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FLEX GRANT

FLEX GRANT . Kathy McGowan Vice President, Quality & Safety Samantha Dulworth Technical & Customer Specialist November 13, 2013. Georgia’s QI Program.

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FLEX GRANT

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  1. FLEX GRANT Kathy McGowan Vice President, Quality & Safety Samantha Dulworth Technical & Customer Specialist November 13, 2013

  2. Georgia’s QI Program • Structured on requirements of Medicare Beneficiary Quality Improvement Project (MBQIP), Culture of Patient Safety, Technical Assistance, Education, and Training for Critical Access Hospitals. • Georgia Hospital Association Research & Education Foundation serves as sub-grantee for the Georgia FLEX QI Program since 2002

  3. QI Program Participation • CMS Core Measures • CMS Partnership for Patients • Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) • Data submission to Hospital Compare • Scheduled education • Scheduled training & technical assistance

  4. QI Objectives • Public quality reporting • Participation in MBQIP • Raising staff awareness regarding patient safety • Examining trends in patient safety culture

  5. QI Overall Program Requirements • Education & training in the use of CART, Core Measures and MBQIP • Public reporting to Hospital Compare on relevant processes of care quality measures: • Inpatient • Outpatient • HCAHPS • Hospital Engagement Network initiative

  6. QI Overall Program Requirements • Actively work towards staff awareness about safety • Examine trends in patient safety culture • Identify areas of strength and possible improvement • Consistently improve the patient quality of care outcomes in Georgia’s Critical Access Hospitals

  7. Purpose & Goal • Ensure patient safety • Deliver expected quality patient care outcomes

  8. Hospital Benefits • Quarterly dashboards • Quarterly core measure composite scores • Minimum of two CART trainings annually • HCAHPS and MBQIP training • QI technical assistance • CART technical and customer assistance • Onsite coaching

  9. Hospital Benefits • Resources • Data collection tools & definitions • CART manuals • Transfer / discharge checklists • Stabilizing core measure data submissions to Hospital Compare

  10. Education / Training • Patient and Family Centered Care • Rounding • TeamSTEPPS • Reliable Process Design • Frontline Defects Analysis • Plan-Do-Check-Act (PDCA) Process Improvement Principles

  11. Education & Training • Organizational Assessment Tool (OAT) • Culture of Patient Safety Survey • Continue focus on core measures • Pneumonia-6 • Heart Failure-1

  12. Education & Training • Phase III of MBQIP (started 9/1/13) • Pharmacist/Computerized Physician Order Entry (CPEO)/Verification of Medication Orders within 24 hours • Outpatient Emergency Department Transfer Communication • Needs assessment survey to all CAHs to establish baseline

  13. Education & Training • ST Elevated Myocardial Infection (STEMI) Program

  14. Conflict of Interest • State Office of Rural Health, Georgia Medical Care Foundation and GHA staff meet once a month • Work together to avoid duplicating efforts

  15. HeRMES Samantha Dulworth

  16. Products

  17. Data Flow using Cart

  18. HeRMES

  19. Care Core Submission Deadlines

  20. CART Inpatient CART Version4.14 for Discharges (7/1/2013 -12/31/2013) Outpatient CART Version1.10 for Encounters (7/1/2013 -12/31/2013)

  21. Looking at Upload Reports

  22. Summary of Data

  23. Running Population Report

  24. Population Report Measures will show in Red if there are not enough cases submitted for Global and Ed throughput

  25. Questions?

  26. Care Core Reports

  27. Creating Report in Care Core

  28. Reports (TJC Core Measures)

  29. Reports (TJC Core Measures)

  30. Reports (Values)

  31. Reports (Drill Down)

  32. Reports (Run Report)

  33. Patient Level Drill Down

  34. Patient Detail

  35. Reports (TJC Core Measures)

  36. Reports (Run Report)

  37. HeRMES

  38. Data Flow using Cart

  39. What CARE Service Line has the Highest Mortality Rate?

  40. What CARE Service Line has the Highest Mortality Rate? • Pick your Quality Indicator • Pick your Values • Pick CARE Service Line in Drill Down • Click Run Report • Find your highest CARE Service Line

  41. Report Outcome

  42. HeRMES

  43. How many patients left your Emergency Department against medical advice?

  44. Left Without Being Seen • Click on High Risk Patient Safety • Click Quality Indicator “ER Patients Who Leave against medical advice” • Click “Run Report”

  45. Running Report

  46. Report Outcome

  47. HeRMES

  48. Which Physician has the highest Mortality Rate?

  49. Which Physician has the highest Mortality Rate? • Click on MedEval • Click on Mortality under Quality Indicators • Click Physician Name and NPI number under “Drill Down” • Click on “Run Report”

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