Rural Health Clinic Annual Program Review FY19 at Bair Memorial Clinic
This document outlines the annual program review for Fiscal Year 2019 at the Bair Memorial Clinic, focusing on the vision, mission, values, governance philosophy, advisory group members, and key regulations such as certification procedures, compliance with laws, physical plant maintenance, and program evaluation.
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Rural Health Clinic Annual Program Review FY19: Bair Memorial Clinic Jane Moe December 30, 2019
Vision Statement Quality healthcare close to home. Values Respect Excellence Stewardship Wholeness Response to need Mission Statement Responsive to the healthcare needs of the communities we serve, Wheatland Memorial Healthcare is dedicated to providing sustainable quality care with respect, compassion and teamwork. Governance Philosophy What good for whom and at what cost.
RHC Advisory Group Members Joan McMahon, MD, Chief of Staff Rick Poss, Interim CEO Don Amundson, Trustee Jane Moe, Interim Clinic Supervisor Abbi Boggess, Compliance Officer Allison Fenley, DON/Quality Bobbie Murry, Informatics Peggy Hiner, Human Resources
Electronic Code of Federal Regulations Purpose and scope 491.1 Definitions 491.2 Certification procedures 491.3 Compliance with federal, state, and local laws 491.4 Location of clinic 491.5 Physical plant and environment 491.6 Organizational structure 491.7 Staffing and staff responsibilities 491.8 Provision of services 491.9 Patient health records 491.10 Program evaluation 491.11 Emergency preparedness 491.12 Reference: state operations manual for Rural health clinics https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som107ap_g_rhc.pdf
Purpose and Scope 491.1 Rural Health Clinic must perform an annual program evaluation and take corrective action if necessary.
Certification Procedures 491.3 A rural health clinic will be certified for participation in Medicare and Medicaid
Compliance with federal, state, and local laws 491.4 Rural health care clinic and its staff are in compliance with applicable Federal, State and local laws and regulations. Clinic and staff licensures, certifications and registrations are all up to date.
Physical Plant and Environment 491.6 This is done so that all essential mechanical, electrical and patient-care equipment is maintained in a safe operating condition. Preventative maintenance Safety inspections are done monthly by maintenance Physical plant safety and inspections Fire martial inspection was November 2019 Environmental rounding with infection control
Organizational Structure 491.7 The clinic is under the medical direction of a physician, and has a health care staff that meets the requirements of 491.8
Staffing 491.8 The clinic has a health care staff that includes one or more physicians
Provision of Services 491.9 The clinic has agreements or arrangements with one or more providers under Medicare or Medicaid. If not in writing then there is evidence that patients are referred by the clinic are being accepted and treated
Provision of Services 491.9 Taking Complete Medical Histories and documenting in Cerner, our Electronic Medical Record Performing complete physical examinations Assessment of health status Diagnosis and treatment for common acute and chronic health problems and medical conditions Immunization clinic to include most immunizations, allergy shots, B-12 injections, flu vaccine and TB tests VFC state stock immunizations Spirometry, Padnet, and unattended sleep studies. Laboratory tests, ultrasound, CT, X-ray, Acute care, ER, Inpatient and outpatient services, and Physical Therapy are available through Wheatland Memorial Healthcare. Bair Clinic has a contract with Ortho Montana to visit the clinic once per month for patient orthopedic needs. Patients can be referred for WIC services, Mental Health, Dietary and Chemical Dependency services that are provided in the basement of the Clinic as outreach services. Podiatry and endocrinology surgery comes once a month. Triage first response services to common life threating injuries and acute illnesses. The responsibility of all Medical staff is to provide quality patient care for all patients treated at Bair Memorial Clinic. Laboratory Tests available at Bair Memorial Clinic: Chemical examinations of Urine Hemoglobin & Hematocrit Blood sugar testing Pregnancy testing (Urine) Primary culturing for transmittal to a certified laboratory
Patient Health Records 491.10 The rural health care clinic maintains a clinical record system in accordance with written policies and procedures. Records are retained for at least 6 years from date of last entry, and longer if required by state statute. The clinic did a purge of records in August of 2019
Evaluation 491.11 The clinic carries out, or arranges for, an annual evaluation of its total program. Overall operations of clinic Financial performance Utilization of Services Review of policies and policy deviation Chart review Recommend any necessary changes approve plan for FY20 Operations
Emergency Preparedness 491.12 On 07/25/2018 the clinic participated in the community wide disaster drill Active participants were Wheatland Memorial Healthcare, Bair Memorial Clinic, Wheatland County Sherriff, EMS, fire, and road departments Response from Sweet Grass and Golden Valley counties as well The clinic learned how they would operate during a time of a community wide mass casualty Closed clinic operations to assist in hospital setting
Bair Memorial Clinic Hours of Operation: Monday Friday 7:30AM to 5:00PM Closed on Major Holidays
Daily Staffing Two Providers Two Clinic Nurses Two Receptionist/Schedulers
Provider Staffing Physicians One Chief of Staff One Primary Care Physician who is also the APP supervising physician Advanced Practice Practitioners (APP) 2 Physician Assistants 3 Nurse Practitioners
Staffing Change FY19 Interim Clinic Supervisor Brooke Stagner from June - December New Clinic Director December 2019 Jane Moe Hired casual providers Dr. Welsh was rehired in February Dr. Rabold was hired in June Beverly was hired in February
Staff-Review Physicians, Nurse Practitioners, Physician Assistants, nursing staff, clinic receptionists and Clinic Supervisor are evaluated on an annual basis using criteria established by Wheatland Memorial Healthcare.
Patient Volumes Update Graphs below
Provider & Nurse Numbers Update Graph Below
Pediatric Immunizations Update Graph Below
Flu Shots Update Graph Below
Clinic Volumes FY 19 Update Graph Below Clinic Encounters 600 500 400 300 200 100 0 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 2018 2019 2020
Outreach Services in 2019 Ortho MT-Orthopedic Services Podiatry Mental Health Services WIC Surgeon general and endocrinology Chemical Dependency Dietician
Policy Review Bair Memorial Clinic
Review of Policy and Procedures October 26, 2016 Compliance 360 implementation to captured clinic policies, allow for review, approval, amend or archive policies. All clinic policies have been reviewed and are being revised on a continual basis. BMC policies are reviewed annually. Documentation of edits, amended or archived policies will be tracked in Compliance 360. See BMC Policy Report 1/1/2018-12/31/2018
BMC Protocol Report January 1-December 31, 2019 Update Graph Below January 1st, 2018 to December 31, 2018 Protocol Report LAST REVISION 10/4/2018 RETIRED 10/9/2018 6/14/2018 10/9/2018 10/9/2018 10/9/2018 10/9/2018 4/17/2018 5/8/2018 10/4/2018 SCHED. REV. DATE 10/1/2019 RETIRED 11/1/2019 6/1/2019 11/1/2019 11/1/2019 11/1/2019 11/1/2019 3/1/2019 4/8/2019 2/1/2019 PROTOCOL LOCATION STATUS # TITLE CREATED BMC - Bair Memorial Clinic (RHC) \ Clinic Protocols Locked BMC - Bair Memorial Clinic (RHC) \ Clinic Protocols Retired BMC - Bair Memorial Clinic (RHC) \ Clinic Protocols Locked BMC - Bair Memorial Clinic (RHC) \ Clinic Protocols Due Soon PP-102 BMC - Bair Memorial Clinic (RHC) \ Clinic Protocols Locked BMC - Bair Memorial Clinic (RHC) \ Clinic Protocols Locked BMC - Bair Memorial Clinic (RHC) \ Clinic Protocols Revision PP-105 BMC - Bair Memorial Clinic (RHC) \ Clinic Protocols Locked BMC - Bair Memorial Clinic (RHC) \ Clinic Protocols Revision PP-108 BMC - Bair Memorial Clinic (RHC) \ Clinic Protocols Revision PP-109 BMC - Bair Memorial Clinic (RHC) \ Clinic Protocols Revision PP-110 BMC-108 Triage of Emergent Clinic Patients 12/19/2016 BMC-111 Suture Removal PP-101 ToxCup Urine Drug Testing Clinic Nursing Guidelines & Standards 12/4/2017 PP-103 Fire Plan PP-104 Liquid Nitrogen Blood Glucose Monitor PP-106 Oxygen Maintenance Spirometry VFC Vaccine Clinic High Risk Medication 9/27/2017 5/15/2017 12/20/2016 12/20/2016 11/14/2017 11/14/2017 4/17/2018 12/28/2016 3/13/2018
BMC Policy Report January 1-December 31, 2019 Update Graph Below January 1st, 2018 to December 31, 2018 Policy Report LAST REVISION SCHED. REV. DATE POLICY LOCATION STATUS # TITLE CREATED BMC - Bair Memorial Clinic (RHC) \ Clinic Revision BMC-101 Drug Security 12/27/2016 6/14/2018 6/1/2019 BMC - Bair Memorial Clinic (RHC) \ Clinic Revision BMC-102 Drug Storage 1/10/2017 6/14/2018 6/1/2019 BMC - Bair Memorial Clinic (RHC) \ Clinic Revision BMC-105 Nursing Care Procedures 12/27/2016 5/8/2018 5/8/2019 BMC - Bair Memorial Clinic (RHC) \ Clinic Revision BMC-106 RHC Advisory Group 2/1/2017 6/14/2018 6/1/2019 BMC - Bair Memorial Clinic (RHC) \ Clinic Retired BMC-114 Tuberculosis Skin Testing 9/25/2017 RETIRED RETIRED BMC - Bair Memorial Clinic (RHC) \ Clinic Revision BMC-115 Medical Records Release To Providers 11/22/2017 6/14/2018 6/1/2019 BMC - Bair Memorial Clinic (RHC) \ Clinic Revision BMC-116 Medication Refills 7/24/2018 7/25/2018 6/1/2019
Quality Review Bair Memorial Clinic
Process Improvement Update Below Process Improvement Plan for RHC Annual Review and State Survey Deficiencies During the time frame of completing the Plan Of Correction for the State Survey, there were staff changes and an electronic go-live for Lawson. Thus limiting us in availability of resources and staff to assist with meeting 42 CFR 491.11 (Program evaluation) . As of 12/14/2017 a new 2018 quality improvement plan was created based on these Plan Of Correction deficiencies.
2019 BMC Quality Improvement Plan Outdates The goal is to have 100% accuracy on completing the outdate checks on the First and Third Tuesday of the month for four consecutive months. The outdate checks plan will change to monthly after four consecutive months with 100% accuracy. Bair Memorial Clinic is performing outdates once a month and continue to work with CSR to get outdates on all items and now getting a 91% for the year of 2019 as of April. Annual Review The Clinic Director will schedule an Annual Rural Health Clinic Advisory Group Meeting within 365 days of the previous Annual meeting. The RHC Advisory Group will advise Bair Memorial Clinic on professional issues regarding Rural Health Clinic activities, participate in the evaluation of the Rural Health Clinic programs and assist the Rural Health Clinic in maintaining liaison with other community health care providers. Previous clinic director resignation led to delay in annual review : 2019 review planed for February 2020. Patient Satisfaction Surveys Update information here
Sample of Active and Closed Clinical Records Dr. Joan McMahon, Chief of Staff, has completed random chart reviews. Three clinic charts per quarter for each provider were randomly chosen for her review. Discussion amongst providers designed for quality and standards of practice. Looked for common themes. These reviews are discussed in Med Staff meetings.
FY2019 Changes and Plans for 2020 Return of attended Sleep Lab Services Updated PADnet equipment, service, and training Spirometry services someone from Lewistown coming down to perform Updated procedure chair Assess possibility of expanded mental health services Improve onboarding providers Assess possibility of expanded telehealth services Chronic Care Management options Including the opportunity to coordinate with CMMC Care Coordination Program Dr. Scott Smith for surgical outreach clinic
