Rural and Critical Access Hospital Archive

[Richard Corcoran]

This roundtable is designed to bring together individuals who have a common interest in the success of critical access hospitals in their communities. I'm thinking three initial objectives:

To share information, materials, and resources relevant to understanding, supporting, and strengthening the quality and safety of critical access hospital care;
To articulate and discuss relevant evidence-based best practices; and
To share observations, thoughts, and opinions in an ongoing discovery of what works and what doesn't work in providing patient-centric, reliable healthcare in rural environments.I invite you to share your responses to anything posted here - share your thoughts, provide information, ask questions, make comments, and otherwise become engaged in an effort to advance our collective ability to continually improve patient care.

Since we're all about patient safety, click here (http://www.flexmonitoring.org/documents/BriefingPaper2_QI.pdf) to read a briefing paper published by the Flex Monitoring Team in September, 2004 describing the patient safety results obtained from a telephone survey of 474 CAH administrators. Let me know you think about these results.

[Richard Corcoran]

For your interest, the number of critical access hospitals continues increase nationally. Click here (http://flexmonitoring.org/documents/CAH_062706.pdf) (takes 12-13 seconds to draw) to find a U. S. map showing the location of the 1,286 CAHs as of June 27,2006. This map is updated quarterly by the Flex Monitoring Team. I’ve also included a link to excel spreadsheets showing the number of CAHs by state (http://flexmonitoring.org/documents/StateCounts_CAH+DPU_6_27_06.xls), and the complete list of 1286 CAHs (http://flexmonitoring.org/documents/CAHlist_current.xls) nationally.

Take a look. You’ll see you are not alone. Awesome!

[nlandor]

Thank You for posting. :D

[Richard Corcoran]

Many small rural hospitals have limited hours of onsite pharmacist coverage, according to a recent national study that assessed how rural hospitals implement medication safety practices, focusing on pharmacist staffing and availability and use of technology. Several of the study’s findings are of particular relevance to critical access hospitals, including the following two observations -

“The majority of hospitals have implemented key medication safety practices including a do-not-use-abbreviations list, a policy of using two patient identifiers for administering medications, a policy of having two health professionals independently check doses of high alert medications, and a high alert drug list. However, only half of the hospitals have implemented all four practices. Three factors are significantly and positively related to implementation of the four practices: JCAHO accreditation; having a medication safety or patient safety committee with active pharmacist participation; and net operating margin.”

“The finding of significant relationships between financial status and pharmacist staffing, use of technology, and implementation of medication safety practices supports a continuation of Medicare policies to help ensure financial stability for small rural hospitals through cost-based reimbursement as a means of helping to support quality and patient safety activities.”

You can read the entire report - Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Safety (http://www.uppermidwestrhrc.org/pdf/medication_safety.pdf) - The report also contains internet links to practical tools and resources you may want to check out. You may also want to share this report with your senior leadership team.

You can also access the most current JCAHO “Do Not Use Abbreviations” (http://www.jointcommission.org/NR/rdonlyres/2329F8F5-6EC5-4E21-B932-54B2B7D53F00/0/06_dnu_list.pdf) list and the ISMP (Institute for Safe Medication Practices) list of “High Alert Medications” (http://www.ismp.org/Tools/highalertmedications.pdf) for your interest.

If you find this useful (or not), let me know. Happy reading!

[Richard Corcoran]

The National Rural Health Association (NRHA) has emerged as a strong leadership voice and advocate for improving health care delivery in rural America. The NRHA describes itself as “….a national nonprofit membership organization with more than 10,000 members that provides leadership on rural health issues. The association’s mission is to improve the health and wellbeing of rural Americans and to provide leadership on rural health issues through advocacy, communications, education, research and leadership. The NRHA membership is made up of a diverse collection of individuals and organizations, all of whom share the common bond of an interest in rural health.”

The NRHA has identified quality improvement as one of its strategic priorities. This thread will update you periodically regarding safety and quality resources, news, and materials that become available through NRHA. I’ve listed three current items related to your quality/safety journey. You can find complete information on the NRHA’s activities at http://www.nrharural.org/ (http://www.nrharural.org/.).

CONFERENCECALL SERIES "PROMOTING QUALITY IMPROVEMENT IN RURAL AREAS" - NRHA is hosting a 3-part conference call series on quality improvement. The first call has already occurred, and the materials are posted to the NRHA web site - http://www.nrharural.org/conferences/sub/Qteleconf.html (http://www.nrharural.org/conferences/sub/Qteleconf.html). The next in the series are March 8 and June 14. A flyer is attached below with more information.
NATIONAL RURAL HEALTH CONFERENCE - May 17-19, 2006 in Reno, Nevada. Quint Studer of the Studer Group will be the keynote speaker. Quint is "helping to change the face of today's health care. An accomplished public speaker and consultant, he encourages health care organizations to return to their "roots," and create a culture of excellence." You can find more conference details at http://www.nrharural.org/conferences/sub/AnnConf.html (http://www.nrharural.org/conferences/sub/AnnConf.html).
CALL FOR NRHA AWARD NOMINEES - NRHA just issued its call for awards applications. There are number of categories, including the Rural Health Quality Award - for an individual, organization, or group that has made significant contributions to the quality and safety of care delivered to rural Americans. The deadline for nominations is March 1 and the details, including on-line nomination forms, can be found at http://www.nrharural.org/AC/sub/awards.html (http://www.nrharural.org/AC/sub/awards.html).Stay tuned for future updates!

[Richard Corcoran]

This national survey, published by the Maine Rural Health Research Center, shows that patients with mental health issues represent a small but significant proportion of the visits to Critical Access Hospital (CAH) emergency departments – over 9%. The survey also documents that for a sizeable number of CAHs, resources for dealing with patients presenting with mental health problems are very limited. The authors offer suggestions for dealing with these issues.

85% of ED managers contacted in 422 CAHs in 44 states responded to the survey. Some of the key findings are:

In over 40% of the communities where CAHs are located, there is no mental health service provider available locally, and less than 3% had psychiatric inpatient treatment available locally.
Travel times are significant, with a mean travel time of 52 minutes to receive services not available locally and some CAHs reporting travel times of up to 4 hours.
Patients presenting with suicidal symptoms represent 18% of the mental health problems in these EDs, and 2% of all CAH ED visits.
Though over 40% of CAHs had a crisis response team available, this service was only used for about 26% of suicide cases. It was more common to simply transfer such patients out of the community (50%).
Many individuals left the ED with no clear plan for their presenting mental health problems.The complete report can be read here – Mental Health Encounters in Critical Access Hospital Emergency Rooms (http://muskie.usm.maine.edu/Publications/rural/wp32.pdf).

[Richard Corcoran]

As you know, the National Rural Health Association (NRHA) has identified quality improvement as a strategic priority. I’ve listed below three current items from their February update that may be of interest to you. You can find complete information on the NRHA’s activities at http://www.nrharural.org/ (http://www.nrharural.org/.).

Access to Health Care for Rural America: Why It Matters (http://www.demos.org/aroundthekitchentable/article.cfm?edition=014&article=health)An interesting brief read that provides an overview of issues related to rural health care access and the importance of health care access to rural communities. The article concludes, “Some of the strategies pursued in our most remote areas ultimately may be the most cutting edge approaches to health care service design.”

Medicare and You 2006 (http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf)The official government handbook, updated with information about the Part D prescription drug program.

Institute of Medicine Rural Health Report: Next Steps in Legislation and Programs (http://www.rupri.org/healthpolicy/Pubs/p2006-1.pdf)Report of the Rural Policy Research Institute (RUPRI) that recommends federal policies that will improve patient safety and health care quality in rural America. The report is based on the 2004 Institute of Medicine (IOM) publication, Quality through Collaboration: The Future of Rural Health Care. (http://www.iom.edu/CMS/3809/13989/23359.aspx)

Let me know if you find any of these useful!

[Richard Corcoran]

The Rural Assistance Center (RAC) is a collaborative effort of the University of North Dakota Center for Rural Health (UND-CRH), the Rural Policy Research Institute (RUPRI), and the federal Office of Rural Health Policy (ORHP) at the U.S. Department of Health and Human Services, and is located at the University of North Dakota.

A product of the U.S. Department of Health and Human Services’ Rural Initiative, the RAC was established in December 2002 as a rural health and human services "information portal." RAC helps rural communities and other rural stakeholders access the full range of available programs, funding, and research that can enable them to provide quality health and human services to rural residents.

RAC offers many services to help inform decisions affecting rural health and human services. All services are provided free of charge.

You may want to check out the RAC web site (http://www.raconline.org/) to see if any of their services might be helpful to you. I found their winter 2006 issue of The Rural Monitor (http://www.raconline.org/newsletter/pdf/winter06.pdf) very informative, particularly regarding oral and dental health in rural areas. Enjoy!

[Richard Corcoran]

It seems clear that public reporting of CAH-specific measures is in the near future for all 1,200 or so CAHs nationally. These measures have already been developed by CMS and will be published shortly. That’s why we are encouraging all CAHs in New York State to get ahead of the curve by downloading and using the CMS Abstraction and Reporting Tool (CART) and to begin exchanging data with the QIO warehouse now. The preparation and practice is important. Additionally, each CAH will be able to establish it’s own benchmarks upon which to assess future performance.

As is stands, 41% of CAHs nationally were already participating in Hospital Compare to some degree by the end of 2005. A recent report, published by the Flex Monitoring Team in February 2006, examines the participation of Critical Access Hospitals (CAHs) in public reporting of quality measures in the Centers for Medicare and Medicaid Services (CMS) Hospital Compare database. This brief report makes for an interesting read. The main finding -

“… results suggest that CAHs as a group are performing as well or better than non-CAH rural and urban hospitals on several measures for patients with pneumonia, including the initial antibiotic in four hours, pneumoccal vaccine, and blood culture prior to antibiotic measures. They are also performing as well or better than small non-CAHs on most AMI and pneumonia measures. However, they are not performing as well as other rural or urban hospitals on most quality of care measures for patients with AMI and heart failure. The measures on which CAHs score lower include administration of aspirin and beta-blockers on arrival and at discharge for AMI patients; assessment of left ventricular systolic dysfunction and discharge instructions for heart failure patients; and smoking cessation advice for all three conditions.”


To read the entire report click here. (http://www.flexmonitoring.org/documents/BriefingPaper9_HospitalCompare.pdf)

[Richard Corcoran]

The Centers for Medicare & Medicaid Services (CMS) general summary about Critical Access Hospitals (CAHs) has been updated. Click here (http://www.cms.hhs.gov/MLNProducts/downloads/2006cah.pdf) to see the February 2006 version. The fact sheet includes a list of rural health websites.

[Richard Corcoran]

From time to time, the National Rural Health Association (NRHA) issues briefs and papers related to rural health issues. I’ve listed below two recent publications that are relevant too improving quality and safety in rural hospitals:

Public Reporting of Hospital Quality in Rural Communities: An Initial Set of Key Issues—May 2005 (http://www.nrharural.org/advocacy/sub/policybriefs/public_reporting.pdf). This 4-page policy brief focuses on issues related to the public reporting of hospital quality in rural communities. The brief addresses the question, “How, from a rural perspective, can the Hospital Compare website (www.hospitalcompare.hhs.gov (http://www.hospitalcompare.hhs.gov)) be improved?” and makes fourteen specific policy recommendations.

Rural Health Information Technology—February 2006 (http://www.nrharural.org/advocacy/sub/issuepapers/0206-HIT.pdf). This 10-page issue paper examines the national experience in moving toward establishing interoperable electronic health records as it relates to rural environments.



Let me know if you find either of these informative or useful! You can find complete information on the NRHA’s activities at http://www.nrharural.org/ (http://www.nrharural.org/.).

[Richard Corcoran]

The FLEX Monitoring Team, comprised of the Universities of Minnesota, North Carolina at Chapel Hill and Southern Maine, has released new information to assist the nation’s 1,200 Critical Access Hospitals (CAH) to understand and strengthen the use of health information technology (HIT) solutions.The Current Status of Health Information Technology Use in CAHs offers survey evidence that rural facilities have a high usage rate of administrative and financial health information technology (HIT) applications, but much lower rates of usage in the areas of clinical applications. This brief report summarizes the FLEX Monitoring Team’s survey and presents an interesting snapshot of the use of HIT solutions nationwide.

You may want to share this report with your senior leadership team.

To read the entire report click here. (http://flexmonitoring.org/documents/BriefingPaper11_HIT.pdf)

[Richard Corcoran]

The NRHA’s Quality Initiative, launched in March of 2005, is a five-year plan designed in response to an Institute of Medicine (IOM) report released in November 2004. The IOM report, Quality Through Collaboration: The Future of Rural Health (http://www.iom.edu/?id=23359&redirect=0), recommends we

develop and highlight quality improvement models that work in the rural environment,
engage federal partners to make rural health care a priority, and
support rural communities in the areas of health care workforce, financing and information and communication technology (ICT).The Quality Initiative, led by Forrest Calico, MD was designed with the belief that rural health care providers can not only achieve high performance standards, but can be leaders in the national quality movement.

To learn more about this initiative and to access the resources available on their web site, click here (http://www.nrharural.org/quality/index.html).

[Richard Corcoran]

The critical-access hospital program in Illinois has had a positive economic impact on both the hospitals involved and their local communities, according to a study published in June by Northern Illinois University. The study -The Economic Impact of Critical Access Hospital Program on Illinois Communities - produced 20 key findings regarding current hospital operations and net changes in operation and services since CAH designation. The upbeat study concludes -

“Critical Access Hospitals throughout rural Illinois serve vital medical and economic purposes. In addition to providing a broad range of primary and emergency care and community services to medically vulnerable populations, particularly the elderly, CAHs are major contributors to the local economic base. Designation as a Critical Access Hospital and access to the financial benefits associated with that program have enabled many of these institutions not only to keep their doors open, but to update obsolete facilities and equipment and respond to the changing healthcare needs of their communities.”

The study report also contains a concise background of the CAH program, including a brief history of early implementation results in other states.

You can read the full 36-page report here (http://www.rdiniu.org/publications/pdf/ICAHN_report_final.pdf) or a 4-page executive summary here (http://www.rdiniu.org/publications/pdf/ICAHN_exec_summary_final.pdf).

[Richard Corcoran]

The National Rural Health Association’s 2nd Annual Quality Conference, held in Denver on July 26-27, brought together a good mix of folks representing a wide range of rural providers and representatives from state and federal agencies. The conference focused on how safety and quality improvement activities are increasingly driving the structure, value, and viability of health care in rural communities. The presentations stressed the need for rural providers to think, communicate, and work together in profoundly new ways to insure access to high-quality, effective, and reliable health care.

You can access all the presentation handouts and materials by clicking here (http://www.nrharural.org/conferences/sub/QualityHandouts.html). All the presentations are useful, but if you have limited time (as we all do) I particularly recommend -


Finding My Way (To Safety and Quality) by A. Clinton MacKinney, MD, MS; Senior Consultant, Stroudwater Associates.
Patient Safety and Saving Lives: The Institute For Healthcare Innovation Interventions In A Critical Access Hospital by Colleen Spike, CEO and Ben Chaska, MD, Medical Director, St. Peter Community Hospital.

[Trish Uldrich]

Thanks for the information it was useful and I will use some of the slide presentations in my Hospital.:D

[Richard Corcoran]

This brief report provides an interesting and provocative overview of the Critical Access Hospital (CAH) program, its benefits, and potential threats to the program's long-term viability. Examines the CAH designation's relative importance to a hospital's credit rating. You can access this report by clicking here (http://tasc.ruralhealth.hrsa.gov/documents/Fitch%20CAH%20Report%207-27-061.pdf).

[Richard Corcoran]

St. Peter Community Hospital is a 17-bed CAH located in St. Peter, MN. The CEO attended an IHI Quality Summit in 2004 and determined to transform her hospital’s culture around the 100K Lives Campaign. The powerpoint presentation (http://www.nrharural.org/QChandouts/quality/Quality02.pdf) tells their ongoing success story. Contains lots of lessons learned and food for thought - highlighting the absolute need for executive, medical staff, and board leadership.

[Richard Corcoran]

Found this very brief article on the Community and Rural Hospital Leadership Center web site (http://www.healthleadersmedia.com/crhlc/index.cfm). The article deals with a few concrete steps that rural facilities can take to improve community perception of the quality and availability of their services and to keep patients in the local community. Thought it was worth sharing. Click here (http://www.healthleadersmedia.com/crhlc/view_news.cfm?cid=17889031&qual=1&nid=27&content_id=82519) to access.

You might want to forward to your executive management team.

[Richard Corcoran]

The National Rural Health Association (NRHA) is hosting a critical access hospital conference in conjunction with a rural health clinic conference (10/3/06-10/4/06) in St. Louis, Mo. The CAH-specific agenda includes pending legislative and regulatory changes, reimbursement issues, impact of replacement facilities, safety, quality, information technology, and more.

Click here (http://www.nrharural.org/conferences/sub/CAH.html) to access more information, the conference brochure, and registration details.

[Richard Corcoran]

The following information was released by the NRHA on September 12, 2006 -

Reps. Greg Walden, R-Ore., and Earl Pomeroy, D-N.D., along with colleagues from the House Rural Health Care Coalition, introduced the Health Care Access and Rural Equity Act of 2006. Designed to improve healthcare access and quality in rural areas, the legislation also would increase disproportionate share hospital payments to rural hospitals and ensure adequate representation of rural health interests on the Medicare Payment Advisory Commission. The bill furthers the Institute of Medicine’s recommendation for demonstration projects in rural communities aimed at improving healthcare quality. It also incorporates all of the provisions contained in The Rural Hospital and Provider Equity Act of 2006.

Other key provisions include:

· Creating a rural community hospital program, which provides Medicare cost-based reimbursement for inpatient and outpatient services for hospitals with less than 50 beds.· Requiring Medicare Advantage plans to pay critical-access hospitals at least as much as they would receive under traditional Medicare. · Authorizing $140 million over five years for health information technology grants for rural providers. · Requiring prompt payment to rural pharmacies from Medicare prescription drug plans. · Re-authorizing rural outreach and network grants, which provide capital investments so rural communities can build networks across providers and increase access to care.For more information, click here (http://www.nrharural.org/about/sub/news/H-CARE06.html).

You may want to share this with your senior leadership team.

[Richard Corcoran]

A report from the Rural Health Research Center at the University of Washington shows the results of a study of critical access hospital workforce issues during 2002-2003. At that time, there were about 600 critical access hospitals (CAH) in the United States – about ½ the number there are today – and most of them were located in the center of the country. The report provides a glimpse of how CAHs were staffed and operated three years ago. The data will give you a starting point to compare where you are today with some of the “early adopters” of CAH status.

Click here (http://www.rupri.org/rhfp%2Dtrack/results/CAHsurvey.pdf) to access the full report.

[Richard Corcoran]

This is a free “e-zine” (a magazine delivered by email) from HealthLeaders Media, a company serving the business information needs of healthcare executives and professionals. When distribution began a few weeks ago, I subscribed.

I have found this to be a very good resource for understanding the focus of hospital and health leadership with regard to many of the key improvement issues before us – quality, patient safety, transparency, pay for performance, culture change, transformational change, etc. The articles are brief and to the point and often contain good “links” to further information and detail.

I’m establishing this thread to highlight articles and information from this web publication that I think are informative and may be useful to you in your efforts to improve the quality and safety of care in your own facilities.


Two recent articles caught my eye that I think are worth sharing. The first succinctly describes the challenges of measuring quality in rural and critical access hospitals. The second provides ten “tips” for establishing an effective quality improvement program. Click on the links below to access:The Challenges of Measuring Quality in Rural Hospitals (http://www.healthleadersmedia.com/crhlc/view_news.cfm?content_id=83427)10 Tips for Establishing Quality Improvement Programs (http://www.healthleadersmedia.com/crhlc/view_news.cfm?content_id=83649)If you wish, you can subscribe yourself by clicking here (http://www.healthleadersmedia.com/crhlc/ezines/index.cfm).

Enjoy!

[Richard Corcoran]

Research shows that hospitals with less than 100 beds are the biggest consumers of mass media advertising; however, online marketing might provide a bigger impact for less money. HealthLeaders contributor Anthony Cirillo offers five reasons why the Web may be rural hospitals’ best marketing strategy.

Click here (http://www.healthleadersmedia.com/crhlc/view_news.cfm?content_id=83319) to read.

[Richard Corcoran]

The 2005 Institute of Medicine (IOM) report,Quality Through Collaboration: The Future of Rural Health Care (http://newton.nap.edu/books/0309094399/html), calls for rural health providers to become more patient-centered and work together to improve community health outcomes. The report states –

“Rural communities should focus on improving both personal and population health programs to realize the greatest improvement in health and health care. An integrated approach to identifying priorities and allocating resources is needed. It will also be necessary to cultivate a new cadre of health care leaders capable of viewing clinical care within the broader context of population health and building communitywide collaborative structures.” Click here (http://www.healthleadersmedia.com/crhlc/view_news.cfm?cid=17889031&qual=1&nid=27&content_id=84012) to read an article about how working together in rural communities can be challenging opportunity. I’m also including a link to the NRHA report mentioned in the article – Collaboration: Modern Relationships Between Rural Community Health Centers and Hospitals. (http://www.nrharural.org/quality/collaboration.pdf)

[Richard Corcoran]

The National Rural Health Association (NRHA) hosted a critical access hospital conference in conjunction with a rural health clinic conference (10/3/06-10/4/06) in St. Louis, Mo. The CAH-specific agenda included pending legislative and regulatory changes, reimbursement issues, impact of replacement facilities, safety, quality, information technology, and more.

Click here (http://www.nrharural.org/CAHhandouts/#CAH) to access the conference handouts.

[Richard Corcoran]

“Value-based purchasing” has become a buzzword among those who pay for healthcare in this country. CMS, health plans, insurers, and employers alike are recognizing that the “value” of a health service can be defined by an equation that has at least quality, safety, and satisfaction in the numerator and only cost in the denominator. This value proposition has emerged as a driving force in “transformational” change. This article begins with the following –


“The shift to a value orientation will require innovation of healthcare’s business models, operations, services and markets. Organizations that embrace value innovation as a culture and strategy and execute changes effectively and rapidly will win in a value-driven market.”
“Those organizations that defend the status quo risk being ignored by consumers.”If you want to read the rest, click here (http://www.healthleadersmedia.com/crhlc/view_news.cfm?cid=17889031&qual=1&nid=27&content_id=84429).

[Richard Corcoran]

The NRHA has put together a brief list of important things that make healthcare delivery in rural America “different” and that offer unique challenges to patients and providers alike. The list includes a side-by-side snapshot comparing key population statistics between urban and rural areas. Click here (http://www.nrharural.org/about/sub/different.html) to access.

[Richard Corcoran]

“Value-based purchasing” has become a buzzword among those who pay for healthcare in this country. CMS, health plans, insurers, and employers alike are recognizing that the “value” of a health service can be defined by an equation that has at least quality, safety, and satisfaction in the numerator and only cost in the denominator. This value proposition has emerged as a driving force in “transformational” change. Part 1 of this article began with the following –

“The shift to a value orientation will require innovation of healthcare’s business models, operations, services and markets. Organizations that embrace value innovation as a culture and strategy and execute changes effectively and rapidly will win in a value-driven market.”
“Those organizations that defend the status quo risk being ignored by consumers.”To read the second part of this article, click here (http://www.healthleadersmedia.com/crhlc/view_news.cfm?cid=17889031&qual=1&nid=27&content_id=84615).

[Richard Corcoran]

This brief article, written by an experienced critical access hospital executive, states that CAH status provides an excellent planning opportunity. The author offers the following 8 planning tips -


Don’t lose sight of your business responsibilities.
Carefully assess community needs.
Be inclusive in your community analysis.
Be deliberate with strategic planning.
Have a current medical staff development plan.
Stay balanced financially.
Educate your staff and your board.
Engage with resource centers.To read more, click here (http://www.healthleadersmedia.com/crhlc/view_news.cfm?cid=17889031&qual=1&nid=27&content_id=84614).

[Richard Corcoran]

The Nebraska Center for Rural Health Research recently released a report summarizing the medication error reports voluntarily submitted in 2005 by 25 critical access hospitals. The CAHs voluntarily submitted to MEDMARX, which is an anonymous, Internet-accessible reporting system for participating hospitals to report and analyze medication errors using standard definitions. The brief (24-page) report, "Implementing a Program of Patient Safety in Small Rural Hospitals: Findings and Trends in Medication Error Reporting from 25 Critical Access Hospitals," is filled with very relevant charts and graphs regarding the number, types, and severity of medication errors as well as follow-up actions taken as a result of error reporting.

Key findings of this interesting study include:

CAHs must use skills in process improvement, culture assessment, teamwork and voluntary reporting to create reliable processes that provide evidence-based, safe care.
A nonpunitive, voluntary medication error reporting program can help critical access hospitals identify system sources of medication errors and understand the level of safety awareness in their organizations.
Differences in reporting patterns between critical access hospitals and all general hospitals were consistent with the limited presence of pharmacists in the majority of CAHs.
Errors reach patients for four main reasons: procedure/protocol is not followed, transcription and documentation is inaccurate or omitted, communication problems exist, or workflow is disrupted.
The primary action taken in response to error—informing the individual involved—reflects the difficulty of building a just culture that balances individual accountability and improving system reliability.
Errors involving high-alert medications, which include blood coagulation modifiers, insulin and opioid analgesics, are most likely to require monitoring, intervention, and to result in harm.
Critical Access Hospitals can decrease the risk to patients by implementing proven medication safety practices consistent with JCAHO's medication-related National Patient Safety Goals and by increasing access to the knowledge base of clinical pharmacists. Click here (http://www.unmc.edu/rural/documents/pr06-08.pdf) to access the complete report.

You may want to share this report with your pharmacist and senior leadership team.

[Richard Corcoran]

Interest in using pay-for-performance programs to improve healthcare quality has grown in recent years, according to the Upper Midwest Rural Health Research Center’s report, “The Implementation of Pay-For Performance in Rural Hospitals: Lessons from the Hospital Quality Incentive Demonstration Project.” The Centers for Medicare & Medicaid Services is in the final phase of its Hospital Quality Incentive Demonstration Project, which tests the effectiveness of financial incentives for improving the quality and cost of care provided to Medicare beneficiaries.

Even though the number of P4P efforts under way in the United States has grown significantly over the past decade, there is still concern over the potential impact on rural providers and communities. Rural facilities are often more isolated, provide a narrower scope of services and have smaller patient volumes; such providers also have limited information system infrastructure, clinical staff resources and capital. These facilities may require a different set of strategies to achieve the goals of a national P4P initiative.

Key findings for rural hospitals participating in P4P initiatives include:

A large number of rural hospitals with low inpatient volumes may participate in P4P in the future, yet the influence of bonus payments incentives is limited for hospitals with low inpatient volumes.
Non-financial incentives can make a difference, especially for physicians and nurses who are more motivated by feedback on the quality of care they are providing to their patients. The close-knit culture of many small, remote rural communities may benefit rural hospitals through more selective and effective peer influence.
Physicians and nurses need feedback on the care they are providing. The more frequent, clear and accurate the feedback, the more effective it will be in helping them improve their daily performance.
Provider feedback can only create performance improvements to the degree to which the necessary tools, education and guidance are made available to reinforce the effort.
Physician and nurse involvement is critical for successful participation in P4P programs. Difficulties recruiting and retaining clinical staff may undermine efforts to engage them in non-clinical direct-care activities.
Limited clinical staff will make it difficult to meet added staffing needs of P4P. Small rural hospitals can benefit from defined skill sets for quality management staff that maximize nursing time for direct patient care. Click here (http://www.uppermidwestrhrc.org/pdf/pay_for_performance.pdf) to access the complete report.

Source: Community and Rural Hospital Weekly

[Richard Corcoran]

A report, recently published by the Flex Monitoring Team, presents 20 financial indicators for Critical Access Hospitals (CAHs). The report includes state and national medians for indicators addressing profitability, liquidity, capital structure, revenue, cost, and utilization. The data in the report is from 2004.

The indicators may be helpful in your efforts to benchmark your own performance. 17 of the 20 are solely financial. Three indicators are also “operational” – FTE’s per occupied bed (p. 14), Acute Bed Average Daily Census (p. 16), and Swing Bed Average Daily Census (p. 16). Information for New York State is summarized on page 44.

Click here (http://www.flexmonitoring.org/documents/CAHFinancialIndicatorsReport3rd.pdf) to access the report.

[Richard Corcoran]

This brief article describes an innovative use of telehealth to treat and monitor cardiovascular disease, diabetes and obesity in a rural community. A federally funded health center in North Carolina has installed RemoteNurse kiosks in strategic locations throughout the county. Enrolled patients transmit information via touch-screen web technology to providers, who then take appropriate action. Initial results of their pilot study are promising. Interesting idea!

Click here (http://www.healthleadersmedia.com/crhlc/view_news.cfm?cid=17889031&qual=1&nid=27&content_id=85208) to read the article.

[Richard Corcoran]

For those of you unfamiliar with the Flex Program, this briefing paper provides an in-depth description of activities proposed by the states during the 2005 grant year. The Medicare Rural Health Flexibility Program (Flex Program) provides grants to states to promote activities that support improvement in clinical quality, operational, and financial performance. Funds are administered through state departments of health. Click here (http://flexmonitoring.org/documents/BriefingPaper12_QIactivities.pdf) to access the report.

[Richard Corcoran]

This is a brief article about a critical access hospital in Georgia that obtained a $14 million dollar USDA loan to upgrade its facility. Clinch Memorial now boasts fully renovated private rooms equipped with wireless technology for Internet access, and also utilizes telemedicine, teleradiology and an electronic medical record. Click here (http://www.healthleadersmedia.com/crhlc/view_news.cfm?cid=17889031&qual=1&nid=27&content_id=85959) to read.

[Richard Corcoran]

Rural hospitals face a wide range of challenges in their efforts to deliver high quality care and compete with larger urban and suburban hospitals. This article discusses one domain of healthcare where rural hospitals may actually enjoy an advantage: proactive health management. Click here (http://www.healthleadersmedia.com/crhlc/view_news.cfm?cid=17889031&qual=1&nid=27&content_id=85842) to read.

[Richard Corcoran]

This brief article is intended to convince hospital board members that the organization’s economic future can be assured by improving quality outcomes of care. It provides a quick summary of the steps trustees might take to become actively involved in quality initiatives and provides a neat description of how to do a root cause analysis using the “5 Whys?” technique.

Click here (http://www.healthleadersmedia.com/view_feature.cfm?content_id=86073) to access.

[Richard Corcoran]

The NRHA has published a document to assist in the planning of telehealth and telemedicine projects for rural community and migrant health centers and other health care organizations.

The purpose of this 14-page document is “…to help organizations plan their program to increase the probability of a successful telehealth program.” The manual describes the following seven steps that lead to telehealth success –

· Evaluate Needs

· Develop Care Services Plan

· Develop Business Plan

· Plan Technology

· Train Personnel

· Test Care and Technology Plans

· Evaluate Outcomes
Click here (http://nrharural.org/pubs/pdf/Telehealth.pdf) to access the manual.

[Richard Corcoran]

This brief article describes a new approach, “focusing on distance learning and shorter, more frequent learning sessions to help get the chronic-care model out to more rural practitioners.”

Click here (http://www.healthleadersmedia.com/crhlc/view_news.cfm?content_id=86760) to read.

[Richard Corcoran]

This article summarizes second-year results from the Premier Hospital Quality Improvement Demonstration (HQID) project. This value-based purchasing project is part of an overall shift in Medicare to pay based on value, not volume of services, i.e. pay-for-performance (P4P). Participating hospitals reported significant improvement in quality of care across all five clinical areas. The average improvement in the project’s second year was 6.7 percentage points, for total gains of 11.8 percentage points over the project’s first two years. The project awarded $8,690,447 in incentive payments to 115 top-performing hospitals.

To read the article, click here (http://www.healthleadersmedia.com/crhlc/view_news.cfm?content_id=86921).

To link to the CMS web site for further details, click here (http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=2076&intNumPerPage=10&checkDate=&checkKey=&srchType=&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date).

[Richard Corcoran]

Two items of interest re upcoming legislation affecting rural hospitals -

The White House released its proposed Fiscal Year 2008 budget in February. The following rural health program funding was eliminated: Rural Health Flexibility Grants, Small Hospital Improvement Program, Rural Health Network and Outreach Grants, Rural and Community Access to Emergency Devices, Area Health Education Centers and Geriatric Education Centers. In addition to the discretionary programs, the proposed budget includes $78.6 billion in legislative cuts to Medicare and Medicaid over five years, with cuts for both programs reaching $102 billion over five years when the president’s proposed regulatory changes are included. Details are on the National Rural Health Association Web site (http://www.nrharural.org/about/sub/news/pres07budget.html).

Senators Feingold (D-WI) and Collins (R-ME) introduced S. 498, the Rural Medicare Equity Act. If passed, this legislation would:
Ensure adequate representation of rural beneficiaries and providers on the Medicare Payment Advisory Commission (MedPAC).
Provide $50 million for quality demonstration projects, focusing on innovative uses for health information technology to improve access and quality of care.
Eliminate the geographic physician work adjustment factor in the Medicare physician

[Richard Corcoran]

Hospitals across the United States have substantially improved the quality of care provided to patients suffering from heart attacks, heart failure or pneumonia over the past four years, according to a new report from The Joint Commission.

The report, "Improving America's Hospitals: A Report on Quality and Safety," outlines the performance of accredited hospitals against standardized national performance measures and the Joint Commission's national patient safety goals.

Key findings include:

The greatest improvement occurred in providing smoking cessation advice to patients admitted to the hospital with pneumonia. The national rate for telling these patients about the benefits of quitting smoking increased from 37 percent in 2002 to 80 percent in 2005.
Hospitals are currently achieving 90 percent performance or higher for about half of the measures tracked since 2002. Yet, hospitals are performing at less than 65 percent for two of these measures--providing pneumococcol vaccination to patients admitted with pneumonia and providing discharge instructions to patients admitted with heart failure.
Considerable variability exists in the performance of hospitals by state on most measures. For example, the statewide averages for providing discharge instructions to patients admitted with heart failure range from 33.5 percent to 89 percent.
More than 90 percent of the nation's hospitals are achieving 90 percent performance on only one measure.
Hospital compliance is lowest for national patient safety goal requirements that a "time out" be taken by the surgical team before surgery to confirm patient identity and correct procedure, and that certain potentially confusing abbreviations not be used in ordering medications. To access the complete report, click here. (http://www.jointcommissionreport.org/)

[Richard Corcoran]

A guide to assist in the planning, design and construction of a Critical Access Hospitals (CAH). Includes information on the process and program requirements, examples of floor plans for 25-bed and 15-bed CAHs, budget information, and more.

Click here (http://www.hud.gov/offices/hsg/hosp/prototype.pdf) to obtain. Have patience! This is a big document (has pictures and floor plans) and may take a while to download.

[Richard Corcoran]

Nearly one-fourth of all community hospital stays for patients who are 18 years old and older—7.6 million of nearly 32 million hospital stays—involved depression, bipolar disorder, schizophrenia and other mental health disorders or substance abuse problems in 2004, according to a report by the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality.

Click here (http://www.healthleadersmedia.com/crhlc/view_news.cfm?cid=17889031&qual=1&nid=27&content_id=88848) to read article.

[Richard Corcoran]

In its proposed rule updating the hospital inpatient prospective payment system for fiscal year 2008, the Centers for Medicare & Medicaid Services proposed to adopt a severity-adjusted diagnosis related group system called Medicare-Severity DRGs.

Click here (http://www.healthleadersmedia.com/crhlc/view_news.cfm?cid=17889031&qual=1&nid=27&content_id=88855)to read article.

Click here (http://www.raconline.org/news/news_details.php?news_id=6244) for more details.

[Richard Corcoran]

Errors in prescribing and dispensing medications cost the healthcare industry millions annually, but contributor Marybeth Regan, PhD, says the involvement of pharmacists and medication therapy management services in the treatment process can cut down risk and reduce costs.

Click here (http://www.healthleadersmedia.com/crhlc/view_news.cfm?content_id=89211) to read more.

[Richard Corcoran]

A new report, published by the Upper Midwest Rural Research Center, discusses the issue that smaller hospitals experience much greater variability in performance scores as a result of statistical sampling characteristics than larger hospitals.

The report “examines whether hospital size impacts the ability to identify hospitals' performance in a pay-for-performance demonstration project based on hospital rankings. Using data from the Premier Hospital Quality Incentive Demonstration and the Centers for Medicare and Medicaid Services' Hospital Compare, the report found that the smallest hospitals would, on average, experience five to seven times more uncertainty than the largest hospitals concerning their true relative performance for heart failure, pneumonia, and acute myocardial infarction. The authors conclude that all estimates of rank need to include adequate measures of uncertainty of those estimates.”

The report has important policy implications as we move into a value-based purchasing (read “pay-for-performance”) environment and highlights the need to develop specific quality measures for small rural and critical access hospitals.

Click here (http://www.uppermidwestrhrc.org/pubs/) to obtain the full report (26pgs) or a policy brief (4pgs).

[Richard Corcoran]

The AHA has published a brief and useful overview of the physician shortage issues faced by rural hospitals. Includes information on current public policy, and resources for hospitals.

Click here (http://www.aha.org/aha/content/2007/pdf/ruralphysshortage.pdf) to obtain.

[Richard Corcoran]

The Flex Monitoring Team has published aggregate findings from a project that tested emergency department quality measures in a voluntary sample of critical access hospitals (CAHs) in Washington State.

Emergency department measures are reported in three categories:

chest pain/AMI assessment
trauma/vital signs
transfer communication. Three quality measures were field-tested that focused on chest pain/AMI assessment: time to electrocardiogram (ECG), aspirin within 24 hours, and time to thrombolytics.

The ED trauma vital signs measure assessed the proportion of trauma patients with systolic blood pressure, pulse rate, or respiratory rate documented on arrival to the emergency department and at least hourly (or until the patient is released, admitted or transferred).

The emergency department transfer measure included 28 elements in seven categories: pre-transfer communication, patient identification, vital signs, medication–related information, physician-generated information, nurse-generated information, and procedures and tests. It assessed the number of information elements sent with patients who were transferred from the ED to another hospital.

For each category, a description of the measures is presented, followed by national comparison data where available. Results from the field test conclude each section.

The report concludes –

“Feedback on the measures suggests that the adaptation of the inpatient AMI measure to assess emergency department management of patients presenting with chest pain/AMI is a useful reporting and improvement tool for small rural hospitals. The elements of the transfer communication measure are easily abstracted, and provide many opportunities for documentation and communication improvement. The trauma measures still need refinement.”

To read the report, click here (http://www.flexmonitoring.org/documents/FlexDataSummaryReport3.pdf).

[Richard Corcoran]

This brief article describes a “patient visibility system” in a critical access hospital that effectively links bed management with improved performance on quality and safety measures. What could be better??

Click here (http://www.healthleadersmedia.com/crhlc/view_news.cfm?cid=17889031&qual=1&nid=27&content_id=89970) to read.

[Richard Corcoran]

A brief article describing the current state and emerging potential for telemedicine technologies to dramatically improve care delivery in rural areas.

Click here (http://www.healthleadersmedia.com/crhlc/view_news.cfm?cid=17889031&qual=1&nid=27&content_id=89790) to read.

[Richard Corcoran]

The 2007 NRHA conference took place in Anchorage, Alaska on May 15-18, 2007. For those of you, like me, who did not make the trip,;) conference handouts are available on-line. Click here (http://www.nrharural.org/conferences/sub/AnnConf.html) to obtain.

[Richard Corcoran]

This brief article may be helpful in understanding that obtaining a grant is not child’s play, but it can be done.

Click here (http://www.healthleadersmedia.com/crhlc/view_news.cfm?cid=17889031&qual=1&nid=27&content_id=90305) to read.

[Richard Corcoran]

The National Rural Health Association is holding back-to-back Quality and Clinical Conferences in Kansas City the end of July. See the attached brochure for details and registration information.

[Richard Corcoran]

The National Rural Health Association reports that the House Appropriations Subcommittee last week gave large increases to many rural health programs such as Outreach and Network Grants, Rural Health Research, State Offices of Rural Health, the National Health Service Corps, Area Health Education Centers, and Community Health Centers.

Click here (http://capwiz.com/nrha/issues/alert/?alertid=9894381) to learn more.

[Richard Corcoran]

This report from the Flex Monitoring Team examines the second year participation and quality measure results for Critical Access Hospitals (CAHs) in the Centers for Medicare and Medicaid Services (CMS) Hospital Compare public reporting database for hospital quality measures.

Over 53% of CAHs nationally are participating in Hospital Compare (up from 41%) and another 20% are reporting data to the QIO warehouse but have chosen not to have their data publicly reported. The report reveals that CAHs have room for improvement in measures related to AMI but that “…the group of CAHs that reported Hospital Compare data for both years significantly improved their performance on almost all pneumonia, heart failure, and surgical infection measures.”

Click here (http://www.flexmonitoring.org/documents/BriefingPaper16_HospitalCompare2.pdf) to obtain.

[Richard Corcoran]

This 2-page report describes the priorities and accomplishments of the Medicare Rural Hospital Flexibility Program's state Flex Grant Programs.

Click here (http://www.flexmonitoring.org/documents/PolicyBrief3.pdf) to read.

[Richard Corcoran]

This archive houses materials and resources posted on JENY of specific interest to rural and critical access hospitals.