Quality Improvement and Patient Safety Assessment

The Southwest Border Rural Health Research Center, Rural Health Office conducts the evaluation of the Arizona Flex Program. Both process and outcome evaluations are used for this purpose. The process evaluation assesses the extent to which the program has achieved its stated objectives and completed the objective’s major activities. The outcome evaluation assesses the program’s impacts on the critical access hospitals and their community health care systems (e.g., improvement of financial profile, patient service mix composition, quality improvement, and health care system changes that include emergency medical services). This year’s evaluation is collecting financial, hospital service, and patient quality/safety information. The summary data will provide the CAHs with feedback that can be used in making decisions with regard to the management of their hospitals in these three areas by providing CAH state and national comparison information.

Both HSAG and Stroudwater Associates have assisted the Flex Program in identifying potential patient quality and safety indicators. The initial Flex Program evaluation financial, hospital service, and patient quality/safety indicator list was presented at the November 2005 Flex Leadership Group meeting for review and discussion. The CEOs were requested to provide additional comments after the meeting. Modifications to the indicator list were made after receiving the additional comments. The revised indicator list was reviewed by outside consultants. The final draft of the indicator list was sent to the CAH CEOs for review and comments. The evaluation financial, hospital service, and patient quality/safety indicator data collection form was sent to all the CAH CEOs in early June 2006 to complete.

The remainder of this section focuses on the quality improvement and patient safety assessment (evaluation). This assessment comprises of two components (see Appendix D for details). The first component is the Centers for Medicare and Medicaid Services (CMS) Eight Scope of Work that includes selected indicators from the 10 measure set for Reporting Hospital Quality Data for Annual Payment Update (Pneumonia, Heart Failure, and Acute Myocardial Infraction) and the full Hospital Measure Set “Public Reporting” – Hospital Quality Alliance (Surgical Care). The data collection period for the three pneumonia indicators began 2002 and the two heart failure indicators began 2003 since the Pneumonia Model for Quality Improvement Workshop and Congestive Heart Failure Quality Improvement Videoconference were given in 2003 and 2004, respectively, and this provides the baselines for comparison. The acute myocardial infraction and surgical care data collection period began 2004.     

The second component is the Rural Performance Measures developed by Stroudwater Associates as part of their Balance Scorecard Program. Quality and patient safety measures are selected from four areas of the hospital: (1) Emergency Department, (2) Laboratory Department, (3) Radiology Department, and (4) Medication Reconciliation and Pharmacy Department. The selected measures primarily examine turn around time, error rates, and conformance to equipment calibration guidelines. The data collection period for all these measures began 2004.

A summary of the Flex CMS Quality Eighth Scope of Work indicators for 2002 – 2005 is presented in Appendix E. HSAG has provided the data for the summary. The summary is broken down by Total CAHs (Community and IHS/Tribal), Total Non-CAHs (Rural and Urban), State and National. This provides the reader with several different comparisons.  Two limitations of the summary are: (1) not all the CAHs are participating in the Volunteer CMS Public Reporting Program and (2) not all the data are provided by the CAHs. These should no longer be limitations when the Arizona Flex Program received all the CAHs’ evaluation indicator data collection forms.                    

If you have questions about the Quality Improvement and Patient Safety Assessment or the Arizona Flex Program Evaluation, call Howard J. Eng at (520) 626-5840 or e-mail him at aeng@ahsc.arizona.edu.

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