MBQIP Flex Patient Safety Flex Calendar

QUALITY IMPROVEMENT MATTERS VOL. 1, ISSUE 1 JANUARY 2016

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WELCOME Back To The Wyoming Flex Newsletter! The Wyoming Flex team is pleased to provide you

with Quality Improvement Matters - the monthly newsletter with information and updates on CAH quality

improvement programs, resources, tools, and training opportunities.

VOL. 1, ISSUE 1 JANUARY 2016 VOL. 1, ISSUE 1 JANUARY 2016

QUALITY IMPROVEMENT MATTERS VOL. 1, ISSUE 1 JANUARY 2016 VOL. 1, ISSUE 1 JANUARY 2016 VOL. 1, ISSUE 1 JANUARY 2016 VOL. 1, ISSUE 1 JANUARY 2016 VOL. 1, ISSUE 1 JANUARY 2016 VOL. 1, ISSUE 19 DECEMBER 2017 PAGE 1

Medicare Beneficiary Quality Improvement Program (MBQIP)

MBQIP—Removal of Outpatient Measures: CMS has announced that four of the Outpatient Measures that are currently required for MBQIP will be removed following Q1 2018 data submissions: OP-1: Median Time to Fibrinolysis OP-4: Aspirin at Arrival OP-20: Door to Diagnosis Evaluation by a Qualified Medical Professional OP-21: Median Time to Pain Management for Long Bone Fracture

Submission of these measures will be included in the evaluation of CAH participation in MBQIP for FY 2018, but will be removed from MBQIP evaluation criteria and MBQIP reports starting with Q2 2018 discharges (encounters as of April 1, 2018). CAHs should continue to collect and report these measures through Q1 2018 encounters (due 8/1/2018). Starting with Q2 2018 encounters, the measures do not need to be collected, and QualityNet will no longer be accepting submission of data for these measures.

Background: As part of the annual rule-making process, CMS regularly removes measures from the Inpatient and Outpatient Quality Reporting programs (IQR, OQR). Once CMS has removed a measure from the IQR or OQR program, it is no longer possible to submit data for this measure to the CMS QualityNet Warehouse. When feasible, FORHP works to align MBQIP measures with other Federal reporting programs. Thus, removal of measures from the IQR or OQR programs typically results in removal of those measures from MBQIP.

Updated! Several MBQIP resources have been updated to reflect recent updates to MBQIP measures: MBQIP Data Submission Deadlines Chart. Single page document contains a chart showing the MBQIP

data submission deadlines. MBQIP Measures Fact Sheets. Provides an overview of the data collection and reporting processes for

the MBQIP measures in a basic, one-measure-per-page overview. MBQIP Quality Reporting Guide. Intended to help critical access hospital staff and others involved with

MBQIP understand the measure reporting process. For each reporting channel, information is included on how to register for the site, which measures are reported to the site and how to submit those measures to the site.

For More MBQIP Information and Resources go to www.wyqim.com.

For questions please contact Rochelle Spinarski at rspinarski@rhsnow.com or Shanelle Van Dyke at Shanelle.VanDyke@QualityReportingServices.com.

QUALITY IMPROVEMENT MATTERS VOL. 1, ISSUE 19 DECEMBER 2017

Brought To You By:

Kyle Cameron—Wyoming Flex-Office of Rural Health 1.307.777.8902 Kyle.Cameron@wyo.gov

Shanelle Van Dyke—Quality Reporting Services 1.406.459.8420 Shanelle.VanDyke@QualityReportingServices.com

Rochelle Spinarski—Rural Health Solutions 1.651.731.5211 Rspinarski@rhsnow.com

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This project is/was supported by the Health Resources and Service Administration (HRSA) of the U.S. Department of Health and Human

Services (HHS) under grant number H54RH00043-19-00 Medicare Rural Hospital Flexibility (Flex) Program, 464,345.00, 0% finance wi th

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 to be inferred by HRSA, HHS, or the U.S. Government.

Flex Program Calendar

Educational Webinars—2018. Below is a list of upcoming events related to education and/or training for

the Wyoming Flex Program Activities.

Discharge Planning Huddle: January 3rd @ 11:00—11:30 am

QI Roundtable: January 11th @ 10:00 am—11:00 am

CAH CFO Financial Benchmarking: January 16th @ 1:00 pm—2:00 pm

Medicare Rural Hospital Flexibility Program (Flex)

Wyoming Flex—Update: 2017 Reflections from Kyle Cameron. Welcome 2018. With the beginning of a new year we look back over past years, visualize the future, and begin setting new personal and professional goals. Traveling around Wyoming and visiting Wyoming's unique and wonderful critical access hospitals is the best part of my job. My favorite experiences are the hospital tours I receive and learning more about the passions we share in improving quality of healthcare in

Wyoming's communities. My concerns for the financial viability and sustainability of our small rural hospitals within our vibrant small communities are shared by many. Medicare Rural Hospital Flexibility (Flex) Program quality and financial improvement projects, population health and emergency medical services will continue into 2019 and I look forward to partnering with you to make this state one of the best places for healthcare.

Patient Safety Culture (PSC)

PSC Tip of the Month — In any health care organization, leadership’s first priority is to be accountable for effective care while protecting the safety of patients, employees, and visitors. Competent and thoughtful leaders contribute to improvements in safety and organizational culture. They understand that systemic flaws exist and each step in a care process has the potential for failure simply because humans make mistakes. In essence, a leader who is committed to prioritizing and making patient safety visible through every

day actions is a critical part of creating a true culture of safety. Leaders must commit to creating and maintaining a culture of safety. Maintaining a safety culture requires leaders to consistently and visibly support and promote everyday safety measures. Culture is a product of what is done on a consistent daily basis. Hospital team members measure an organization’s commitment to culture by what leaders do, rather than what they say should be done. —The Joint Commission https://www.jointcommission.org/