Critical Access Hospital (CAH)
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Ohio KePRO, the Medicare Quality Improvement Organization (QIO) for Ohio, began a new three-year contract with the Centers for Medicare & Medicaid Services (CMS) on August 1, 2005. This contract, known as the 8th Statement of Work (8 th SOW) delineates the responsibility of Ohio KePRO to promote transformational change in Critical Access Hospitals (CAHs) through the improvement of clinical performance measures and organizational safety culture. In addition, select CAH and rural prospective payment system (PPS) hospitals will work in an identified participant group (IPG) called the Rural Organizational Safety Culture (ROSC), which is an initiative to assess and improve hospital safety culture.

 

About the CAH Project

The CAH project will utilize the collaborative environment already in place and known as the Ohio Rural

Hospital Flexibility Program, Quality Improvement Work Group. Ohio KePRO, Ohio Department of Health's

Office of Rural Health, and the Ohio Hospital Association (OHA) will continue to support the CAHs in

system level improvements, performance measurement and reporting, and patient safety efforts to

facilitate the recognition of CAHs as leaders in quality healthcare in Ohio.

Project objectives:

• Improve one core measure by reporting hospitals*
• Increase the number of hospitals reporting performance measurement data to the Clinical Data
  Warehouse. The CMS Abstraction and Reporting tool (CART) will be available for this initiative.
  The tool is free.
• Improve the safety culture of CAHs.

* Reporting hospitals are defined as Critical Access Hospitals who submitted data to the Clinical Data

Warehouse for 3 rd and 4 th quarter 2004 on the 10 core measures (also known as the starter set for

public reporting).

 

Rural Organizational Safety Culture (ROSC) Identified Participant Group (IPG)

Ohio KePRO will work with senior leaders i.e. Chief Executive Officer (CEO), Chief Operating Officer (COO),

Chief Information Officer (CIO), and Chief Financial Officer (CFO), to assess their baseline organizational

safety culture, determine improvement opportunities, implement process improvements, and conduct

reassessment.

 

The baseline and reassessment will be done through the use of a standardized methodology and tool.

Ohio KePRO will assist each hospital with the methodology and in the use of the tool. Each hospital will

identify a target area for patient safety culture improvement based upon the results of the assessment.

Both CAHs and rural PPS hospitals can participate in this project.

 

Benefits of Participating

Participating in the CAH ROSC project is an opportunity to:

• Enhance your hospital's reputation in the community by being able to show significant and
  verifiable improvement in quality care
• Work collaboratively with your medical staff on improving care
• Be recognized as an early adopter and leader of quality improvement standards
• Learn and adopt new quality improvement methodologies
• Provide networking opportunities to learn about best practices from peers

Additional benefits:

• Access to resources and successful interventions
• Technical and data collection support
• Access to national benchmarking data
• Tools to help you communicate with your community
• Enhancement of patient safety strategies
• Relevant Data Reports

What Participation Involves

Hospitals will be asked to:

• Form a multidisciplinary team
• Conduct team meetings on a regular basis
• Develop an overall action plan and timeline
• Share progress, barriers and successes
• Strategize to incorporate a variety of improvement methods
• Meet with your Ohio KePRO Project Leader regularly
• Demonstrate commitment through signature of the CEO
• Help identify physician or other clinical champions
• Continue to abstract same 10 core measures and submit to the clinical data warehouse
• ROSC IPG participants: Conduct the AHRQ "Hospital Survey on Patient Safety Culture" as a
  baseline and a remeasurement for improvement development

What Ohio KePRO will do for CAH Hospitals

• Share best practices
• Facilitate utilization of the MedQIC web site ( www.MedQIC.org )
• Provide:
  - Monthly on-site visits
  - A project manual outlining all aspects of the project
  - Education and training on the data collection tools
  - Technical assistance for data collection
  - Individual consultation and education in QI methodology, specifically as it relates to rapid
  cycle testing of change and improvement
  - Regular project meetings/teleconferences

Statewide Hospital Quality Improvement Goals

Ohio KePRO will work with all Ohio hospitals toward improvement in the following areas:

• Increase the number of hospitals reporting the expanded set of twenty-two (22) quality measures
  for the Hospital Quality Alliance
• Increase the number of hospitals achieving a passing score (80% accuracy) on data validation
• Improve performance measure results on SCIP-1, prophylactic antibiotic received within one hour
  of surgical incision
• Increase the number of critical access reporting hospitals by fifty percent (50%)