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. Now I will turn the meeting over to Mr. Craig Williamson. Sir, you may begin.

C. Williamson

Thank you very much. Hello, everyone, and welcome to the second in a series of three conference calls on the topic of quality improvement in rural health clinics. As you probably all are aware, on December 24th, 2003, CMS published a final rule detailing guidelines for the implementation of the Quality Assessment and Performance Improvements, or QAPI, program in rural health clinics. This regulation charge … off of the rural health policy with providing technical assistance to RHC's who are seeking to implement a QAPI program.

Just to review what we did in the last call - and the first call was held on March 3rd - Mary Collins, of CMS's Operative Clinical Standards and Quality described the QAPI regulations, while Scott Cooper, also of CMS, gave an example of a model QAPI program. Jacqueline Kosh-Suber from CMS's Center for Medicaid and State Operations discussed the rural health clinic survey process. Finally, Forrest Calico and Bill Finerfrock provided a conceptual overview of rural quality issues.

The transcript and other materials from that call are available on the ORHP Web site, which is http://ruralhealth.hrsa.gov or you can just type ruralhealth, one word .hrsa.gov into your browser window to access that information.

So the purpose of today's call is somewhat different than the previous ones. Last call, having discussed the … regulation in detail, today we're going to shift gears and focus a bit more heavily on providing resources and ideas for implementing the QAPI program that is appropriate for your facility.

I'm going to spend a few minutes describing some resources that are available to you, both online and in print, to obtain additional information on quality improvement. Then Dr. Forrest Calico will briefly discuss an intervention that you might consider incorporating into a QAPI program.

Finally, we have some representatives from three different RHC's on the call, who are going to describe the quality improvement projects that they have ongoing.

I'd also like to take a moment to remind you that the primary purpose of these calls is to offer information to rural health clinics and to give a forum for them to ask quality-improvement related questions. I realize that there are also a number of consultants and folks from other providers who are listening in to call. I encourage them to hold off of their questions so that we have time to directly address the questions of as many clinics as possible.

If you do have an unanswered question during this call, you'll certainly have a chance to ask them on the next one. We're going to be asking people to submit questions for the final call in May, and that will be an open-door forum where we will try and get to as many of these questions as possible.

With that said, at this point I'd like to go ahead and point out a few resources that might be useful to rural health clinics who are trying to implement a QAPI program. In particular, on the ORHP Web site, there's a document entitled RHC Resources that lists several Web sites, books and journal articles that we think can provide a useful introduction to quality improvement issues.

We've also posted a Frequently Asked Questions page that we hope will be helpful, and there's a conceptual flow sheet style explanation of the Quality Assessment and Performance Improvement process that you can look at. All of these documents are also available from the Rural Assistance Center, which is at www.raconline.org. Again, that's www.raconline.org, which, if you're not aware of the Rural Assistance Center, it's a great source of information for all things related to rural, in addition to rural health clinic matters.

So first, I'm just going to talk about a few specific Web sites who we think might offer useful information for RHC's. During the last call, one commenter mentioned the Texas Department of Health Diabetes Management tool kit, and since then I've talked to several clinics who've also used this tool, so if you're interested in implementing a diabetes management program, this is a great source of evidence-based practice guidelines and also patient education materials that you can use.

This can be accessed through our Web site; we have a link up on the General Resources page or also at www.tdh.state.tx.us. In addition to that, the Agency for Healthcare Research and Quality has a large database of evidence-based practice guidelines and other information on disease management and performance measures that you can tailor to a QAPI program.

If you have sufficient time, I recommend that every health professional take a look at the Institute of Medicine's report, Crossing the Quality Chasm. This outlines a comprehensive vision of quality improvement in the US healthcare system. It lays down six principle aims that healthcare be safe, timely, efficient, effective, patient-centered and equitable, or STEEPE, to use the acronym. And really, this should provide the conceptual basis for almost any quality improvement program.

I know many of you don't have enough free time to read the entire thing, but Don Brook has also published a brief user's manual to the report that is published in the May and June 2002 issue of Health Affairs; that's Volume 21, Issue 3 and it begins on page 80, I believe, if you're interested in that.

And finally, there's a growing body of research literature on healthcare quality issues. As a matter of fact, The Journal of Rural Health is planning, in the fall, to release an entire issue dedicated to rural quality research.

On our Web site, we list several recommended articles on quality improvement issues. In particular, I'd like to draw your attention to an article published in the February edition of the Joint Commission Journal on Quality and Patient Safety that, to my knowledge anyway, is the first-ever published account of an RHC's quality improvement program. In a few minutes you're going to hear from someone from that RHC who's the subject of the article.

In addition to all these resources, I encourage everyone to seek out and engage your state's designated quality improvement organization. In each state, Medicare contracts with a group to provide quality improvement assistance to that state's providers. If you're not already familiarly with your state's QIO, a directory is available on the CMS Web site for quality, which is www.cms.gov/quality.

There are a number of additional resources posted on the ORHP Web site and I just encourage all of you to visit the site periodically during the coming months, because we've been continuously trying to update that and we'll keep on doing so for the next month or two. And right now we're also starting to work on a how-to guide for rural health clinic quality improvement. And this is going to serve as a supplement to the how-to manual just published last Monday. They discuss how to go through the certification process for rural health clinics and this is going to summarize some of the information on these calls and give a little more information on quality improvement in RHCs.

And finally, if there are other resources that any of you out there are aware of that you find useful in implementing quality programs, feel free to share them with us because we'd like to share those with as many clinics as possible. My e-mail address is CWilliamson@HRSA.gov. That's CWilliamson@HRSA.gov.

So, with that said, I'll go ahead and turn the call over to Dr. Forrest Calico, who's going to talk briefly about some specific interventions that you can use in a QAPI program, and he'll talk for a few minutes about that; then we're going to open things up to questions, and then we'll actually be turning call over to three rural health clinics who are going to tell you about the actual quality improvement programs that they have ongoing. So, Forrest, I'll let you go ahead and take this away.

F. Calico

Thank you, Craig, and good afternoon, ladies and gentlemen. This is Forrest Calico and I have been interested in rural health quality and it's improvement for quite a while, particularly here in the office of Rural Health Policy.

As Craig mentioned, I'm going to talk briefly - I think he made that point very well - to you about some areas of rural health clinic practice that I think are particularly amenable to quality and performance improvement - things that can substantially improve patient care. I'd like to refer you to the Sample Interventions document on our ORHP Web site that lists a few of these.

Now, first let's talk about chronic disease management, focusing, in particular, on diabetes management. In the course of these calls, you've heard quite a bit about diabetes management and I think that's largely for three very good reasons.

First, diabetes is a significant problem, and you all know that it's quite common in a primary care practice, and the need to manage it well is enormous.

Second, diabetes is particularly well suited to disease management initiatives. It really can't be well-managed in the context of occasional physician office visits. There are also a number of well-documented guidelines and measurements that can be applied as you care for your diabetic patients.

Third, learning and the tools and capabilities that you develop as you implement a diabetes management project can be expanded to other chronic conditions as well, and also can improve your entire practice in your rural health clinic.

I don't want to give the impression that just because it's talked about so much, diabetes is the only chronic disease that can and should be successfully managed. It's really a good place to start, but, in my experience, depression is a very common illness seen in our primary care practices, and management and patient education are particularly important with depression, as well as other mental illnesses.

The recently released National Quality Report states that half of all patients prescribed antidepressants stop taking them in the first month; a very significant statistic. Don't take this wrong, but, as a family physician, I can say, I think quite safely, that most of us are not well-trained in diagnosing and treating depression and we often do not identify the condition.

So, many of you really might want to consider implementing depression screening and patient education, and also doing follow-up phone calls for patients who have been prescribed antidepressants.

On another topic, it's really important to monitor referrals to other mental health providers as well. Additionally, evidence-based guidelines are also available for other chronic conditions such as hypertension, congestive heart failure, obesity. Each of you can identify what the greatest needs of your patient population are and seek out the corresponding quality tools to help you improve care in those areas.

Now, as we talk about disease management and evidence-based practice guidelines, don't lose track of some more simple things that can significantly improve care. There's a lot that happens in the clinic's front office that could be improved to increase access and patient-centeredness of care. I strongly encourage all of you to look at ways to reduce patient waiting time and make your clinic's scheduling more flexible.

You can also improve your office's phone system and it's management, to reduce busy signals and provide more prompt attention to your patients' needs.

And then, to the extent that resources allow, I can't overemphasize the value of investing in information technology. It's a big investment; it's probably a real stretch for many of us, but I'd really be remiss to discuss performance and quality improvement without at least touching on that subject.

The QAPI regulation recognizes the value of information technology and states that an initial investment in IT will be counted toward fulfilling the QAPI requirement. If you're yet connected to the Internet, check it out. If you're still using dial-up, work with other community leaders to bring broadband into your community.

Also, there are a number of software packages available, of variable costs, that can be incorporated into a Quality Assessment and Performance Improvement program. Soon, you're going to hear from a rural health clinic that has made significant investments in information technology.

As medicine and information increasingly become more high-tech, I think it's really important that rural practices try to keep in the technology game. Information technology can improve care and it's also been shown to improve your community's perception of your quality, helping to dispel the "bigger is better" notion that so common in many of our communities.

Well, that said, I think we ought to open the lines up for a few minutes and take some time to address your issues at this point in the call. And then, as Craig said, after that we'll turn the call over to three of your peers who are going to share their experiences with implementing quality and performance improvement programs.

C. Williamson

Operator, can you go ahead and inform participants of what they need to do to call in and ask any questions, if there are any at this point.

Coordinator

Thank you, sir. One moment. Our first question comes from John Fleming. You may ask your question.

C. Williamson

Hello, John. How are you doing?

J. Fleming

Hey, just fine. I appreciate you taking my question. Actually, there were a lot of Web addresses put out real fast and I didn't catch even one of them. But I'm very interested in the one that - I forget how you described it, but it's the center for evidence-based practice. I guess it has the various protocols and that sort of thing. Can you give me that one?

C. Williamson

Sure. That's the Agency for Healthcare Research and Quality, which is a branch of the Department of Health and Human Services. And their general Web site is www.AHRQ.gov. And there's a number of different databases they have on evidence-based practice guidelines, performance measures and a whole host of resources.

And there's also - I think it's http://www.qualitytools.ahrq.gov/ that - the list of different tools can be used. And if you go to the Rural Health Policy Web site - actually all of the Web sites that were given - those are linked to from the Rural Health Clinic page so if you go to www.ruralhealth.hrsa.gov, which is our Web site, and right at the very front, on the main page, there's a link to click onto for technical assistance for rural health clinics, and there's a number of documents and resources there. And if you click on RHC resources, we've got links to about ten different Web sites: all of the ones that I talked to, and also some other ones that I didn't talk about that you should check out, and also books and journal articles that provide information.

So I would encourage you to check out the ORHP Web site first, and go from there, and find some other resources.

J. Fleming

Alright. Now, what is the address for that Web site?

C. Williamson

The Office of Rural Health Policy?

J. Fleming

Yes.

C. Williamson

Sure. We are http://ruralhealth.hrsa.gov.

J. Fleming

Dot H-what?

C. Williamson

Dot H-R-S-A.

J. Fleming

H-R-S-A dot gov?

C. Williamson

Dot G-O-V. So you can just type in ruralhealth.hrsa.gov and it should come up.

J. Fleming

Okay, great. Alright, great. Thanks. And then, a suggestion on that is, because we're all going to really need to be referring to these is, to place that very prominently, some of those Web sites very prominently, so we can find them quickly and easily, because we're all going to be needing to refer to them.

C. Williamson

That's a great suggestion. We'll do what we can to try and make the site as user-friendly as possible.

J. Fleming

Right. Okay, thank you.

C. Williamson

Thank you for calling in.

Coordinator

Wayne Hooks, you may ask your question.

W. HooksHello?

C. Williamson

Hey, Wayne. How are you doing?

W. HooksI don't know. I'm at work; that's a bad sign.

C. Williamson

I think we all are.

W. Hooks

Okay. With the enactment of QAPI, if I remember the legislation, there were supposed to be grants for people to implement quality assurance and, of course, the grants weren't funded. And what I was wondering is, what are the chances of the grants getting funded this year? We've just finished or are in the process of finishing an integrated telephone system to facilitate our patients' access to our clinic, and the next thing we need to do is some heavy-duty software buying. And the question is, do we wait for the grants or go ahead and jump and start investing in software?

T. Barnes

Hi, my name's Tom Barnes. I'm also with the Office. The Congressional Appropriations process is a largely unpredictable one. That program you referenced has been on the books since 2002 but, as you noted, has not received funding. And they are going through the appropriations right now, and if there was a groundswell of interest in that that was expressed to the Appropriations Committee, they might fund it. But, I think if you were waiting for that, you might end up, a year from now, in the same boat.

So, you might want to talk to the people who hold elected office and see if they're interested in getting that program funded. But if I was a betting man, I would say go ahead with the investment yourself because there are always other things you could do with that grant money if it gets funded down the run.

The other thing is, there are other grants that are actually are funded, such as the National Library of Medicine has a number of grants that are related to software acquisitions and linking different providers together to share patient information and you might want to look at that, and I'll share that information with Craig. If you want to follow-up with him, separate from this call, he might be able to direct you where to go to for those.

W. Hooks

What was that Web - what was that site that you mentioned for the grants?

T. Barnes

I don't know it off the top of my head. It's the National Library of Medicine, which is in the National Institutes of Health. But we'll put a link to that on our Web page and some other resources that we know are receiving funding now that might be of interest.

C. Williamson

And the Agency for Healthcare Research and Quality also has some grants for information technology, as it comes to network development. I believe that there is a new program out there that we're going to look into and see if we can't find some more information about that to put up for you guys.

And then, this may be a topic that, if a lot of people are interested, that we we'll see if we can cover in the final call in May, which would be looking to find some other resources for implementing IT and some other grant resources you guys might look into.

Does that take care of your question?

W. Hooks

Yes. And you are going to be posting sites for us to go to to look for some funding, it would muchly appreciated.

C. Williamson

We will. That's a great suggestion. We will look into that right away. Thanks, Wayne.

W. Hooks

Things are thin out here in the country.

C. Williamson

We know.

Coordinator

Joanne Greeley, you may ask your question.

J. GreeleyHi. We hear so much information on diabetes management program in the rural health clinics as one of the suggested areas for QAPI. Are we able to bill for a dietician who would be an important part of the management program? If not, is this something that's going to be looked at as billing his or her professional service?

T. Barnes

Hi, this is Tom Barnes again. Of course, I would defer to my colleagues at CMS. There is a diabetes self-education management benefit that is available to Medicare beneficiaries, but it requires some certain qualifications around Medicare diabetes management team. You have to be a certified diabetes educator. There are some other quality standards they have to meet. And what I'm not sure of is how that interacts with - that's a regular Medicare billed service. I don't know where that plays out in terms of those services that are covered under the standard rural health clinic benefits.

M. Collins

Right, Tom, this is Mary Collins.

T. Barnes

Thank you, Mary. Take it from there.

M. Collins

I'm not sure at this point. My sense is that it's not, but let me research that and that's something that we can address in the May call.

J. Greeley

Okay, thank you.

C. Williamson

That's another great suggestion and we'll try and find out more about it and follow up on. I believe there are also some provisions in the MMA involving chronic care management that are including diabetes, and CMS is looking into some ways to promote that. And I'm not sure what the status with that is. We can also follow up on that as well.

J. Greeley

Thank you.

C. Williamson

Sure.

Coordinator

At this time, we have no additional questions.

C. Williamson

Alright. Wonderful. Well, let's go ahead and move on and hear directly from some rural health clinics that are very graciously willing to come in and talk about what they've been doing around quality improvement. So, first off, I'd like to go ahead and introduce Cheri Elmore. She handles Operations for Healthcare Network Associates, which is a health system based in Springfield, Illinois that includes six rural health clinics; and if you guys have happened to have visited our Web site today, we've just posted a couple of documents that Cheri sent to us. One was some of her ideas for starting small and doing quality improvement, and also lists her contact information.

She's also put up a really nice template that she asks the rural health clinics to fill out to explain what their QAPI program is, what the justification for it, what performance measures they're using. It might be a nice thing for clinics to look at if you're looking for a way to document what you're doing around quality improvement, because most clinics do some quality improvement; one of the challenges can be to finding a way to document it. So she's put together a nice thing to help with that.

So, with that said, let me just go ahead and turn things over to Cheri.

C. Elmore

Great. Thanks a lot, Craig. Just as Craig was saying, I come out of Springfield, Illinois and we have six rural health clinics that are located within about a 40-mile proximity of Springfield. I would also like to say, though, that my background before this was working in Southern Illinois, primarily calling on a lot of the physicians that are probably in the rural health clinic now. And so I guess the reason why I wanted to make the presentation that I was today is because we all have to start somewhere, and as wonderful as it is to have sites on electronic medical records and technology, I realize, at least in my state, especially in downstate, that the resources might not be there for that.

But the exciting thing is is that there are so many things that can be done that are simple and basic and I think that you have to start somewhere. And so, that's really what I wanted to tell you is just a story, a little bit, about how we got started, which was back in 1995 and that's when we were first forming our physician network. Right now we have four other clinics that are non-rural health in our network with the six rural health clinics kind of being our main focus.

When we first got started with our quality efforts, it ended up being in areas that we were almost forced to respond to or react to. We're like a lot of offices in the fact that we had surveys that were conducted for lab and for x-ray. We had a lot of medical records reviews that were being done by payers and they would always leave us with reports of what we should try to do better.

We had input from physicians; we had staff; we had patients that were all talking about unmet needs and problems that we were having and, over time, what happened is they became opportunities to make improvements.

We started measuring areas that we could, and then we'd make changes and then we'd measure again, so, in a nutshell, we started surveying ourselves against regulations like Rural Health and like OSHA and CLIA and we realized that there were so many of the basics that were worth our attention. And the good thing is that they still are.

The point is, it wasn't rocket science, but it did take effort, and it made a difference in our quality. So our quality path really started with improving processes that affected compliance, and compliance is a great place to start. I'm sure that we're not a whole lot different than people that are listening. We had important functions that we were not consistently performing and the key here is the word consistently.

So we would design a new process and see if we could make the changes that we wanted, and, again, these were really basic things like making sure that all our medications and supplies were current and were maintained according to the manufacturer guidelines and implementing quality controls outlined and package inserts for our CLIA-waived labs.

We looked at our emergency preparedness and realized that some of our clinics needed to rethink their emergency strategies. They needed to make sure that they had the right equipment matched to the skill level of the people who would be needing it and the staff that would be using it. And these are all basic areas that a lot of rural health clinics struggle with.

We found it necessary to start small at first, but since then, we've been steadily increasing the scope of our activities. And the system that we're a part of has recently competed for a Lincoln Award, and has received a Bronze medal.

Over the next few years, we will be preparing to make application for a Malcolm Baldridge Quality Award. But it's not the award that we're after; it's everything we accomplish along the way that counts. We learned so much about quality through these types of experiences. Our clinics' QAPI efforts are a part of this larger initiative.

When we started conducting QI activities, we listened. We listened to our patients and our employees and our physicians and others who did business with us. We also looked to resources like NCQA and MGMA to help us define the direction we wanted to go.

One of the areas we worked on was appointment availability. Patients complained about having to wait several days to get in, and staff complained because there were not enough open slots to see the people that wanted to be seen that day. And physicians were complaining because they were getting out of clinics so late all of the time from all of the bring-ins that we were trying to work in in a day.

So, one of the changes that we made is we implemented same-day scheduling, otherwise known as open-access. And we continue to take monthly measurements to see how we're doing with this.

We also started doing things like ensuring that every one of our patients' charts had up-to-date medications and allergy lists. Not only does this help prevent medication errors and drug interactions, but it also helps us monitor patients more carefully.

Recently, clinics have identified a problem with having an up-to-date demographic data for all of our patients, so we set benchmarks and performance goals for updating the system. We are using the percentages of return letters and problems with filing insurance based on address as a performance measure for this initiative.

Similarly, we identified blood pressure measurements as an important procedure and we're working with staff to reduce the variation of how this very simple task is being completed.

Recently, we've begun a diabetes management initiative in all of our clinics. We are maintaining data on hemoglobin A-1C level system-wide for a period of time and hope to eventually expand the program to other measures.

Like Craig said, I've developed a template that I have all of our clinics fill out and it asks them to cite data indicating the need for a proposed initiative. It asks them to describe the specific steps and the measures that they'll be using to implement their idea and what they anticipate the expected effect to be. So, this template is posted on the ORHP Web site and you might take a look at that and see if that helps you whenever you're trying to find a way to document or communicate your clinic's QAPI initiative.

Overall, I think the biggest thing is that we believe it's important to deliver high-quality care and we have dedicated significant resources, and we've found it useful to find appropriate resources and to start small and then steadily increase the scope from there. And ultimately, we all want to deliver and measure quality care, and that's what doing the job of medicine is all about, in our minds.

So, the final thought is basically you have to start somewhere; start simple; make sure that you all get there together. Anything you can do to try incentives with physicians and employees together is going to help your efforts and, finally, if there's anything that I can do, my contact information is posted on the Web site and I'll be happy to talk with people one-on-one, just about our struggles and our successes here in Central Illinois.

C. Williamson

Thank you very much, Cheri. That was wonderful to hear from. Getting a little feedback on my phone here; I hope you're not hearing that out there.

We'd like to move on now, and I was going to go ahead and introduce Pam Schlauderaff, and correct me if I pronounce name wrong; I'm trying to get it right. She's with Olympic Physicians, which is in Shelton, Washington. She's also the President of the Washington Association of rural health clinics and has been actively involved in doing a diabetes collaborative and some other quality initiatives for a number of years. Without any further ado, Pam, why don't you take it away?

P. Schlauderaff

Thank you, Craig. I'm just, first of all, going to give a little bit of history of where we started and where we're at now. We started small, just like the last clinic. In 1999, after many years of being in private practice, Olympic Physicians added three providers and we became a rural health clinic, all within six months. In the middle of all this chaos and financial stretching, one of our providers wanted to embark on a quality improvement project to improve the care that we give to our diabetic patients.

Washington State Department of Health, in partnership with Qualis Health, which is our QIO, or Quality Improvement Organization - used to be called PRO - were looking for clinics to partner with them in a pilot study to see if quality improvement principles could work for clinics and improve the lives of our diabetic patients.

The Department of Health developed a diabetes registry software tool that was available if we purchased Excel software. I was a hard sell. Finding the financial resources necessary to take on a project of this scale was daunting but I can tell you, from hindsight, I became a believer in the value of improved quality.

Word of mouth spread about what we were doing. We received positive publicity from our local news media and our lead physician was chosen as Washington State Rural Physician of the Year. We now care for over 800 diabetic patients and have helped spread the diabetes registry to three other local clinics and other rural clinics throughout the state of Washington.

It was expensive. One or two of our doctors attended eight days of classes where they could learn and network with other clinics. In addition, there was a lot of time that we spent extracting chart data, meeting to plan for change, doing data entry.

Was it all worth it? In my mind, absolutely. I became a believer, so much so that we went on to partner with Qualis and the Department of Health in a cardiovascular collaborative in 2001 and a wellness collaborative in 2003.

While not all clinics are going to embark on a project the same scale as ours, you will find that improving what you are doing is important to every clinic. As providers, we know that nothing stays the same for long. When we see an area that we can improve and do a better job of, it is natural for us to look for ways to improve what we are doing. QAPI is looking at what we are doing, finding ways to do it smarter, more efficiently or, perhaps, differently.

I'm just going to kind of outline the principles of what a QAPI program is, in our mind. Before you really start your QAPI program, though, you need to develop a policy for your manual and a place to document what your efforts have been. I've started a notebook detailing what we have done in the past, and am continuing to add our current data, successes and failures.

So, quarterly, I print out, from our database, what it is, where we're at and then I share that with our providers to show what are your glycohemoglobin rates? Where are they at now? How many of your patients have had mammograms? Just so they get that constant feedback.

And I will say, also, that the better your data, the more reliable your data is, the more likely your physicians are to buy in and participate actively.

Quality improvement uses the principles of plan, do and act, more commonly called PDA. PDA cycles can be used to plan, do and act the whole project, or they can be used on a smaller scale to implement change within any one area of the project. And I'll give an example of one that we used.

Our PDA for the whole diabetes registry development was to develop our goals and our plan, how we were going to get there, and what was the final action we learned that was sustained or what were the ongoing efforts? What was the ongoing long-term solution?

An example of the PDA within the larger project or a smaller PDA cycle is, how are we going to get our baseline data within this whole large plan? How are we going to pull charts and extract the data and what form are we going to use? And, what did we learn along the way, so that if we go through chart extraction again, that we can use the next time? We have many, many, many PDA cycles within our large PDA cycle of improving the care of diabetic patients.

Your first step is to develop your plan or what you can do better. Your project can be from any area in your practice. You could survey your staff or patients to find out an area that you need to improve. Some examples - and these are just a very few - I think Forrest mentioned that your quality improvement can come from any area within your office.

Some examples that I have listed are develop or improve a flow sheet to track pap smears, mammograms, immunizations. Survey your patients after they've been at your office to see what were their wait times or their patient satisfaction. Develop a pamphlet to hand out, including local resources such as gyms, your local AA or local support groups. Negotiate discounts at your local gyms like Curves for patients that you can refer there so that they can get more reliable at exercising.

Make your billing statements more user- friendly. Reevaluate your sliding fee schedule and track your usage. How are you making that available to your patients? Randomly pull - you don't have, don't want to go into - when we started, we did 250 patients with our diabetes study. You could randomly pull 25 charts, which I think is doable for most of us, and check to see what - get a baseline glycohemoglobin and come up with a baseline average. Or you could see what percentage of patients over 65 have had a Pneumovax, or you could pull women's charts ages 50-65 and see what percent have had a mammogram in the previous 12 months. Or you could also do a depression screen; see what percentage of your patients have had a baseline depression screen.

And then pull those same charts in six months and in twelve months again, and see where your data is then, after you've done a little bit of teaching, and say, this is what we're going to focus on for this six months, and just see how much improvement you get. If you're doing 25 charts, that should be something that should be meaningful enough, yet doable enough for even the smallest clinics.

One of the things we're looking at doing, that's going to be an ongoing QAPI project for us, in addition to the registries that we're doing, is we're going to try having a modified hospital lists. Our docs feel that they could a better job of caring for patients if they could devote more time to either the office or the hospital. We have four doctors, and they want to have one week, so it'd be every fourth week where they'd do all of the hospital care for the office, and they're only in the office four hours a day, rather than their full eight or nine hours a day. Will it work? We don't know, but we're going to give it a try. We're going to document our efforts, evaluate and see what long-term changes this causes.

The list is really endless as to what you can do for QAPI projects. It can be small; it can be large. You just need to look at what is going to work for your clinic and give it a shot, and give it a go. You won't always find success but it's working through that process and trying to make things better.

Plan also includes how am I going to reach my goal or many PDAs? When we did the wellness collaborative, we had to cite which patients do we include? How do we extract the data? What data do we want to target? And can all our providers agree on our targets? How do we get the ongoing data from the chart to data entry? How do we get the flow sheet into the chart? The principle of PDA, which is many times within the larger PDA as the whole project.

Next, onto the D of PDA or Do. This is where we are done planning and get to start making the change. As you are doing your project, you will also be learning what is working and what is not, having ongoing feedback and study as necessary. As you are implementing change, issues may come up that cause you to make adjustments. You may have to develop many PDAs along the way to work through new issues as they arise.

An example for us was, the nurses thought that medical records was sending the ongoing data to data entry, and medical records thought the nurses were doing that. So, here we are, three months into the project, and our data hasn't changed. So we had to go back and clarify who was doing what, repull charts and reextract the missing data from the charts of the patients that we'd seen in that interim period. So, with change, you'll learn and adjust as you go. PDAs just give you a way of formalizing and documenting the changes as they occur.

And finally, the third step in a PDA cycle, or Plan, Do, Act, is Act. This is what have I learned and what sustained change or improvement has occurred? With diabetes collaborative, the results were profound and we were able to spread it to many other practices and maintain our registry today.

With the wellness collaborative, change came slow. Those patients come in seldom and was the most pain out of pocket for preventative services they did not buy into the need for what we were measuring such as hemo-cluts, cholesterol screening, depression screening, etc. We decided that spreading the wellness registry to all of providers was not useful and focused instead on improving our flow sheet and training our staff to better utilize the flow sheet that tracks our wellness measures.

Throughout all these efforts, I've become a firm believer that there is a place for quality improvement in rural health clinics. When we do a great job, word spreads in our small communities and people will have greater confidence in the care we provide. I would encourage you to watch for opportunities to partner with others. Quality improvement does not have to be scary. Use the principles of Plan, Do and Act, or PDA, to document your efforts. I have found that quality pays for itself.

And while I was waiting for the other - while we've been here, I've been looking at some other Web sites and I noticed that Qualis Health, which is our quality improvement organization, has posted, on their Web site, a free download of the computer tool to do a registry. Their Web site, if you'd also like to add this to your list, is www.qualishealth.org. Thank you, Craig.

C. Williamson

Thank you, Pam, for all of your insights and experiences, and thanks for sharing that last resource with us. We'll be sure and get that up right away and get that to as many people as possible.

Pam was modest, too. She didn't mention that she had such success with their diabetes management program and lowering HBA1-C levels, that her clinic was actually the subject of an article, I believe in the March or even the April issue of the Joint Commission and Journal of Quality and Patient Safety on her diabetes management program. So if you'd like to learn a little bit about that side of it, we've got the reference to that article up on the ORHP Web site. So, thank you very much, Pam, for coming in.

And moving on to the final clinic we have coming in to share experiences with you is coming from Alma, Georgia. Rene Childree is going to be talking. She's a nurse practitioner at a provider-based clinic in Alma, Georgia, which is in South Georgia. She's also a board member of the Georgia Association of rural health clinics. So, Rene, why don't you go ahead and talk a little bit about what you have going on in your clinic.

R. Childree

Okay. Thank you, Craig, and good afternoon, everybody. As Craig said, I'm Rene Childree. I'm a family nurse practitioner and I'm the Director of two small rural health clinics. We are affiliated with a 35-bed hospital in Alma.

Our Alma plan started quality improvement activities in 1996, in conjunction with our hospital systems preparation for our first joint commission accreditation. Based on recommendations from a consultant that our facility hired, we started with chart audits and peer review of the nurse practitioner charts, as well as with patient satisfaction surveys. The greatest emphasis at that time, really, was on the chart audits, where you focused primarily on complete and correct documentation, as well as review of the nurse practitioner charts by the medical director. And as a new clinic, that seemed a reasonable place for us to begin with our quality measurements and our assessments.

During the time of our second joint commission survey, based on recommendations from the surveyor at that time, we expanded our focus to include patient and family education. As a part of this initiative, we developed and tried several different tools to assess and document both patients' and family members' ability and readiness to learn, as well as looked at our own documentation of the education we provided and our evaluation of the impact of that education. This is a tool that we have continued to tweak over the years, and we continue to focus on this important aspect in healthcare.

We've tried several different tools, and this has finally led us to one that seem to work real well, and has become an integral part of our patient record and our progress note form. That's just one example of how process improvement continues to work as a dynamic entity in our clinic.

Most recently, based on recommendations, again from a joint commission liaison, we've expanded our focus to look at adherence to evidence-based standards for care for our more frequently seen diagnoses. I suspected that diabetes, hypertension and dyslipidemia were among our most frequent patient conditions and we collected data from our records that substantiated this. An online search for practice guidelines lead me to the Texas Department of Health Diabetes Toolkit that's been mentioned previously.

The flow sheet that's available on that Web site was adapted to our practice, with feedback from our medical director, the LPNs in both of our clinics and our other nurse practitioner. The flow sheet tracks the frequency and the findings of different tests, such as hemoglobin A1-C, blood pressure measurements, weight, lipid profiles, foot exams, patient education, medications that are on board for that patient, and other standards.

The ideal standards are included on the flow sheet that's placed in each chart, so it makes it easy for both providers and nursing staff to see at a glance what needs to be done for each patient visit into the clinics. Using this same tool, we developed a method to audit the charts so that we could collect the data and track our progress and we developed a policy and procedure for conducting the chart audits for diabetes care.

The policy and procedure, as has been mentioned, is really important so that everybody who participates in the process does have a guideline to follow. We haven't used our flow sheets yet for an entire quarter, so we're really anxious to see how they've helped us improve. Once we've tracked these for at least three months, we'll determine if we need to continue working on this particular protocol or if we can begin expansion into other areas, including hypertension and dyslipidemia.

We're also in the process of revising and initiating a new patient satisfaction survey. This was a quality initiative that we previously had tracked, but after over three years of nearly 100% approval ratings, we dropped it about two years ago. Since that time, we've had significant staff turnover and a lot of changes in our operation, so we're interested to see if we still rate so highly.

This is an example of how you can go back and revisit standards that were previously met to check your progress and see if you've maintained your game. We're also looking at developing some quality initiative criteria that are specific for our clerical staff, including methods that can enhance our billing and scheduling functions, and other front office procedures.

When we started our quality program in 1996, the entire hospital system underwent an education program to help everybody effect a cultural change in the way we all functioned. Our system includes a nursing home, the hospital, a rehab center and the two rural health clinics. We've lost and added staff in our clinics since that big sweep education time, so we've had to continue our educational process with the employees in the clinic and to be diligent to encourage everybody to continue focusing on process improvement.

We all get tired of chart audits; we all get tired of the paper trails and we all get tired of checking behind ourselves to see how we're doing. But we try to encourage and, in fact, we actually require all of our staff to participate in some way. And by assigning different positions and specific responsibilities that helped meet our quality standards, everyone gains a sense of ownership, a sense of accountability and a sense of pride in doing a job well and improving what we do on a daily basis. So this becomes not an added burden, but a habitual way of functioning.

All of our quality data is collected and collated on quarterly basis and it's submitted to our systems' Professional Activities Committee. This committee looks at quality data for our entire system and it meets on a monthly basis. The committee submits the findings to the medical staff, and ultimately to our governing board. So, in this manner, the whole system is made aware of the quality initiatives of every department in our system and the medical staff and the board is informed of how these initiatives can impact services provided.

Significant changes for quality improvement, especially those that have a major dollar figure attached to them, or that really impact services provided by any department, has to be submitted for approval before they can be initiated.

We also use the Plan, Do, Check and Act format for our quality performance activities. If you're not familiar with this format, a really good Web site that gives you some information on it is www.rootcauseanalyst.com/focus.

Pam talked about the steps of this format in her presentation, but we have a little variation on this as she presented it. And we include the Check component. The Check area is simply an ongoing evaluation of what you did and how it worked. Did your plan meet your guidelines? Did it fulfill the criteria that you hoped to meet? If it did, then you Act to continue doing what worked for you. If it didn't, then you Act to change what you did. You go back through the process of Planning and Doing until, when you Check, you've met your goals, as desired, to accomplish your process improvement.

Then you continue the format as a circular process, constantly reevaluating whether the process is working to meet your goals as your practices, your policies, your patient population and other variables change. In this way, process stays dynamic and ongoing and really becomes a function that let's you reevaluate how you meet your standards within your practice.

One way that we've made the PDCA thinking real for our employees is to offer, throughout the system, a PI short form. This is a one-page form that let's any staff member suggest a way to improve. These improvements can be very small things, like a different way to post a more visible sign for clinic hours, or really large things like major software changes to enhance billing and scheduling activities.

The short form is also submitted to the Professional Activities Committee and it's a great way to recognize how individual employees contribute to the overall functioning, both in the clinics and in our hospital system. The short form can be a complete improvement process in and of itself, or it can lead to a more extensive process, as would be appropriate for more expansive and more costly projects.

The important point with these short forms is that it gives an easy mechanism to any employee to make any suggestions for improvement in how things are done. Oftentimes this may involve a better way to do that employee's job, and who knows their job better than that particular employee?

Quality improvement is a continuous process, and if you use it, you're always going to find ways to improve what you do. Projects don't have to be big to be significant. No one employee should be totally responsible for the entire process; though, most likely, you're going to have somebody who's got to oversee it and be responsible for assimilating and reporting the data. But if you use it properly, it becomes a habit for employees, as it has for us, basically a way of thinking and a way of being that each person is encouraged to look for a better way to do their routine activities for daily clinic life.

In closing this, I would warn those of you without quality programs in place that many of the people you work with will see this as a negative endeavor initially. It's more paperwork; it's more people checking what you're doing; it's more work to do. The list of complaints goes on and on and on.

So, if you have an individual who's overseeing this and who really values the worth of quality initiatives to begin with, then this is a major plus factor in keeping other people excited about it. In addition, management's got to value this. They have to own it, and they have to display that attitude to every single employee throughout the whole system. If employees perceive that this is not something in which everybody's involved and for which everyone is responsible, it won't be a smooth process.

Continuing education on quality assessment and process improvement gives an enhanced value as a culture of quality. It helps your organization and every employee in it focus on quality. And with the general nationwide focus on quality issues in general, we all have to remain focused in these initiatives. It does become a way you work and not a thing that you have to do, so I think that we all benefit in the long run.

Thank you.

C. Williamson

Thank you, Rene. As always, we really appreciate your comments. You said things very clearly and it's … and we especially value your comments on the role of cultural change and implementing quality improvement that I think were particularly insightful.

What we'd like to go ahead and do now is open things up to the audience for questions, and if you have questions, particularly for Cheri, Pam or Rene to ask more specifically about what they're doing, they talked a long time and threw a lot of information at you, and Web sites, and we're doing a lot of different things, so feel free to ask them questions, or also, if you have more general questions for Forrest or myself, or others here in the Offices of Rural Health Policy, now is the time to express those. So, Operator, can you go ahead and open things up for questions?

Coordinator

Certainly. Anne Skinner, you may ask your question.

P. Hearth

Hi. Actually, this is Pat Hearth, I'm here with Anne Skinner. This is a question, I think, mostly directed at Pam, but perhaps Cheri or Marie. I was just curious, Pam, when you actually got your diabetes management program implemented, and it was running along, I was just kind of wondering if there were any impacts or changes in things, just basic things like patient load or visits or revenue or anything on even the satisfaction of patients or provider happiness.

P. Schlauderaff

You know, I haven't gone back and surveyed patients specifically to that, but I can tell you that when we started out we had 250 patients, and within two years we had 800 patients that had diabetes. And there's a definite positive impact when you're caring for 800 patients with diabetes every three months or every six months. So what I found is that doing that and becoming known for that, patients started seeking us out and, pretty much, most of those patients we schedule for half an hour, to be honest, and they bill pretty much always level fours or level fives on those. So I find that it's paying for itself.

P. Hearth

Thank you.

P. Schlauderaff

You're welcome.

Coordinator

Kate Clemens, you may ask your question.

K. Clemens

Thank you. I'm with the Oregon Office of Rural Health. We've been working with a lot of our rural health clinics on getting the QAPI initiative going, and one of the questions that has come up that I'm not real clear on is when they choose what they're going to do, they start it; they get it going; it's been a year. Is it reasonable to evaluate it and if it hasn't met what they wanted to, using the suggested models, perhaps, from some of the clinics today, reevaluate why didn't it work and how we might approach it? Is it appropriate to just use that as a continuing initiative the next year instead of adding a new one, because we have a lot of clinics with one and a half or two providers.

C. Williamson

CMS, do you have a response to that question?

M. Collins

This is Mary Collins. If I understand the question correctly, you're saying should you stay with a project for a year or should you abandon that and, perhaps, go on to something else. I think if you've identified that as a real need for your clinic, and you still want to try to implement improvement efforts, that you should continue with that until you're satisfied that you've improved that. If that's a priority for your clinic, that's my suggestion.

But it's something that each clinic might need to evaluate.

K. Clemens

Right. So if it is something that they want to continue with at the end of the year, so it's appropriate, I guess, my question is, to just continue with that one and that they're not going to be required to add additional initiatives if they are still working on the one that they started, as long as they can show that they're continuing on with it, that they did make some effort to meet some benchmarks that they perhaps didn't; they've evaluated why not and they are moving forward with a revised plan.

M. Collins

Right. Correct.

K. Clemens

Okay, thank you very much.

P. Schlauderaff

I would also add that this is really - this is Pam. This is really up to each clinic to define what they want to do, and if you find that you want to work on diabetes and you want to work on that for five years, or ten years, I don't think that that's a problem. I think the principle here is that you're working on quality and that you've got a policy in place and that you're constantly evaluating and seeing what it is you can do better and constantly meaning it's different for every clinic.

K. Clemens

Right.

P. Schlauderaff

So, for us, we're looking at our diabetes quarterly, but in addition to that, we're also doing wellness, and we're looking at that quarterly, and, in addition, we're going to look at some other smaller things that come up, like patient survey. We're going to start re-implementing that. We've got a new provider so we're going to look at what is patient satisfaction with our new provider.

Switching to this modified hospital lists. We're going to try that for a few months; maybe it will work; maybe it won't. So, as things come up, you're just documenting as you go along.

K. Clemens

Right. And you had some good suggestions for documentation. I appreciated that. Thank you.

F. Calico

And I would just make one comment. This is Forrest Calico, also. You mentioned that one-year timeframe, but as you study or check what you're doing, you really may want to modify your improvement process in a much shorter timeframe actually, depending on what kind of feedback you're getting as you collect data.

K. Clemens

Okay. Thank you for that.

Coordinator

Nancy Brennan, you may ask your question.

N. Brennnan

Yes, thank you. I had a question for the Georgia folks. I was wondering if you could talk a little bit more about your patient education program. You talked about evaluating readiness and doing the patient education and measuring what they learned. Could you talk about that process and who does it and how you get reimbursed for it?

R. Childree

Sure. When we first started it, we had a template that I cannot remember where we found it, but basically it asked the patient's age; it identified who was completing the form; it looked at their education level. Any barriers to learning were identified. That included things like how well they could hear, if they had a hearing aide, if they had hearing problems; if they needed glasses or contacts, and if they had those. We have a lot of indigent patients that have these problems and they don't always have the tools to surmount those problems.

And once we had them complete that form - and that was done as part of their initial registration into the clinic - then whichever provider was seeing them, and, by the way, we have myself as a full-time nurse practitioner and a part-time nurse practitioner in our other office, and a physician that we share between the two. So whoever was seeing that patient then looked at that educational needs assessment form, as we called it.

If the patient is too young or if the patient is illiterate and they can't complete the form, either we help them to do it or they have a guardian or parent or friend in the clinic with them that helps them do it. And we adjust our level of education to them. We have different patient education tools that we hand out, some that we've developed, some we've gotten through drug companies, some that we've ordered. And kind of depending on their ability and their readiness to learn, we determine what level of education they're ready for.

And then, at the bottom of our progress note, we just have a very simple check sheet that indicates what the patient was instructed on; whether it was medication, self-care, pain management, the disease process itself. And then we have another checklist under that where we simply check that they've verbalized understanding or that they're able to give a return demonstration, for, for example, for wound care, or that they are unable to comprehend or that they need more instruction.

And this is something the question earlier from, I believe it was from Kate, asked about how long you can do something. This was an initiative that we focused on for over two years. We tried about five or six different tools to make this work. And the one that we're using now seems to be functioning for us pretty good, but I'm sure that, within another year, we'll change it again, too. Did that answer your question? Does that help?

N. Brennnan

Do all the providers do this, or just the nurse practitioners?

R.Childree

Every patient that comes in the office fills that out and we reevaluate that once a year. That's in our policies and procedures that they update that once a year; and every provider, all three of us, utilize that tool in documenting the patient education that we provide, and we utilize that tool in tailoring our patients' education so that it's appropriate for that patient's level of readiness or their ability to learn.

N. Brennnan

Thank you.

R. Childree

You're very welcome.

Coordinator

At this time, we have no additional questions.

C. Williamson

Anyone lining up to call in? This is the final chance for another month. Alright. Well, it looks like that's it for today. I'd just like to thank Cheri and Pam and Rene for taking time out of their busy days and talk with us and answer questions. They really did a wonderful job of describing what they're doing and giving some good ideas for other health clinics and illustrating, to some degree, the value of quality improvement. So thank you very much to you all for coming in.

And thanks everyone else who called in for … ask questions, too. We hope you found this helpful and also will find the documents that we have up on our Web site to be useful.

We went ahead and set a date for that will be the final call in this technical assistance initiative from the Office of Rural Health Policy. That's going to be Wednesday at 2:00 again on May 19th. And what we'd really like for this call is for all of you out there who are listening, and some of those who aren't, to let us know what questions you have, whether it be some funding issues and grants you can apply for, and what we will try to do here at ORHP is, if we don't know the answer ourselves, we'll try and get in touch with people who do and get them on the call to share things.

So what we're asking people to do is, between now and May 19th, as you get a little further into the process or another question comes up, to submit any questions that you have that you'd like covered in the next call to us and we're going to give you an e-mail to send those to. The person we're having compiling those is Matthew Newland or Matt Newland and his e-mail is mnewland@hrsa.gov.

And if you didn't catch all of the Web sites and things that were thrown out, there will be a complete transcript of this call posted on our Web site by the end of the week; that should be up. That will have all the dialog on this. And you can also call and listen to it again, if you decide that you really like what you heard. We'll have a number up on our Web site. I believe it's up there now, actually, that tells how you can call in through May 15th of next month.

With that said, thank you for everyone who called in. Does anyone else who's … have any final comments?

Coordinator

We do have a question, if you would like to take that, sir?

C. Williamson

Okay, sure. Let's just take one last question.

Coordinator

Okay. Anne Skinner, you may ask your question.

WHi, this is Mary … When you initially started with your programs, how did you get the resources to start? Did you get any kind of grants, any type of funding from the state, and, if so, what other resources might the state have provided? Any kind of models or guidelines or anything?

R. Childree

This is Rene. Initially, I was my resource. I developed the tools and I collected the data, and I reported the data because I was it. I was the only person in the clinic that was there full-time. But since we've expanded, our staff does this and I use the Internet as a resource, as well as any textbooks or articles that I come across. We've gotten no additional money for any of the quality improvement procedures that we've put into place.

P. Schlauderaff

This is Pam. I can tell you, when we did the diabetes collaborative, there was no funding, no grants, no nothing. It was something that we did just on our own and I figured, at the end of the year, with physicians going to eight hours of classes, it probably was at least $40,000 was the initial start-up cost that first year.

When we did the cardiovascular collaborative, there was no help. When we did the wellness collaborative, we did receive a $10,000 grant, which at least helped with part of the cost. But I find that collaboratives is something that you pay for yourself, but it does pay for itself in the end because people feel better about the work that they're doing. They can see that they're doing things to help people.

I had one of our providers say that doing the diabetes collaborative was the most rewarding thing he'd ever done in medicine. And it took a burned-out physician, who was thinking of maybe not staying a physician, and it just reinvigorated and reexcited him, and to be able to see that what he was actually doing improved people's lives was a really significant impact for us.

C. Elmore

Ma'am, this is Cheri, and likewise, we have sought no additional funding for any of the projects that we are facing in the future. We are getting ready to purchase an electronic medical record and so, outside of that, most of the items, we've just used resources that we've already had available to us and they haven't been extremely resource-dependent up to this point.

R. Childree

I think, again, this is Rene. I think that one of the most import things is that whoever your governing body is has got to recognize that their input has got to provide the resources in the form of salary and time for whoever is doing the initiation of quality improvement projects to have that time available to them. It's probably more time-costly when you first start doing this than it is financially costly in any other way, if that makes sense.

P. Schlauderaff

I would agree with that, and I would also reiterate but I think somebody from Georgia said, that having a team collaborative is probably the most important thing; that it can't really fall on just one person. It needs to be a whole practice, because when you're doing something, the front desk has to pull the chart, whomever, everybody is involved. And it really is a team concept and everybody needs to buy-in together and share and spread the burden some.

F. Calico

If there are no further questions, this Forrest Calico. I just wanted to add to what Craig said because I just so much appreciate the contributions that Cheri and Pam and Rene have made on this call. It's just been fantastic. You guys really get it and I just can't tell you how much I appreciate what your doing and your willingness to share it with the group.

M. Collins

I think - this is Mary Collins in CMS. I would just like to say ditto. I really appreciated hearing what the clinics have done. I think that quite a few clinics have a very good grasp on the regulation and QAPI activities and it just has actually demonstrated to us that the flexibility allowed in clinics, the flexibility to develop its own QAPI program, has really paid off significantly.

C. Williamson

Wonderful. Thank you all for your comments and insights and for everything you've done on this call. So I hope to hear from you again in a month or so and we'll have our … these initiatives, and keep checking out our Web site; we're going to keep posting stuff up there. There have certainly been a lot of ideas and Web sites and documents thrown out during this, and we'll try and follow up what we can and get as much as we can up on our Web site.

Thank you all. Have a great day, and good luck with everything.