1. Office of Rural Health Policy FLEX Multi-State Medicare Beneficiary Quality Improvement Project Paul Moore, DPh Senior Health Policy Advisor Department of Health and Human Services Health Resources and Services Administration

2. FLEX - Key Rural Program

3. Flex Program:

4. State Flex Program Guidance for Fiscal Year 2010 Work plans submitted by State Flex programs must include at least one of the following QI objectives: 1)encourage CAHs to publicly report data to Hospital Compare on relevant process of care quality measures for inpatient and outpatient care, and HCAHPS patient experience of care survey results; 2)support participation of CAHs in a multi-hospital QI project that addresses a priority QI need identified using state-specific CAH quality data;

5. State Flex Program Guidance for Fiscal Year 2010 Work plans submitted by State Flex programs must include at least one of the following QI objectives: 3) support CAH participation in quality reporting and benchmarking initiatives other than Hospital Compare (e.g., state and multi-state CAH quality networks; and /or 4) support CAHs in implementing a multi-hospital quality/patient safety project focused on leadership and organizational culture (e.g., Team STEPPS, AHRQ patient safety culture surveys).

6. Summary of Flex Program Quality Improvement Activity in the Study States* SUPPORT FOR CAH PARTICIPATION IN QUALITY MEASUREMENT, REPORTING, AND BENCHMARKING 1)Support for CAH participation in Hospital Compare States :Georgia, Washington 2) Support for CAH participation in other individual or multi-state performance and quality reporting and benchmarking initiatives States: Alaska, Nevada, Kansas, Idaho & Nebraska * Flex Monitoring Team Briefing Paper No. 25 Models For Quality Improvement In Critical Access Hospitals: The Role Of State Flex Programs March 2010

7. BUILDING QUALITY AND PATIENT SAFETY IMPROVEMENT SYSTEMS AND CAPACITY Multi-Hospital Patient Safety And Quality Improvement Programs States Support for Patient Safety Initiatives Idaho, Nebraska Inpatient and Outpatient Quality Improvement Georgia EMS Quality Improvement Arizona, Washington Performance Improvement Networks Montana Peer Review Programs Washington, Georgia Hospital Surveys Kansas, Nevada

8. Quality Improvement Education and Training Programs 1) Quality Improvement Training States: Alaska, Arizona, Montana 2) Executive Fellowship Program States: Nebraska

9. CMS Hospital Compare Process Measures Outcome Measures

10. Pneumonia Process of Care Measures Percent Pneumonia Patients: Assessed and Given Pneumococcal Vaccination Whose Initial Blood Culture Was Performed Prior to the Administration of the First Hospital Dose of Antibiotics Given Smoking Cessation Advice / Counseling Given Initial Antibiotic(s) within 6 Hours After Arrival Given the Most Appropriate Initial Antibiotic(s) Assessed and Given Influenza Vaccination

11. Heart Failure Process of Care Measures Percent Heart Failure Patients: Given Discharge Instructions Given an Evaluation of Left Ventricular Systolic Function Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) Given Smoking Cessation Advice / Counseling

12. Heart Attack Process of Care Measures Percent of Heart Attack Patients Given: Aspirin at Arrival Aspirin at Discharge ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) Smoking Cessation Advice/Counseling Beta Blocker at Discharge Fibrinolytic Medication Within 30 Minutes Of Arrival PCI Within 90 Minutes Of Arrival But wait…. How many patients transferred?

13. ED Patient Transfer Communication* Pre-Transfer Communication Information (0-2) Patient Identification (0-6) Vital Signs (0-6) Medication-Related Information (0-3) Physician or Practitioner Generated Information (0-2) Nurse Generated Information (0-6) Procedures and Tests (0-2) * NFQ Endorsed

14. Hospital Outcome of Care Measures 30 Day Readmissions: (Shows how often patients are readmitted within 30 days of discharge from a previous hospital stay for heart attack, heart failure, or pneumonia.) Mortality Rate: (shows how the 30-day risk-adjusted death rates for heart attack, heart failure and pneumonia at different hospitals compare to the U.S. National rate. For some hospitals, the number of cases is too small (fewer than 25) to reliably tell how well the hospital is performing, so no comparison to the national rate is shown.)risk-adjusted

15. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) 34% of CAHs reported HCAHPS patient assessment of care survey data in 2008. On average, CAHs have significantly higher ratings on HCAHPS measures than all US hospitals. Policy Brief #15 March 2010 Critical Access Hospital Year 5 Hospital Compare Participation and Quality Measure Results Michelle Casey, MS, Michele Burlew, MS, Ira Moscovice, PhD University of Minnesota Rural Health Research Center

16. CMS Hospital Compare Are these rural-appropriate measures? Do they represent the quality we provide in our CAHs? Will they “drive” quality improvement in our hospitals?

17. Measuring Quality vs Driving Quality Where can the most improvement actually be made.... …then measured and reported?

18. “…a hospital patient can expect on average to be subjected to more than one medication error each day.” July 20, 2006

19. Medication Errors (the most common medical error) The human cost…. Harm at least 1.5 million people/year Average of 7% of all hospital patients suffer an adverse drug event (ADE) Over 7,000 ADE deaths/year

20. Medication Errors (the most common medical error) The economic cost… US spends $3.5 billion/year to treat drug related injuries. Increased length of stay (“never pay” rules) Possible litigation; Affects the “bottom line” of the hospital.

21. Medication Errors (the most common medical error) The public relation cost… “Word of mouth” – the “by-pass” factor The “ 6 O’Clock NEWS” The deleterious impact on staff; Also… Affects the “bottom line” of the hospital.

22. Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Medication Safety Michelle M. Casey, M.S. Ira Moscovice, Ph.D. Gestur Davidson, Ph.D. December 2005 A partnership of the University of Minnesota Rural Health Research Center and the University of North Dakota Center for Rural Health

23. “The results of this study indicate that many small rural hospitals have limited hours of on site pharmacist coverage. Over one-third of the hospitals report having a pharmacist on site for less than 40 hours per week, including 31 hospitals where a pharmacist is on site for two hours or less per week. These findings are consistent with survey data on CAHs (Casey, Moscovice, and Klingner, 2004) and ASHP data on small hospitals (Pedersen, Schneider, and Scheckelhoff, 2005) and have implications for the role of pharmacists in implementing medication safety initiatives in small rural hospitals.” p. 31

24. Medication Management and Patient Safety Measures Review of All Orders by a Pharmacist within 24 hours Medication Reconciliation Upon Transition of Care

25. Pharmacist Review of Orders Potential Drug-Drug Interactions Patient Allergies / Sensitivities Appropriate Drug / Dose / Frequency Accuracy of order entry / transcription Therapeutic monitoring / recommendations Formulary substitution

26. Medication Reconciliation 1)develop a list of current medications; 2)develop a list of medications to be prescribed; 3)compare the medications on the two lists; 4)make clinical decisions based on the comparison; and 5)communicate the new list to appropriate caregivers and to the patient.

27. ??? The Project ??? Across Multiple States Involving significant number of CAHs Aggregating the data – national benchmarking. Rural Appropriate Measures & Processes -Heart Failure, Pneumonia, Heart Attack - 30 Day Re-admissions Outcomes -ED Outpatient Transfer Communication -HCAPS -Medication Management & Patient Safety Measures

28. Driving Outcomes Focus Organization on Driving Outcomes Evaluate Current Problem Areas Measure Progress and Continuously Improve Utilize Innovative QI Tools to Improve Practices and Processes PDSA Plan Do Study Act LEAN FMEA Failures Modes and Effects Analysis FADE Model Focus Analyze Develop Execute Evaluate Six Sigma QI Toolbox

29. At the end of the day…

30. Contact Information Paul Moore, DPh Office of Rural Health Policy 5600 Fishers Lane, Rm 10B-45 Rockville, MD 20857 Tel: 301-443-1271 Fax: 301-443-2803 pmoore2@hrsa.gov http://ruralhealth.hrsa.gov