QualityAn Information & Quality HEALTHCARE (IQH) Publication Serving Mississippi Physicians and Providers

MattersDr. Sue C. Dillon has

joined IQH as clinical coordinator.She comes to IQH from Coloradowhere she has been in a family/emergency medicine practice since1998. Her practice included anemphasis in sports and high altitudemedicine.

A native of Jackson, Dr.Dillon, who is board certified in fam-ily medicine, studied at the Univer-sity of Southern Mississippi, gradu-ating from Colorado State Univer-sity-Pueblo with a B. S. degree inbiology and pre-med. She earnedthe doctor of osteopathic medicinedegree from the Midwestern Uni-versity-Chicago College of Osteo-pathic Medicine. Her internshipwas completed at Presbyterian/St.Luke’s Medical Center in Denverand her residency in family medi-cine at Aurora Medical Centers inAurora, Colorado.

Additionally, she has ateaching certificate in secondaryscience from the University ofColorado and completed a mo-lecular genetics fellowship atL’Universite de Louvain-leNeuve,Louvain-le-Neuve, Belgium, 1989.

Dr. Dillon served as a vol-unteer physician for the HarrisonCounty Emergency OperationsCommand, Remote Area Medicaland International Medical Allianceon the Mississippi Gulf Coast.

Dr. Dillon Explains . . .See page 8.

Dr. Sue Dillon Joins IQH asClinical Coordinator

She has participated in theKatrinaHealth.org project with theMarkel Foundation and was ap-pointed by Gov. Haley Barbour tothe Southern Governors Associa-tion Health Information Technology(HIT) Task Force. Among Dr. Dillon’s numerous

interests are hiking, mountain climb-ing, cycling, kayaking, painting andphotography. She has walked1000 miles of the Appalachian Trailand climbed about half of the Colo-rado mountains having greater than14,000 feet in elevation. She hascompleted two sprint triathlons andplayed right wing position for theBreckenridge Medical Center icehockey team. “We welcome Dr. Dillon,” saidDr. James S. McIlwain, president.“Her experience and dedication topatient quality will serve IQH well.”

(See page 2)

Vol. XXIV, No. I

January 2007

Contents:Review Department News,

See pages 4-6

Home Health Project News,pages 9-10

Nursing Home Project News,pages11-12

HospitalPatient Safety, page 13

NMMC Among ThreeReceiving PresidentialAward for Excellence North Mississippi MedicalCenter was named as one of threerecipients of the 2006 MalcolmBaldrige National Quality Award,the nation’s highest Presidentialhonor for organizationalperformance excellence. Announced by PresidentGeorge W. Bush and CommerceSecretary Carlos M. Gutierrez, theprestigious award went to threerecipients, including NMMC,recognized for excellence in healthcare; MESA Products, Inc., inTulsa, small business; and Premier,Inc., in San Diego for service. The 2006 Baldrige Awardrecipients were selected from 76applicants. All of the applicantswere evaluated rigorously by anindependent board of examiners inseven areas.

Quality Matters is a quarterly publication ofInformation & Quality Healthcare (IQH)385 B Highland Colony Parkway, Suite 504Ridgeland, MS 39157601-957-1575 (fax) 601-956-1713Web site www.iqh.orgCarole Kelly, Editor

Page 2 Quality Matters

(Continued from page 1)

established by Congress in 1987 to enhance thecompetitiveness and performance of U.S. businessesand expanded in 1998 to include education and healthcare. In 2007, non-profit organizations will be eligibleto receive a Baldrige Award. The award is not givenfor specific products or services. Since 1988, 67organizations have received Baldrige Awards.

Dr. Ken Davis, a member of the IQH Boardof Directors, is medical director of NMMC.

Baldrige Recognition Goes to NMMC,Tupelo

IQH Board of Directors*Steven Brandon MD, Starkville, Chairperson

*Kenneth Davis, MD, Tupelo, Vice-Chairperson*Philip Merideth, MD, Jackson, Treasurer

Larry Black, MD, SenatobiaSidney Bondurant, MD, Grenada

Peggy Davis, MD, Jackson*Hursie Davis-Sullivan, MD, Jackson

*Lucius Lampton, MD, MagnoliaSusan Chiarito, MD, Vicksburg

Rodney Frothingham, MD, GreenvilleWilliam Jackson, MD, Corinth

Keith Mansel, MD, OxfordL. Lee Montgomery, MD, Magnolia

Kenneth Stubbs, MD, Natchez* Executive Committee

Hospital AdministratorsWilliam H. Peters, MD

Forrest General Hospital, HattiesburgMary Ellen Pratt

University Hospital, Lexington

Consumer Representatives Walter Howell, PhD, ClintonClaudell Weaver, Louisville

Lex Taylor, Lousville

IQH President James S. McIlwain, MDReview Medical Director Ralph Dunn, MD

Clinical Coordinator Sue C. Dillon, DOVice President, Government Services

Barbara MooreVice President, Program & Operations

Becky RobersonVice President, Corporate Services Bo Bowen

This newsletter was prepared by IQH under a contract with theCenters for Medicare & Medicaid Services (CMS), an agency of theU.S. Department of Health and Human Services. The contents pre-sented do not necessarily reflect CMS policy. IQH publication no.

8SOW MS Comm 978-06.

The areas are leadership; strategic planning;customer and market focus; measurement, analysis,and knowledge management; human resource focus;process management; and results. The evaluationprocess for the 2006 Baldrige Award recipientsincluded about 1,000 hours of review and an on-sitevisit by teams of examiners to clarify questions andverify information in the applications. “Having North Mississippi Medical Center namedas a recipient of the 2006 Malcolm Baldrige QualityAward is a great reflection of years and years of hardwork by all involved,” said John Heer, president andchief executive officer for North Mississippi HealthServices, NMMC’s parent organization.“Our employees, medical staff, NMMC and NMHSBoard of Directors and volunteers worked togetherto make this happen. This is a truly phenomenalaccomplishment.” The 2006 Baldrige Awardrecipients are expected to be presented with theiraward in a ceremony in Washington, D.C., early in2007.

Named after Malcolm Baldrige, the 26thSecretary of Commerce, the Baldrige Award was

Quality Matters Page 3

2007 MSMD Survey Begins in January:Physician Participation is Critical

A survey beginning inJanuary will seek information todescribe the state’s physicianworkforce. The 2007 MississippiPhysician Workforce Survey(MSMD) will update findings fromthe 2003 MSMD survey thatresulted in a study describing thestate’s physician workforce andassisting legislators in forminglegislative policy.

In the nearly four years thathave passed since 2003 MSMD,tort reform in Mississippi,Hurricane Katrina, and other trendshave changed the physicianworkforce landscape. Updatinginformation through the 2007MSMD is important to allphysicians in the state.

For the new study to beuseful to physicians and legislators,it is critical for every physician toparticipate in the study. Data qualityis only as good as the response ratethat allows for meaningfulgeneralization.

Questions or concernsabout participating in the study canbe directed to Lynne Cossman atMississippi State University (662-325-3791) or e-mail atLynne.Cossman@msstate.edu.

The study can becompleted on-line in about 20minutes. An e-mail will be sent inmid-January directing participantsto the 2007 MSMD survey Webaddress. The goal is for allMississippi physicians to completethe survey by mid-February.

Funding for the studycomes from the MississippiPhysicians Care Network, the

Human ResourcesManager Is CAHRAVice President Donna Marshall, PHR, whoassumed the duties of IQH human

r e s o u r c e smanager inNovember, isserving as thevice presidentfor the CapitalArea HumanR e s o u r c e sAssociation(CAHRA). In

2000 she was certified by the So-ciety of Human Resource Manag-ers as a Professional in Human Re-sources. She is a member of theSociety for Human ResourcesManagers and the MadisonCounty Human Resources Man-agers. Donna has a bachelor’s de-

Mississippi Academy of FamilyPhysicians, the American Academyof Family Physicians, the Universityof Mississippi Medical Center’sMississippi Institute forImprovement of GeographicMinority Health and HealthDisparities and the Mississippi StateUniversity Social Science ResearchCenter.To Quit: 1-800-QUITNOW or1-800-784-8669

The Mississippi TobaccoQuitline is alive and well, with coun-selors available only a telephone callaway: 1-800-QUITNOW (1-800-784-8669) to assist anyonedesiring to stop a tobacco habit.

Physician intervention isessential to comprehensive, effec-tive, tobacco dependence treat-ment. In fact, the cornerstonedocument of cessation treatment,the Public Health Service’s “Treat-ing Tobacco Use and Dependence,Clinical Practice Guideline,” fo-cuses on ways physicians, dentists,and other health care professionalscan help tobacco users kick thehabit.

Interventions are especiallyeffective when health care provid-ers follow the five A’s of asking ifpatients use tobacco; advising themto quit; assessing their readiness toquit; assisting with counseling andNRT Rx; and arranging followup.

If tobacco use status is in-cluded in a patient’s vital signsstamp, it may serve as a reminderfor doctors to encourage cessationand recommend appropriate treat-ments.

gree in education from MississippiState University and is pursuing amaster’s degree in business tech-nology. In the human resourcesfield for over 10 years, her formerexperience includes human re-sources work at “The Clarion-Ledger” and private consulting.

* * IQH Vacancy * *-Manager, Quality

Improvement Department-Management experience in

health care qualityimprovement necessary.

Contact Donna Marshall,Human Resources manager,

601-957-1575 ext. 258

Quality MattersPage 4

Review Department:

Hospital Payment Monitoring Program (HPMP) Update Introductory letters were mailed on Oct. 18 toseven hospital administrators and case managementdirectors selected for the project. Along with theproject goals, the letter included information on whyIQH was conducting the project and why the hospitalwas chosen. Included was a list of 25 medical recordsthat were being requested for baseline review and aproject contact from each hospital. The initial mailingof the letters was delayed because of the need to ob-tain CMS approval for project changes. Requestedchanges included shifting of the timeframes to assurethat 25 records could be obtained for baseline reviewand shifting of re-measurement timeframes. On site visits and medical record review began Nov.1 and was completed Dec. 5. Two of the seven hos-pitals had electronic medical records, and the projectreview team was in-serviced on each program priorto review. Review results have been compiled and initial analy-sis shows an aggregate of 38.86 percent as being un-necessary admissions. Individual hospitals ranged from16 percent to 68 percent as unnecessary admissions.Estimated dollars in overpayment range from$19,756.16 to $126,659.01, with an aggregate totalof $374,392.86 in the seven selected hospitals. A Dec. 28 meeting at IQH for 18 contacts fromthe hospitals featured a presentation by Dr. RalphDunn, IQH medical director. Hospital packets werepresented to the participants with individual data alongwith the aggregate statistics from the hospitals. “Ob-servation Care vs. Inpatient Admission” posters and“Medicare Outpatient Observation--Physician Guide-lines” brochures were provided for use in the hospi-tals. The tools were developed and shared throughthe HPMP QIOSC and the HPMP Compliance Work-book. For further information, contact Nellie Dukes at601-957-1575, ext. 211 or Stephanie Champion, RN,CPUR, Utilization Quality Review manager, 601-957-1575, ext. 233.

One and Two-Day Stays for DRG 127, a heart fail-ure project with the focus on unnecessary one andtwo-day admissions, has been underway since Oct.1, 2006. Nellie Dukes, RN, is serving as the HPMPspecial project leader.

Copies of the “Observation Care vs.Inpatient Admission” poster, shownabove, were distributed to projectcontacts at a Dec. 28 meeting at IQH. Any hospitals desiring copies of theposters or “Medicare OutpatientObservation” brochures should contactStephanie Champion at 601-957-1575ext. 233.

This material was prepared by IQH, the Medicare Quality Improvement organization for Mississippi, under contract with the Centers for Medicare & Medicaid

Services (CMS), an agency of the U. S. Department of Health and Human Services. The contents presented to not necessarily reflect CMS policy. 8SOW-MS-

RD-960-06

Thanks to MPRO and Lumetra.

Long-term, acute-care hospitals (LTCHs) are in-vited to the first nationwide Webinar on the Programfor Evaluating Payment Patterns Electronic Report(PEPPER), the electronic report of hospital-specificdata for areas likely to result in Medicare paymenterrors. Compliance officers and utilization, health in-formation management and coding professionals areencouraged to attend this one time only educationalseminar.

The PEPPER Webinar will be held on Tuesday,Feb. 6, 2007, from 1 to 2 p.m. CST. This event isprovided free of charge as part of the Medicare pro-gram, but space is limited. Registration is available byvisiting www.hpmpresources.org and clicking on“Events.”

This Webinar will cover the fundamentals of usingPEPPER. Participants will:

· Learn about PEPPER and why it was devel-oped

· Become familiar with PEPPER terminology· Understand how to read and interpret PEP-

PER· Learn how PEPPER can support the auditing

and monitoring components of a complianceplan

A second Webinar, which will provide more ad-vanced PEPPER training, will be held on March 6,2007.

(See About Pepper on page 6.)

An upcoming series of nationwide Webinars de-signed to enhance compliance efforts is available fornew or longtime users of the Program for EvaluatingPayment Patterns Electronic Report (PEPPER) . These educational seminars will feature hospitalsthat have been successfully using PEPPER, the elec-tronic report of hospital-specific data for areas likelyto result in Medicare payment errors. Key staff mem-bers from these facilities will share best practices andanswer any questions. Compliance officers and utili-zation, health information management and coding pro-fessionals are invited to attend. The first Webinar in the series of three will beheld on Wednesday, Feb. 7, 2007, from 1 to 2 p.m.Central time. This event is provided free of charge aspart of the Medicare program, but space is limited.Registration is available by visitingwww.hpmpresources.org and clicking on “Events.” The Feb. 7 Webinar will feature Donna D. Wil-son, RHIA, CCS, revenue integrity manager at RoperSt. Francis Healthcare. “Analyzing PEPPER data ona quarterly basis has become the foundation of ourcoding and clinical documentation educational pro-cesses,” said Ms. Wilson.

Long-Term, Acute-Care Hospitals:Learn How To Reduce MedicarePayment Errors With PEPPER

Hospital Best Practices:Preventing Payment Errors,

Reducing Audit Risk with PEPPER

During her live presentation, Ms. Wilson will sharehow her hospital has:

· Collaborated with the state Medicare Qual-ity Improvement Organization to integratePEPPER into their coding compliance audit-ing and monitoring activities

· Taken advantage of opportunities for processimprovement while fostering an atmosphereof teamwork among coders, nurses and phy-sicians

· Used PEPPER data to focus on improvingpolicies and procedures related to ICD-9-CM inpatient coding, reducing their risk ofMedicare payment errors.

PEPPER Webinars: Tuesday, Feb. 6, 1 p.m. Advanced training: March 6

Webinar series begins Wednesday, Feb. 7, 1 p.m.

PEPPER Webinar Details AnnouncedQuality Matters Page 5

PEPPER provides summary statistics of admin-istrative claims data on target areas (areas likely tohave payment errors due to billing, DRG/coding and/or admission necessity issues) identified by CMS.Hospitals can use PEPPER to review their data forthe current quarters and the previous three fiscal yearsfor each of these target areas while comparing theirdata to that of other hospitals. They can also use PEP-PER to:

· Compare data across years to identify signifi-cant changes in billing practices

· Pinpoint areas in need of auditing· Identify potential DRG under- or over-cod-

ing problems· Identify target areas where length-of-stay is

increasing

In Mississippi, PEPPER is provided to hospi-tals at no cost by IQH.

“PEPPER can provide hospitals with bench-marks on where they stand on compliance and auditrisk, and these presentations will help in these riskreduction efforts,” said Stephanie Champion, IQH Re-view Department manager. “We encourage hospitalsin Mississippi to participate.”

About PEPPER

Page 6 Quality Matters

Long-Term, Acute-Care Hospitals:Learn How To Reduce MedicarePayment Errors With PEPPER

PEPPER Webinars: Tuesday, Feb. 6, 1 p.m.

Advanced training: March 6

Hospital Best Practices:Preventing Payment Errors,

Reducing Audit Risk with PEPPER

Webinar series begins Wednesday, Feb. 7, 1p.m.

Review Physicians Needed at IQH Physicians are needed to help with the reviewprocess at IQH, according to Dr. Ralph Dunn, Re-view medical director. Questions arise from some charts that need prac-ticing physicians in a particular specialty to reviewthem. “We have a need for more review physicians inorder to keep from overburdening the physicians cur-rently working with IQH,” said Dr. Dunn. “We ap-preciate all the physicians who are working with us.” For details, contact Dr. Dunn at 1-800-844-0500ext. 252 or Stephanie Champion, RN, ext. 233.

IQH Remembers Dear Friends: Dr. Jimmy Waites of Laurel Dr. Mal Morgan of Natchez

Dr. Millard Costello of CarrolltonDr. Gilbert Mason of Biloxi

The IQH staff fondly remembers these physicians who died this past year. They have worked withthe organization in its quality improvement efforts over the years and have been pivotal in health care inthe state. Their contributions included such efforts as supporting programs, giving testimonials, andposing for special project brochures. Sympathy is extended to the families and friends of these physi-cians along with the message that their contributions will be long remembered.

Registrations are still being accepted for the Sat-urday, Jan. 27, cardiovascular health and diabetes sym-posium. To be held at the Hilton Convention Centerin Jackson, the symposium is sponsored primarily bythe Mississippi Department of Health and IQH. The registration fee is $75. Application has been submitted to the Missis-sippi Department of Health as an approved providerof continuing education in nursing by the MississippiNurses Foundation, which is accredited as an approverof continuing education in nursing by the AmericanNurses Credentialing Center Commission on Accredi-tation. Anyone with questions about other credit hoursmay call Lynn Mitchell at 601-957-1575 ext. 201.

Agenda7:00 Breakfast and Registration8:00 Cardiovascular Risk Factors in the Diabetes

Patient: Assessment, Early Diagnosis,Treatment--Rodrigo Valderrama, MD

9:00 Metabolic Syndrome - Annette Low, MD10:15 Cardiovascular/Diabetes Disease in Women:

Under-Diagnosed, Under-Treated,Misunderstood - Myrna Alexander, MD

11:15 Cardiovascular/Diabetes Diseases in MentalHealth Patients - to be announced

12:15 Lunch Speaker Cultural Competency - JaneKelly, MD

1:15 Pharmacy Update for Patients with CVD andDiabetes - James Pitcock, PhD

2:30 Break-Out Sessions: Bariatric Surgery, AlternativeTreatment - Adam Dungey, RN;Glucose Monitoring during Surgery -tba;Total Patient Care - Judy Tepper, RN, BS, CDE;Wound Care - Cindy Neal, FNP, CWS

Sponsors include the Mississippi Departmentof Health Cardiovascular Health Program and Diabe-tes Prevention and Control Program, IQH, the Uni-versity of Alabama School of Medicine Division ofContinuing Medical Education, American Heart As-sociation, Jackson Heart Study, Mississippi Academyof Family Physicians, University Medical Center-Dia-betes and Metabolism Center.

Cardiovascular/DiabetesEvent Is Jan. 27

PVRP Changes UnderwayThe Physician Voluntary Reporting Project

(PVRP) that began in January 2006 is continuing, butthe form and manner of reporting for 2007 has not yetbeen determined by CMS.

CMS is planning to expand the PVRP coremeasure set from 16 to more than twice that number,covering nearly all of the 39 physician Medicare Phy-sician Fee Schedule specialties. The ultimate goal isfor the PVRP measure set to include measures thatare applicable to all physician specialties and practi-tioners listed in the Medicare Physician Fee Schedule.The new measures and specifications will be added tothe PVRP 16 Core Starter Set and posted on the CMSWeb site and on the QMIS Web site.

CMS has actively promoted the use of physi-cian quality measurement that is focused on primarycare physicians in the office setting. PVRP enablesphysicians to report clinical quality data through theexisting Medicare claims process and via DOQ-IT,using the QIO Clinical Data Warehouse. CMS con-siders it essential to extend quality measurement be-yond primary care in order to improve effectivenessof care, efficiency, and beneficiary quality of services.

For more information or to sign up to partici-pate in the voluntary reporting project, contact TrannieMurphy at 601-957-1575 or 1-800-844-0500 ext.222.

Page 7Quality Matters

Page 8 Quality Matters

As Dr. Charles Guess returns to clinical practice,after many years of dedicated service at IQH, I amhonored to have the opportunity to step into the roleof clinical coordinator. I graduated from college inColorado and returned to Denver for internship/residency training, following graduation from medicalschool in Chicago, but I am a Mississippi native.

When I am asked why I decided to return homeafter all these years, I tell them that I was blown in byHurricane Katrina. When I was unable to contact myfamily in Scott County after the storm and having onlyCNN as a source of information, I quickly plannedmy mission. I packed clothes, tools, medical andcamping equipment and then with a supply of food,water, and gasoline in the back of my Subaru, I headedsouth. Once I located friends and family and attendedto them, I turned my attention to the coast. Afterwitnessing the destruction in Jackson and areasnortheast, I could only imagine how much worseconditions were further south. It was a challenge tovolunteer through established channels, but I wasdetermined to enlist my services in the disaster zone.

I volunteered as a physician at the Harrison CountyEOC in Gulfport for the first 10 days, then returnedon two more occasions to care for patients throughthe volunteer organizations, Remote Area Medical andthe International Medical Alliance. During this period,I was asked to participate in the KatrinaHealth.orgproject and their Lessons Learned meeting inWashington, DC, to share my perspective on theusefulness of Internet access to medication history forevacuees as provided by the KatrinaHealth.org Website. Of course, my colleagues and I were caring forpatients in the coastal areas of greatest impact, whereutilities and computers were limited. This realityemphasized the need for further disaster planning.Shortly after this meeting, I was appointed by GovernorHaley Barbour to the SGA Health InformationTechnology Gulf Coast Task Force, as was Dr. JamesMcIlwain, our IQH, president. IQH had coordinated

the credentialing of volunteer physicians, so he and Ihad spoken several times. When the SGA task forceconvened, I had the privilege of meeting him in person.In the course of our work for the SGA, he asked me ifI would consider a position at IQH. When he describedto me the IQH mission, I just smiled, and told him Iwould have to think about his offer. On the inside, Iwas doing back flips!

As a physician, I am passionate about any issuethat affects the quality of patient care and have alwaystaken my role as patient advocate very seriously. Myexperience as a Katrina volunteer physician, however,opened my eyes to the need for a broader platform ofpatient advocacy, beyond the exam room. With theinitiatives to establish interoperable electronic medicalrecord systems and the need for refining our nation’sdisaster response, I no longer believed that I couldmake a positive difference from an individual position.Knowing first hand the public impact of a disaster, Irealized that physicians needed to be involved in morethan direct patient care. I personally felt compelled toaccept the opportunities to work with theKatrinaHealth.Org project, the SGA HIT Task Force,and more so, to join IQH. After some consideration,I proudly accepted Dr. McIlwain’s offer and joinedthe IQH staff.

It’s an honor to share this platform with such adistinguished team of individuals whose commitmentand compassion to quality improvement mirrors myown. So, WELCOME 2007! Let’s roll up oursleeves, and move forward.

By Dr. Sue DillonIQH Clinical Coordinator

New Clinical Coordinator: Blown in by Hurricane Katrina

2007 Home Health Quality Improvement

National Campaign

Who: The Centers for Medicare & Medicaid Services (CMS), in conjunction

with the Home Health Quality Improvement Organization Support Center(HHQIOSC), has launched a national home health quality improvement cam-paign targeting home health agencies and other key stakeholders.

What: The Campaign seeks to unite the home care community under the

shared vision of reducing avoidable hospitalizations to improve patient qualityof care. This will be accomplished through the distribution of tools and re-sources, guidelines, information and best practice education. Agency recruit-ment will occur locally through state and national home health associations andQuality Improvement Organizations (QIOs), which will combine to serve asLocal Area Networks for Excellence (LANEs).

When: Campaign registration began Jan. 11, 2007, and is ongoing. The

campaign will provide home care agencies with a monthly intervention packetthat includes educational tools and resources, information sharing, best-practice education and individual agency reports to assist with reducing avoid-able hospitalizations.

Where: The Campaign Web site (www.homehealthquality.org) allows

agencies to register and receive monthly intervention packets. Interestedagencies can contact IQH for more information.

Why: Patients desire and prefer to stay at home whenever possible. Being

hospitalized can unnecessarily create financial and emotional burdens forpatients and their families and can negatively impact the health care deliverysystem. Currently more than one in four home health patient episodes willresult in a hospitalization. This campaign addresses avoidable hospitalizations,seeking to reduce them nationally.

For more information, call Information & Quality Healthcare (IQH),Mississippi’s Quality Improvement Organization (QIO),

Sonja Tolbert, RHIA, or Dianne Greenlee, RN, BSNHome Health Project Leaders

1-601-957-1575 1-800-844-0500 , ext. 250 or 260stolbert@msqio.sdps.org dgreenlee@msqio.sdps.org

Page 9Quality Matters

Premier and Participating Statusfor Home Health Agencies

The 2007 Home Health Quality Im-provement national campaign that beginsthis month featured a kickoff event in Bal-timore Jan. 11. Sonja Tolbert, IQH projectleader for home health, was present forthe kickoff. Representatives from severalstate home health agencies also attendedthe event.

Premier status in the campaign wasgranted by registering atwww.homehealthquality.org from noonJan. 11, 2007, through midnight Jan. 12,2007. A special logo goes to those agen-cies that registered in the designatedtimeframe of Jan. 11-12. The designationdemonstrates the commitment to qualityimprovement from the onset of the cam-paign.

Participating status will be grantedto any agencies signing up after midnightJan. 12, 2007. These agencies will be senta participating home health logo.

www.homehealthquality.org

Agency recruitment in the national homehealth qualityimprovement campaign will be achieved through homehealth associations and Quality Improvement Organiza-tions (QIOs), such as IQH in Mississippi, which will serveas Local Area Networks for Excellence (LANEs).

Quality Matters

Ten Reasons for Home HealthAgencies to Participate in theHHQI National Campaign The number one reason for participa-tion in the Home Health Quality Improve-ment National Campaign is because pa-tients and families will benefit throughimproved quality of care. Continuing with the nine other specialreasons for participation:2. To receive true national and statewideACH rankings based on CMS data.3. To work collaboratively with state andnational home health stakeholders to re-duce hospitalizations.4. To receive ACH data broken downmonthly (in contrast to the rolling 12-month OBQI data).5. To receive multi-disciplinary continuingeducation contact hours.6. To use as a marketing tool: “We par-ticipate in the HHQI National Campaign.”7. To receive hospitalization data morerecent than CMS tally reports.8. To identify the role of administrationand management relating to best practiceinterventions.9.To enhance best practices from otheragencies’ success stories.10. To improve or sustain their ACH rate.

Page 10

Shown at a nursing home project workshop held in Lucedale are, from left, motivational speaker StevenMaxwell, and from IQH, Pamela Luckett, Pat Broadrick, Jane Kelly, Barbara Tapps and Kirby McGahagin.

The Advancing Excellence in America’s NursingHomes campaign is approximately 100 days old andalready has grown to 1200 participating homes, as ofmid-January. Currently the national partners and LocalArea Networks for Excellence (LANES) are in a veryactive recruitment phase and are setting recruiting goalsfor the year. On September 29, 2006, national leaders from theAmerican Health Care Association, the AmericanAssociation of Homes and Services for the Aging, theAlliance for Quality Nursing Home Care, the Centersfor Medicare & Medicaid Services, the AmericanMedical Directors Association, the National Citizens’Coalition for Nursing Home Reform, and many othersstood side-by-side to launch the AdvancingExcellence in America’s Nursing Homes campaign.The national partners shared one message in launchingthis campaign, that everyone has a role and aresponsibility when it comes to improving quality longterm care.

By joining IQH, nursing home providers, caregivers,government agencies, and consumers already part ofthe broad-based coalition leading the voluntary, two-year Advancing Excellence campaign, Mississippi

nursing homes are helping to promote improved qual-ity of care and quality of life for residents and staff inAmerica’s nursing homes. Detailed information is available at nhqualitycampaign.org. Providers and consumers alike will findspecific information; follow the left navigation bar—click “For Nursing Homes” to learn more. Being a part of the campaign is a way to earn morerecognition for ongoing QI work without any addi-tional burden on staff. Advancing Excellence inAmerica’s Nursing Homes measures quality effortsmost facilities are already working on, looking at someof the same clinical quality improvement goals, whileadding concrete measures and new organizational im-provement goals aimed at improving customer satis-faction and staffing retention. The campaign brings existing efforts together alongwith consumer support, new resources, and more waysto help foster continuing quality improvement for bothresidents and staff. One of the added benefits to join-ing the campaign is that commitments will be publiclyacknowledged when a nursing home facility is addedto the campaign Web site as a participating provider,a feature searchable by state.

Advancing Excellence in America’s Nursing Homes

Quality Matters Page 11

(See page 12)

While participation in the campaign may not changethe current focus and efforts of a facility already com-mitted to quality improvement work with IQH, joiningthe campaign may strengthen it. Facilities are remindedthat joining the campaign is not automatic and that sign-ing up is necessary.

The Advancing Excellence in America’s NursingHomes campaign is fully supported by the Centersfor Medicare & Medicaid Services (CMS). CMS isencouraging nursing homes to enroll in the campaign.It is important to remember, however, that CMS willnot have access to the campaign data or individualprovider data information, except what is already avail-able on Nursing Home Compare.

“Signing up for the campaign is easy and requirescompleting three simple steps,” commented PatBroadrick, IQH nursing home project coordinator.“Start by visiting www.nhqualitycampaign.org.Then commit to working on three or more of theeight campaign goals, including at least one clinicalquality goal (pressure ulcers, restraints, long-stay orshort-stay pain) and one organizational improvementgoal (target setting, staff retention, measuring residentsatisfaction or consistent assignment).” Detailed explanations of each goal and how it ismeasured are available. Facilities can join the campaign by filling out theprovider registration form. The facility’s 6-digit Medi-care/Medicaid provider number should be readilyavailable, with three or more goals selected to qualifyas a Participating Provider. Data collection and re-porting for the clinical quality goals(Goals 1-4) are automatic; however, additionalsteps are required to collect data on the organiza-tional improvement goals (Goals 5-8). Work can be begun on selected campaign goalsby using campaign tools and resources available byclicking on the “For Nursing Homes” tab on the leftnavigation bar, then clicking “Technical Assistance.”Also, the facility should connect with the Local AreaNetwork for Excellence (LANE) to find other localand regional community members committed to

improving the quality of care and quality of life for resi-dents and staff in America’s nursing homes. Contact Pat at 601-957-1575 ext. 249, for moreinformation.Using Advancing Excellence Campaign

to Prepare for P4PThe P4P implementation can be prepared for

by providers through the national Advancing Excellencein America’s Nursing Homes campaign.

The Advancing Excellence campaign ispurposefully designed around quality measures andgoals that are in effect a continuation of Quality First,an initiative developed by AHCA, the Alliance for LongTerm Care, the American Association of Homes andServices for the Aging, and the CMS Nursing HomeQuality Initiative. The Advancing Excellence goals arederived from or correspond to the measuresdeveloped for previous campaigns. The measures chosen by CMS for its nursingfacility P4P demonstration are strikingly similar to theAdvancing Excellence goals. The measures have beendesigned to encompass quality of care, appropriatehospitalizations, resident outcomes, and surveydeficiencies. Also, in its recent analysis of the CMS nursingfacility P4P demonstration, Abt Associatesrecommends the use of quality measures from NursingHome Compare for the demonstration. Some health care policy experts have seen thevalue of utilizing established measures to support P4Pprograms. From Harvard University professorMeredith Rosenthal, speaking at a gathering of stateMedicaid directors, came the suggestion that sinceMedicaid data from nursing facilities “is substantial,and increasingly there are good data from CMS andother places, (it may be useful) to track theperformance of nursing homes on quality of care anduse that information for P4P.” P4P has been widely suggested as a key strategy inany effort to make this change.(For detailed thoughts on preparation for P4P, see the January

2007 issue of “Provider,” Vol. 33, No. 1.)

Page 12 Quality Matters

Advancing Excellence in America’s Nursing Homes(Continued from page 11)

Page 13

What is the Hospital Survey on Patient SafetyCulture? The patient safety culture survey by the Agencyfor Healthcare Research and Quality (AHRQ) is a toolhospitals use to assess their safety culture as a wholeor for specific units. Hospitals also use this survey totrack changes in patient safety over time and to evalu-ate the impact of patient safety interventions. The Hot Springs County Memorial Hospital in Wyo-ming received an 88 percent response rate on its sur-vey. Hot Springs Quality Improvement CoordinatorBelenda Willson, who helped implement the AHRQsurvey tool, shared secrets on how it was successfullyutilized.

Sharyn Sanderson, IQH project leader forSIOC, ROSC, and Critical Access Hospitalsprojects, reports that an article in Mountain-Pacific Quality Health’s ‘Quality Review’newsletter shares excellent tips for success toincrease the response rate on the part ofhospital employees completing surveys. With permission granted from Mountain-Pacific Quality Health, Sharyn suggestedsharing these ideas with IQH “Quality Mat-ters” readers.

She first enlisted CEO support to engage hospi-tal leadership, with survey information then presentedto senior leadership. Hospital leaders also attended apresentation by Mountain-Pacific, which described theAHRQ tool and identified strategies to maximize itseffectiveness to achieve a high response rate. Thenvolunteers met to share ideas on how to conduct thesurvey. Staff revealed the survey team’s plan duringanother meeting with the CEO and senior leadership,and the survey was implemented with full support atthat level. Via e-mail and payroll, the CEO and quality im-provement coordinator sent employees a letter de-scribing the survey. During the staff meeting, depart-ment managers distributed the survey and return en-velopes. At that time employees also received a cou-pon, which was redeemable for a gift when they re-turned the survey. Lessons learned: Provide education/informa-

tion about the purpose and importance of the survey,sharing through numerous methods such as employeebulletin boards, e-mail, and paycheck inserts. Ensure confidentiality for honest results. Confi-dentiality was a high priority in planning the survey.Particularly in small hospitals, this aspect reassuresemployees that identities are not disclosed, thus pro-moting honest answers. Use a team approach to survey implementation,recruiting assistance form other departments such ashuman resources, technology, and marketing. Be creative to maximize response. Piggybackthe surveys with other events such as National Hospi-tal Week or employee health fairs. Provide incentives, being aware that people aremore apt to respond when they know “what’s in it forthem,” no matter how small the incentive. Some de-partment managers used candy bars to encourage aresponse. Make the process simple. Surveys were given todepartment managers with instructions, blank enve-lopes and redeemable coupons. Follow up on surveys that haven’t been returned.Let people know their response matters and will beused to improve patient safety. Maximize your budget. Take advantage of plannedhospital events, save on postage costs by includinginformation in employee paychecks.

Tips for Success in Evaluating Patient Safety CultureQuality Matters

www.medicare.gov Nursing Home Compare Home Health Compare

Hospital Compare

1-800-MEDICARE(1-800-633-4227)

Tobacco Quitline1-800-784-8669

www.iqh.org