Madison Regional Health System Quality Improvement Team

Front, L to R: Kathy Hansen, Director of Quality; Kay Kramer, LPN, Amber Oines, RN, BSN, Quality Nurse Specialist;, Beth Graff, Director of Clinic and Community Services; Back, L to R: Vanessa Walter, RN, Dr. Laura Hoefert, Derek Dudley, Director of IT, Tamara Miller, Chief Executive Officer, Dr. Mary Beecher


Amber Oines, RN, BSN, the quality nurse specialist for Madison Regional Health System in Madison, SD, engaged Great Plains Quality Innovation Network (QIN) to support their healthcare quality team through the transition to the Quality Payment Program (QPP). Below Oines shares the steps and challenges of integrating quality measures from the beginning of the QPP to the first positive payment adjustment.

Madison Regional Health Systems - Madison, SD1. How did you become engaged with the Great Plains Quality Innovation Network (QIN)?
When our hospital and clinic merged, we transitioned the quality department from medical records to a nurse quality director. As the emphasis on quality continued to grow over the past several years, our quality director started to network at conferences and became familiar with the Great Plains QIN. She heard Holly Arends speak at a South Dakota Association of Healthcare Organizations (SDAHO) conference and was impressed with her knowledge and ability to explain complicated topics in a practical, easy to understand way. When the Quality Payment Program (QPP) began, our facility reached out to Holly in early 2017 for support.

Holly Arends, CHSP, CMQP, Program Manager for Great Plains Quality Innovation Network Holly Arends, CHSP, CMQP, is a change agent and has a strong passion for assisting rural and frontier provider practices. She has enjoyed over 20 years in the healthcare industry and has built her skill set from several different areas of the healthcare community.  As a program manager for the Great Plains QIN, her expertise is primarily focused on quality work around cardiac health, quality payment programs and large-scale transformation through the Transforming Clinical Practice Initiative (TCPI).

Her long list of experience and background is highlighted with positions including clinical research specialist, director of quality management, risk manager, utilization review supervisor, health information management director, phlebotomist, office manager, and health information management college faculty. She is certified as a MIPS quality professional by 4MED and has an associate degree in applied science, health informatics.

2. What role did Great Plains QIN staff play in your quality improvement efforts?
When the program started, our team had a lot of unanswered questions about how the program worked, and how to best implement the program in our facility. With Holly’s organized, practical approach, we were able to identify and prioritize the steps our facility needed to take in order to be successful in implementing the new program. Holly also assisted our facility in making a plan to strengthen our quality improvement process organization-wide. We are an independent, critical access hospital with less resources than larger facilities, so the support from the Great Plains QIN was greatly appreciated.

3. Describe how you identified high impact priority areas for quality improvement?
In the first year of the QPP, quality was 60 percent of our score, so we knew we wanted to focus our efforts on the quality measures. We developed a team that consisted of two physician champions. Our Electronic Health Records (EHR) vendor supported 24 of the EHR submission quality measures. As a team, we identified nine quality measures to focus our efforts on. This decision was based on: physician input, workflow adaptations and training needed based on how our EHR captured the data, and measures with highest potential for positive impact on the health of the patients in our community.

4. What interventions did you implement?
After we identified the priority quality measures, one-on-one education was done with each provider. This education included an overview of the quality payment program, as many of our providers were not familiar with the details of the program. Each provider was given a detailed explanation of the nine quality measures, including all of the criteria and scoring for each measure, and the providers were shown how our EHR captures the data for each quality measure. The individual education allowed each provider to learn and ask questions in a relaxed setting.

Education was also done with all of the clinic nurses during a staff meeting. Nursing staff requested individual education as questions arose, and they created a one-page “cheat sheet” with measure descriptions, criteria and exclusions, and nursing tips that would improve outcomes for each measure. A team approach with each doctor and their nurse was emphasized, and each doctor/nurse team individualized their workflows to best meet the criteria for each quality measure.

5. Explain the challenges and how you addressed them.
With anything new and unfamiliar, staff buy-in is always a challenge. The individual education that was done did help with this. Once the providers realized the quality measures related to quality care they were already providing on a daily basis, like controlling high blood pressure, they were more receptive to the program. Another challenge included getting staff to understand the need to change a workflow or how they document in the EHR to capture the data accurately. Making sure that our data is being captured correctly by the EHR is a continued challenge, and data validation can be very time consuming.

6. What methods did you use to evaluate the impact and progress?
After the initial individual education with providers and nurses was done, each provider and their nurse received monthly updates on their quality scores. This monthly update included each provider’s individual scores for each of the nine quality measures for the current and preceding month, which showed improvements or worsening of scores from month to month.

We also included the facility group score for each measure, allowing each provider to see how their individual score compared to the group’s score. Providers were also educated on the Centers for Medicare and Medicaid Services (CMS) averages and top box scores for each quality measure. If staff had questions on their scores, we would meet individually and discuss to see if any modifications could be made to improve scoring. This monthly update allowed us to track progress and make adjustments when needed, which did result in improved overall scores for our facility.

7. Provide a summary of the overall impact of the quality improvement effort at Madison Regional Hospital.
The overall impact was a measurable improvement in quality of patient care. By providing education and continued feedback, the providers and nurses saw improvement in their scores, which meant that they were making a positive difference in the care of their patients. The monthly updates with the individual scores compared to the overall group scores sparked a friendly competition, as many of the providers stated, “I don’t want my score to be the lowest.” Support from our facility’s administration has also contributed to our success. Our facility received a positive payment adjustment in the first year of the QPP, which helped to validate efforts and motivate staff to continue their efforts in quality improvement.

Great Plains QIN is committed to ensuring that local providers continue to be successful in maximizing reimbursement opportunities, improving quality of care and finding the joy in their work. Access our team of experts using the Quality Payment Program Service Center, featuring email, telephone and live chat support.