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. 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.
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