1. Trisha Doering, MPH, CGW Clinical Excellence Coordinator II

2. About Me
Bachelors of Science (Biology and Dietetics) from Missouri State University
MSU Lady Bears Handball Team
Master of Public Health from Missouri State University
Certified Grant Writer from AGWA
Internship at Taney County Health Department
Environmental Health Specialist/ Performance Management at TCHD
Community Health Manager/ Grant Writer for Stone County Health Dept.
Clinical Excellence Coordinator II for Cox Monett Hospital
I want to thank MHA for allowing me to come speak today and I also want to commend them on being a great state hospital association, providing resources whenever needed, providing programs like MBQIP, and being so supportive- Thank you!

3. About Me

4. Objectives History and services of Cox Monett Hospital
Our MBQIP journey
Keys to success
Benefits of MBQIP for our hospital
Challenges
Opportunities
Lessons learned

5. History and Services of Cox Monett Hospital
25-bed Critical Access Hospital
18-bed hospital in 1928
Sold to the Vincentian Sisters of Charity in 1943
Acquired by CoxHealth in November 1993
We treat more than 14,000 patients per year
Services:
24/7 emergency department
Decontamination facility
Full lab
Radiology
Respiratory care services
Maternity/ Labor and Delivery
Inpatient Services
Swing Bed
Rehabilitation
Surgical services
General Surgical Services
Head/ Neck/ Skin
Endoscopy
Pathology
Sleep Studies
Diabetes Intervention
Healthy Schools/ Healthy Communities
In 2014, Cox Monett Hospital was awarded a grant from the Missouri Foundation for Health and was one of 11 organizations around the state to start this program.   The foundation awarded the Monett R-1 School District a $125,000 grant, potentially renewable for five years, with a goal of reducing the body mass index (BMI) of students from kindergarten through eighth grade by 5 percent over five years. Cox Monett Hospital’s grant focuses on the same goal, but it involves more of a community-based approach.

6. Accomplishments of Cox Monett Hospital
Health Care Organization of the Month (January 2014) by the Studer Group
Level IV Stroke Center Designation through the Time Critical Diagnosis (TCD) System (March 2015)
Only CAH with Level IV Designation in Missouri
Newly Renovated ED (June 2015)
Fund Raising
Dining for Diabetes- $55,697
American Heart Association (Soup and Chili Cook Off)- $350
Crosslines of Monett- 1,635 diapers
Studer Group:
A firm that helps organizations attain and sustain outstanding results in clinical, operational services excellence.
Cox Monett Hospital is recognized for high marks in inpatient satisfaction, reduced infections and falls and other quality indicators.

7. Our MBQIP Journey Leadership support Staff engagement/Nursing
Physicians we engaged
Right culture – Receptive to change
Timely data to drive strategy
Data transparency – Good or bad
PI/CQI tools
Timely support from MBQIP contacts with MHA
Networking
Leadership support – Top leadership team support
Staff engagement/Nursing  - Involved them in projects
Physicians we engaged – They like to see their data and how it compares with their peers.
Right culture – Receptive to change
Data used effectively to drive strategy
Data transparency – Good or bad, it was shared to create urgency of change.
Right PI/CQI tools used to effect change – Evidence based tools i.e. PDSA among others.
Timely support from MBQIP contacts with MHA
Networking -Regional meetings and conferences through MBQIP helped us learn from other CAH’S.
Timely reports available from the HIDI Analytics database was extremely helpful

8. Keys to Success Engaged leadership and staff
Front Line staff are members of the Clinical Excellence and Patient Satisfaction Committee (CEPS)
Senior Leaders (3) are members of CEPS
Using MBQIP data to drive improvements
Monitoring of ED Transfer Outliers and Core Measure Outliers with Nurse Managers
Policy change discussions and Transfer Form alterations
Action Plans for HCAHPS Survey Questions

9. Medicare Beneficiary Quality Improvement Project (MBQIP)
Cox Monett Hospital

10. HCAHPS data for our Inpatient departments- MedSurg and Labor and Delivery
Quarterly data because our sample size is low per month. We average responses per quarter.
Most of 1st quarter percentile ranks are low.
Much improvement across the board over the year. Implemented Action Plans focusing on one of 3 things in 3rd Quarter:
Increase survey response
Increase Pain scores
Increase one other area on the survey.
MedSurg focused on Communication with Nurses.
L&D focused on Care Transitions- Instructions for Care at Home.

11. Interventions
Patient Engagement (Satisfaction) has been combined with the Clinical Excellence Committee and meets monthly.
Implemented action plans focusing on one of 3 things in 3rd quarter:
Increase survey response
Increase pain scores
Increase one other area on the survey
MedSurg focused on Communication with Nurses.
L&D focused on Care Transitions- Instructions for Care at Home.
Patient Engagement (Satisfaction) has been combined with the Clinical Excellence Committee and meets monthly.

12. HCAHPS Action Plans: Pain
4th Quarter Pain Management Questions.
Circles show the increase from 3rd quarter to 4th quarter in Rank and Score.
Distribution of Responses- Focus on Good as our Opportunity for Improvement.
We probably won’t change the minds of those who say Very Poor, but with a little more effort and using Key Words at Key Times, and our AIDET technique to minimize anxiety of the patient, those Goods can become Very Goods- and they have been!
MedSurg Pain Action Plan- Communicating with patient regarding pain goals and how we are trying to meet those goals.
L&D Pain Action Plan- Focusing on educating the patient about the birthing process, expectations, and options.

13. HCAHPS Action Plans: Nurse Communication and Care Transitions
We know that it is important to improve scores across the board, but we know its more important to focus on 2-3 key areas and make those areas the best we can.
That way it doesn’t burn out the employees or make it an impossible mission.
Med Surg Nurse Communication Action Plan- Stressing importance of completely filling out the patient communication boards.
L&D Care at Home Action Plan- Each patient gets the same discharge information and they are not rushing when they go through it, utilizing the teach-back method to ensure the patient understands.

14. Communication Board Phone number Room number Nurse name Doctor name
Today’s plan
Current pain level
Pain goal
Improvement on pain scale
Focus on celebrating the improvement in pain. Goal is a 4, but now we’re at a 3.
Communication is key- understand expectations and options.
Let them know when they can have their next pain medication dose- tell them 5-10 minutes later than when they can really have it, so they get it early and expectations are exceeded.

15. Patient Safety- Influenza Vaccination
Interventions
Employee Vaccination
Condition of employment
Patient Vaccination
Started screening Sept 15
Task fired last day of Sept to assess and vaccinate patient who had not been vaccinated
Daily compliance report
Feedback on outliers
Employee immunization Outliers-
Influenza vaccination is a condition of employment with Cox Health.
100% of capable employees are vaccinated.
4 with medical excuses and 1 physician who chose not to get vaccinated and opted to take Administrative leave until after flu season.
2 laboring mothers not reassessed after delivery
1 flu vaccine assessment not completed
1 documentation of no flu vaccine for this season without order placement for administration or documentation of refusal
Updated vaccine screening form & vaccine information sheet (VIS) that prints for patients
Developed and implemented daily reports that prints out on units before 7am to identify patients who have not been vaccinated and patients who have nursing task to get an order for vaccination or reassessment
Developed and implemented a hospital wide report that is sent to Directors to identify patients that are not assessed and vaccinated
Feedback to nurse manager for outliers for abstracted data and periodic review of report
Educational update regarding the need to get information for screening and consent from family when patient cannot provide inability to consent and need to

16. EDTC Outliers-
Physician to Physician Communication- missing name of receiving physician to VA hospital transfer.
Education given to nurses from nurse manager.
Blood Pressure- Missing blood pressure on a 5 year old child.
Current policy calls for blood pressures on children older than 7.
MBQIP guideline is for children over 3y/o. Nurse Manager, ED Director, and CNO are discussing changing the policy to meet MBQIP guidelines.

17. EDTC Outliers:
History and Physical: Information was not relayed within 60 minutes from transfer.
Education on proper documentation and signing off was provided to nurses and physicians.
Catheters/ IV: Detailed information for IV placement was not included in the documentation.
Education on proper documentation was provided to nurses.

18. EDTC Interventions Random patient chart audits
Outliers reviewed with management
Moving toward electronic transfer forms
Moving toward blood pressure policy change
Continued monthly audits and reporting
For 2015, 110 random patient chart audits were completed for review of EDTC measure compliance.
Discovered outliers were reviewed with ED Nurse Manager and reported to Clinical Excellence Committee and Medical Executive Committee meetings.
Action has been taken to provide electronic Transfer Forms instead of handwritten forms to prevent missing information and illegible data.
Discussion on changing the blood pressure policy for children.
Continued monthly audits and reporting will ensure measure compliance.

19. Core Measure Description Oct-Dec 2015 Preliminary Data
Outpatient Measures
Measure
Core Measure Description
Oct-Dec 2014 Final Data
Jan-March 2015 Final Data
April-June 2015 Final Data
July- Sept 2015 Final Data
Oct-Dec 2015 Preliminary Data
MO Average
National Average
OP-1
Median Time to Fibrinolysis
N/A 52 31
OP-2
Fibrinolytic therapy received within 30 minutes
33%
50%
OP-3
Median time to transfer to another facility for acute coronary intervention 60 71
OP-4
Aspirin at Arrival
100%
95%
97%
OP-5
Median Time to ECG 7 6
203.1
OP-20
Door to diagnostic evaluation by a qualified medical professional
27.5 26 20
31.5 27
OP-21
Median time to pain management for long bone fracture 51 85 62 56 36 55
OP-22
Patient left without being seen
0.67%
1.0%
1.39%
0.52%
0.55%
*2%
No cases for OP 1, 2, or 3 in 2015
OP5- 3rd quarter: 2 cases: 6, 401- Late onset of symptoms. Came in for a fall and developed symptoms after they’d been here for a while.
OP20: 20 Cases for 4th Quarter, median time is 31.5 minutes. We’ve started the conversation about the ED physician start times missing.
We plan to work with Si3 to get some wordage changed so that it works for the abstraction.
OP21: We really try to manage pain with other methods, such as elevation and ice, before giving a medication. Sometimes the patients refuse medication, which happened in January not reflected on this table.
Core measure data is submitted to CMS through Truven- CoxHealth’s vendor for data submission.
OP-22: Patient Left Without Being Seen is monitored and reported from within.

20. Benefits of MBQIP for Our Hospital
Quality Improvement Culture
Engaged in quality reporting and improvement activities
Prepare for future reporting requirements
Help us see where we can improve
Help us see what we are doing well
Funding

21. Challenges Low volume for Core Measures and HCAHPS
Increased use of contracted ED physicians
Feeling of “too many” action plans with staff

22. Opportunities Focus on increasing survey responses
Increased Nurse Practitioner coverage in ED
Remember the bottom line
What’s best for the patient?
Bring it back to values
Increased preparation for future reporting requirements

23. Lessons Learned Phases/ measures can change
All new measures are painful at first
Unconsciously Skilled to Consciously Unskilled
Upper management always has our backs
Always room for improvement
Not just MBQIP, but with core measures- they can change over time, especially as the kinks are worked out.
Physicians and nurses- after doing their jobs for a long time, become Unconsciously Skilled- they can do it without thinking about it.
Add in a new measure and suddenly they’re Consciously Unskilled- they know what they don’t know, and they don’t like it.
Upper management understands there is a learning curve, but is always supportive of starting a new program and making sure we are successful. We even call Bev- our CHO the “Barrier Knocker Downer”!
Always room for improvement. We may have some measures that are 100% every time- but that doesn’t mean we can sit still and not think about it again. There is a process or a higher achievement that would make it easier, more efficient, or cost less and we can look for those things.

24. Thank You! Trisha Doering, MPH, CGW Cox Monett Hospital
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