March 3, 2004
1:00 p.m. CST

Coordinator

Good afternoon and thank you for standing by. At this time all participants are in a listen-only mode. After the presentation we will conduct a question and answer session. Today's conference is being recorded, if you have any objections you may disconnect at this time.

I would like to introduce you to your conference host, Mr. Tom Morris, Office of Rural Health Policy. Sir, you may begin.

T. Morris

Thank you. Let me first express my regrets at the phone number screw up. Thanks to everybody who persevered and got through. I want to welcome you to the National Technical Assistance teleconference on implementing the Quality Assessment and Performance Improvement programs in Rural Health Clinics. My name is Tom Morris; I'm the acting deputy in the Office of Rural Policy. For this presentation I'm joined by other staff from our office as well as Bill Finerfrock of the National Association of Rural Health Clinics and staff from the centers for Medicare and Medicaid services and we will introduce them in just a minute. I also want to acknowledge the work of Craig Williamson and Heather Demeriss in setting up this call and the subsequent calls we'll be having over the next two months.

As most of you are aware, CMS published a final rule December 24th in the Federal Register that outlined the guidelines for implementing the new Quality Assessment Performance Improvement program, or QAPI as it has been called. The purpose of this call is to begin the process of providing some technical assistance in understanding and implementing these kind of programs for the new guidelines. This will be the first of three monthly calls.

In today's call you are going to hear from Mary Collins of the CNS Office of Clinical Standards and Quality. She'll provide an overview of the new reg and will offer a draft framework for Quality Assessment Performance Improvement. She'll be followed by Jackie Kosh-Suber, also with CNS, who works in the Center for Medicaid and State Operations and she'll go over some of the survey and certification review issues involved with this regulation. Finally, we'll hear from Dr. Forrest Calico of our office and Bill Finerfrock with the National Association of Rural Health Clinics and they're going to create kind of a conceptual base for you to consider as you think about what you're going to do to comply with these new regulations. After each of these sessions in this call we'll have some time, about 10 minutes each, for question and answer and then we've also built in some time at the end of the call for additional question and answer, in case there's more on that.

Let me also note today what the call is not going to be focused on. We really want to keep the focus just on the Quality Assessment and Performance Improvement program. Given that, we really don't want to take any time talking about things like RHC payment issues or other RHC regulatory issues that are beyond the scope of the new QAPI requirements or any of the politics involved in getting the rules passed. We also caution callers from using the Q&A time to tell us what they're doing or asking CMS whether what they're doing might meet the new requirements; ultimately, that's the job of the surveyors in field. What we're hoping today to do is just to set up more of a dialogue on quality that will help you then go back and think about how you want to comply with the new requirements.

Anyway, we'll also be posting some materials on the Web in the next probably six weeks; we have to get them through clearance, so please check back with us as time goes on. We promise also to have the right and correct phone number for the next call so there will be no confusion with that. So without any further ado, let me turn it over to Mary Collins and Scott Cooper from CMS.

M. Collins

Thanks Tom. I also want to welcome everyone on the call. I hope that this and the subsequent calls prove to be helpful to you. I just want to start today by giving a little bit of the background and rationale for the development of the QAPI requirement for Rural Health Clinics. In 1997 Congress mandated that Rural Health Clinics have a Quality Assessment and Performance Improvement program. The requirements were effective January 1, 1998 but it was decided at that time that we, CMS, could not enforce the requirements without going through notice and comment periods. Since that time, however, we have encouraged Rural Health Clinics to begin looking at its operation and to think about how they can restructure its current annual evaluation process to incorporate an outcomes approach to improving care and patient satisfaction.

In developing these QAPI standards the goal for us at CMS was to develop a standard that was both flexible and effective. Flexible enough so that all Rural Health Clinics, regardless of their size and resources, could comply with the requirement and yet have the requirements that are effective in achieving desired results under the QAPI format. We believe that we achieved our goal in the final regulation for the QAPI program.

The requirements for the Quality Assessment and Performance Improvement program, which we refer to as QAPI, is as follows: the Rural Health Clinics must develop, implement, evaluate and maintain an effective, ongoing, data-driven Quality Assessment and Performance Improvement program. The self-assessment and Performance Improvement program must be appropriate for the complexity of its Rural Health Organization and services and focus on maximizing outcomes of care by improving patient satisfaction and quality of care.

There are three standards to the QAPI requirement. The components of the program is the first standard, we have program activities and also program responsibilities. Under the components of the QAPI program we face that the Rural Health Clinics QAPI program must include, at a minimum, the use of objective measures to evaluate its organizational processes, functions and services. It must include a utilization of clinic services, including at least the number of patients served and the volume of services.

Under the second standard, program activities, the clinic must have performance measures that reflect processes of care and RHC operations that are shown to be predictive of desired patient outcomes or be the outcomes themselves. Clinics must use those measures to analyze and track their performance. They should set priorities for performance improvement based on high-volume, high-risk services or the care of acute and chronic conditions, patient safety, coordination of care, convenience and timeliness of available services or grievances and complaints.

We state that clinics must conduct distinct improvement projects. The number and frequency, however, of those improvement projects conducted must reflect the scope and complexity of the clinic's service and available resources. The clinic must maintain records on its program and Quality Improvement projects. A clinic may also undertake a program to develop and implement an information technology system explicitly designed to improve patient safety and quality of care.

The third standard program responsibilities, the professional staff, administrative official or governing body are responsible for ensuring that the QAPI efforts effectively address the identified priorities that I mentioned under program activities. The governing body is also responsible for identifying or approving those priorities and for the development implementation and evaluation of improvement actions.

These standards, we believe, give Rural Health Clinics the ability to develop an effective program that will focus on maximizing outcomes by improving safety, quality of care and patient satisfaction. This new standard will change the focus in performing the evaluations; instead of focusing on process, clinics will now focus in improving outcomes in patient satisfaction. Rather than making remedial changes, the QAPI requirement requires clinics to continuously improve the quality of care they provide. The new QAPI requirement will replace the current annual program evaluation requirement. Resources that are currently used to comply with the existing annual program evaluation can be used to meet the new QAPI requirements.

So with that, I will stop and at this time have my colleague, Scott Cooper, discuss the diagram or flowchart, if you will, for QAPI activities. We will take questions after Scott.

S. Cooper

Thank you, Mary. Good afternoon, everyone. I'm going to just quickly go through the suggested diagram of the QAPI activity that was posted on the HRSA Web site, so hopefully everybody has that in front of them. This is the diagram that Mary developed; it's a suggestion, it's intended not to be prescriptive and to follow this, it's more a suggestion of the flow of how the development and implementation of how a QAPI program would go.

Starting off with, the first thing is identifying any of the areas where, we've got high-volume service identified but it also could be high-risk patients, care of chronic acute conditions, coordination of care, etc. that are listed in the regulation. From that, then narrowing down and prioritizing with regard to certain areas, with that actually there could be some overlap and multiple areas to explore. In the case we've got diabetic patients, if that's a high volume it may also open up to looking at coordination of care as well as it would certainly fall under care of chronic conditions.

Once the priority is set, then looking at whether current clinical guidelines or recommendations or protocols are being followed, if the care that's being done at the particular clinic is consistent with those guidelines. Of course, those guidelines are available through various outside sources.

Looking at those with regards to diabetic patients, we've got the example of screening for nephropathy, retinopathy, foot ulcers and also checking hemoglobin A1c as indicated by the current guidelines. Once that is identified then randomly pulling the charts and looking at those patients who are diabetic patients, going from there and then looking at what the objective data is, measuring that whether these guidelines, what percentages, as we've got it broken out, are being followed. From there it's the point of where once the problem area or area for improvement has been identified the intervention that's going to address this area. We've noted there that this also can be designed by the clinic or there are outside sources that can be used to aid with this.

Then once the intervention has been put in place and the improvement project is underway it is periodically checking the effectiveness of the intervention and whether that's only we've got on a quarterly basis, but you know it really is open, and then measuring that. This is really designed to be an ongoing process, I think it will, it will open up other areas. I'm going to end with that because I think we really wanted it to be more a suggestion as opposed to say, "If you do this, do this," it's not particularly an ABC approach. But I'll end with that, and turn it back to Tom.

T. Morris

Thanks, Scott. Operator, we'll go ahead and take about 10 minutes of question and answer right now before moving on to the next session.

Coordinator

Okay, thank you. Once moment, sir. Judy Knudson, you may ask your question.

J. Knudson

I'm having trouble finding the slides on the Web, is there a better address than the one I've got?

C. Williamson

The Web site is www.ruralhealth.hrsa.gov, just type that into the browser.

J. Knudson

When I went for the slides they told me the Web site wasn't accessible.

C. Williamson

There may be some problem with your computer. If you access the home page, for those of you out there, click on the top left part, there's something that says "technical assistance for Rural Health quality improvement." Click on that and then down at the bottom of the next document there are two documents, one is an HTML file and one is a .PDF file. If you click on the hyperlink next to either of those it should open up both the diagram that was discussed previously as well as the slides.

T. Morris

Did you put www before you typed in ruralhealth/hrsa?

J. Knudson

I've got the HRSA homepage, I just can't get to the slides.

C. Williamson

We may just be having some problems with a lot of people trying to download at the same time. We'd be happy to follow-up with you afterwards if you want to dial and ask for Craig. Dial the main number at our office, which is 301-443-0835 and if it comes down to it, we'll fax it to you.

J. Knudson

That's great. Thanks so much.

Coordinator

Connie Massie, you may ask a question.

C. Massie

Yes, I was actually wanting to know if you could give me some suggestions for some of the outside sources for some of the guidelines? I'm just kind of awash because I'm trying to work with a multitude of providers. Is there any one standard or several standards that I could use to get some protocols and guidelines?

M. Collins

I think, and I'm not sure, that we will cover that issue as we move along in the presentation. If not, we can certainly have those posted on HRSA's Web site, additional resources and guidelines. The primary source would be at HRSA on their Web site and there are other additional excellent sources.

C. Massie

So as far as protocol for diabetic care, whatever?

C. Williamson

Right now we're sort of doing a summary of literature and looking at research articles and also other Web sites out there that are covering a lot of these issues. There are several organizations out there like the Institute for Chronic Care Improvement, the American Academy of Family Physicians listed a number of these, the Institute for Health Improvement. So there are a lot of other outside sources that do give various types of chronic care management guidelines and other ideas for physician office practice improvement. Right now here at HRSA we're working on compiling those into a list and getting them through clearance and those should be posted, hopefully sometime within the next six weeks.

C. Massie

The difficulty I'm having is that we get different guidelines from different insurance companies, depending on largely what they want to pay for and it gets to be very confusing.

C. Williamson

I don't think that CMS folks or the surveyors are necessarily going to be looking at whose guidelines you're using. I think if you adopt reasonable guidelines that come from a reputable source, even though one guideline may suggest one avenue to pursue and another guideline may do another, as long as those are from reputable sources that you can cite as to where you drew it from, I think that would be sufficient to meet the requirements.

C. Massie

Okay, thank you.

C. Williamson

We'll also be, I think in subsequent calls, we're going to have some examples and folks talking about some projects, ideas, things that you can look at or consider for implementation within your facilities.

C. Massie

Thank you.

Coordinator

Tracy-Jill Jones, you may ask your question.

T. Jones

Yes, can you hear me now?

Coordinator

Yes, we can hear you.

T. Jones

I'm having a hard time finding the flowchart and wanted help with that. Also, the flag, because we are in a very small rural health clinic, we have a staff of three and we are doing a queue out program now and then later I'm sure you will answer if what I am doing is sufficient. But I was very interested in finding that flowchart because that would greatly help me.

T. Morris

Ma'am, I think what we're having is a lot of people logging on at the same time and sometimes the connection could be tough. If you would follow up with Craig Williamson of our staff, we'll make sure we get you a copy, even if we have to fax it to you. He's also in the process with Heather Demeriss of our staff of interviewing a lot of different Rural Health Clinic folks and they might be a good group to bounce some ideas off of based on what they've heard some of the other clinics are doing.

T. Jones

Wonderful.

T. Morris

The number you can reach both of them at is 301-443-0835.

T. Jones

Thank you.

Coordinator

Dave Jolly, you may ask your question.

D. Jolly

Yes, Rural Health Clinics and federally qualified health centers are similar and in many ways two sides of the same coin. Will these same standards apply to FQHCs as well?

M. Collins

FQHCs are currently, well prior to this regulation, have their own Quality Assessment program that we felt was sufficient and what is in this regulation only applies to Rural Health Clinics.

D. Jolly

Thank you.

Coordinator

Linda Goode, you may ask your question.

L. Goode

Can you hear me?

Coordinator

Yes, we can.

L. Goode

My question is that once we choose one of these topics for our project, what percent of the patients would be a statistically valid sample? Ten-percent? Twenty-five percent? I mean, how many records are we supposed to look at?

C. Williamson

I'll defer to the folks at CMS about this. It may be part of what Jackie is going to talk about.

L. Goode

Thank you.

Coordinator

Woody Dunn, you may ask your question.

W. Dunn

Yes, thank you. Have you already planned training or done training for the clinic staff and the surveyors to maintain consistency of enforcement?

M. Collins

That topic will be discussed by Jackie Kosh-Suber; she's next on the agenda.

W. Dunn

Thank you.

T. Morris

We have time for maybe one more question and then I'm going to go on to Jackie's presentation.

Coordinator

Pam Schlauderaff, you may ask a question.

P. Schlauderaff

Thank you. To kind of summarize what I heard you saying to begin with, we really need to have two different projects, one continues to look at utilization to make sure that we're doing what we're supposed to be doing; the second one would be a Quality Improvement project and you've given the example of doing the diabetes registry. Did I understand you correctly?

M. Collins

That's correct in terms of the components of the QAPI program that you would continue as you have been during the utilization of clinic services. In addition to that, develop measures to evaluate other areas of the organization.

P. Schlauderaff

Okay, thank you.

T. Morris

Operator, let's take one more call before we go into Jackie's presentation.

Coordinator

Wanda Tubb, you may ask your question.

W. Tubb

Hello?

Coordinator

Wanda Tubb, your line is now open.

W. Tubb

Okay, thank you. I've actually taken Wanda's end for her; she had to leave the room. We currently have three Rural Health Clinics that are associated with a hospital environment and all of those are JACO accredited, we're already doing CQI projects that relate to similar activities that you were discussing today. Is there any reason for us to reinvent the wheel?

M. Collins

We feel very strongly that if a clinic currently has a QAPI program that is addressing the components of this final rule and you are associated with a provider, we don't see a need to duplicate those efforts as long as you are following what's required here in this final rule.

W. Tubb

You don't think we'll have any differences? I mean, obviously some outcomes of disease processes are a little bit harder for us to track than others, but we do meet all of these different criteria regarding utilization type issues, customer satisfaction, issues on turnaround times and laboratories and those things as well.

M. Collins

If you're addressing the components of the QAPI program here then you should have that covered, but we can't validate that, only the surveyor could come out and see that. You can certainly take a look at the regulation, the key areas, the standards and if you're meeting those I don't see where you would need to duplicate your efforts or do anything differently.

W. Tubb

This will all be evaluated along with the total program evaluation process in the state?

M. Collins

I'm sorry?

W. Tubb

As we have a state surveyor handling our total program evaluation, this will just be a component of the evaluation, is that right?

M. Collins

That's my understanding.

W. Tubb

Okay.

M. Collins

But I would defer to Jackie in survey and certification.

T. Morris

Okay, and that's a great segue into Jackie's presentation. So we're going to close off questions at this point and then Jackie's going to talk about the QAPI review process.

J. Kosh-Suber

Hi, this is Jacqueline Kosh-Suber. Can everyone hear me?

Coordinator

Yes, we can hear you fine, thank you.

J. Kosh-Suber

Before I get started I'd like to inform everyone that the guidelines that I am going over are draft guidelines for the Rural Health Clinic surveyor. They are currently going through our CMS internal approval process but we have started providing calls to our regional offices on the survey review updates and we are planning several consecutive conference calls to cover the QAPI program. We will also be putting out a survey insert instruction that will go to the state surveyors and every two years we do have Rural Health Clinic training for our state surveyors.

In reviewing the process for the Quality Assessment and Performance Improvement efforts, this may be done by the Rural Health Clinic, the group of professional personnel that are required under the regulations at 491.9. This group of professional personnel includes one or more physicians, one or more mid-level practitioner and at least one member, not an employee of the clinic. It also will allow this performance improvement effort to be done through arrangement with other appropriate professionals.

Surveyors will take into consideration that each clinic may approach the requirement differently based on its resources and orientation to performance improvement. The surveyor will be familiar with the templates of materials available by HRSA's Office of Rural Health Policy. As soon as they get those up online we will be filtering that information to the regional and state offices. The clinic may utilize resources available from HRSA and other online resources that may be available. I advise you to let the surveyor know if you have done this so that's considered at the beginning of the survey process.

The models chosen must be one that is relevant to the Rural Health Clinic and its patient population. I think there was a question earlier as to the different models that you can choose, there is going to be a lot out there and available, but the most important thing is that it's relevant to the health clinic and the population. You don't want to be doing something elaborate on cardiac patients if your population is very young and you don't have that many cardiac patients in your population.

Surveyors will also survey information technology systems that are clearly designed to improve patient safety and quality of care. The surveyors are aware that there may not be a presence of a demonstrable benefit in the initial stages of this technology system, but will look for quality improvement goals and their achievements incorporated in the plans for these programs. They will look at the Performance Improvement program for its continuous and periodic collection and assessment of data.

If a facility has been operating for less than one year or is in the startup phase, they should have a written plan that specifies who, when and how the Performance Improvement program will be done. The QAPI program developed should be consistent with the requirements discussed by Mary Collins at 491.11. If the facility has been in operation for at least a year at the time of the initial survey and has not developed and began an ongoing implementation of its Performance Improvement program, this will be reported as a deficiency on the surveyor's survey report form. There must be evidence of distinct improvement projects conducted that reflect the scope and complexity of the clinic's services and resources.

The surveyor will review daily reports of recent Performance Improvement program projects to verify the self-assessment and Performance Improvement efforts have met the standards identified in 491.11. It should be evident that the performance measures analyze and track performance and that resources and information necessary are available to support the operation and monitoring of processes chosen. When the program identifies corrective action and it has been recommended to the clinic, the surveyor will verify that such action has been taken or that there is sufficient evidence indicating that the clinic has initiated corrective action.

Surveyors will interview the staff person or persons responsible for management of the QAPI program. During the survey he or she will be ensuring that the program addresses the priorities after they have been identified and approved for use and evaluation. The surveyor will discuss prioritizing efforts with you. For example, why did you choose what you are assessing? The current level of performance and how you came up with your selection, whether it through chart audits, patient satisfaction surveys, identified high-volume or problem prone issues. The surveyor will have a discussion with you on how the clinic policies and procedures are revised based on your QAPI program results.

During the observation, when the surveyor is out, when they are observing and doing their interview, the methodology known as Plan, Do, Check, Act, which is a quality improvement methodology that's been around for years and years by Deming or Shewhart, that will be applied to all the performance improvement efforts utilized by the clinic. What I mean by this is they'll look at your plan, they will assess how you will understand the situation, how did the clinic identify the issue, the problem, the service or opportunity for improvement. Did you have meetings where you had brainstorming with interdisciplinary groups within the clinic that had a specialty in these areas to help you understand it? They'll look at what did you do? How did the clinic implement the processes and track the performance measures. They will check how is the clinic monitoring and evaluating processes against policies and requirements and procedures and reporting these results? Your acts, what actions are taken to continually improve process performance based on objective measurements?

Finally, your question is, "How do I communicate to the surveyor that I have an ongoing systematic method for improving processes and services?" As soon as they start questioning you about your QAPI program, already be prepared to show them how you fell on your process improvement opportunity, communicate to them your clinic staff that are involved and understand the process or service well, reveal what you have identified as the cause of your poor outcome or variation, then discuss your planning, actions taken on your plan and the monitoring evaluation that has taken place. Then show them how you continually strive to improve by adopting changes and going through the cycle again. Remember, this is an ongoing process and your survey is unannounced so you should always be prepared.

I can take questions now.

T. Morris

Operator, let's open up for questions.

Coordinator

Okay, thank you. Beverly Timmons, you may ask your question.

B. Timmons

Thank you. Do you have specific recommendations for how do you suggest how to staff the clinics for personnel who can take the time to do all this administrative work? Do you have any suggestions on that?

J. Kosh-Suber

I think the way it was identified in the regulations originally, the burden of additional staff and personnel really shouldn't be more than what you have, because as I mentioned in it, you want to make sure that your staff is a part of what's going on in this whole process, you don't really want to have somebody that's really not there and not knowing what's going on and who cannot assess and understand what the problems are. You need people who are there, who are a part of the day-to-day activities that can see that we have, for example, and increased number of pneumonias and we haven't had a good method of inoculations or something. You need to have people that are actually there and are part of the processes, not add additional personnel. I don't think it's really necessary to add additional personnel to do this.

M. Collins

I just wanted to add that you only need to develop a program that your resources and staff can support. For small clinics with very limited staff and resources we expect you to have a program that would reflect that. Try something on a smaller scale.

J. Kosh-Suber

Right, we wouldn't expect you to have real complex computer programs. I mean you can put together little charts to calculate, to have charts or just flowcharts of exactly how you're tracking them, what's going on, just as long as you keep a day-to-day or month-to-month evaluation of what you're doing. It doesn't have to be complex if you're a small facility.

B. Timmons

Right, I appreciate that. I guess my concern is that all the staff here is so busy all the time in direct patient care that it's difficult to find the time to do all the data evaluation and the data gathering.

J. Kosh-Suber

I don't want to get into a specific example that everyone thinks could apply to them, but if you just have a simple little checklist that you have in each physician or mid-levels office, you know, you have a checklist to check that you have done one through five and you monitor that one through five item for all your patients for a month, then that's going to take care of it. Then you can have someone just tally up all of your numbers to make sure that you've met all your criteria or you do your percentages to see what you haven't met.

B. Timmons

Thank you very much.

Coordinator

Robin Tuggle, you may ask your question.

R. Tuggle

Yes, I have a question, we are a provider-based owned rural health clinic, we have currently entered into a relationship with Texas A&M University to study diabetes and the outcomes. Would this facilitate that part of the QAPI program? Would this put us in compliance?

J. Kosh-Suber

I can't really say if it would or not. As long as you meet all the requirements and 491.11 and you can show that when the surveyor comes out then it could potentially meet it, yes. If it's something that within that program you're cooperating with, you're taking action to show that you're continually improving, if you're getting results back from them and you're continually improving results then that's something that could potentially meet it.

R. Tuggle

Okay. Should we have more than one of these projects? Let's say from the business office side versus the clinical side?

M. Collins

You're asking how many improvement projects you can have or conduct at any given time?

R. Tuggle

Should we try to undergo more than one at a time? Do we need one from the business office side and the clinical side or can we just go with the diabetes on the clinical side? Because it does kind of flow into both areas.

M. Collins

In the regulation we're not dictating the number of improvement projects that you conduct, so it's totally up to you and the resources that you have available as to how many projects at a given time you will conduct.

R. Tuggle

Okay, so if we do this study on diabetes and the outcomes of our diabetic patients, we meet all the criteria, that should suffice for meeting actually the requirement for the QAPI?

M. Collins

The whole focus with the QAPI is a continuous process. You might do the study that you're talking about currently for two months. When you do your assessment you will go through and identify many areas where you would like to make improvements or impact patient outcome and satisfaction. We say in the regulation to prioritize, "prioritize" meaning you have so many things you want to do you can't do them all at one time, just given the resource constraints. So you can have them, number one, you're doing the diabetes and when you evaluate that and take a look at your improvement efforts you can go onto other projects; it's a continuous process.

R. Tuggle

Okay, I think you answered my question. Thank you.

M. Collins

Okay.

Coordinator

Beth Ann Perkins, you may ask your question.

B. Perkins

Yes, I would somewhat disagree with you in terms of the resources. Previous program evaluation was required on an annual basis and obviously this one is going to be ongoing. Even in the discussion here you've suggested on a quarterly basis. So if you're looking at something like diabetes and it's supposed to be ongoing and you haven't hit like 80%, which is what you want in terms of the indicators for foot care and ophthalmology consults and what have you, and that continues to go on. At what point do you allow the clinics to drop that and pick up a new area of concern for them? Or must they continue to be monitoring that until they hit a certain threshold and then at that point they've demonstrated that they've overcome that weakness in that program and they can go on?

J. Kosh-Suber

I think that at a point if you're working on something like that and you find that you're staying in your 80-percentile and you're not doing any better, of course we would like you to continue to improve. But if as you're prioritizing things and you identify that you have something new that is of higher priority then you go ahead and you start monitoring and tracking that process.

B. Perkins

But it's conceivable that you could be on this same project for the whole year.

J. Kosh-Suber

No, in other Quality improvement programs in hospitals, if you're involved in monitoring like that and after about six months you notice that it's still the same, I don't think there's really a need to continue to do it quarterly, you can do it twice a year and just work on criteria to improve. Apparently whatever criteria you have is not being effective, so you have to go back and look at the methodology again and find out what you need to do, identify what other opportunities that you have that you can improve this using a new, different criterion.

M. Collins

I agree, Jackie, in terms of that, if the intervention is not effective you need to go back and take a look at that. When I gave my answer previously the assumption was made that they had made a certain threshold of their goal and then would be able to move on to another project. But you're right, it's ongoing and if it takes a year to do a project and complete it, going back through the cycle and checking the data again to see if you've made any impact, maybe you need to develop some different interventions to address the problem. I hope that's clear and maybe we can continue to discuss this concept later in the call or on a subsequent call.

B. Perkins

Yes, I would just submit to you that I think the burden is a little greater than what you all have suggested here on the part of clinics. An ongoing process as you're suggesting, on a quarterly or more frequent or a couple of times a year compared to what the requirement has been up to now is going to be a real switch for a lot of these independent clinics.

J. Kosh-Suber

I think when Scott mentioned quarterly, that was just an idea that he threw out there; we're not trying to bind you to quarterly. If you have a program that looking at the data quarterly is not really effective then looking at it quarterly really would not be a good thing. You know there may be something that you maybe only need to look at every six months. And when we say "ongoing," also put it in it that it could be a periodic ongoing, not that every single day you have to do this, but on the first Tuesday of every month. You know that periodically you go in and you look at this to collect data to see how things are going.

B. Perkins

Will that be left up to interpretation, in terms of by the surveyor in terms of if your intervals for looking at that are appropriate?

J. Kosh-Suber

The way the surveyor is going to interpret it is that it's periodic and ongoing. If you looked at it and once you looked at what your results are and you find that you need to do put certain action into place for four or five months before you go back and evaluate again, then these are things that you write down, these are things that you communicate to the surveyor you know, "This is why we did this, we had a problem with this, once we looked at it we realized that we really needed to get out and do more with the community so therefore we didn't look at it again for six more months." As long as you can explain that, there's not going to be any problems. Just look at that cycle of Plan, Do, Check, Act. If you've done something and you've found that your criteria is not effective or you didn't pull enough data, then you go back and you check to see what was wrong and then you start it over again. No one is going to ever criticize or say that because you don't have an end result and you have not shown improvement that it's a failed program.

T. Morris

Thanks, Jackie, I think that's a great answer. I think we might all clear up a little more of this in the next session. So why don't we, Operator, move to the next session. Let me introduce Forrest Calico and Bill Finerfrock, who are going to talk about a conceptual framework for Rural Quality. We're going to start with Lawrence and turn it over to Bill.

F. Calico

Good afternoon, ladies and gentlemen. Thanks for joining us on the call. I would say first of all that my comments aren't going to be directly tied to the QAPI regulation, more these few brief comments will be kind of going on a way of thinking about clinic operations, into which, in my view the QAPI program really fits very nicely.

I would just bet that if we took a vote that pretty much everyone on the call would agree that if you thought of your Rural Health Clinic as a factory that your product is high-quality care. At least, I hope that's the way you view it and I think you do, because high-quality care is what we produce for the people that we serve. So I guess my point then from that is essentially every activity that we do in our daily work has to be tuned to create that product. So that if I'm filing lab results or if I'm pushing patients through the process of care, those aren't just ends in themselves, but they are part of our activity to assure that we are producing high-quality care.

So I believe that the whole operation of a Rural Health Clinic needs to be designed, whether we're looking at our staff and our education or management processes or whatever, are designed to that end, to produce high-quality care. We want to be the provider of first choice in our communities and to me this is the kind of way we do it, by very visibly producing high-quality care.

So it's important then, to me, to remember that quality is not a static characteristic. Each and every one of us lives in an environment of constant change and constant learning. So the only way that we can maintain high quality is by continuously examining what we do and improving it. Now I've got a very simplistic definition of quality improvement. To me it means doing my job better tomorrow than I did it yesterday because of what I'm learning today. I would just underline the word "learning" there because we all need to learn from one another, from studying and from our daily experience.

Everybody knows also that there's a huge amount of activity at the national level in quality improvement. Ever since the "To Err is Human" report came out in1999 there has been enormous interest at all levels in making quality of care better. Many different organizations are involved in that and I would submit to you that every one of us must be one of those organizations, every Rural Health Clinic in the country has to be a part of that mainstream interest. It seems to me also that sort of the guiding principle for most of the focus on quality improvement revolves around the six aims of healthcare as described by the Institute of Medicine. Let me take just a second to go over those because I think they're very important and when you put them all together they kind of equal quality.

The Institute of Medicine says that healthcare has to be safe, it has to be timely, it has to be effective and efficient, it has to be patient-centered and it has to be equitable. So those are six words to remember and I will repeat them later on. "Safe" means we don't hurt anybody. "Timely" means that we respect people's time and that people get the care when they need it. "Effective" means that we do what we intend to do in terms of healthcare. "Efficient" means that we do what we mean to do with the minimum consumption of resources. "Patient-centered" to me means that we keep our patients comfortable, we make things convenient for them, we actually do everything that can be done to improve their condition and we enable them to fully participate in the process of care. "Equitable" I think means that we deal with the issue that we hear a lot about of disparities in healthcare where some people get better than others. But that's just a little overview of some of the national activity.

The ethics of healthcare, our reimbursement programs and service to our communities all require that we maintain a focus on quality and obviously as we've just been discussing clearly it's a requirement for Rural Health Clinics now. So quality and its improvement cannot be viewed as an activity that's added on to the important work that we already do, we have to view it as the way we do our work, not as something we add on.

Now let me just make one comment here about complexity. I think that what you do in rural health clinics is very complex. I've just listed here, I just counted them, there are 18 different kinds of activities that you all do essentially every day and I did not include in that your quality improvement and quality assessment activities, actually. So there is a lot going on in a Rural Health Clinic. Some people might say, "Well doesn't the small scale of a Rural Health Clinic compensate for that complexity?" Well I don't really think so because basically what that means is that each person has lots of different jobs and you can all attest to that, I have no doubt.

I guess sort of on the bright side, all of those activities that you do are amenable to quality, improvement and performance improvement and they all directly impact the quality of the care that you provide. And they essentially all can be assessed in terms of those six aims that we talked about just a moment ago, safe, timely, effective, efficient, patient-centered and equitable. So as you look at your assessment of your quality programs, think about those six aims of healthcare, I think is a good way to conceptualize how you assess what you are doing.

Now let me just give briefly an example of what I think a Rural Health Clinic operation that's really organized around the product of high-quality care might be doing. These are sort of to be thought of for the folks who aren't deeply involved in Quality Improvement projects already but maybe are more starting out.

One of the things that I was just, as I thought about this, you can pick three projects that are very different. Let's say you want to speed up your billing process and let's say you want to shorten your waiting time for your patients and let's say you want to very efficiently handle your lab results or improve the way you handle your lab results. So you're dealing with three different areas of your operation, the business office, the patient care process and how you manage information. So you will be using most people in your staff if you start studying and improving those three things. At any rate, all the staff members with relevant responsibilities to those can be assigned to improvement projects in those areas. Again, they're built into the way you do your daily work; it's not a big add-on.

In addition to improving those identified processes, I think lots of other benefits accrue to the organization as well. Leadership of the clinic is involved but beyond that, leadership is delegated so that you broaden the span of leadership responsibilities and activities, and I think that's a very good thing. Also, the staff owns that process and they own the improvement of it and they're learning all the time about improvement skills and attitudes and how to build a culture of improvement within the organization, which as you remember back from our early slide, we we're talking about the operating principal of continuous improvement as being sort of a mantra for a healthcare organization.

In Rural Health Clinics quality is many things but primarily I think it's building the way you do your work, your system of care to consistently produce optimal processes and outcomes, to consistently produce patient satisfaction and to consistently produce positive impacts on health status. I think it's also looking ahead and designing programs that are very responsive to your community and that are designed to improve health status in your community. It certainly also is examining our work every day, the work we do each day, and using what we learn in that process to make it better.

Quality includes measurement, we have to measure things, you know, we pay attention to what we measure. The reason for measuring, first of all and foremost, is to use that data for making things work better. The guiding principle always ought to be how to make things work better.

Quality also includes assuring that we work with our community to make sure that we're providing the services to the best of our ability that our community wants and needs and also that we're developing a set of relationships beyond the community to ensure that the people we serve have available services that can't be provided within the community.

Quality requires the interdisciplinary team to work together; it's not just the doctor or just the nurse or just the therapist. The team has to work together as we improve care. Also, not one rural health clinic has everything; we have to collaborate with other providers in our community across the continuum of care to ensure that we're providing high-quality care in this environment. We have to stay in touch with our community to make sure that we're providing services that are satisfactory for them.

So in closing I would just go back to my example that I mentioned earlier where we could conceivably think of addressing our business functions, our patient care functions and our information management functions, which we all have to do every day, get everybody involved and realize that host of benefits. I give that as an example of a place to start and I think that that sort of a place to start has the advantage of, first of all, not costing very much. Secondly, it uses what you have; it builds into the work of the staff that's already there, examination of their activities and figuring out how to make them better and it sort of requires us to start where we are, which is about the only place we can start, and use what we have and it is something we can do; I think it's entirely doable. So that to me is sort of a practical way of thinking about quality improvement and performance improvement into which the QAPI program can fit very nicely.

I'll hand off now to my colleague, Mr. Finerfrock, who will probably say things that will make more sense to you than I just did.

B. Finerfrock

Thanks, Forrest, I don't know about that; I think you did a great job. I wanted to talk to you a little bit about the context for some of this. I think some of the CMS speakers have identified it and spoken to some of these points, but when the QAPI initiative first came out and I saw the word "quality" it, like some of you may have, raised some eyebrows because so often in the rural community I think we feel as though the measures of quality that sometimes are looked at are not necessarily relevant to a rural environment. We see an IOM study that comes out and talks about patient death and medication errors in hospitals and we see that it maybe has very little relevance to a rural practice where, as one of our callers indicated earlier, they have three people and the kinds of problems that they're encountering or the issues that encountering in a small rural practice are worlds apart from what the IOM may be looking at.

But I think the important parts of the QAPI to me to focus in on are the "assessment" and "improvement" words that are in QAPI and really taking a look at what it is that you're doing in your practice, whether it's a three person rural health clinic that's an independent RHC in a frontier area of Montana or a provider-based rural health clinic that's affiliated with a large hospital and has access to significant resources. But there's always something you can do to improve what you are doing in your clinic, but the only way that you know what it is that you need to do is to make an assessment and I think sometimes in rural communities we sometimes don't do enough of that. We, because we're the only game in town very often as a rural health clinic and everybody is always coming to us, we presume that what we're doing we must be doing it well because the waiting room is always full. That may be true, but that doesn't mean that you can't still improve on something and do a better job for your patients and for the clinic in terms of how you operate. It's sometimes clinical, sometimes it's even on the business side, as Forrest mentioned, the billing process and improving that for your community.

I think it's also important, and I think again the folks from CMS without perhaps saying it directly, I think their words were indicative of this, that this isn't a punitive process. I think Jackie spoke to this, that the expectation on the part of the surveyors is that they'll engage you in a dialogue, in a conversation. In that area I think as I looked at I was asking myself if you've ever seen how a journalist goes about writing a story there is a series of questions that they are typically supposed to put into a story and it's called the Who, the What, the When, the Where and the Why of writing a story. In a lot of ways I think that's the process that we need to look at for the QAPI initiative. What is it that you're doing? What are the specific actions that you're doing here in the clinic to try and meet this requirement? Then secondarily, but the fundamental question there is why are you doing it? Why did you choose to identify this particular activity to engage in for this RHC? How did you determine that diabetes, if that's what you want to go and do a diabetes education management program, why did you choose that? Did you do a patient assessment? Did you just pick it out of a hat? Did you do it because you saw it on a HRSA Web site and you said, "Well that looks like something I might be able to do?" How did you then go about meeting that need? What were the activities that you undertook to fulfill the plan that Jackie talked about, that you set about for your RHC? Where did you do it? Well, we did it here, we did it out in the community, we went out to a senior center, we did an assessment there. And then when did you do it? The time period over which you did your assessments.

So I don't think this is a process that necessarily needs to be feared by the RHC community. I think as Forrest alluded to, many of you are already doing a lot of stuff that would qualify. CMS isn't going to be in a position right now to say, "Does it or doesn't it?" because so much of this will be fact-specific and clinic-specific. But the reality is that you probably are engaging in activities now that will be able to meet the QAPI initiative, you just haven't put it down on paper, you haven't talked about it, but you're probably doing a lot of stuff that very easily will allow you to meet this initiative.

I think the final point I want to make before we open it up to questions is the notion that this is something that should be relevant for your community. Just as we have rural health clinics that run the gamut from very small RHCs in very frontier areas to much larger rural health clinics with many providers, the needs of each community are going to vary greatly. For some it may be a diabetes education program, for others it's hypertension, for others smoking cessation, for others it's reducing waiting time. But only you will know what the needs are for your community and that's the real point, it's to try and make it relevant for the patients that you're serving.

A final point is keep it simple. Don't try to overdue something. Do something that really can have value in your community and you've made an improvement. It doesn't have to be a huge undertaking. If you have an opportunity to affiliate with an academic health center and do something, that's great, but many of you won't have that opportunity. If you keep it simple and you do something that's relevant to your community I don't think you'll have any problem meeting the QAPI requirements.

F. Calico

I would just like to add, I appreciate so much what Bill said there, this project should be something that does not add burden but in fact adds value. That was very important, I think.

T. Morris

Thanks to both Bill and Forrest for that, and prior to that to the CMS folks. Why don't we open it up for some Q&A for a little while and then we'll close out with some information about the next call?

Coordinator

Once moment please. Dr. Benjamin, your line is now open.

R. Benjamin

Hi, my name is Regina and I've been involved a lot with the quality process around the country. I've been involved with the Institute of Medicine on their quality committees for the crossing of quality chasm and I talk about this and various things you're saying; there's a different feeling sitting on this side of the table. I think I want to go back to earlier, I have a small Rural Health Clinic, there's just me, my nurse and my receptionist. While we want to do things to constantly improve and serve our patients better because they deserve it, this call has been really frightening because it sounds like I've got to spend a ton of time trying to document why I'm doing the improvements that I'm doing and I don't really have that kind of time.

The first questioner basically asked, "How are we going to get the resources to hire somebody," because it does sound like I need to go hire somebody; I've got to see patients, I don't have the time to sit down and do all of this. It would help if CMS or HRSA or someone could give us some sort of a, not just technical assistance, but a binder, if you will, that we could use so we didn't have to redevelop everything. Because what I'm hearing on this call is you develop what you want to and I'm too busy trying to see patients. I've taken an hour and a half today to sit on this call; I don't have that kind of time and I'm sure that the smaller clinics don't. While I am probably very knowledgeable and can get things from other places, I still have to put them together. If there was a resource that we had to use so that we could be compliant and also get some good data to improve what we're doing every day it would help and it wouldn't be so frightening.

T. Morris

Regina, you know we're in the process of trying to gather materials from clinics that we think, that might offer us models. We're hoping over the next several months we can develop that into something that people would be able to pick right from and if they like it and they think it's adaptable to their clinic, they'll do that. Having said that, this is the first time we've ever done anything like this so we're kind of coming up with it as we go along. Later on I'm going to ask Craig to talk about if anybody has anything interesting that they'd like to share, we could do that. I think that's maybe one of the best things we can do is be a place that takes in a lot of ideas that folks are already doing and maybe share them with folks who haven't had time to think about this or might be able to adopt something that's already been developed.

M. Collins

Regina, I have a question for you in terms of the annual evaluation, how have you been able to do that?

R. Benjamin

We do that with no problem. I have another physician who comes and goes over it with us. We actually do it about twice a year; we don't do it once a year, just for our benefit. But that hasn't been a problem.

M. Collins

That has not?

R. Benjamin

No.

M. Collins

Have you identified through your annual evaluation any opportunities for improvement or areas where you need to improve?

R. Benjamin

We do that every day. At the end of the day we sit down and talk about it with each other and say, "Well, how could today have been better?" and those sorts of things, but to sit down and write down a plan is what I was getting at.

M. Collins

Developing the plan that you think would be time consuming.

R. Benjamin

Right, and every day we'll say, "Well, we had so and so happen today, how could we have done that better?" and we always save that time at the end of each day. But to sit down and write a plan, and I guess Jackie's was kind of frightening because she's saying, "You've got to have this and when a surveyor comes in the surveyor isn't coming there to teach you, they're coming there to survey you and they're coming there to make sure that you're doing I guess what you say you're going to do." That's what's frightening I think, and that's what I heard from the first questioners.

J. Kosh-Suber

If I could say to you, you know you're saying to me when you do your program evaluation that every single day you sit back and you review things of how you could have done better. If at least one of those days you didn't do that and you just evaluated, I think that, I'm hearing what you're saying but I think you're making it more complicated than what it really is for you. It seems as though what you were doing or what you're doing now ongoing for your program evaluation is exactly what you can be doing, instead of taking that 15 or 20 minutes and talking to the staff, the staff could sit down and do the documentation at that time. Every day of the week you don't have to necessarily sit down and say, "What could we do better?"

R. Benjamin

When you're brain-dead at the end of the day it's easier to talk about it, it's not as easy to write it.

J. Kosh-Suber

But all we're asking you to do is to write exactly what you're saying. All you're doing is you're understanding the situation, you're identifying your issues, your problems, your asking each other questions. Then your next question to yourself is, "How can we improve this tomorrow?" and there's your plan right there. It's already there, it's already done, you're already doing it ongoing. It sounds like you're doing it daily when you don't even have to do it that often.

R. Benjamin

Now, if you ask me to fax that to you I can't. Not at this moment, anyway.

J. Kosh-Suber

You're only going to write that plan down once. Then if you're sitting down every day and you're talking about how well you did then if you develop some kind of little checklist or you just write down, "This is what we're going to do, one through five" and then all you've got to do is check off, "Did we do all this today?" and you check off yes, yes, yes. The person who is your front desk person could be your monitor that you and the nurse or your nursing assistants are doing these things and then you all come together at a point or she just provides you the data. Really, it's just keeping it simple.

I really believe that, I mean we're not looking for long, drawn out analysis, you know, a paragraph of "This is what's going on" and "This is what we're going to do to improve this." We've had meetings and if you're having monthly/weekly meetings then when you're talking to the surveyors and they're asking, "How have you improved on this opportunity?" you say, "We sit down every day and we talk about this and we brainstorm." You're doing exactly what I said you need to do in your Plan, Do, Check, Act methodology.

R. Benjamin

Okay.

J. Kosh-Suber

Give me a call in about a month because then I'll have mostly everything down and I'll talk with you about some of the things that you're doing. I would like to see some of the resources on the Web site first before I give any input. My number is 410-786-0618.

R. Benjamin

Okay, great, thanks.

Coordinator

Patricia Janasky, you may ask your question.

P. Janasky

Yes, I was listening with Ms. Kosh-Suber and she was talking about the quality assurance panel, I think at the beginning of her presentation, there was so much information. We're a brand-new Rural Health Clinic, just standing up, and I'm responsible for getting these policies and procedures in place. Did I understand her to say that the personnel who had to be on the panel be the MD, the mid-level practitioner and a member, not an employee of the clinic?

J. Kosh-Suber

Yes, when you have your performance improvement as of when you're writing the policies for it, you need to ensure that you have at least one, if you don't have a mid-level you don't have it. You've got to have an MD regardless, because an MD will come in.

P. Janasky

The MD and I, I'm the mid-level, we are collaborating on these but I thought I understood you to say you must also have one member who is not an employee of the clinic?

J. Kosh-Suber

That's for your policies and procedures that you're putting together. When you're doing your policy and procedure you'll be discussing your performance improvement efforts, so that should already be inclusive when that person is helping you with your policies and procedures.

T. Morris

You're already required to have that external person there, I think is what Jackie's saying. Regardless of anything with QAPI, you should have already had somebody from the outside world working with you on the development of your policy and procedures.

P. Janasky

I see, so our consult group?

J. Kosh-Suber

Correct.

P. Janasky

They qualify as that?

T. Morris

Yes.

J. Kosh-Suber

Yes.

P. Janasky

Okay, I understand. And also, you said that this new QAPI will replace the annual program evaluation, did I understand that correctly?

J. Kosh-Suber

Yes, it does.

P. Janasky

Okay, thank you so much.

Coordinator

Beverly Timmons, you may ask your question.

B. Timmons

Thank you, I already did. I appreciate it.

Coordinator

Terry Benware, you may ask a question.

T. Benware

Yes, this basically relates to the last caller's question. Can you give me an example of how, or at least what type of an outsider would be involved in writing these policies and procedures?

J. Kosh-Suber

If you have a specialized board set of people who set up to help you to organize the Rural Health Clinic, those will be someone of that sort. Not an employee of the clinic.

T. Benware

Right, we've been a Rural Health Clinic now for about six years and I've only been here three-and-a-half years. We use somebody just within the building that we share space with, just at our annual meeting.

J. Kosh-Suber

Yes, that's fine.

T. Benware

But writing policies and procedures, they need to be involved in that also?

J. Kosh-Suber

Yes, if you look in the regulations at 491.9 B2, this is a requirement that you had upon initial certification.

T. Benware

Okay, does it have to be another professional person?

J. Kosh-Suber

No, it doesn't have to be a professional person. Just someone with the knowledge that will be effective worthy of giving input.

T. Benware

Okay, thank you.

Coordinator

Linda Meredith, you may ask your question.

L. Meredith

I was wondering, especially for some of the smaller providers in different states, could they not be working with the quality improvement organizations in the states? I know they have a lot of helpful information.

J. Kosh-Suber

Yes, any resources could be used. The more specific thing to be concerned about is that it's relevant to your clinic and your patient population. If you see somebody doing something out there that fits something that you have, because you have a lot of patient complaints, you did a satisfaction survey and they don't like that, they have to wait for an hour-and-a-half to see you but you're the only ones there and you see a local organization doing something about patient satisfaction and how to improve, you can grab that tool and use it.

L .Meredith

I was specifically, in Texas, you know we have the Texas Medical Foundation that's our quality improvement organization or what used to be the peer review organization. They have wonderful standardized products that people could use, if there's somebody out there in Texas. I don't know what the other states have, to look at immunizations, flu shot, pneumovax, if someone got a mammogram, and it will help people in their first steps if they really just don't have a clue to where to get started. Because certainly prevention is applicable to everyone in the population.

T. Morris

I think that's a really good idea and I know other states have similar organizations that have programs that they can take off the shelf and make available to RHCs. Many of them were developed within the hospital environment but they'll have a hospital outpatient program that you can take. So what you may find is that some of the off-the-shelf stuff is a little more complex or high-end than what you need but you can take those and scale them to the RHC and what's relevant for your community.

Coordinator

Rachael Sherard, you may ask your question.

R. Sherard

Thank you, I have a couple of questions. The one is will there be an annual survey from the state surveyors, if that replaces the annual evaluation?

J. Kosh-Suber

No, the surveyors will not be coming out to do additional surveys just for the quality assessment improvement program. The surveyors are on a schedule according to budgetary allowances for Rural Health Clinics and on the average, most states overall, they'll come out every three to five years, some states come out more frequently like the every three year mark, but the frequency will not increase unless moneys increase.

R. Sherard

Okay, and then the second question, I just didn't catch, Jackie, did you say the interpretive guidelines and guidance to surveyors would be available at some point soon? I didn't catch that.

J. Kosh-Suber

What will happen, they have to go through an approval process at CMS to be part of a state operations manual;, as soon as we have them finalized I will ensure that the Office of Rural Health Policy and the National Rural Health Clinic Association, they do have a copy of the old one on their Web site, I'll make sure they have an updated copy so that if you just keep an eye on those two Web sites, and if they happen to be approved by the time we have our last meeting then we'll make sure they're on the HRSA Web site at that time.

I do believe that HRSA has a "How-to Become an RHC" manual that's going to be coming out in the near future. I hope that however that vehicle goes out that I'll provide to the Office of Rural Health Policy copies of the interpretive guidelines and any other guidance that Mary Collins and I put together so that you will have that.

R. Sherard

Okay, thank you very much.

T. Morris

Let me just add that the manual is getting ready to come out; we're hoping to go to the printer here in the next week or so.

J. Kosh-Suber

Yes, so just be mindful that when you look in that manual, the interpretive guidelines and the survey report form that you'll be looking at are going to be revised according to the regulations that were just passed on December 24th. So it's not going to show you the updated things that are part of the regulations, which right now you can only get out of the Federal Register because it's not in the CFR at this time.

R. Sherard

Yes, I just went down and did the - you're right, it's not there at this time.

J. Kosh-Suber

Yes, you can get it out of the Federal Register.

R. Sherard

Right, I got that. Thank you.

Coordinator

Mike Tamburini, you may ask a question.

M. Tamburini

Thank you. I have to share some of the doctor's comments, it seems kind of daunting. But with anything new and the fear of the unknown, I guess I need to wait until I meet my first surveyor before I know exactly where I stand with this. One question I have of several, how much difference can we expect from a surveyor that we've identified are the right issues in our particular facility? That's one question I have.

Another question I have is, have you given any thought to providing a resource, a reference, any reference material or a link on your Web site where as we get into this and clinics who have developed a practice that might be useful to other clinics, sort of a best practices type of resource, if you will, will something like that be available down the road?

And finally, similarly somebody was talking about some resource in their state of Texas, have you developed any reference material that Rural Health Clinics in their particular state could know where to go or who to call?

C. Williamson

As Tom indicated earlier, what we're working on right now and what we'd really like all of your help with is putting together a list of best practices and finding out what you guys are doing out in the field. So I'm going to go ahead and give you my phone number and e-mail address now. Those of you who are doing a Quality Improvement, have QAPI things ongoing, we'd really like to hear what you're doing and sort of compile one of those … that you're talking about that are a list of best practices. So my phone number is 301-443-4784 and my e-mail is cwilliamson@hrsa.gov.

M. Tamburini

Now in sharing those practices with you, Phil, is fine, but how do the rest of us, how does that get telegraphed to all the rest of us?

C. Williamson

Those are going to be made available on the HRSA Web site; we'll be making them available on the Rural Health Clinic's Web site. We are going to do everything possible between ORHP and the Rural Health Clinics Association to get information out there. I mean that's the whole purpose of this call, and this is frankly the first time we've been able to do this for the RHC community as a means of trying to get information out. But because this is new and we have to look at things it's going to take a little while to get those materials together, to get them up there, to make sure that they're relevant and appropriate. I think they'll also probably be shared with the state Offices of Rural Health. And I would encourage folks to contact your state Office of Rural Health as another resource who can either refer you to entities within their state or they make some of this available on their state Office of Rural Health Web sites as well.

I would just like to suggest also, you mentioned, I think maybe your first question was how do you know if you picked the right ones. It seems to me that if it's relevant to the care that you provide, it can't be wrong.

M. Tamburini

I don't understand that.

C. Williamson

Basically there is no right or wrong. If you've done an assessment of your environment, your patients and you've drawn a conclusion from that assessment and you've engaged in an activity based on that assessment, then you have fulfilled the requirement of the program, regardless of what it was. I mean there may be something, but by and large if you followed that process of saying, "We did the assessment, we identified a problem, we took these actions and we documented what we did in order to improve whatever it was."

So it's the process that is important to follow I think more so than to say, "We have to do a diabetes program" or "We have to do a hypertension program" or "We have to do a weight management program." That's clinic-specific, but as long as you follow the process, whatever conclusion you draw from that process I think you don't go wrong.

M. Tamburini

Okay, thanks.

Coordinator

Mary Peterson, you may ask your question.

M. Peterson

Just an observation, and I know, Jackie, I think with several of your callers you must have gotten the impression that, and I'm not going to say we fear this requirement because I think most of us do this, we do it every day, when things come up as problematic or whatever. We're doing it but we don't formalize it and that's where you have to, I don't care how big you are, somebody has got to be in charge of this to be able to document and to go through all those steps and that's an unfunded mandate. I'd bet money that we're all going to have to hire somebody or pay additional hours to be able to incorporate this formally into our organizations, something we're already doing today but we're not doing it to the level that a hospital does it for joint commission.

You know, independent Rural Health Clinics are not doing it today formally, they're doing the process, they have every intent to have good quality or they wouldn't be in business, but they don't have enough man hours in the day, just as the good doctor stated. Everybody has a job here and they don't have extra time, so how can you take somebody who's already working a full eight hours and put them in charge? That surveyor you said is going to talk to somebody about this program, that somebody has to be in charge and has to know all facets of it.

So it's going to take some extra overhead and it's going to take some more formalized planning to continue to do what we're doing. It's going to take more paper and that's why physicians are getting so frustrated, because they're dealing with constantly more unfunded mandates to handle more paper, and that's frustrating. So I don't think we fear it, I think we're frustrated and I think we're overwhelmed with additional regulatory burdens. I know we have to do it, I'm not really here to criticize you guys, but it's not fear, it's frustration. Thank you.

Coordinator

Aleta Stout, you may ask your question.

B. Knight

This is actually Barbara Knight. In talking about the measurement of outcomes, if let's say we decide to survey our diabetes management, are we looking at measuring success with the program or just the fact that, yes, in the charts we are following all the protocols we've established? Or is it both, are we measuring both patient outcomes and improvements or just chart assessment?

J. Kosh-Suber

You're measuring patient outcomes and improvements.

S. Cooper

You may also find that there isn't any improvement, and again, this goes back to the process and following the process through to find out. So it's not necessarily having to - you know you're not going to be held that you've actually made improvements at that time, but that you've put interventions in place to try to make improvements.

J. Kosh-Suber

Right, you'll say, "Okay, I have 0% improvement this month or this quarter. I'm going back to assess what's going on in this situation" and then you assess it, plan, you track and measure again and then you evaluate to see if you've had any improvement. If you don't have any improvement, we have 1% or whatever, then after you've done this for a year we would hope at some point that when you go back to plan you're changing your criteria, you're looking at other ways to identify why you still have no improvement. That's where you're going to have the change.

But the tracking, the measuring, the monitoring, the evaluation and the improvement, you know looking at your improvement is a continual process and when you get to where you're coming back around the cycle to your planning stage, that's where we at least want to see, "Well, we sent out a flier this time and we gave the patients a checklist" or something to do this time to bring back for appointments. You know, just a little simple process that you may have done and then you look at it at the end to see if that new thing that you implemented improved anything. You're not going to always have an improvement, necessarily, but you want to evaluate why we're not doing better because we want to do better.

B. Knight

Okay, thank you.

Coordinator

John Begley, you may ask your question.

J. Begley

Am I on?

Coordinator

Yes, you are, sir.

J. Begley

This is more of a comment more than anything. I sense a lot of fear in everybody and my basic comment is to try and put at ease. We've been doing a Quality Assurance program here at this clinic, we're all based health three people in the clinic and we've been doing it for three years on diabetes, immunizations and mammography using 14 parameters of diabetes. Most of the material, what started us off we got at the Texas Medical Foundation. All charts, all graphs, any guidance we needed should be able to be found at a state organization or state level and then it's just a matter of every time you see a diabetic you fill out your chart; this is the ongoing portion I think you were talking to. We didn't have to hire anybody, it didn't cost us any overhead and it has become such a routine thing that we don't even recognize it as being a Quality program per se because we're doing it every day. When we see a diabetic or we see somebody who needs a mammography and we chart these.

So I would really encourage everybody to get a hold of your state level, get these forms because they are so easy to use and this program has been so easy to implement and it is not at all difficult like I think everybody is assuming so. Rest assured, the first place I would look is at your state level and if you can't find them then, yes, here in Texas, like my other caller, we have a wonderful organization who has given us all the supporting literature and material we need to implement these programs.

M. Collins

I think that's a good suggestion in terms of something you might want to just pass along to maybe Craig or Tom and HRSA in terms of best practices that can be utilized.

C. Williamson

I was just getting ready to butt in, Mary Ann, and say that's exactly what we're looking for. And to people out there who are doing things like that, we would love to have you share those with us and also share the resources with us that you've drawn from in developing these. That way we can take a look at those and make them more widely available through our Web site and through other national publications and try and get them out to as many RHCs as possible.

T. Morris

Why don't you give me your name and number?

J. Begley

This is not a time-consuming project that everybody seems to think it is, it really is not, it's been so simple to set up. So I think everybody should be rest assured, once you get the material in your hand you're going to find it so simplistic.

J. Kosh-Suber

Thank you very much for adding that.

Coordinator

Mr. Ron Rehn, your line is now open.

R. Rehn

Yes, as I understand it's always going to be important to actually review the law and you said it was in the Federal Register. You don't have that on the HRSA Web site do you?

M. Collins

I don't think there's a link there. Tom, you might want to jump in. It might be a good thing to do, however I can certainly either send this to you by e-mail, the regulation, or provide a site for you to check. But give me a call and I can certainly get that to you.

R. Rehn

Okay.

M. Collins

Mary Collins, 410-786-3189, or you can e-mail me; I'll go ahead and give my e-mail address out, mcollins@cms.hhs.gov.

C. Williamson

And we'll make sure to get that up on the HRSA Web site right away.

R. Rehn

Thank you.

T. Morris

I think we've got a little bit of time left, let's take one more call and then we'll talk a little bit about the next call.

Coordinator

Once moment sir. Patrick Lipford, you may ask your question.

P. Lipford

Tom, would you have ORHP make available a transcript of Dr. Calico's comments, please? Thank you.

T. Morris

We have a transcript of the entire call, Patrick. And then for our slides that everyone's having such trouble downloading, but I think that has more to do with server issues than anything else, but we'll leave those up there.

C. Williamson

And you can also, there's a number on our Web site that you can dial into and listen to this call over again if you're interested in doing that as well.

P. Lipford

Really what I want is a print copy of Dr. Calico's opening comments.

T. Morris

If I'm not mistaken I think there is a transcript available.

C. Williamson

Yes, there is. We'll get that put up as well.

P. Lipford

All right, thank you.

T. Morris

Why don't we just wrap it up then. First of all I want to thank everyone for participating in the call and I want to reiterate our commitment to help you in complying with this regulation the best way we can and improving quality in the Rural Health Clinics across the country. I encourage you to come back and look at our Web site and hopefully you won't have as much problem getting to it as you did today. We'll be updating a lot of these quality related materials and also putting, hopefully this time correct information about the call on there so people have no problem with that, that's going to be our first quality improvement project here.

In the meantime, feel free to call myself or Craig in the office or Heather. Bill Finerfrock from National Association of Rural Health Clinics is a wonderful resource; do you want to give them any contact information?

B. Finerfrock

Yes, if you have questions you can e-mail me at info@NARHC and we have some, we can send you the RHC, the reg that came out and as other materials come out we make it available. Just send me an e-mail.

T. Morris

I want to also just really thank the folks from CMS, I think you guys were incredibly helpful to the folks out there today and I appreciate you taking the time to do this, Mary, Jackie and Scott.

M Collins

Absolutely.

T. Morris

Let me turn it over to Craig for information about the next call.

C. Williamson

Sure. We're going to go ahead and have another call on the first Monday in April, as this one, that's Monday, April 5th at 2:00 Eastern Time and that will last an hour-and-a-half to two hours. What we'd like to do with this call is really give some examples and we're going to have some other Rural Health Clinics and give examples of Quality Improvement things that they have ongoing and give some best practice ideas.

Again, along those lines I'd like to encourage all of you out there who are doing stuff to share your resources and share what it is that you're doing with us here in the office so we can make those more widely available. So let me just give you my e-mail and phone number one more time. It's cwilliamson@HRSA.gov and my number is 301-443-4784. We'll have information about date and time and dial-in information for the upcoming call in April. I think Bill needs to fill in stuff as well.

B. Finerfrock

No, I just wanted to, on behalf of the Rural Health Clinics community, thank both CMS and ORHP for this opportunity. This, as I mentioned earlier, is the first time we've been able to do something like this for the Rural Health Clinics community. It would be my hope that we'll be able to do these types of informational calls in the future, not just on QAPI, but on other Rural Health Clinic issues because I think what we find is that it's very difficult for you folks to get access to information. We put on meetings but we realize that that's expensive, it's time consuming and that through this type of technology we can get information out to the RHC community.

It's because of ORHP and making this resource available and the CMS folks in making their staff available that this was possible and we just want to say thank you.

T. Morris

You're welcome. I hope it was helpful to folks. Operator, I was wondering if you could just let us know how many total people were on the call.

Coordinator

Approximately 350, I'm not really sure. I was just going to start the list as soon as the call ended.

T. Morris

Great. That is testament enough, especially with the wrong number. Thanks, everybody.