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Rural Hospital Flexibility Program Tracking Project Chapter 3G Ira Moscovice, Ph.D., and Walter R. Gregg, M.A., M.P.H.
The flexibility inherent in the Rural Hospital Flexibility Program (Flex Program) provides participating hospitals with an opportunity to carve a more realistic niche given their resources and capabilities, but also raises issues concerning the quality of care provided in these institutions. From regulators to consumers to other area providers, questions will arise because of the apparent change in hospital status. In some cases, the change may have been preceded by a reputation in the local community that undercut attempts to increase patient volume. In others, the questions are directly related to the status change itself (e.g., different scope of services than traditional hospitals, greater flexibility in the use of non-physician staff, arbitrary limitation on length of stay). Regardless of the source, concerns about the quality of care provided in a critical access hospital (CAH) are unavoidable and need to be addressed if the facility is to be successful and survive. The survival of the CAH is dependent on many factors, including its ability to generate, monitor, and in some cases, reclaim the level of community and professional acceptance necessary to achieve financial sustainability. CAHs face problems similar to those of many small rural hospitals in implementing quality assurance or quality improvement (QA/QI) initiatives, including limited resources, knowledge, and data availability, small medical staffs, low patient volumes, and the orientation of accreditation criteria toward urban hospitals.1 The authorizing legislation for the Flex Program provides opportunities, through technical assistance and financial support, for CAHs to improve their QA/QI activities. It also requires CAHs to have agreements for credentialing and quality assurance with at least one hospital in a network to which the CAH belongs, one peer review organization (PRO) or another qualified entity identified by the state.2 This chapter describes the QA/QI activities of CAHs in the second year of the program and the nature of external linkages (e.g. relationships with affiliated hospitals and the state PRO) developed by CAHs to support their QA/QI activities. The data sources for this chapter include a telephone survey of CAHs certified as of September 1, 2000 (n=217), and a review of the information collected during the site visits and follow-up phone calls completed during the first two years of the Tracking Project.
CAHs that were certified as of September 1, 2000, were asked about their involvement in a range of QA/QI-related activities and the characteristics of their post-conversion QA/QI efforts (see Tables 1 and 2). The vast majority of CAHs reported the use of continuing education programs for staff, medical error reporting policies, systems to avoid or prevent medical errors, hospital QA/QI training initiatives, and data collection approaches for staff feedback. After conversion to CAH status, almost all chief executive officers (CEOs) reported that the above QA/QI-related activities remained the same or were stronger. These findings most likely result from the recent emphasis on quality of care and QA/QI strategies by health care purchasers, regulators, professional groups and other entities involved with health care policymaking, as well as the opportunities provided by the Flex Program.3 Table 1. CAH Quality-Related Activities
Table 2. Post-Conversion QA/QI Characteristics
In sync with the results noted above, the large majority of CAHs reported stability or improvements in the post-conversion period in a range of hospital QA/QI characteristics. These included efforts to pool or coordinate resources with other facilities, the number of staff available for QA/QI activities, the appropriateness of credentials for QA/QI staff, and the use of protocols for critical pathways, admissions and patient transfers. Once again, the Flex Program appears to be supporting ongoing hospital industry efforts to enhance QA/QI activities. In particular, the increases in pooling and coordination of resources with other facilities, and the enhanced use of protocols for patient admissions and transfers, likely are direct outgrowths of participation in a program like Flex that fosters these actions. Accreditation by an external body is a standard practice for ensuring quality in hospitals. However, only a small portion (16%) of CAHs were accredited by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) (see Table 3). The percentage of JCAHO accreditation for CAHs is similar to that for all small rural hospitals, and the small number reflects the growing costs of the accreditation process and the lack of appropriateness of JCAHO standards for small rural hospitals.4 JCAHO has reported it is working on a special accreditation status designed specifically for CAHs. Table 3. CAH Accreditation and Use of Performance Measurement System
Despite the limited number of CAHs that were JCAHO-accredited, the large majority of CAHs reported that they currently use a QA/QI performance measurement system. On average, these performance measurement systems had been in use for more than five years, and half of them provided reports that benchmarked the CAH performance with that of other hospitals. The large majority of these systems were adapted for internal use in conjunction with CAH linkages with a system, network, PRO, and/or state hospital association. In response to an open-ended question, the administrators of CAHs identified a wide range of post-CAH conversion activities that made the most significant contribution to improving quality of care in their facilities (see Table 4). By a wide margin, the most frequent activity identified was the formation of a networking relationship with an affiliated hospital. Other activities identified included improvements in case management and discharge planning; improved recruitment, retention and training of staff involved with QA/QI activities; equipment upgrades that led to improved patient care; participation in a survey process that led to improvements and updates in policies and procedures; development of supportive relationships with the state hospital association that involved the useful sharing of information on QA/QI; and improved process for peer review of small medical staffs. Table 4. Significant Post-CAH Activities to Improve Quality of Care (%)
The importance of the relationship between the CAH and its affiliated hospital for QA/QI was highlighted in other ways. Affiliated hospitals were identified by the majority of CAHs as the organization that played a major role in the refinement and improvement of their QA/QI capacity (see Table 5). In addition, QA/QI was identified by 53 percent of CAHs as a major area covered in their affiliation agreements with a support hospital. This was the second most frequently mentioned area covered in the affiliation agreements, after medically-related patient transfers (see Chapter 3C). For those hospitals that had an affiliation agreement in effect prior to CAH conversion, only 29 percent included QA/QI as a major area in the agreement. The post-CAH increase likely reflects the emphasis of the Flex Program on the development of affiliation agreements for credentialing and QA/QI purposes. Table 5. Organizations Involved with QA/QI Capacity of CAH* (%)
The Flex Program authorizing legislation also encourages CAH linkages with PROs to meet their credentialing and QA/QI needs (see Table 6). However, only one-fourth of CAHs participated in any activities with their state PRO beyond those required in federal statute and regulation. Typical examples of activities with the PRO included participation in QA/QI studies initiated by the PRO and continuing education and training sessions sponsored by the PRO. A few CAHs identified more expansive efforts with PROs to develop new QA/QI models for CAHs. The limited involvement of CAHs with PROs is not surprising given the incentives that PROs have to target their activities to larger hospitals, which have the best potential for improving average performance statewide.5 In some states there is confusion about whether PROs can or should be involved in "consulting" activities with the same hospitals they are regulating. Oregon, for example, is proceeding very cautiously while waiting for an opinion from the Centers for Medicaid and Medicare Services (CMS). Table 6. PRO Linkages
The barriers to addressing the QA/QI needs of small rural hospitals were identified earlier. When asked to rate the extent to which various issues made it difficult (1-to-5 scale) to address the QA/QI needs of CAHs, few CEO's rated them as very or extremely difficult (see Table 7). Barriers identified as most difficult to address involved the limited size of the medical staff and patient volume rather than technical or Management Information System (MIS) limitations. The results noted above may reflect the renewed interest and optimism of these institutions in addressing QA/QI activities that has been stimulated by the Flex Program. Table 7. Barriers to QA/QI
Examples of Initial Efforts by States and The site visits and follow-up phone calls during the first two years of the Tracking Project identified several examples of promising initial efforts by states and CAHs to address issues and stimulate activities related to QA/QI. Five of these initiatives are described below.
Arkansas - Using the State PRO to Implement The Arkansas Department of Health chose Health Data Solutions (HDS), a division of the state PRO, to provide a performance measurement system for the CAH program in Arkansas. HDS has been part of the JCAHO ORYX initiative since late 1997 and has been used in more than 25 projects. A goal of HDS is to provide benchmark data and performance measurement that is affordable for hospitals and is based on hospital discharge data. To ensure that HDS is relevant for CAHs, it has been adjusted to focus on the four most frequent Arkansas CAH Diagnoses Related Groups (DRGs) and 11 related performance indicators. CAHs submit UB-92 claims data to the PRO on a monthly basis and complete data abstracts for a particular case if additional data are required from the medical record. Quarterly reports are sent to each CAH and include benchmark and comparative data for all CAHs and the majority of hospitals in Arkansas. These data can be used by individual CAHs for their internal QA/QI activities and provide relevant benchmarks for small rural hospitals. Ideally, CAHs will be able to use the system to learn about the best practices of other CAHs in the state. The PRO also will complete individual projects for a CAH, and its staff is available to CAH QA/QI staff for technical assistance.
North Dakota - Enhancing QA/QI Activities Through Links The state hospital association is very much involved, along with the Center for Rural Health at the University of North Dakota, and the state health department, in encouraging quality-related projects and raising the awareness of the importance of improving hospital performance. The hospital association is working closely with the state PRO to provide training for hospital staff in peer review. The hospital association and several CAHs have expressed some concern that in the future either the government or communities are going to ask for evidence that the services provided at CAHs are comparable to those at larger facilities. The training being offered will address that concern by permitting hospitals to record their performance using the same criteria used by the state PRO. One of the issues being explored at this time is how compatible this approach will be with existing statute. The expectation of the PRO is that when it redefines its scope of work with CMS in 2003, there will be far more emphasis on urban/rural differences in terms of service outcomes. There is a possibility that the state may launch a pilot project to this effect in the near future. Both the health departments and PRO are concerned about credentialing and are supportive of developing more of a network-based/regional credentialing process. The Northland Healthcare Alliance, with its 13 hospitals covering 32 western counties in North Dakota, received support from the state to develop a network-wide peer review and quality improvement process. Efforts to develop quality benchmarks applicable to CAHs have been launched. A state statute regarding "discoverability" and medical record review poses some challenges, so a number of options are being explored. The person reviewing the medical record must be an employee of that facility (not a hired consultant or expert). If not, whatever that person discovers can be ordered to be revealed in a state court of law. Another option being considered is distance peer review through telemedicine networks.
Mackinac Straits Hospital and Health Center, Saint Ignace, Michigan - CAH conversion has had an impact on quality management issues within the Mackinac Straits Hospital (MSH). MSH has worked with hospitals in the Upper Peninsula (UP) on a joint quality improvement initiative funded by a CAH mini-grant from the state. The intent of the project is to get hospitals to work together on training, protocol and system development, data sharing, and similar activities. MSH has hired a staff person to run the project. Staff from MSH are working with other UP hospitals to develop clinical pathways for congestive heart failure, particularly useful for emergency room (ER) staff. The process is being conducted using video-conferencing. It will be challenging to develop these clinical pathways due to the equipment differences across hospitals, the detailed nature of the work, and the need to get nurses and physicians to work together to use the protocols. Under the previous QA/QI system, each hospital department was responsible for preparing its own reports. There was little investment in the process as the hospital was not using the data to make decisions, and there were no feedback loops to the patient care system. MSH's Quality Management Plan dates back to 1991-92. Although it needs to be updated, the current priority is to develop and implement continuous quality improvement (CQI) teams. The hospital is using a team approach, and its first project addressed blood-borne pathogens. The team looked at all existing policies, then brought all departments together to examine and re-write the policies. An Oversight Committee was also established to consider recommendations for change, and it includes the director of nursing (DON), risk management staff, safety staff, and others. Under the new system, patient and staff complaints will be forwarded to the Oversight Committee. Teams will be formed to examine specific complaints and develop plans to address the immediate concern, as well as indicators that can be used to monitor performance. Quality and risk management programs are consolidated across long-term care and acute services. On the long term care unit, Minimum Data Set (MDS) information and incident reports are used to identify problems. The Family Council, a volunteer advisory group of families of residents, is also a good source of information. Some of the lessons learned by MSH in developing its QA/QI programs include the following:
Nebraska - Emphasis on Emergency Medical Service (EMS) Issues and The Nebraska Office of Rural Health has made quality assurance an essential component of agreements between CAHs and their network partners. Each CAH is required to have a QA plan and the network hospital is bound to provide guidance on it to the CAH. The state encourages strong network relationships as a necessary stepping-stone to good quality. In Year 02 of the Flex Program, Nebraska invested in developing an electronic data system to measure and monitor clinical outcomes (called COMS, for "Clinical Outcomes Management System"). The hospital association has taken the lead on this initiative, since hospitals are struggling to implement their QA/QI plans. COMS is a uniform discharge reporting system that presents participating hospitals with data for their facilities, and compares each hospital to its peer group members as well as to all hospitals in the state. Flex Program grant funds pay half the costs for each CAH to be equipped with the software to participate in the system and/or to receive reports from the hospital association. Hospitals receive their results on specific indicators (e.g. mortality, readmission rates) and comparisons to other CAHs in the state, other rural hospitals in the state, and all hospitals in the state. These data can be used by the CAH to stimulate QI activities through links with the state PRO, their support hospital, or simply internal efforts. Beyond efforts to develop the system, Nebraska's state office of rural health and state hospital association help the hospitals review their data to identify areas where out-migration of patients might be the result of deficiencies in quality (or the result of a too-narrow scope of services, or too little consumer awareness of the services offered). Smaller hospitals are looking to COMS because they lack alternatives for assessing outcomes/quality data. The state also provided support to improve hospital-ambulance service communications. Rural hospitals initially were hesitant to tackle quality issues related to EMS because of turf issues. The Flex Program provided incentives and funding for CAHs and EMS programs to work together, providing a forum and the financial support to open the doors of communication. As a result, some Nebraska CAHs are hosting educational programs with or for EMS programs, as well as examining the feasibility of upgrading the level of service provided by ambulance squads. Nebraska's state office of rural health sponsored a project to interview representatives from local ambulance services and CAHs, and found that most of these entities were not coordinating planning efforts. The state office supported the development of a QI manual that provides a structured approach for CAHs, medical staffs, and EMS providers to jointly develop a QA/QI plan. In Year 02 of the Flex Program, consultants are working with a limited number of CAHs and local ambulance systems to develop local QA/QI plans. Kansas - An Emphasis on Network-Wide QA/QI Activities In addition to the core activities of hospital conversion, network development and EMS and quality issues, Kansas began to explore community reaction to the CAH model in order to identify strategies for strengthening community relations. The Kansas Foundation for Medical Care took the lead in developing and launching a patient satisfaction survey in all of its CAH communities. A key finding of the survey was that the twenty-three CAHs operating at that time were thought by residents to provide comparable or better care than a comparison peer group (rural hospitals of similar size). Specific areas of interest for Kansas in funding new projects will be network development efforts with a strong quality-oriented focus. Top priority will be given to projects that focus on using system approaches to enhance patient and consumer safety and reduce medical errors. Support will also be provided to foster network-wide credentialing efforts, quality standards, clinical pathways, and quality indicators. There are currently 12 networks operating in the state along with the 35 CAHs. In Syracuse, Kansas, Hamilton County Hospital is one CAH in a network of hospitals that has a relationship with St. Catherine Hospital. In the past quality issues were discussed, problems solved on a case-by-case basis, and then staff moved on. Now, network hospitals are monitoring on an ongoing basis to see whether they are improving. QA criteria are developed for monthly network monitoring. Data are reported to St. Catherine Hospital, where they are analyzed and reported back to the network hospitals. Transfers are monitored this way (whether guidelines are met, whether patient conditions are communicated, and whether appropriate information on the patient is provided).
An important component of the Flex Program is its emphasis on quality of care. We anticipated that states and CAHs initially would focus on other components of the program (e.g., CAH designation, network development) before using their resources to address quality of care issues. The survey of CAHs and site visits to CAHs and states identified substantial interest and involvement in QA/QI activities despite the short time since conversion and the limited number of CAHs that were JCAHO accredited. The timing of the Flex Program fortunately coincided with overall hospital industry trends serving to reinvigorate QA/QI activities. Most CAHs are not able to address QA/QI issues by themselves. The Flex Program encourages CAHs to use linkages with external entities to support their quality-related efforts. The examples described in this chapter provide good evidence of the value of linkages with support hospitals, state hospital associations and PROs. The majority of CAHs used network relationships with their affiliate or support hospital to stimulate new QA/QI activities, but less than one-fourth of CAHs developed relationships with their local PRO beyond those required by the Federal government. These findings suggest that:
Finally, CAHs are a new institutional model designed to preserve access to basic primary care, inpatient and emergency medical services for the populations they serve. They do not provide the same range or quantity of services as larger, urban-based providers, and would welcome the development of external review and accreditation policies and QA/QI indicators specifically designed for CAHs. Efforts to ensure and improve quality in CAHs would benefit from such an approach. Footnotes * Multiple responses allowed. 1 Moscovice, I. and Rosenblatt, R. "Quality of Care Challenges for Rural Health." Journal of Rural Health. 16:168-176, 2000. 2 Rural Hospital Flexibility Program, Guidance for Program Grant Funds for FY 1999, Office of Rural Health Policy, April 15, 1999. 3 Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press, Washington, D.C., 2001. 4 Brasure, M., Stensland, J. and Wellever, A. "Quality Oversight: Why are Rural Hospitals Less Likely to be JCAHO Accredited?" Journal of Rural Health, 16:324-336, 2000. 5 Med PAC, Report to the Congress: Medicare in Rural America, Washington, D.C., June 2001. 6 CAH QIP Users Guide, Health Data Solutions, Arkansas Foundation for Medical Care, Fort Smith, AR May 2000. 7 JCAHO's ORYX initiative is designed to integrate outcomes and other performance measurement data into the accreditation process. 8 MedPAC, Report to the Congress: Medicare in Rural America (Chapter 3), Washington, D.C., June 2001. RHFP
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