1. MPRO Update MICAH Quarterly Meeting
Donna Modras
May 19, 2017

2. Objectives News and updates
2017 Governor’s Award of Excellence recipients
Registration for the next Governor’s Award of Excellence program
NHSN technical assistance for CDI
Antibiotic stewardship initiative
Resource materials available in SharePoint at Program Resources > Training and Events > CME
See Margaret LeDuc for assistance with planning for CME credit.
Example objectives
Refine and further develop action plans based on learning and sharing among collaborative teams
Identify key concepts of business planning, marketing, and measurement related to palliative care
Identify resources available to support palliative care
Develop objective that use verbs such as: Apply, Arrange, Articulate, Assess, Categorize, Classify, Compare, Construct, Convey, Create, Describe, Develop, Diagnose, Diagram, Discriminate, Distinguish, Discuss, Employ, Explain, Evaluate, Formulate, Identify, Illustrate, Implement, Integrate, Interpret, List, Manage, Predict, Recognize, Relate, Report, Solve, Translate, Write
Avoid: Appreciate, Internalize, Know, Understand

3. 2017 Governor’s Award of Excellence Recipients of the Effective Reporting and Measurement Award for CAHs

4. 14 CAH 2017 Governor’s Award of Excellence Winners
Allegan General Hospital Aspirus Iron River Hospital Bronson Lakeview Deckerville Hospital Hayes Green Beach Memorial Hospital Hills and Dales General Hospital Marlette Regional Hospital McKenzie Health System

5. 14 CAH 2017 Governor’s Award of Excellence Winners
Mercy Health Lakeshore Campus MidMichigan-Gladwin OSF St Francis Hospital and Medical Group Sparrow Clinton Sparrow Ionia Spectrum Health Kelsey

6. Participate in MPRO’s Next Governor’s Award of Excellence Program

7. Governor’s Award of Excellence
Register at

8. Effective Reporting and Measurement: Critical Access Hospitals
Achievement Criteria
Submit signed participation form for CAH with MPRO
Submit all required Governor’s Award of Excellence documentation
Select at least two inpatient quality reporting (IQR) or outpatient quality reporting (OQR) measures
Submit data quarterly for two measures
Achieve the evaluation performance standard of 3 percent absolute improvement or 3 percent relative improvement (whichever is better) for one of two selected IQR or OQR measures from the baseline time period (7/1/16-6/30/17) to the 4th data submission time period (7/1/17-6/30/18)

9. NHSN Technical Assistance CDI

10. MPRO & the HIIN
MPRO aligns with the HIIN to provide technical assistance and quality improvement resources for the CMS healthcare associated infection (HAI) measure clostridium difficile (CDI)
Technical assistance includes getting started in NHSN through submitting CDI data
Quality improvement resources include webinars, data reports and other various resources to end CDI

11. Improving Antibiotic Stewardship in the Outpatient Setting Initiative

12. Improving Antibiotic Stewardship in the Outpatient Setting
CMS identified antibiotic stewardship as a national priority to improve health outcomes and decrease patient harm
Reduce and prevent the misuse/overuse of antibiotics and minimize the development of antibiotic resistance
Involves targeted outpatient settings (including RHCs, physician offices and CAH emergency departments)

13. Improving Antibiotic Stewardship in the Outpatient Setting
Benefits of participation include the following :
No cost to participate
Assessment, development and implementation of antibiotic stewardship programs and activities
Education on the principles and Core Elements of Outpatient Antibiotic Stewardship as defined by the Centers for Disease Control and Prevention (CDC)
Learning sessions that include thought leaders from federal, state, academic and professional societies; front-line and prescribing clinicians; health systems; and beneficiary representatives

14. Participation Participants must commit to the following:
Signing a participation agreement with the required two signatures: clinical leader and setting champion
Implementing an intervention(s) for all four of the CDC’s Core Elements of Outpatient Antibiotic Stewardship and tracking and reporting these elements on a quarterly basis
Identifying a team clinical leader and champion
Remaining active in the project for it’s duration (July 2019)

15. CDC Core Elements of Outpatient Antibiotic Stewardship
CDC outpatient core elements include the following:
Commitment
Can your facility demonstrate dedication to and accountability for optimizing antibiotic prescribing and patient safety related to antibiotics?
Action
Has your facility implemented at least one policy or practice to improve antibiotic prescribing?
Tracking and Reporting
Does your facility monitor at least one aspect of antibiotic prescribing?
Education and expertise
Does your facility provide resources to clinicians and patients on evidence-based antibiotic prescribing?

16. CDC Website
Please visit the CDC website for more information about antibiotic stewardship in all settings of care:

17. Get Involved! Recruitment time sensitive: June 15, 2017
Recruitment information is posted on the Lake Superior QIN website
Visit for additional information and participation forms
Contact Anne Messer for more information at or

18. Questions?
Donna Modras

19. Thank you!