Carroll County Memorial Hospital

Mindie Stovall LPN, CPHQ

Director of Quality and Clinic Nurse Staff

About Myself…• Graduated from Saline County Career Center with my LPN

in 2007• Began Working for CCMH in July 2007• I worked on the Medical Surgical Unit for 5 years• April of 2012 I took the position as Quality Coordinator• In May 2014 I accepted the position of Clinic Nurse Director• In November of 2014 I took my CPHQ Exam…and PASSED!!

The Journey Continues….

My personal life consist of 2 daughters that are my life and a wonderful husband who completes us!

Carroll County Memorial Hospital

• We currently have 3 physicians and 4 mid-level providers• We are a 25 bed facility• We have an Outpatient Clinic that currently treats patients

in the following specialties:• Cardiology• Podiatry• Pulmonology• Urology• Orthopedic• Surgery• GI• Wound Clinic• OBGYN• Oncology

• Currently expanding our facility with a 43,000 square foot, 3 story addition for Outpatient Clinic, Same Day Surgery, and Physician Office Space

• 19,989 Outpatient Visits • 235 Inpatients• 3,353 ER Visits• 3,350 Home Health Visits• 28,881 Rehab Therapy Visits

A Glance at Our Services for FY 2013-2014

Core Measure Reporting

I personally have been reporting Core Measures since I became Quality Coordinator in 2012.

CCMH has been submitting Inpatient Core Measure data since approximately 2004.

In 2010 Outpatient Measures were added for submission.

Benefits of MBQIP

• Improve best practice• Improve outcomes • Decrease cost• Assist in making sure that the

patient gets the right care every time

Engagement… Where to

Start• CEO • Providers- (Relate to $$)• Nursing Staff• Ancillary Departments

• Daily Interdisciplinary Team Meetings followed by rounding to patient rooms

• Implementation of Bedside Reporting • Education to all providers in Medical Staff

and notes above computers• Mandatory training for all nurses on Core

Measures• Cerner Core Measure Order Sets• Daily check-off sheets for all inpatients• Monitoring with re-education as needed• Monthly staff meetings

Some of Our Secrets to Success

Best Practices

• 100% CEO support!!!• Interdisciplinary Team Meeting every morning for

discussion of patient needs, plan of care, and Core Measure indicators

• Education to all providers, including nurses, regarding Core Measure importance and what it means for CCMH

• Charting/QM orders in the EHR to assist with indicators

• Core Measure Checklist placed outside patient rooms • Discharge Planner/Case Management discharges all

patients to assure that discharge instructions are clear and accurate according to patient diagnosis

• Small laminated cards/notes placed at provider workstations for easy access to Core Measure indicators

• Medical Staff monthly meeting. Review and present Core Measure results and give updates as needed.

Core Measure Checklist

EHR Assistance

Cerner Order Screen- Placing the QM order in Cerner reassures that all indicators are clearly stated for providers to view

Quality Measure Indicators for Nurses and providers- This screen is viewable on the patient summaries tab. Providers can order from this screen and nurses can document from this screen to meet all Core Measure indicators