Texas County Memorial Hospital will take part in a two-year Hospital Improvement and Innovation Network (HIIN) project sponsored by the Centers for Medicare Services (CMS), board members heard at their monthly meeting on Tuesday.
“TCMH has entered into a contract with the Missouri Hospital Association (MHA) to provide data for the CMS project,” Wes Murray, chief executive officer at TCMH, reported.
The hospital will not receive any significant funding for participating in the project, but TCMH staff will have access to data and resources related to the project.
“The broad goals of the project will be an overall reduction in all causes of patient harm and a reduction in readmission of hospital inpatients less than 30 days since the first admission,” Amanda Turpin, TCMH quality management director, explained.
TCMH is one of over 100 hospitals in the state participating in the program. The MHA will collect and compile data from TCMH and other hospitals in the state. The state data will then be collected and compiled into national data by the American Hospital Association Health Research and Educational Trust. The program will last two years with the possibility of a third year.
Turpin highlighted key parts of the program which include antibiotic stewardship, hospital acquired infections, workplace violence, physician leadership, patient engagement and healthcare disparities.
“This project focuses on new and upcoming CMS requirements, and it will help us prepare appropriately,” Turpin said.
There will be ongoing reporting of data to MHA and “immersion projects” that will require intense focus and rapid updating of data. Webinars, networking, and on site education will also be part of the project.
TCMH is already making plans to participate in two immersion projects related to the HIIN project—Safe Training and Responsible Restraint (STARR) and antibiotic stewardship.
The STARR program will provide workplace violence training for TCMH staff. With the training, TCMH will develop a violence de-escalation program to use when needed at the hospital.
According to Doretta Todd-Willis, TCMH chief nursing officer, TCMH should have a violence de-escalation program in place, but the hospital has lacked the funds for successful planning and implementation of such a program.
In 2017 all hospitals will be required to have an antibiotic stewardship program in place. An antibiotic stewardship program is designed to promote the appropriate use of antibiotics to improve patient outcomes, reduce microbial resistance, and decrease the spread of infections caused by multidrug-resistant organisms.
TCMH will use the HIIN immersion project to develop policies and procedures for an antibiotic stewardship program at the hospital.
“While this project does require additional data collection and reporting, it is an overall benefit for our hospital,” Murray said. “We will benefit and be better prepared for CMS regulations coming our way by participating in HIIN.”
Murray reported that an obstetrics department face lift was completed earlier in the month by the hospital’s maintenance department.
New lighting, ceiling tiles, paint, and bathroom floor covering were included in the work.
“It had been awhile since we freshened things up in the OB department, and a little bit of work has gone a long way in making improvements,” Murray said.
TCMH added family medicine/obstetrician, Cory Offutt, MD, in July. Jennifer Groner, DO, also a family medicine/obstetrician, is joining TCMH in mid-November.
Offutt and Groner joined three family medicine physicians, an obstetrician/gynecologist and a certified nurse midwife providing complete maternity care and obstetrics services at TCMH.
“Our OB department is doing a great job providing an excellent patient experience, and with the diverse slate of OB providers we have available for patients to choose from, we hope to grow our OB services in the upcoming year,” Murray said.
The TCMH maintenance department is now working on renovating four old patient rooms on the hospital’s East wing for use in the new cardiopulmonary rehabilitation program.
TCMH recently received a $357,000 grant from the Missouri Foundation for Health (MFH) to fund a three-year outpatient cardiopulmonary rehabilitation program. Patients will qualify for the multi-disciplinary program following testing for lung disease. The 12-week program will help patients improve lung function and activities of daily living.
Murray reported that funds from the grant will be utilized to employ a part-time secretary for the program and a full-time respiratory therapist. Dr. Juan Mella, pulmonologist at TCMH, will oversee the program and the patients in the program.
Linda Pamperien, TCMH chief financial officer, presented the financial statement for the month of September.
A decline in inpatient revenue and an increase in contractual adjustments for patients that are not able to pay for their healthcare services left TCMH with a negative bottom line of $468,744.65 for the month of September and a year to date negative balance of $985,745.77.
“In September we had an average daily census of nine patients, and only nine patients were admitted to swing bed, too,” Pamperien said, noting that there were times the census dropped to two patients during the month.
Outpatient volumes were up at the hospital in September, according to Pamperien.
Murray reminded board members that TCMH physician staff levels are still not where they were several years ago. TCMH continues to recruit for an additional full-time general surgeon.
Present at the meeting were: Murray; Turpin; Pamperien; Todd-Willis; Joleen Senter Durham, director of public relations; Dr. Jonathan Beers, TCMH chief of staff, and board members Dr. Jim Perry, DO; Janet Wiseman and Omanez Fockler.
TCMH board members, Russell Gaither and Mark Hampton, were not present at the meeting.
The next meeting of the TCMH board of trustees is Tue., Nov. 22nd at 12 p.m. in the TCMH board room.