Quality Improvement Team

Amanda Bridges, MBA
QI Manager

Nadyne Hagmeier, RN
QI Project Manager

Brenda Groves, LPN
QI Project Manager
Kansas Culture Change Coalition (KCCC)
Board of Directors Communications Chair

Kaitlin Nolte, BA
QI Project Manager

Brenda Davis, BSN, RN, CIC
Infection Prevention Manager

Johnathan Reeves, BA
QI Project Manager

Tamara Elliott, BSN, RN
QI Project Manager

Rachel Holthaus, RN
QI Project Manager

Tisha Carlson, AA
QI Specialist

Tami Sterling, AA
QI Specialist

Kara Irey, BSM
QI Specialist

Kelly Haywood, BA
Communications Coordinator

Dana Thompson, AA
QI Project Coordinator

Healthcare Associated Infections National Health Safety Network Validation

Kansas Foundation for Medical Care, in collaboration with the Kansas Department of Health and Environment’s (KDHE) Healthcare-Associated Infections (HAI) Program, is pleased to announce a new opportunity for technical assistance on surveillance practices and data quality improvement in selected Prospective Payment System (PPS) hospitals statewide. The initiative, which will include data validation, will focus on metrics designated by the Centers for Medicare and Medicaid Services (CMS) Inpatient Quality Reporting Program: catheter-associated urinary tract infections (CAUTI) in adult ICU locations, and Clostridium difficile infection (CDI LabID Events), house-wide. Voluntary participation in the program assists your organization in preparation for CMS validation activities and will help promote a high standard of accountability among all facilities with no additional cost to you. Facilities that participate will be acknowledged by the KDHE with a certificate of participation and a report of validation findings.

Hospitals in Kansas participating in the CMS Inpatient Quality Reporting Program are eligible to participate in this project.

NHSN HAI Validation Webinar September 2, 2015



For more information, please contact Nadyne Hagmeier, RN, QI Project Manager, KFMC, or Robert Geist, MPH, CIC, HAI Epidemiologist, KDHE.


Great Plains Quality Innovation Network

Please visit the Great Plains QIN website by clicking the logo above to learn more about our Quality Improvement Initiatives, and to access provider-specific resources and tools.

For many years, the Medicare Quality Improvement Organization (QIO) Program has provided beneficiary protection, case review services and quality improvement technical assistance to providers through state-based contracts with the Centers for Medicare & Medicaid Services (CMS).

CMS made some significant changes to the QIO program. Under the new structure, case review and quality improvement functions are being performed by two different types of contractors. This change went into effect on August 1, 2014. Healthcare providers and Medicare consumers within Kansas must now contact KEPRO at 855-408-8557 for all Medicare discharge/termination of service appeal requests and quality of care concerns.

The Kansas Foundation for Medical Care, CIMRO of Nebraska, Quality Health Associates of North Dakota and the South Dakota Foundation for Medical Care recently aligned to form a new not-for-profit organization—the Great Plains Quality Innovation Network (Great Plains QIN)—which has been awarded the CMS contract to serve as the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Kansas, Nebraska, North Dakota and South Dakota. Our focus will continue to be on quality improvement and offering technical assistance.

Each of the four Great Plains QIN state partners share a commitment to improving quality of care and working to ensure that all consumers receive the right care, at the right time, every time. KFMC will continue to focus on improving care in conjunction with the other state partners, while pooling resources and common elements into an organization that can best serve the needs of healthcare providers and Medicare consumers across the Great Plains region. We will collaborate with providers and the community on multiple, data-driven quality initiatives to improve patient safety, reduce harm and improve clinical care locally and across the network.

The Great Plains QIN will engage providers, consumers, caregivers and stakeholders in Learning and Action Networks (LANs) focused on various quality improvement initiatives. These networks will serve as information hubs for learning, collaborating and elevating the voice of the consumer during the current five-year QIN-QIO contract. We will offer skills and assistance in the following focused areas:

Improving Cardiac Health and Reducing Cardiac Health Disparities
Our planned improvement efforts align with the national Million Hearts® initiative that seeks to prevent one million heart attacks and strokes by 2022. Partnering with providers in the home health and physician office settings, we will offer resources and technical assistance in using data to drive quality efforts and improve clinical quality measures, including aspirin use, blood pressure control, cholesterol management and smoking cessation and intervention. Innovative best practices to improve cardiac health and empower Medicare consumers to make heart-healthy choices will be identified and shared.

Reducing Disparities in Diabetes Care: Everyone with Diabetes Counts
Working with healthcare providers, practitioners, Certified Diabetes Educators (CDE™) and community health workers, KFMC seeks to improve the quality of life for persons with diabetes by preventing and lessening the severity of complications resulting from the disease. In addition to teaching people with diabetes self-management skills and the importance of seeking regular screenings by healthcare providers, KFMC will work directly with physician offices and providers to improve adherence to clinical guidelines for diabetes screening and management.

Nursing Home Quality Improvement
Partnering with nursing home and Skilled Nursing Facility partners and stakeholders, we will identify strategies to enhance consumer engagement, strengthen processes and standards, create strategic partnerships and advance quality. The goal is to increase resident outcomes and improve overall satisfaction. This work will be carried out using the National Nursing Home Quality Care Collaborative as a framework. Specifically, we will work to improve the Nursing Home Quality Composite Measure Scores, improve the mobility of residents, decrease the unnecessary or inappropriate use of antipsychotic medications, decrease healthcare-associated infections, decrease other healthcare-acquired conditions and decrease avoidable hospitalizations. Brenda Groves is leading the nursing home project; contact Brenda Groves for more information.

Nursing Home Quality Improvement: C. difficile Reporting & Reduction Initiative
Eliminating infections, many of which are preventable, is a significant way to improve care and decrease costs. CDC’s National Healthcare Safety Network provides long-term care facilities with a customized system to track infections in a streamlined and systematic way. When facilities track infections, they can identify problems and track progress toward stopping infections. NHSN’s long-term care component is ideal for use by: nursing homes, skilled nursing facilities, chronic care facilities, assisted living facilities and residential care facilities. KFMC is partnering with nursing homes across the region to prepare them for future quality reporting requirements, improve infection control practices, and improve resident outcomes. Participating Nursing Homes are using NHSN (National Healthcare Safety Network) to track CDI (Clostridium difficile) rates as well as receiving tools, resources, and education for infection prevention, control and communication. Brenda Davis, BSN, RN is leading this work in Kansas nursing homes; contact Brenda Davis for more information.

Quality Reporting and Incentive Programs (Physician, IP/OP CAH, IP/OP ASC, IPF, Hospital)
Great Plains QIN partners with both clinicians and healthcare facilities to review the legislation, analyze performance data and assist providers in maximizing reimbursement opportunities and navigating the Quality Payment Program (QPP). Great Plains QIN is here to help providers succeed with the new Merit-Based Incentive Payment System (MIPS) and other Value Based Purchasing programs by providing a variety of no-cost services and education. Great Plains QIN is assisting eligible clinicians in the transition from the existing Medicare reporting programs into the new Quality Payment Program. In 2017 and 2018, MIPS eligible clinicians (ECs) include physicians, nurse practitioners, physician assistants, clinical nurse specialists, and certified registered nurse anesthetists. Additional provider types will be affected in future years. Additionally, we continue to help other healthcare facilities (i.e. PPS and CAH Hospital Inpatient and Outpatient departments, Ambulatory Surgical Centers (ASCs), Inpatient Psychiatric Facilities (IPFs)) with successful participation in other value based purchasing programs. For more information about resources and assistance available to Kansas providers, please visit the Great Plains QIN Service Center.

Communities of Care
Improving care coordination leads to better consumer outcomes and overall satisfaction, reduces avoidable hospital admissions and readmissions, and improves medication safety. KFMC partners with communities throughout the region to unite stakeholders, consumers and healthcare providers to reduce avoidable hospital admissions, readmissions and medication harm, and increase community tenure. The national goal is a 20 percent reduction in avoidable hospital readmissions and admissions and a 10 percent increase in community tenure by August 2019. To learn more, contact Amanda Bridges.

Consumer and Family Engagement
Collectively, our project teams will communicate with providers and practitioners regarding the needs of healthcare consumers and their family members and/or representatives. Our staff will work to equip consumers and their families with the tools and strategies necessary to enable them to successfully navigate the healthcare system. Across Kansas, healthcare consumers, family members and advocacy organizations will actively and fully participate in project design and implementation to ensure that the needs of the consumers we serve are always taken into account. Consumers' and family stories will be shared during working sessions, educational events, via newsletters, social media and other communication channels to create momentum for quality improvement activities. Special emphasis will be placed on capturing and sharing a diverse set of stories highlighting the impact of disparity issues as they relate to healthcare experience. To ensure materials are of value and user-friendly, healthcare consumers will be asked to review and offer input on the content and distribution methods of educational materials developed as part of the various quality improvement projects. Utilizing evidence-based tools, KFMC will provide healthcare professionals the necessary tools and support for improving consumer communication and involving an individual in his or her own care. For more information on how you can become more engaged in your health, contact Tami Sterling.

Outpatient Antibiotic Stewardship Initiative
Everyday thousands of Americans are impacted by the improper use of antibiotics. According to the CDC, 2 million people become infected with bacteria that are resistant to antibiotics and at least 23,000 people die each year as a direct result of these infections. Antibiotics account for nearly 1 in 5 adverse drug events, and of those about 6% require hospitalization. An estimated 34 million unnecessary prescriptions for antibiotics are ordered each year to treat acute respiratory conditions. KFMC is partnering with community providers including hospital emergency departments, urgent care centers and clinics, Rural Health Clinics, Federally Qualified Health Centers, local health departments and community pharmacies to improve care through antibiotic stewardship. Through this effort we are working with outpatient providers across Kansas to slow the emergence of resistance bacteria and prevent the spread of resistant infections. Through this work, we are sharing information and education on the principles of antimicrobial stewardship, which is defined as 'coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy and route of administration.' Antibiotics are a precious resource and preserving their usefulness will require cooperation and engagement by all. For more information, please contact Nadyne Hagmeier, RN.

Improving Immunization Rates
Great Plains QIN collaborates with physician offices, pharmacies, public health departments, hospitals and home health agencies to adopt proven best practice approaches to improve adult immunization rates in Kansas. We offer a wealth of free evidence-based resources to promote influenza, pneumococcal and herpes zoster screening and vaccination best practices, guidelines and tool to break down barriers to care for disparate populations. Through this work we are partnering with the Kansas Immunization Program and the Immunize Kansas Coalition to advance this work. For more information, please contact Tami Sterling.

Special Innovation Projects
The Centers for Medicare and Medicaid Services (CMS), in an effort to ensure that Medicare beneficiaries receive better care, better health, and greater value, has provided Quality Innovation Network-Quality Improvement Organizations to propose innovative projects that address local healthcare quality issues. These projects, known as Special Innovation Projects (SIPs) represent a paradigm shift in how CMS identifies and recognizes the tremendous quality work occurring every day in our local communities, and seeks to capitalize on interventions that have not yet made it into mainstream adoption. Great Plains QIN is currently working on the following, innovative projects in Kansas:

  • 2015 Special Innovation Project: Improving Colorectal Cancer Screening Rates – Great Plains QIN works with primary care clinics to implement interventions that improve colorectal cancer screening rates, and follow up for all patients. This work aligns with the National Cancer Roundtable “80% by 2018” Campaign. The National Colorectal Cancer Roundtable (NCCRT), an organization co-founded by the American Cancer Society and the Centers for Disease Control and Prevention (CDC), has recognized six honorees in 2017. Great Plains QIN was one of these six honorees selected as a National Achievement Award Winner for work in this areas, read more about this recognition here.
  • 2016 Special Innovation Project: Home Health Infection Prevention and Management – Great Plains QIN is facilitating a small collaborative group of home health agencies to develop and test home health specific tools and resources to reduce home health acquired infections that may lead to unnecessary admissions or avoidable readmissions. For more information regarding this project, please contact Brenda Davis, BSN, RN.
  • 2016 Special Innovation Project: Pain Management and Appropriate Utilization of Opioids – KFMC works in selected communities to target education, disseminate Self-Management interventions and facilitate targeted improvement efforts to demonstrate that appropriate pain management (including pharmacological and non-pharmacological interventions) coupled with appropriate prescribing guidelines can change the trajectory of opioid prescribing practices. For more information regarding this project, please contact Amanda Bridges.

Next Steps
We are very excited about this opportunity and will share more details about our work and how you can get involved. We look forward to partnering with you and expanding our efforts across the State. We hope you join our efforts as we strive to achieve better care, better health for people and communities, and more affordable care through quality improvement.


Quality Improvement

A Quality Improvement Organization (QIO) is a group of health quality experts, clinicians, and consumers organized to improve the care delivered to people with Medicare. QIOs work under the direction of the Centers for Medicare & Medicaid Services (CMS) to assist Medicare providers with quality improvement and to review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.

The QIO Program, one of the largest federal programs dedicated to improving health quality for Medicare beneficiaries, is an integral part of the U.S. Department of Health and Human Services' (HHS) National Quality Strategy for providing better care and better health at lower cost. By law, the mission of the QIO Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. Based on this statutory charge, and CMS's program experience, CMS identifies the core functions of the QIO Program as:

  • Improving quality of care for beneficiaries;
  • Protecting the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting; and
  • Protecting beneficiaries by expeditiously addressing individual complaints, such as beneficiary complaints; provider-based notice appeals; violations of the Emergency Medical Treatment and Labor Act (EMTALA); and other related responsibilities as articulated in QIO-related law.

QIN-QIOs improve healthcare services through education, outreach, sharing practices that have worked in other areas, using data to measure improvement, working with patients and families and convening community partners for communication and collaboration. QIN-QIOs also work to improve the quality of healthcare for targeted health conditions and priority populations and to reduce the incidence of healthcare-acquired conditions to meet national and local priorities.

CMS relies on QIOs to improve the quality of health care for all Medicare beneficiaries. Furthermore, QIOs are required under Sections 1152-1154 of the Social Security Act. The QIO Program is an important resource in CMS’s effort to improve quality and efficiency of care for Medicare beneficiaries. Throughout its history, the Program has been instrumental in advancing national efforts to motivate providers in improving quality, and in measuring and improving outcomes of quality.