Cover Story
The rural case for quality
By Laurie Larson
(And Why It Matters)
As concerns multiply about the state of America’s health care system, so do the analyses and measurements of ways to improve quality and patient safety. And, although no federal edicts have been issued about the best ways to make care better and safer, one pronouncement has become sweeping: Every hospital, large or small, must step up to the quality challenge and provide data on its performance. With a host of challenges already unique to their situation, rural hospitals must address the quality imperative as well.
“These days, every provider has to prove [its] quality,” says Richard Umbdenstock, president-elect of the American Hospital Association and executive vice president of Providence Health & Services, Spokane, Wash. “There are no more exceptions, no levels of omission that are acceptable anymore.” And, although rural hospitals have typically sought even standing with their urban counterparts, it’s a case where being considered their equals may not be an advantage.
“Historically, because of small volumes and not enough data, small, rural hospitals have not been allowed to participate in federal and other initiatives for reporting quality,” says Ira Moscovice, professor and director of the Rural Health Research Center at the University of Minnesota, Minneapolis. “But now, policy-makers are asking what they’re getting for the money they are spending, asking for public reporting and quality improvement initiatives—and rurals need to participate.”
As a prime example, the Centers for Medicare & Medicaid Services (CMS) recently began offering all prospective payment system (PPS) hospitals an increase in their Medicare reimbursement of four-tenths of a percent in exchange for voluntarily submitting data to CMS’ “Hospital Compare” Web site on specified sets of quality measures. This year, that incentive increased to 2 percent. And, even though the country’s nearly 1,000 critical access hospitals (CAHs) receive cost-based reimbursement, they must still pay attention to what CMS is asking of PPS hospitals and report quality data, because the same quality expectations will eventually affect them as well, Moscovice and others believe.
“The federal government will not allow more than a quarter of all the nation’s hospitals to not participate in public reporting initiatives,” Moscovice says. “Rural hospitals have to believe it’s important.”
Apparently, a good portion of them do. Last year, 41 percent of CAH hospitals participated in some level of Hospital Compare, Moscovice says, submitting data that allow consumers to compare how well hospitals in their area perform against each other relative to acute myocardial infarction (AMI), pneumonia, heart failure and prevention of surgical infection.
They’re doing so to show their commitment to quality and transparency, explains Mary Wakefield, chair of the Center for Rural Health at the University of North Dakota in Grand Forks.
“Rural hospitals can’t afford to not be part of public reporting on quality,” she explains. “Pay for performance is driving quality improvement [and] rurals can’t be left out of tying payment to performance. Meaningful reporting measures will allow them to be held up to scrutiny, but measurement and payment strategies must really work.”
Measurements That Matter
The key term is “meaningful.” To help determine what measurements make sense and will allow rural hospitals to be equal players on the quality playing field, the Institute of Medicine produced a report in 2004 called “Quality Through Collaboration: The Future of Rural Health Care.” Wakefield chaired the committee that produced the report, and Moscovice was also a committee member.
The report examined both the general level of quality among rural hospitals as well as what quality improvement approaches could be tailored specifically for them. It was written at the request of the Federal Office for Rural Health Policy, the Agency for Healthcare Research and Quality, the Kellogg Foundation and others, who wanted to “drill down separately” on rural health care quality, Wakefield says, since most quality research to date has focused on urban health systems or been more generalized.
“Rural providers have said that the focus of quality measures is irrelevant to them … that quality approaches and expectations don’t fit … that the rural context is not taken into consideration,” Wakefield says. For example, the Leapfrog Group recommends that ICUs be staffed by an intensivist. Rural hospitals typically don’t have either.
Wakefield says that, while payers and the federal government want to see data from hospitals that report on quality of care, “they need [multiple] cases, sets of numbers, to statistically report with validity, and rurals don’t see enough numbers to report on a big enough set” of quality indicators. Collectively, however, with one-fifth of the U.S. population living in rural communities, there is a significant “number set” among rural hospitals overall that needs to be taken under its own consideration—and that bears quality measurement merit.
“There are unique circumstances in rural health that influence delivery and quality, and unique strategies are needed to improve quality,” Wakefield says. In addition to large distances between services and facilities, rural hospitals have a unique clinician mix comprising mostly primary care physicians, as well as many nurse practitioners and physician assistants, who provide some primary care. Specialty and more complex general acute care is typically provided in larger towns. Within the patient mix, chronic health conditions and substance abuse are prevalent, as well as large numbers of low-income, uninsured patients and a significant elderly population.
Why is the IOM looking at rural quality reporting now? In addition to seeking process improvements that are more appropriate for rurals, Wakefield explains, “this is part of a broader push over the past five to seven years … to make U.S. health quality better. We should never talk about a second-tier health system … there should be no geographic quality divide.” She adds, “If we don’t look at rurals specifically, they will be left out of the debate.”
Moscovice explains, “Having [rural] quality information available is important to the local community, and it is [also] externally important, so the world sees that [rurals] are there. When an institution doesn’t report [on quality], it looks like they’re not good enough to report.”
Moscovice’s Rural Health Research Center at the University of Minnesota, in partnership with the state’s Quality Improvement Organization (federally supported in every state to improve care for Medicare beneficiaries, although some QIOs cover more than one state) have done field testing with hospitals in Nevada, Utah and Washington, in addition to Minnesota, to devise quality measurement sets that are aligned with CMS’ Hospital Compare data, but that also cover core rural hospital functions not considered in existing measurement sets. In addition to AMI, pneumonia and congestive heart failure, these added rural functions include timeliness of ED care, patient transfer communication and medication safety checklists. Participation is voluntary, and by the end of the trials, 40 rural hospitals will have participated, Moscovice estimates.
Looking at hospitals with fewer than 50 beds, his team has found that CAH hospitals do better with pneumonia outcomes than non-CAH hospitals, but not as well with AMIs when they do not transfer patients out of their facility.
However, transferred AMI patients have done well in study results, which points up an area where rurals particularly excel. Patient transfers, and equally importantly, the decision of whether or not to transfer patients, “that’s the rural hospital differentiater,” Moscovice says. “To send a patient 40 miles away is a crucial decision, and little research has been done on the timeliness and appropriateness of those decisions, as well as what happens after the transfer and what happens after those patients go home and in their future health care … the transfer decision is the quality key … rurals can really take the lead here.”
Moscovice says rural hospitals should take the same quality lead in emergency department care, particularly concentrating on timeliness of trauma care. “Rurals need to be good at these things and they can develop measures before other hospitals. These are core aspects of what those institutions provide,” he says.
Ideal Laboratories
In truth, there are many factors that make rural health care providers models of particular excellence. “Rurals have historically had to make do with less; there are no extra resources in their infrastructure—it’s invention by necessity,” Wakefield says. “There are great places that have invented and created because they don’t expect resources. That mindset in rural areas is an advantage.” In addition, rural providers know each other and their patients, and their facilities “can make changes on a dime for the whole hospital,” Wakefield says. “The stakeholders are there, and all the players are easily brought to the table.”
The University of Minnesota study has been testing this flexibility, looking at whether designated hospital staff can gather necessary quality data, and then, if the hospital is able to change its procedures based on what it learns—and the answer is yes. As an example, participating hospitals have tracked how well they’ve transferred necessary patient information, as well as the patients themselves, to receiving hospitals. Moscovice says that “within a week” of tracking their accuracy, those hospitals have been able to fix glitches in patient information transfer, improving care and further avoiding duplication of services.
Because of their size and flexibility, Wakefield says rural hospitals “are perfect learning laboratories. If you want to look at the impact of change, the rural community is small [so] you can look at research immediately … you can evaluate clearly what impact changes make. When we think of places to demonstrate new approaches, rurals are ideal.”
For example, because rurals excel at transfers, both between facilities and within their own walls, their procedures could potentially determine standardized protocols—an example of rurals acting as these “learning laboratories.” Taken one step further, health care quality for entire populations can be evaluated in rural communities, Wakefield believes, since it is easy to engage and track outcomes for all participants in a study, such as improving diabetes management or lowering rates of obesity.
To do all this, Wakefield and others agree that rural hospitals must find ways to put information technology (IT) into their infrastructure that is both cost-effective and functionally tailored for what they do, with high-speed connectivity (see “IT Funding,” on opposite page). The IOM rural quality report says hospital strategic planning should consider the financial resources that rurals need to participate in quality improvement and encourages federal agencies to ensure rurals have broadband network access. Wakefield believes that CMS and other federal agencies should give financial rewards to rural providers who implement electronic medical records and other IT infrastructures and that the Health Resources and Services Administration should look at ways for rurals to become paperless as well. Bottom line, “Financial resources should be tied to expectations about IT,” she asserts.
The Collaborative Imperative
But getting support from the government and other funding sources is only half the equation. Both from the standpoint of cost and standardization, rurals need to collaborate, experts agree. “By natural market and natural service area, that’s the way to gather together,” Umbdenstock says. “Smaller organizations can get [IT] faster in collaboration with others … and the [resulting] scale takes the learning curve up in a hurry.” Additionally, he says that “regional collaboration improves and maintains local assets—and people want to keep health care local.” His system also works with regional rural hospitals through a Rural Health Care Quality Network to compare quality data with each other.
“You can’t work in a vacuum,” says Nancy Vorhees, chief operating officer of Inland Health Services in Spokane, an affiliated Providence company. “What are your established relationships with other hospitals? Where is the ‘hub’ where referrals go? In areas where collaboration can make a difference, who do you want to collaborate with?”
Similarly, in shopping for IT, Vorhees advises against “buying something that only works for you … that’s where partnerships come in to get it done. The ability to connect with each other is critical.” Umbdenstock adds, “When you increase communication and contact [in a health care system] … there is better coordination of care. It’s financially prohibitive for each hospital to build its own IT system. The more you can build a community utility for health care information, the better you serve people—you have to learn how to collaborate and compete at the same time.”
Vorhees says, “Sometimes you have to set aside that competitive edge. I think you have to take a risk and ask what’s best for patients. If you don’t have patients, you don’t have a hospital.” And, those who need to ask that question first and foremost are hospital leadership and the board.
“Rural hospital board members need to ask for quality and safety data in the same way that urban hospitals do,” Wakefield says. “They should get reports on quality at every meeting, ask what can be done to make quality better and allocate resources to improve quality of care.” Moscovice adds, “What is clear is that the information can be collected—and it has to be collected identically to CMS—but it depends on [hospital] leadership saying it’s important.”
“To sustain and strengthen their hospital, trustees need to focus like a laser on quality of care,” Wakefield says. “Increasingly, payment policies are being crafted and linked to quality. Boards of directors have to be focused on both payment and quality—they are no longer separate universes—these two tracks are converging rapidly. And you can’t lead if you don’t have data to measure quality.”
“My hypothesis is that rurals can show the rest of the field how we do things,” Moscovice says. “We can take the lead on [quality of] patient transfers and timeliness and appropriateness of ED care—and that’s better than a model being developed in an urban hospital that rurals are expected to follow.” He adds that “rural is not ‘small urban.’ There is a mythology that bigger is better, that urban is better than rural. I think it’s important that rurals show they are interested in providing the highest quality of care and that urbans can learn from rurals, and vice versa.”
Laurie Larson is Trustee’s senior editor.
This article 1st appeared in the December 2099 issue of Trustee Magazine.
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