The IHC Compass PTN is a monthly email featuring success stories, TCPI updates and other local/national educational resources.
January 18, 2016
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Welcome to the Compass Practice Transformation Network Newsletter! We give clinicians the support and tools needed to thrive in value-based care.
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Quality and Resource Use Report

The QRUR report cards are out for 2015, the report helps practices and clinician’s asses their quality of care given and the cost of that care. Please see Figure 1 below to see how costs are calculated. Costs will not be calculated in year one (2017) of the QPP but the following years costs will be based on claims data. To help you prepare, Compass PTN is asking for you to start sharing your 2015 QRUR reports with your quality improvement advisor. The PTN’s intention is to help you understand your scores, report cost savings, and help you reduce costs in preparation for 2018. The information shared with the PTN is kept confidential and numbers are never attributed to an organization. You can share your QRUR with your quality improvement advisor or you can share top priority items from 2015 Annual QRUR (top priorities)
  1. Exhibit 5-AAB
  2. Exhibit 5-BSC
  3. Exhibit 3-CCC-B
  4. Cost Composite Score
  5. Value Modifier Score
To receive your QRUR, go to register and follow the prompts. The NHRI SAN has three learning modules that you can access for better understanding of your QRUR:
Module 1: QRUR 101 – Introducing the Value of Using QRUR
Module 2: QRUR 201- Understand How to Use Your QRUR
Module 3: Drilling down- How to use the Supplemental QRUR
Figure 1.

Picture courtesy of American College of Radiology

CMS QPP Portal Testing Request

 CMS is interested in the feedback of TCPI enrolled clinicians to test the QPP Portal:

1. CMS is looking for names of clinicians who would commit to gaining immediate access in a yet unreleased version of the QPP portal designed to;
  • Validate engagement of a public eligibility tool based upon NPI look-up
  • Validate engagement of a personalized account which does not yet include practice managers, office managers, or other staff authorization (i.e. surrogacy configuration)
  • Validate the data acquisition & load process
  • Gauge user reaction to seeing real eligibility data to identify volume, degree, and type of data issues anticipated once eligibility letters are disseminated, NPI look up made public, and authentication provided
  • Provide advance development of training and service center staff
  • Validate top questions and triaging process 

2. This next version of the Quality Payment Program portal includes a new website tool to help Medicare providers understand their program eligibility by simply providing their NPI number.  Additionally, QPP is developing a more personalized account whereby providers can login to the website and learn even more about their detailed eligibility, special status, and APM participation. 

Contact Katie Pfadenhauer at
Clinician Engagement

Physician engagement is essential to transforming from volume-based healthcare to value-based healthcare. The practice environment is a very busy place and many clinicians along with staff feel they do not have time to work on quality or that it adds more work to the already full workload. Quality improvement initiatives can actually decrease workloads and disperse amongst the team members, increase time with patients, and provide quality care to the patients while decreasing times. Quality improvement work takes engagement at all levels but to sustain change, the clinician must be involved in the change. If clinician engagement is low at your practice, please contact your quality improvement advisor to help with engagement. Compass PTN has clinician faculty specifically trained to help with clinician engagement who can come on-site to lead the discussion of engagement.
Sanford Health Finds Success  

 Sanford Health made initial introductions in July with our assigned QINs to discuss how to involve them in our practice assessment work. At the time, Sanford Health had nearly completed all baseline PATs, so we began focusing on how we would collaborate on follow up assessments. The Sanford Health footprint covers North Dakota, South Dakota, Minnesota, and Iowa. We chose not to coordinate with the QIN from Iowa because only a few practices are enrolled there.

Sanford QIAs, the Program Manager and representatives from the Great Plains and Stratis QINs started meeting via Skype to brainstorm how best to accomplish assessments. The new process needed to support the reporting requirements for QINs and Sanford’s requirements to Compass PTN. It also needed to include how best to use the Sanford Strategy & Scoring Guide and establish a relationship with the practices and the QIN representatives. To streamline future follow up assessment due dates, Sanford Health wanted to submit all follow up PATs for practices in December.

The new process was discussed at multiple meetings. Ideas were shared from the QINs experience with other practices within TCPI. QIAs shared lessons learned from the baseline assessment process. We strategically talked about incorporating the QINs into the work while still using the assessment process as education on the Sanford Guide. For this first follow up for Sanford practices, it was decided that the QIAs would lead the assessment process with the QINs in attendance to learn Sanford expectations. This would hopefully make it possible for future assessments to be done solely by the QINs.   

We are excited to report that 316 follow up assessments, 100% of Sanford Health practices, were completed in the month of December! We believe this is because of a collaborative process and dedicated staff. We look forward to continuing to work with our QIN partners!

"Together We're Better"
Kansas Healthcare Collaborative

Frequently unintentional silos keep team members and co-workers from collaborative work.  It happens in many organizations, including health care.  People on different teams, who don’t see one another often or at all, may miss otherwise obvious chances to work collaboratively.
With a new take on an old adage, making sure the right hand knows what the left hand is doing can make a big difference in providing better patient outcomes, more efficiency and cost savings.
Recently Kansas Healthcare Collaborative (KHC), which offers both PTN and HIIN programs, began applying that from within and recognizing more opportunities for collaboration.  By sharing tools and ideas developed for each project, they have begun to find opportunities for shared learning, resources and information they can use with their separate clients.
One of the first steps has been to coordinate their hospital site visits, scheduling Quality Improvement Advisors and HIIN directors together. KHC staff from both programs are going together to meet employees of organizations that own both hospitals and clinics. KHC is finding this is breaking down some of the silos and improving communication between the health care providers. 
visit the website at

Family Health Care Clinic in Kansas Makes Strides with Compass PTN
Family Health Care Clinic in Lindsborg, Kansas became part of the Compass Practice Transformation Network last year.
After completing the Practice Assessment Tool, FHCC found that they weren’t capturing structured data consistently to document the quality care that they were providing as a practice.
Mary Monasmith, Quality Improvement Advisor, from Kansas Healthcare Collaborative met with FHCC staff in April 2016 to explain MACRA and the transition needed to the Quality Payment Program. Monasmith worked with the Kansas Foundation for Medical Care to assist in filing an informal review for the PQRS Negative Payment Adjustment. With her help and review of the data, FHCC achieved resolution that was favorable for their providers.
Transformation Metrics and Measures
“We are at various stages on our transformation journey for quality metrics and measures,” says Julie Worcester, Clinic Quality Improvement Coordinator for FHCC. “We are however, consistently in the ‘’Use Data to Drive Care, Achieve Progress on Aims and Achieve Benchmark Status’ areas.”
Setting Aims
In April 2016, FHCC was at 0 percent for closing the referral loop. They set an aim to reach 60 percent by the end of 2016. As of now, they are sitting at nearly 85 percent.
Use Data to Drive Care
As a family practice clinic, FHCC focuses on several measures of preventative care, including breast cancer screening and colorectal cancer screening. They use data generated by their electronic medical record and qualified clinical data registry to identify patients who need screenings.
At point of care, reminders are set in the patient’s chart to alert clinic staff of screening needs. “Since we started using this data, we have doubled our referrals for colonoscopies and mammograms,” Worcester says.
Achieving Progress on Aims
FHCC demonstrated impressive progress in closing the referral loop. As noted above, they were at 0 percent for the measure in April. At that time, they weren’t capturing any structured data, nor did they have a formal process in place for ensuring a consult note was received from a specialist after a referral was made. 
Since, they’ve identified how to capture structured data, implemented a workflow process engaging frontline staff for input, tested the process and scaled it for clinic-wide use. 
At the end of December 2016, FHCC was at approximately 85 percent for providers for this measure.  “We now consistently have consult notes from referrals that were made to specialists, ensuring accurate documentation in the patient record for treatment by a specialist, new medications started, procedures performed and more,” Worcester says.  “This correlates to improved patient care and the loop is closed.”
Practice Transformation Challenges and Benefits
The biggest challenge that FHCC came across was engaging their staff members on changes that were needed. “Understanding that changes will bring improvement in healthcare outcomes for patients is central to our efforts,” Worcester says. “We continue to learn despite the challenges that we’ve had.”
The specification sheets for the Quality Measures are complex. The Quality Payment Program website has been a great tool for transitioning to a value based environment.
“With practice transformation, we are improving patient outcomes with quality measures,” Worcester says. “Patients that are due for immunizations, lab tests and other screenings are now being addressed at the point of care during clinic visits.”
Compass PTN Virtual Event-From Education to Execution: Moving the Dial on Diabetes

Diabetes is a leading cause of disability and death in the United States. The average person living with diabetes spends 2.3 times as much on their healthcare than those living without diabetes.  With more than 20 million Americans diagnosed with diabetes, the cost of diabetes is staggering at $245 billion and rising.  For every $5 spent on healthcare, $1 is spent on caring for people with diabetes.  That figure increases to $1 of every $3 for Medicare.  These direct dollars translate to increased inpatient hospital stays, medication and supply costs, physician office visits, and nursing facility stays.  While these figures are not new to most, they exemplify the crippling burden of diabetes, and the reasons that Diabetes was named as a key clinical focus area in the Transforming Clinical Practice Initiative.  This event shared opportunities to address the diabetes epidemic among our patients in real ways to achieve real improvements that will not only impact patient lives, but will also bring us closer to value-based care.
If you missed the diabetes webinar in December, you can still access it at


Compass PTN Data Submission Schedule

Data should be submitted monthly through Compass PTN Portal:

Each enrolled clinic has received an email from the Compass PTN Portal with login instructions. If you need assistance, please contact the Portal support desk: (800) 679-7351 or email You may also contact your Quality Improvement Advisor for assistance as needed. Each clinic will be expected to enter data on at least one measure each month.

Learn more...


American Board of Family Medicine SAN Spotlight

ABFM targets primary care practices but can modify any of its’ programs to fit the needs of specialty practices. ABFM offers access to the PRIME Registry to support practice quality measure extraction, provide feedback to clinicians and practices, monitor outcomes and report to PQRS and Meaningful Use. Those who are ABFM members receives free MOC credit for participating in TCPi.

Questions? Please contact Elizabeth Skees directly.

 Participating Clinics

There has been some interest in clinics across the PTN to know other clinics participating in Compass PTN. With this information, clinics can collaborate and share best practices. The information will be posted on the Compass PTN website at  There is an understanding that you may want to opt out of having your clinic being published, you can opt out of having your clinic name published. To opt out of this, please send an e-mail to Katie Pfadenhauerk at stating you would like to opt out.

Compass PTN Academic Peer Group

This month, Compass PTN is establishing an academic medical center peer group to accelerate achievement of TCPI Aims in the academic setting.  Membership is open to any Compass PTN participants interested in the subject matter. The peer group will be led by Dr. Dale Bratzler, OU Physicians and Dr. Tom Evans, Iowa Healthcare Collaborative.


The kickoff meeting will be held January 25, 2016 from 1-2 pm CST during which an ongoing monthly meeting schedule will be established.


The goals is to create synergy among academic settings participating in Compass PTN. Academic Medical Centers are a key stakeholder, representing approximately 22% of our enrolled providers. Please join us for the kickoff call to learn more!


Copyright © 2017 Iowa Healthcare Collaborative Compass PTN,
All rights reserved.


 The Compass Practice Transformation Network is supported by Funding Opportunity Number CMS-1L1-15-003 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the views of the U.S. Department of Health and Human Services or any of its agencies.

Register Now!

Compass PTN Academic Community Peer Group Webinar

January 25, 2017
Follow this link to register

Medication Safety LAN Event - Interventions to Reduce the Risk of Opioid Abuse

January 26, 2017
Follow this link to register.

Compass PTN Partners Call

January 26, 2017
Follow this link to register.

FREE Continuing Education: "The Opioid Epidemic"

February 7, 2017
Follow this link to register.

February 21, 2017
Follow this link to register

February 28, 2017
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Compass HIIN

Office Hours
Every Wednesday at 11am CT
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Quality Improvement and the Science of Process Management
February 1, 2017

Managing Care Means Managing the Process of Care
February 8, 2017

If You Cannot Measure It, You Cannot Improve It
February 15, 2017

The Right Data, In The Right Format, At the Right Time
February 22, 2017

Engaging the "Smart Cogs" of Healthcare
March 1, 2017
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