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.
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