Quality Toolkit Cover sheet.pub

893 Pages·2017·24.08 MB·English

Quality Toolkit

Prepared by: 
Offered by HomeTown Health in conjunction with the Iowa Department of Public Health through the
2016-2017 SHIP Grant Program #5887SH01.
1
QUALITY TOOLKIT INDEX

Several themes recurred during coaching calls and conversations with quality leaders in the Iowa
2016-17 SHIP Critical Access Hospital (CAH) consortium. HMA has assembled a Tool Kit
comprised of the most recent, public-domain articles and weblinks that address these
Iowa-specific themes. We have endeavored to select authoritative resources that are most
relevant to the unique challenges of CAHs. Our hope is that these resources – organized and at
your fingertips – will streamline your ability to learn and plan your journey through the world of
quality improvement.

We have included resources related to the following topics:

A. Planning and Leading QI projects within CAHs:

Based on learnings from the Medicare Beneficiary Quality Improvement Project (MBQIP), a
general-purpose guide provides basic directions and resources for conducting and streamlining
quality improvement projects in rural hospitals.

“Quality Improvement Implementation Guide for Critical Access Hospitals” - In May, 2016,
Strasis Health published a guide and toolkit to assist CAHs in planning, streamlining, and
implementing quality improvement and safety initiatives. The resource includes:
• A quality improvement implementation model focused on small, rural hospitals
• Suggestions and considerations for identifying and prioritizing areas for improvement
• A table detailing key national quality initiatives including links to external websites for
further information
• A ten-step guide to leading quality improvement topics

Prepared by in conjunction HomeTown Health and
the Iowa Department of Public Health through the 2016-2017 SHIP Grant Program #5887SH01.

* INDEX *
B. Engaging Key Stakeholders: Physicians, Board of Directors, and Patients & Families

- Physicians – Physicians play a critical role in every aspect of healthcare but involving
them in QI, while necessary, can be tricky.
o “CPNET –A Roadmap for Trust – Enhancing Physician Engagement” – This
resource summarizes the evidence on physician engagement, drawing on peer-
reviewed articles and reports from the grey literature, and suggests an integrative
framework to help healthcare managers better understand and improve physician
engagement.
o “Healthcarecollaboration – Practical Strategies for Engaging Physicians” – This
slide deck summarizes in bulletpoint form multiple do’s and don’ts related to
engaging physicians. Although a sizeable section is focused on physician
recruitment and retention, the advice in this section related to culture and
communication has general applicability for increasing physician involvement in
quality improvement.
o “HealthCatalyst - The-Best-Way-Hospitals-Engage-Physicians-Nurses-and-Staff”
-Overwhelmed and ill equipped, and plagued by limited understanding of risk-
based payment models and how their behavior contributes to healthcare waste and
inefficiency, physicians are struggling in the new environment. Financial
incentives are overrated – this article reviews alternative (and more successful)
ways of engaging physicians and other caregivers.
o “IHI - Engaging Physicians in a Shared Quality Agenda” – This whitepaper from
the Institute for Healthcare Improvement continues to stand as a vital framework
for engaging physicians, especially those who are independent members of a
hospital’s organized medical staff.

- Boards of Directors - safeguarding and improving quality and patient experience does not
fall solely on frontline clinicians - it is a core governance responsibility (multiple
resources).
o “Hospital Board Oversight of Quality - Synthesis of Research” – This Milbank
Quarterly article from 2013 presents a narrative review of 122 empirical research
papers, finding a correlation between high-performing hospitals, on the one hand
and, on the other, strong and committed leadership that prioritizes quality and
safety and sets clear and measurable goals for improvement.

Prepared by in conjunction HomeTown Health and
the Iowa Department of Public Health through the 2016-2017 SHIP Grant Program #5887SH01.

* INDEX *
o “Hospital Governance and Quality of Care” - This Health Affairs article is
based on a large survey of non-profit hospital board chairs. A key finding is that
among respondents there is less than-optimal focus on clinical quality and large
differences between high- and low-performing hospitals. There are major
opportunities to shift the knowledge, training, and practices of hospital boards to
promote a greater focus on improved clinical quality.
o “How to Guide - Governance Boards on Board for QI” – The Institute for
Healthcare Improvement has developed a “getting started” toolkit that provides
practical guidance in the establishment of a board membership structure and set of
activities that will allow the board to spend more than 25% of its time on quality
and safety issues.
o “Questions to Ask When Forming a Board Quality Committee” – A succinct,
high-value, bullet-pointed summary of key questions to address when pursing a
board focus on quality.
o “Telling QI stories to Boards of Directors” – Stories are compelling ways to
educate and engage boards in quality and safety. This one-page document
sketches out best practices related to sharing stories with boards of directors.
o “The role of governing boards in improving patient experience” – This article
evaluates board engagement around improving patient experience and offers
practical examples of how to increase board involvement. Part of this requires
developing a nuanced understanding of board member attitudes.

- Patients and families – Patient and family advisory councils can be instrumental in
transforming the culture of CAHs towards patient-centered care (an all-purpose guide).
o https://www.stepsforward.org/modules/pfac - The American Medical
Association’s STEPSforward program, in partnership with Consumers Advancing
Patient Safety and Project Patient Care, has developed a sophisticated set of
online modules to assist hospitals in the creation of patient and family advisory
councils.
o “AHRQ - Working With Patient and Families as Advisors” – AHRQ has
developed an implementation handbook to assist hospitals develop effective
partnerships with patients and family members with the ultimate goal of
improving hospital quality and safety.
o “Toolkit - Patient and Family Advisory Council” – BJC Healthcare has released a
comprehensive, step-by-step guide to establishing hospital-based patient and
family advisory councils.

Prepared by in conjunction HomeTown Health and
the Iowa Department of Public Health through the 2016-2017 SHIP Grant Program #5887SH01.

* INDEX *
C.Measuring and Improving Patient Experience beyond HCAHPS:
Recognizing that CAHs must often participate in HCAHPS, but that in rural settings HCAHPS
survey responses are often insufficient in number, reporting is delayed, and actionable
information is frequently lacking, we offer resources that describe rapid-cycle, real-time
alternatives for assessing and improving patient experience.
Today, every healthcare provider is struggling to lift its patient satisfaction ratings. Yet providers
often learn about patient complaints far too late in a hospital stay to affect those perceptions. And
that can be costly. Medicare in 2017 started to use patient satisfaction scores to determine up to a
quarter of the 2% penalty or reward in its value based purchasing program. Traditional methods
of evaluating a visit from the patient’s side that focused on satisfaction with care through post-
care surveys and interviews have been limited by a number of factors, including low response
rate, recall bias related to delay in obtaining information, selection bias related to which patients
actually complete a survey, and the halo effect, which reflects patients’ desires to speak highly of
their providers. Several innovative approaches to obtaining and acting to improve patient
experience in real time are noted in resources provided below.
o Real Time Patient Experience Methods
o Alberta Health System Emotional Care Pathways
o The Current State of Patient Experience Surveying and Future Innovations
o At the University of Pennsylvania, researchers tested the use of a kiosk delivered survey
offered to patients to elicit feedback on care experiences as a method for obtaining patient
feedback in real-time. http://www.ajmc.com/journals/issue/2011/2011-7-vol17-
n7/AJMC_11jul_DiRocco_e270to276/
o At Denver Health Medical Center, a QI team instituted a brief, three-question verbal
survey that asked a group of patients to rate their doctor on listening, explaining, and
being helpful. It turned around and immediately provided that feedback to the frontline
caregivers. They also provided training for clinicians in cases where there were areas for
improvement. http://www.journalofhospitalmedicine.com/jhospmed/article/127060/real-
time-patient-experience-surveys#jhm2533-bib-0022
o Wofford and colleagues at Wake Forest University Medical Center tested the use of web-
based survey technology to elicit patient feedback on clinical care experiences in a
primary care setting. Of the 727 available patients during clinic survey days, 293 (40%)
completed the survey. For the 12-question survey, the average time per survey was 40
seconds. Yes/No questions took less time than multiple choice questions (average 9.6
seconds versus 14.0). http://medinform.jmir.org/2015/1/e13/
Prepared by in conjunction HomeTown Health and
the Iowa Department of Public Health through the 2016-2017 SHIP Grant Program #5887SH01.
*INDEX *
D. Transitions of Care:

Safely discharging patients to their home environment and avoiding readmissions is an
intensifying priority. A variety of landmark studies and toolkits support the ability of CAHs to
tackle this thorny challenge.
Resources included on best practices in care transitions in this toolkit include the following:
o The Project RED toolkit
o The IDEAL Discharge program from AHRQ
o Links to Project BOOST and the Transitional Care model
o The Institute for Healthcare Improvement Guide to Care Transitions

Prepared by in conjunction HomeTown Health and
the Iowa Department of Public Health through the 2016-2017 SHIP Grant Program #5887SH01.

* INDEX *
Quality Improvement Implementation Guide
and Toolkit for Critical Access Hospitals

May 2016

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services
(HHS) under grant number U1RRH29052, Rural Quality Improvement Technical Assistance Cooperative Agreement, $490,194 (0% financed
with nongovernmental sources). This information or content and conclusions are those of the author and should not be construed as the official
position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.
Quality Improvement Implementation Guide and Toolkit for CAH Hospitals

Table of Contents

Overview ......................................................................................................................................... 2
About MBQIP ............................................................................................................................. 2
Purpose of This Guide ................................................................................................................ 2
How to Use This Guide............................................................................................................... 2
Rural Hospital Quality Improvement – A Model for Implementation ........................................... 3
Prioritizing Opportunities for Improvement ............................................................................... 5
Ten Steps to Leading Quality Improvement Topics ....................................................................... 7
MBQIP Quality Improvement Focus Areas ............................................................................. 12
Additional Resources ................................................................................................................ 13
Appendix A – FORHP MBQIP Infographic ................................................................................. 14
Appendix B – Federal and National Quality Programs ................................................................ 15
Appendix C – MBQIP Acronym Guide........................................................................................ 17
Appendix D – Measure Quick Reference Guide .......................................................................... 18
Appendix E – Patient Safety Measure Summary .......................................................................... 19
Appendix F – Outpatient Measure Summary ............................................................................... 22
Appendix G – Patient Engagement Measure Summary ............................................................... 27
Appendix H – Care Transitions Measure Summary ..................................................................... 30
Appendix I – Glossary .................................................................................................................. 34
Appendix J – Tools ....................................................................................................................... 35

Stratis Health Rural Quality Improvement Technical Assistance │ www.stratishealth.org 1
Quality Improvement Implementation Guide and Toolkit for CAH Hospitals

Overview
About MBQIP
The Medicare Beneficiary Quality Improvement Project (MBQIP) is a quality improvement
activity under the Federal Office of Rural Health Policy’s (FORHP) Medicare Rural Hospital
Flexibility (Flex) grant program. Implemented in 2011, the goal of MBQIP is to improve the
quality of care provided in critical access hospitals (CAHs) by increasing voluntary quality
data reporting by CAHs and then driving quality improvement activities based on the data.
Critical access hospitals have historically been exempt from national quality improvement
reporting programs due to challenges related to measuring improvement in low volume settings
and limited resources. It is clear, however, that some CAHs are not only participating in national
quality improvement reporting programs, but are excelling across multiple rural relevant topic
areas. Small rural hospitals that participate in Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS) often outperform prospective payment system (PPS) hospitals
on survey scores. MBQIP provides an opportunity for individual hospitals to look at their own
data, compare their results against other CAHs and partner with other hospitals around quality
improvement initiatives to improve outcomes and provide the highest quality care to each and
every one of their patients.
As the US moves rapidly toward a health care system that pays for value versus volume of care
provided, it is crucial for CAHs to participate in federal public quality reporting programs to
demonstrate the quality of the care they are providing. Low numbers are not a valid reason for
CAHs to not report quality data. It is important to provide evidence-based care for every patient,
100 percent of the time. MBQIP takes a proactive approach to ensure CAHs are well-prepared to
meet future quality requirements.
For more information about MBQIP, please see the FORHP infographic in Appendix A.

Purpose of This Guide
This guide is intended to help CAH staff structure and support quality improvement efforts, as
well as identify best practices and strategies for improvement of MBQIP measures.

Measures included in the MBQIP Quality Guide
This guide focuses on measures reported for MBQIP as part of the fiscal year (FY) 2015 Flex
grant cycle, which ends August 31, 2016. Recognizing the evolving nature of health care
quality measures, this guide will be updated on a routine basis to align with changes made to
MBQIP. A current list of MBQIP measures is posted here.

How to Use This Guide
This guide provides basic directions and resources for conducting and streamlining quality
improvement projects in rural hospitals, with a particular focus on MBQIP. This guide and
toolkit includes:
 A quality improvement implementation model focused on small, rural hospital settings
 Suggestions and considerations for identifying and prioritizing areas for improvement

Stratis Health Rural Quality Improvement Technical Assistance │ www.stratishealth.org 2
Quality Improvement Implementation Guide and Toolkit for CAH Hospitals

 A table detailing key national quality initiatives that align with MBQIP priorities,
including links to external websites for further information (Appendix B)
 A ten step guide to leading quality improvement topics
 An internal monitoring tool to assist with tracking and displaying MBQIP and other
quality and patient safety measures
 A list of acronyms related to MBQIP measures (Appendix C)
 Summaries of current MBQIP measures by domain including best practices for
improvement (Appendix D)
 A glossary of key words with definitions. Throughout the document key words are
hyperlinked so the reader is able to click on the word and go directly to the glossary
Rural Hospital Quality Improvement – A Model for
Implementation
When structured in a way that leverages the advantages of smaller scales such as easier access to
key people, and less cumbersome decision-making hierarchies, rural hospital quality
improvement can be achieved efficiently and effectively. A hub and spoke model can be used as
an illustration. Rather than initiating full teams for every topic area or initiative, one core quality
and patient safety committee (hub), led by a designated chair, might initiate and oversee multiple
topics or projects, active and sustained, by designating a leader or “owner” (spokes) for each of
them. Individual project leaders might be chosen based on topic expertise, enthusiasm, or
proximity to the process being improved. Active project implementation can be conducted in ad
hoc working sessions, with the leader attending quality and patient safety meetings only upon
special request, if the leader is not a standing member of the quality and safety committee. The
flow of information from the quality and safety chair to each project or topic leader is critical to
the success of the hub and spoke model. Below is an illustration of the model, suggesting
possible MBQIP topic area designations.

Stratis Health Rural Quality Improvement Technical Assistance │ www.stratishealth.org 3