RURAL HEALTHCARE QUALITY NETWORK 2010 ANNUAL REPORT 2011 STRATEGIC PLAN

1. RURAL HEALTHCARE QUALITY NETWORK 2010 ANNUAL REPORT 2011 STRATEGIC PLAN Randy Benson, Executive Director

2. Introductions • Elizabeth Evans, B.S. RHQN Executive and Program Assistant • Scheduling of External Peer Review Physician Site Visits • Coordination of Subspecialty External Chart Review • Conference Planning and Coordination • Support for the Executive Director

3. Introductions • Bev McCullough, RN, MBA, CPHQ RHQN Quality Improvement Manager • Coordination of Quality Improvement Processes Identified Through External Peer Review • Provision of Continuing QI Education for Facility QI Leaders • Implementation of Statewide QI Initiatives at the CAH Level

4. Introductions • Randy Benson, B.S.Ed., MS, Ph.D. RHQN Executive Director • Oversight of all RHQN programs • Lead and Manage RHQN Activities to Meet Organizational Goals • Cultivation of Grant Funding • Develop and Implement Quality Improvement, Safety and Infection Prevention Programs

5. Introductions • Myron Bloom, M.D., M.M.M. Medical Director, Peer Review Physician • Senior Peer Review Physician • Provides Peer Review Services for 16 Facilities • Writes Monthly Newsletter “Hospital Peer Review” • Provides Consultation and Assistance on Conditions of Participation for CAH Status

6. Introductions • Bruce Stevenson, M.D. Medical Director, Peer Review Physician • Provides Peer Review Services for seven Facilities • Writes Monthly Newsletter “Quality Matters” • Provides Consultation and Assistance on Conditions of Participation for CAH Status • Provides Privileging and Credentialing Review

7. Introductions • Scott Edminster, M.D. Medical Director, Peer Review Physician • Provide Peer Review Services for four Facilities • Provide Consultation and Assistance on Conditions of Participation for CAH Status • Provide Assistance With Medical Staff Privileging and Credentialing Issues

8. Introductions • Todd Lang, M.D. Medical Director, Peer Review Physician • Provide Peer Review Services for three Facilities • Provide Consultation and Assistance on Conditions of Participation for CAH Status • Provide Assistance With Medical Staff Privileging and Credentialing Issues

9. The Rural Healthcare Quality Network 2010 accomplishments included: • Management • Organization • Quality Improvement • External Peer Review • Infection Prevention

10. RHQN Management Accomplishments: • All of the 2010 RHQN assessed dues were collected. • All member facilities received at least one site visit by the Executive Director or Quality Improvement Manager. • All of the 2010 FLEX Grant deliverables were completed and reimbursed ($145,000). • RHQN 2010 net assets increased substantially.

11. RHQN Operations Accomplishments: • Fourteen DOH pre-survey safety rounds. • Monthly peer review, quality improvement and safety newsletters. • Monthly “Members Conference Call” presentations. • Peer review physicians statewide, strategic initiative driven, quality improvement plan based on individual hospital findings. • Sub-specialty peer review was expanded to include ENT, Ophthalmology, Trauma Surgery, Radiology (Mammography) and Podiatry.

12. RHQN Operations Accomplishments con’t: • Co-hosted the “Third Annual ECS Systems of Care Conference” in Seattle and Spokane , 320 Attendees (EMS, Hospital, MD) • Comprehensive infection prevention risk assessment now adopted by all members and by hospitals in three foreign countries. • Peer review physicians made 178 site visits and reviewed 6753 charts.

13. RHQN Strategic Initiatives 2011

14. RHQN Quality Accomplishments • RHQN 2010 STEMI/ACS Initiative • Implementation of the Standardized STEMI/AMI Transfer Protocols 2nd QTR 2009 2nd QTR 2010 4th QTR 2010 86.4% 96% 100% • Community EMTs Doing ECGs in the Field 2nd QTR 2009 2nd QTR 2010 4th QTR 2010 35.0% 41% 61%

15. RHQN Quality Accomplishments • RHQN 2010 STEMI/ACS Initiative (con’t) 3. Once Call Agreement with Urban PCI Center 2nd QTR 2009 2nd QTR 2010 4th QTR 2010 68% 74% 81% 4. Standardized AMI Transfer Terminology 2nd QTR 2009 2nd QTR 2010 4th QTR 2010 81% 92% 100%

16. RHQN Quality Accomplishments • RHQN 2010 STEMI/ACS Initiative (con’t) 5. Average Arrival to ECG Time 2nd QTR 2009 2nd QTR 2010 4th QTR 2010 <12 min. 75% 82% <10 min. 75% 6. Average Door to Transport Time 3rd QTR 2009 1st QTR 2010 2nd QTR 2010 4th QTR 2010 182 mins. 118 mins. 100 mins. 126 mins.

17. Quality Improvement Accomplishments

19. Stroke Care Strategic Initiative • “3rd Annual ECS – Emergency Cardiac and Stroke Systems of Care Conference” Held May 17, 2011 (Seattle) and June 7, 2011 (Spokane) • Provide Continuing Medical Education and clinical newsletters on “Care of the Stroke Patient in the Rural Setting” and • Continuing Medical Education and clinical newsletters on“Recognition of Stroke Symptoms and Transfer of Stroke Patients to a Primary Stroke Center (PSC)”

20. Continuing Education • “Adverse Event Recognition and Root Cause Analysis” for Process Improvement • “A Taste of LEAN Process Improvement” As a Means of Developing Critical Thinking Skills • Development and Documentation of Staff Competency

21. Collaborations • Washington State Department of Health • American Heart Association/American Stroke Association • Washington State EMS and Trauma Council • Emergency Cardiac and Stroke Technical Advisory Committee • Regional Quality Improvement Organizations • Qualis Health • Washington State Hospital Association • Oregon Rural Healthcare Quality Network • Washington State Rural Health Association

22. Randy Benson RHQN Executive Director randyb@wsha.org (206) 577-1821