The document discusses quality improvement in rural healthcare settings in Virginia. It recommends establishing a Rural Health Performance and Quality Advisory Council to support quality improvement efforts. Several databases and quality measures are mentioned that could help measure progress, identify health inequities, and increase transparency of quality data. The document also discusses survey results showing areas for improvement in rural hospitals, such as staffing, handoffs, and nonpunitive responses to errors. It proposes expanding membership of the Advisory Council to include more stakeholders and continue planning quality improvement initiatives.

1. Edna Rensing, RN, MSHA, CPHQ

2. Discuss Today Quality in perspective The year in review Where we go from here

3. Quality: In accordance with VA‐RHP core principles, performance and quality improvement must be central to all rural health care services. Thus, the VA‐RHP must provide recommendations that support and promote an increased awareness of and dedication to performance and quality improvement. D.1. Establish the Virginia Rural Health Performance and Quality Advisory Council. D.2. Create a database that supports the identification of health inequities and approaches for measuring progress against baseline measures. D.3. Host a statewide Rural Health Quality Summit. D.4. Establish a plan to improve transitions in care (e.g., from hospital to home). D.5. Create a database that supports rural‐relevant and meaningful indicators and increased transparency of quality data. D.6. Increase the number of health promotion/disease prevention programs through grants to rural communities. D.7. Develop common quality measures for program assessment and outcomes.

4. Quality Perspective? Internal infrastructure or readiness to implement changes External or needs of the people in the community Survey or needs assessment

5. Surveys and Data are Available Internal infrastructure or readiness to implement changes Leapfrog - www.leapfroggroup.org Agency for Healthcare Research and Quality (AHRQ) Hospital survey of staff perception of patient safety Nursing home survey of staff perception of patient safety Hospital Leadership Quality Assessment Tool (HLQAT) American Hospital Association (AHA) survey External or needs of the people in the community Leapfrog CMS – hospital, home health (HH) and nursing home (NH)compare www.hospitalcompare.hhs.gov www.medicare.gov/NHCompare www.medicare.gov/HHCompare Virginia Health Information - www. vhi .org Virginia Department of Health – Central line associated bloodstream infections Data Portal

6. Internal infrastructure or readiness to implement changes

7. Computerized Physician Order Entry system (CPOE) ICU Staffing with intensivists High Risk Treatments Leapfrog Safe Practices Score –17 key procedures to reduce preventable medical mistakes are put into place. Nationwide - 2oo rural hospitals completed Leapfrog survey. Question applicability to Virginia rural - small number of Virginia rural hospitals report Safe %Fully Practice Met Description SP1 13.0% Leadership Structures and System SP2 25.0% Culture Measurement for Performance SP3 15.0% Teamwork Training & Skill Building SP4 31.5% Identification & Mitigation of Risk & Hazards SP5 13.5% Informed Consent SP6 13.0% Life Sustaining Treatments SP9 22.0% Nursing Workforce SP12 28.5% Communication of Critical Information SP14 28.5% Labeling of Diagnostic Studies SP15 18.0% Discharge Systems SP17 34.5% Medication Reconciliation SP19 43.5% Hand Hygiene SP21 40.5% Central Venous Catheter Related Bloodstream Infections SP23 48.5% Prevention of Aspiration & Ventilator Associated Pneumonia SP25 25.5% Catheter-Associated Urinary Tract Infection Prevention SP28 35.5% DVT/VTE Prevention SP29 16.5% Anticoagulation Therapy Leapfrog

8. AHRQ – Hospital survey Safety Culture Composites Hospitals (22) Rural (9) Urban (13) Mean Median Mean Median Mean Median Overall Perceptions of Safety 64% 64% 67% 67% 62% 61% Frequency of Events Reported 64% 64% 65% 68% 63% 63% Supervisor/Manager Expectations & Actions Promoting Patient Safety 77% 77% 79% 80% 75% 76% Organizational Learning--Continuous Improvement 75% 76% 77% 77% 73% 72% Teamwork Within Units 82% 82% 81% 80% 82% 82% Communication Openness 64% 63% 64% 66% 63% 63% Feedback & Communication About Error 66% 66% 68% 69% 65% 64% Nonpunitive Response to Error 43% 44% 46% 44% 41% 43% Staffing 53% 52% 56% 55% 51% 49% Hospital Management Support for Patient Safety 73% 72% 75% 77% 72% 71% Teamwork Across Hospital Units 56% 56% 58% 57% 55% 55% Hospital Handoffs & Transitions 40% 39% 41% 39% 39% 36%

9. This tool was created at the University of Nebraska Medical Center as part of an AHRQ-funded Partnerships in Implementing Patient Safety Grant (AHRQ Grant 1 U18 HS015822-01). NOTE: This tool was developed in Microsoft Office Excel 2007 and is available at www.unmc.edu/rural/patient-safety.

11. What stands out? In lowest three for hospitals and nursing homes Nonpunitive response Staffing Handoffs Followed closely by Teamwork and communication Similar to Leapfrog results

12. HLQAT & AHA Surveys HLQAT Hospitals completed surveys 1/31/2010 No data yet AHA survey Data collection period was extended

13. Quality: In accordance with VA‐RHP core principles, performance and quality improvement must be central to all rural health care services. Thus, the VA‐RHP must provide recommendations that support and promote an increased awareness of and dedication to performance and quality improvement. D.1. Establish the Virginia Rural Health Performance and Quality Advisory Council. D.2. Create a database that supports the identification of health inequities and approaches for measuring progress against baseline measures. √ D.3. Host a statewide Rural Health Quality Summit. D.4. Establish a plan to improve transitions in care (e.g., from hospital to home). D.5. Create a database that supports rural‐relevant and meaningful indicators and increased transparency of quality data. D.6. Increase the number of health promotion/disease prevention programs through grants to rural communities. D.7. Develop common quality measures for program assessment and outcomes.

14. D.3. Host a statewide Rural Health Quality Summit Recommended funding of travel grants to allow hospitals to attend conferences related to quality improvement techniques, culture change and team building/communications. VIPC&S VHQC’s October conference TeamSTEPPS Root Cause Analysis and other QI techniques Virginia Business Coalition on Health

15. External or needs of the people in the community

16. CMS Hospital, HH & NH Compare Hospital Heart attack, heart failure, pneumonia, surgical care Readmission rates Patient Satisfaction And more Nursing homes Star rating based on health inspections, staffing, quality measures and more Home Health Activities of daily living, readmissions, and more

17. Computerized Physician Order Entry system (CPOE) ICU Staffing with intensivists High Risk Treatments Leapfrog Safe Practices Score –17 key procedures to reduce preventable medical mistakes are put into place. Nationwide - 2oo rural hospitals completed Leapfrog survey. Question applicability to Virginia rural - small number of Virginia rural hospitals report Safe %Fully Practice Met Description SP1 13.0% Leadership Structures and System SP2 25.0% Culture Measurement for Performance SP3 15.0% Teamwork Training & Skill Building SP4 31.5% Identification & Mitigation of Risk & Hazards SP5 13.5% Informed Consent SP6 13.0% Life Sustaining Treatments SP9 22.0% Nursing Workforce SP12 28.5% Communication of Critical Information SP14 28.5% Labeling of Diagnostic Studies SP15 18.0% Discharge Systems SP17 34.5% Medication Reconciliation SP19 43.5% Hand Hygiene SP21 40.5% Central Venous Catheter Related Bloodstream Infections SP23 48.5% Prevention of Aspiration & Ventilator Associated Pneumonia SP25 25.5% Catheter-Associated Urinary Tract Infection Prevention SP28 35.5% DVT/VTE Prevention SP29 16.5% Anticoagulation Therapy Leapfrog

18. Data exists Virginia Health Information - www. vhi .org Virginia Department of Health – Central line associated bloodstream infections Data Portal

19. Projects Exist Care transitions Get With the Guidelines (GWTG) Use of telemedicine Comprehensive Unit-based Safety Program/Central Line- Associated Blood Stream Infection (CUSP/CLABSI) MRSA, pressure ulcer, physical restraint reduction

20. Quality: In accordance with VA‐RHP core principles, performance and quality improvement must be central to all rural health care services. Thus, the VA‐RHP must provide recommendations that support and promote an increased awareness of and dedication to performance and quality improvement. √ D.1. Establish the Virginia Rural Health Performance and Quality Advisory Council. D.2. Create a database that supports the identification of health inequities and approaches for measuring progress against baseline measures. D.3. Host a statewide Rural Health Quality Summit. D.4. Establish a plan to improve transitions in care (e.g., from hospital to home). D.5. Create a database that supports rural‐relevant and meaningful indicators and increased transparency of quality data. D.6. Increase the number of health promotion/disease prevention programs through grants to rural communities. D.7. Develop common quality measures for program assessment and outcomes.

21. Expanding Membership American Heart Association/American Stroke Association Anthem Blue Cross and Blue Shield Telemedicine – VTN and NNMPT Hospitals Virginia Department of Health Business Coalition Physicians Pharmacists Welcome others in the community

22. Where we go from here Begin the planning at a meeting this evening Internal and external