strategies• Escorting patients, family members, and visitors to
their destinations • Scripting: “Can I get you anything before I go?” • Certified nursing assistants (CNAs) or patient care
technicians (PCTs)• Patient centeredness and customer service staff
education
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Pain Management: Key Strategies
Whiteboards
Setting Goals and Expectations
Alternative Therapies
• Pain scales, pain goals, next medication or treatment due
• Reminder for staff and patients• Leader rounding with staff
• Type of pain, severity, and treatment options
• Establish level of pain acceptable and goals
• Pre-hospital for scheduled events
• Re-visit goals regularly
• “This is for your pain”• Heat or cold• Positioning, massage• Relaxing music, aroma therapy,
distraction activities• Pet therapy
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Pain Management: Additional Strategies
• EHR or call system reminders • Frequent pain assessments• Hourly rounding • IV insertion skill development • Ten minute turn around time for pain medications
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Communication About Medicines: Key Strategies
Pharmacist Visits
Patient Education
Key Words
• Trigger and process varied• Medication reconciliation• Interdisciplinary huddles and
rounds
• Written, easy to read• At the time of new meds, daily,
at discharge, • Teach back• EHR reminders, hard stops
• “education on your medications”• “side effects of your
medications” • “this medication is for your
heart”
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Communication about Medications:Additional Strategies• Discharge phone calls • Medication reconciliation• Bar code scanning• Medication organizers
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Cleanliness of Hospital Environment: Key Strategies
Cleanliness Auditing
Notices of Cleaning Services
Cleaning Schedules
• Adenosine triphosphate (ATP) monitoring
• Glow gel monitoring • Rounding inspections
• Tent cards, calling cards, white board notes
• Name, time, contact information
• Morning cleaning• Afternoon or evening tidy up• PM by nurse, CNA, volunteer
or environmental services staff
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Cleanliness of Hospital Environment: Additional Strategies• Everyone is responsible for cleanliness• Environmental services staff engagement as an integral
part of the health care team• Environmental services education on customer service
– “anything I can get for you before I go?”• Access to environmental services staff via two way
radios or electronic requests• Patient and Family Advisory Council (PFAC)
environmental assessments
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Quietness of Hospital Environment:Key Strategies
Awareness
Structural Changes
Environmental Noise
• Noise monitors• Reminders – verbal,
written, scheduled, real time
• “SHHH” Campaigns
• Enclosed nurses stations• Decentralized nurses
stations• Carpets or floor padding
• Doors, carts • Cleaning or maintenance
schedules• Communication devices
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Quietness of Hospital Environment:Additional Strategies• Quiet times• Keep patient doors closed• White noise• Soothing music on care channels• Earplugs or pillows
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Discharge Information vs. Care TransitionsDischarge Information - 89%
• “During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?”
• “During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?”
Transitions of Care – 52%• “During this hospital stay, staff took my
preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left”
• “When I left the hospital, I had a good understanding of the things I was responsible for in managing my health”
• “When I left the hospital, I clearly understood the purpose for taking each of my medications”
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Discharge Information: Key Strategies
Discharge Planning
Discharge Education
Discharge Phone Calls or
Home Visits
• Start at the time of admission• Social worker, discharge planning
nurse, case manager• Rounds or huddles• Interdisciplinary involvement
•Discharge packet, folder or binder•Written discharge instructions, discharge care plan, after visit summary (AVS)
• Simple language•Teach back
• Phone calls in two or three days • Discharge planner, nurse,
pharmacist• Selected patients by risk or
diagnosis vs all• Home visits less common
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Discharge Information:Additional Strategies• White board in nursing care room – names of all
patients, discharge plans• Dedicated staff• Staff education on discharge planning• EHR triggers for discharge visits
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Transitions of Care StrategiesSimilar to discharge information except: • Community care collaboration • Readmission committee• Care transition programs• Explaining patient responsibilities• Key words: “We want to have a good understanding
of your preferences related to discharge needs”• Education on patient experience survey questions for
staff
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CAH Wish List“Given no resource limitations, what strategies would you implement to improve HCAHPS performance?” • Staffing Resources
– dedicated patient experience positions, pharmacists, dedicated discharge positions, and transition coaches or programs
• Employee and physician engagement programs• Equipment
– Computers, hands free communication systems • Patient experience amenities
– care channels, a blanket warmer in every room, and “a big hospitality basket for little things that patients may have forgotten”
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Patient Experience and Overall Performance• Growing evidence of positive correlations between
high perception of patient experience and:– Health outcomes– Adherence to recommended medication and
treatment– Preventative care– Health care resource use – Quality and safety of care
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Source: http://bmjopen.bmj.com/content/3/1/e001570.full
Patient Experience Best Practices Alignment• Leadership and Culture• Communication
– Among team members– With patients and families
• Employee Engagement • Workforce Resiliency
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Resources
• Study of HCAHPS Best Practices in High Performing Critical Access Hospitals (full study including resource list, summary brief):www.ruralcenter.org/resources/study-hcahps-best-practices-high-performing-critical-access-hospitals
• Quality Improvement Implementation Guide and Toolkit for CAHs (Best practice lists by measure):www.ruralcenter.org/resource-library/quality-improvement-implementation-guide-and-toolkit-for-cahs
• HCAHPS Online: www.hcahpsonline.org
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Best Practices Discussion
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• What best practices does your hospital already use?
• Are there best practices your hospital has identified that were not listed?
• Which best practices might you consider?
• Do you see any ‘easy wins’?
• What can you do next week?
Stratis Health is a nonprofit organization that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities.
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $625,000 with 0% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official view of, nor an endorsement, by HRSA, HHS or the U.S. Government. (11/2019)
Next QI Roundtable:January 16, 10:00 am – 11:30amAgenda – TBD, EDTC
FLEX & OTHER CONTACTSKyle Cameron, Flex Program Coordinator
Rochelle Spinarski, Rural Health Solutions
Shanelle VanDyke, Quality Reporting Services
Eric Boley, WHA
Brandon Kelley, WY EMS
Deb Anderson, QIO – Mountain Pacific