Quality Improvement Strategies and Best Practices in Critical Access Hospitals

ABSTRACT: Context: Critical access hospitals (CAHs) face many challenges in implementing quality improvement (QI) initiatives, which include limited resources, low volume of patients, small staffs, and inadequate information technology. A primary goal of the Medicare Rural Hospital Flexibility Program is to improve the quality of care provided by CAHs. Purpose: This article describes key quality improvement initiatives for a national sample of CAHs that are actively involved in implementing quality-related initiatives in collaboration with support hospitals and statewide organizations. Methods: Researchers conducted a national telephone survey of 72 CAHs and 2 in-depth case studies of CAHs. Findings: The survey and case studies demonstrate that many CAHs are successfully implementing QI activities, including patient safety initiatives, improvements in overall QI processes and peer review processes, and implementation of QI projects focused on treatment of 1 or more specific diseases. The CAHs are involved with multiple external organizations in these activities. The administrators of the 2 case study CAHs have made QI a priority for their hospitals; ensured that resources are available for QI activities; and worked with their support hospitals, statewide organizations, and other CAHs to develop and implement rural-relevant QI initiatives. Conclusions: Cost-based Medicare reimbursement has been a key factor in the ability of CAHs to fund additional staff, staff training, and equipment to improve patient care. The commitment of hospital leaders and key staff is a crucial factor in moving QI initiatives forward in CAHs.     

Rural Relevant Quality Measures for Critical Access Hospitals

Purpose: To identify current and future relevant quality measures for Critical Access Hospitals (CAHs). Methods: Three criteria (patient volume, internal usefulness for quality improvement, and external usefulness for public reporting and payment reform) were used to analyze quality measures for their relevance for CAHs. A 6‐member panel with expertise in rural hospital quality measurement and improvement provided input regarding the final measure selection. Findings: The relevant quality measures for CAHs include measures that are ready for reporting now and measures that need specifications to be finalized and/or a data reporting mechanism to be established. They include inpatient measures for specific medical conditions, global measures that address appropriate care across multiple medical conditions, and Emergency Department measures. Conclusions: All CAHs should publicly report on relevant quality measures. Acceptance of a single consolidated set of quality measures with common specifications for CAHs by all entities involved in regulation, accreditation, and payment; a phased process to implement the relevant measures; and the provision of technical assistance would help CAHs meet the challenge of reporting.     

Intensive Care in Critical Access Hospitals

CONTEXT: Although critical access hospitals (CAHs) have limitations on number of acute care beds and average length of stay, some of them provide intensive care unit (ICU) services. PURPOSE: To describe the facilities, equipment, and staffing used by CAHs for intensive care, the types of patients receiving ICU care, and the perceived impact of closing the ICU on CAH staff and the local community. METHODS: A semistructured interview of directors of nursing at CAHs that provide intensive care services. RESULTS: Two thirds of CAHs that provide intensive care do so in a distinct unit. Most have continuous or computerized electrocardiography and ventilators. Other ICU equipment common in larger hospitals was reported less frequently. Nurse:patient ratio ranged from 1:1 to 1:3, and some or all nursing staff have advanced cardiac life support certification. Most CAHs admit patients to the ICU daily or weekly, primarily treating cardiac, respiratory, gastrointestinal, endocrine, and drug- or alcohol-related conditions. ICUs are also used for postsurgical recovery. Respondents felt that closure of the ICU would be burdensome to patients and families, result in lost revenue, negatively impact staff, and affect the community's perception of the hospital. CONCLUSIONS: Intensive care services provided by CAHs fall along a continuum, ranging from care in a unit that resembles a scaled-down version of ICUs in larger hospitals to care in closely monitored medical-surgical beds. Nurse to patient ratio, not technology, is arguably the defining characteristic of intensive care in CAHs. Respondents believe these services to be important to the well-being of the hospital and of the community.     

The Presence of Ethics Programs in Critical Access Hospitals

The purpose of this study was to assess the presence of ethics committees in rural critical access hospitals across the United States. Several studies have investigated the presence of ethics committees in rural health care facilities. The limitation of these studies is in the definition of ‘rural hospital’ and a regional or state focus. These limitations have created large variations in the study findings. In this nation-wide study we used the criteria of a critical access hospital (CAH), as defined by the Medicare Rural Hospital Flexibility Program (Flex Program, 2007), to bring consistency and clarity to the assessment of the presence of ethics committees in rural hospitals. The Flex Monitoring Team conducted a national telephone survey of 381 CAH administrators throughout the United States. The survey covered a wide variety of questions concerning hospitals’ community benefit, impact activities, and whether the hospital had a formally established an ethics committee. About 230 (60%) of the respondents indicated they had a formally established ethics committee or ethics consultation program at their CAH. The prevalence of ethics committees declined as the CAH location became increasingly rural along a rural–urban continuum. Unlike CAHs, all rural Department of Veterans Affairs Medical Centers have ethics committees. The results of this study provide an understanding of the limited presence of ethics committee in rural America and the need to consider new approaches for providing ethics assistance. A virtual ethics committee network may be the most efficient and effective way of providing rural hospitals access to a knowledgeable ethics committee or consultant.     

Critical Access Hospitals and Retail Activity: An Empirical Analysis in Oklahoma

Purpose: This paper takes an empirical approach to determining the effect that a critical access hospital (CAH) has on local retail activity. Previous research on the relationship between hospitals and economic development has primarily focused on single‐case, multiplier‐oriented analysis. However, as the efficacy of federal and state‐level rural health subsidies come under increasing scrutiny, more comprehensive investigations can provide support for continued funding. Methods: Data from 105 rural Oklahoma communities are used to explore whether the presence of a CAH impacts several measures of retail activity. The measures are: total retail sales, total number of retail establishments, and number of micro and small retail establishments. Ordinary least squares regression is used to evaluate the impact of a CAH after controlling for a host of other factors influencing retail activity such as local demographics, unemployment rates, and the presence of a Wal‐Mart. Findings: The presence of a CAH has a positive and significant influence on each measure of retail activity. The parameter estimates suggest that a CAH has a similar influence on rural retail sales as a Wal‐Mart, increasing total retail sales by approximately 28% over towns without a CAH. Other model results indicate that a CAH presence significantly increases the number of total retail establishments and the number of micro and small business establishments. Conclusions: The positive results provide additional evidence on the far‐reaching economic development impacts of CAHs. The results also emphasize the importance of continued support for these rural institutions, including federal and state subsidies.     

Impact of Conversion to Critical Access Hospital Status for Oklahoma''s Rural Hospitals

CONTEXT: The Medicare Rural Hospital Flexibility Grant Program established a new hospital category, the Critical Access Hospital, designed to provide financial stability to small rural hospitals that were losing money after changes in the Prospective Payment System implemented by Medicare. PURPOSE: This article describes the impact of conversion to Critical Access Hospital (CAH) status for 15 small rural hospitals in Oklahoma. Objectives of the study were to identify how conversion to CAH affected hospital utilization and finances for the first year after conversion. METHODS: A telephone survey was used to collect information from hospital administrators. Fifteen of 16 eligible hospitals participated in the study. FINDINGS: In general, services and patient census declined slightly with conversion to CAH. All 15 hospitals had reported losses prior to conversion, totaling $6,985,033. Ten hospitals reported losses after conversion. After converting to CAH status, the hospitals reported total losses of $3,094,547. The hospitals had a net change of $4,293,040. CONCLUSIONS: Most of the 15 study hospitals greatly improved their financial situation in the first year after conversion to CAH status, but in aggregate still operated at a loss.     

Patient Bypass Behavior and Critical Access Hospitals: Implications for Patient Retention

PURPOSE: To assess the extent of bypass for inpatient care among patients living in Critical Access Hospital (CAH) service areas, and to determine factors associated with bypass, the reasons for bypass, and what CAHs can do to retain patients locally. METHODS: Six hundred and forty-seven subjects, aged 18 years and older, who had been admitted to a hospital for inpatient care in the past 12 months and lived within 15-20 miles of 25 randomly selected CAHs were surveyed by phone during the period from early February through late July 2005. Survey questions included demographic characteristics, general health status, travel time/distance to health care, questions on satisfaction with local health services, bypass behavior, and solicited suggestions on how local hospitals could retain patients locally. FINDINGS: About 60% of surveyed patients bypassed their local CAHs for inpatient care including 16% who were referred to another facility by the local CAH/health care providers and would use the local hospital if needed services were available. Bypass rates ranged from 16% to 70% across the sampled CAHs. Factors associated with bypass included age, income, satisfaction with the local hospital, and traveling distance/time. Lack of specialty care, limited services, and the quality/reputation of local services/doctors were most frequently mentioned as reasons why patients bypass local CAHs. CONCLUSIONS: The bypass rate for sampled CAHs is considerably higher than the 20%-50% bypass rates documented in the literature for all hospitals in general using discharge/administrative data. The sizeable variation in bypass rates across CAHs suggests that the appropriate response/fix should come from the facility/community levels.     

Variations in Financial Performance Among Peer Groups of Critical Access Hospitals

CONTEXT: Among the large number of hospitals with critical access hospital (CAH) designation, there is substantial variation in facility revenue as well as the number and types of services provided. If these variations have material effects on financial indicators, then performance comparisons among all CAHs are problematic. PURPOSE: To investigate whether indicators of financial performance and condition systematically vary among peer groups of CAHs. METHODS: Suggestions from CAH administrators, a literature review, expert panel advice, and statistical analysis were used to create peer groups based on whether a CAH: (1) had less than $5 million, $5-10 million, or over $10 million in net patient revenue; (2) was owned by a government entity; (3) provided long-term care; and (4) operated a provider-based Rural Health Clinic. FINDINGS: Significant differences in financial performance and condition exist among CAH peer groups. CONCLUSIONS: CAHs should ensure that they use appropriate peer comparators when assessing their financial performance and condition. If quality, outcome, safety and access are affected by financial performance and condition, it may also be important for research in these areas to control for peer group differences among CAHs.     

Implementation of Quality Assurance and Performance Improvement Programs in Nursing Homes: A Brief Report

The purpose of this article was to investigate nursing homes' (NHs') readiness to implement a quality assurance and performance improvement (QAPI) program as required by Section 6102 of the Affordable Care Act. Nursing home administrators (NHAs) in 3000 NHs (response rate, 67%) were surveyed using a 70-item questionnaire to assess: (1) current facility approaches to quality, (2) NHA's self-assessed knowledge of QAPI techniques; and (3) the use of QAPI techniques. The Online Survey, System for Certification and Administrative Reporting data and the Area Resource File were also used to examine and compare facility and market characteristics. As rated on a scale of 1 to 10, NHs are more likely to use quality assurance (rating, 7.2) and least likely to use total quality management (rating, 4.1). Few NHAs use tools for QAPI such as flow charts (23%), Plan-Do-Check-Act cycles (13%), or run charts (9%). A gap in knowledge of quality improvement tools has been identified signifying that the new QAPI regulations may pose an issue for NHAs who possibly lack the knowledge and technical expertise to implement a comprehensive QAPI program.     

Translating Research Into Practice: Voluntary Reporting of Medication Errors in Critical Access Hospitals

CONTEXT: Low service volume, insufficient information technology, and limited human resources are barriers to learning about and correcting system failures in small rural hospitals. PURPOSE: This paper describes the implementation of and initial findings from a voluntary medication error reporting program developed by the Nebraska Center for Rural Health Research (NCRHR) to overcome these barriers in 6 Nebraska critical access hospitals (CAHs). METHODS: Participating Nebraska CAHs mailed copies of medication error reports to the NCRHR monthly for entry into a database. Quarterly summaries enabled each CAH to compare its reports by severity, type, phase of the medication use process, contributing factors, and causes to those of its peers and MEDMARX, a national medication error reporting program. Workshops emphasized learning from the reported errors by identifying system sources of variation in medication use and initiating change to achieve best practices. FINDINGS: Similar to MEDMARX, 99% of medication errors reported by 6 Nebraska CAHs were not harmful, reported errors most often originated in the administration phase, and the most common error type was omission. The CAHs reported significantly smaller proportions of "near miss" errors and errors originating in the prescribing phase than in MEDMARX. CONCLUSIONS: By collaborating with CAHs, an academic medical center, and a national reporting program, the NCRHR is translating the Institute of Medicine's recommendation for voluntary error reporting into practices that allow CAHs to learn about and improve their medication use systems. However, limited presence of pharmacists in CAHs is a barrier to implementing double checks and learning from system failures in the medication use system.     

Measuring the Performance of Critical Access Hospitals in Missouri Using Data Envelopment Analysis

Purpose: Rural hospitals are critical for access to health care, and for their contributions to local economies. However, many rural hospitals, especially critical access hospitals (CAHs) need to strive for more efficiency for continued viability. Routinely evaluating their performance, and providing feedback to management and policy makers, is therefore important. Method: Three measures of relative efficiency are estimated for CAHs in Missouri using an Input‐oriented Data Envelopment Analysis with a variable returns to scale assumption and compared with the efficiency of other rural hospitals in Missouri using Banker's F‐test. Using 30‐day readmission rate as a measure of quality, CAHs are evaluated against efficiency‐quality dimensions. Findings: CAHs in Missouri had a slight decline in average technical efficiency, but they had a slight gain in average cost efficiency in 2009 compared to 2006. More than half of the CAHs were neither economically nor technically efficient in both years. The relative efficiency of other rural hospitals was statistically higher than that of CAHs in Missouri. Conclusions: This study validates the finding of relative inefficiency of CAHs compared to other hospitals paid under the Prospective Payment System at a state level (Missouri). However, with considerable variation in socioeconomic as well as health care access indicators across states, a relative efficiency frontier may not be the only relevant indicator of value for the evaluation of the performance of CAHs. Access to health care and the impact on the local economy provided by these CAHs to the community are also critical indicators for more comprehensive performance evaluation.     

论临床路径实施中的持续质量改进

临床路径的实施在一些地方取得了不错的经验,如整合医疗资源、提高医疗机构和医务人员的工作效率、降低医疗成本;通过提高病种的医疗护理质量,提高了病人满意度。但国内医院目前的管理和技术水平良莠不齐,在推行临床路径的过程中也遇到了不少困难,比如在临床路径设计和流程标准制定上缺乏循证支持,准备不足,医疗机构内部的资源动员有限,缺乏科学有效的实施效果评价和完善机制等等。需要从完善临床路径制度的设计、改善临床路径的基础条件、把握临床路径关键环节的控制等多角度进行持续改进。     

Technical efficiency of Critical Access Hospitals: an application of the two-stage approach with double bootstrap

The Critical Access Hospital (CAH) Program has offered Medicare cost-based reimbursement to small hospitals that meet certain eligibility criteria to improve their financial viability and quality of care. However, cost-based reimbursement has been associated with inefficiency in hospital operations. This study uses a two-stage approach and bootstrap procedures to examine the effects of environmental variables on the technical efficiency of CAHs. The two-stage approach with quality controls significantly improved statistical efficiency of parameter estimates in the second stage bootstrapped truncated regression relative to a similar model without quality controls. Overall, our results suggest that enhanced Medicare reimbursement may not have had detrimental effects on the technical efficiency of CAHs.     

A Multistate Asian-Language Tobacco Quitline: Addressing a Disparity in Access to Care

Objectives. We conducted a dissemination and implementation study to translate an intervention protocol for Asian-language smokers from an efficacy trial into an effective and sustainable multistate service.Methods. Three state tobacco programs (in California, Colorado, and Hawaii) promoted a multistate cessation quitline to 3 Asian-language-speaking communities: Chinese, Korean, and Vietnamese. The California quitline provided counseling centrally to facilitate implementation. Three more states joined the program during the study period (January 2010–July 2012). We assessed the provision of counseling, quitting outcomes, and dissemination of the program.Results. A total of 2004 smokers called for the service, with 88.3% opting for counseling. Among those opting for counseling, the 6-month abstinence rate (18.8%) was similar to results of the earlier efficacy trial (16.4%).Conclusions. The intervention protocol, based on an efficacy trial, was successfully translated into a multistate service and further disseminated. This project paved the way for the establishment of a national quitline for Asian-language speakers, which serves as an important strategy to address disparities in access to care.Smokers who speak Asian languages and have low English proficiency have had limited access to tobacco cessation resources in the United States. The idea of a multistate cessation program for this population grew out of a desire to address this disparity in access to care. The goal was to provide Asian-language smokers the same quality of tobacco cessation services currently afforded to English- and Spanish-speaking smokers.Smoking is the leading preventable cause of death and is a primary contributor to health disparities.1–3 Yet even among long-term smokers, quitting smoking has immediate health benefits and reduces long-term harms.4,5 Telephone quitlines are a proven strategy for helping smokers quit.6 The effectiveness of telephone counseling has been well documented, and tobacco quitlines are accessible to any resident of the United States.7,8 Quitlines offer an individualized intervention, but with a broader reach than clinic-based programs. Prior to the multistate project, California was the only state with a quitline offering direct service in Asian languages; most other states used third-party translation services to accommodate Asian-language speakers.9 Translation services have proven beneficial in fact-based information exchanges, such as physician and hospital visits, but behavioral counseling can be more nuanced if provided directly by someone who speaks the client’s language.10–12Asian immigrant men have higher rates of smoking than do their US-born counterparts, perhaps because of the cultural acceptability of smoking in their home countries.13,14 For example, smoking among men is estimated to be 56% in Vietnam, 52% in China, and 40% in Korea.15–17 Asians are the only ethnic group in the United States for whom cancer is the leading cause of death, with especially high mortality rates from lung cancer.18 And although Hispanics still represent the largest ethnic minority in the United States, since 2009, more Asians than Hispanics have immigrated to the United States.19 Most Asians living in the United States (74%) are foreign born, and of those, only about half are proficient in English.19 Limited English proficiency is a major barrier to health service access and results in underuse of services, less compliance with medications and programs, and greater likelihood of stopping treatment prematurely.20–25One public health dilemma is how to ensure that Asian-language speakers receive the same level of smoking cessation service as their English- and Spanish-speaking counterparts. The California quitline, which is operated by the University of California, San Diego, established its Chinese-, Vietnamese-, and Korean-language quitline services in 1993. A large randomized controlled trial was conducted from 2004 to 2008 to establish the efficacy of the Asian-language counseling protocol. The study showed that telephone counseling significantly increased quitting success (odds ratio [OR] = 2.26; 95% confidence interval [CI] = 1.73, 2.94), both overall and for each language group.26 However, until the multistate program, California was the only state to offer direct Asian-language quitline services.To facilitate the adoption of Asian-language services by other states, we obtained an dissemination and implementation (D&I) grant from the Centers for Disease Control and Prevention (CDC). D&I research is the study of the processes involved in translating evidence-based research into practice.27 D&I studies represent the final stage of research from efficacy to implementation. They examine issues related to making a program work and ensuring its sustainability. Our D&I grant proposed the creation of a multistate Asian-language quitline with several simultaneous aims. One aim was to replicate the results of the randomized efficacy trial with a broader clientele, thereby showing the real-world effectiveness of the counseling service. Another aim was to show that the multistate service could be adopted by several states and implemented from a centralized location while retaining the counseling impact. The final aim was to show that the service could be disseminated more broadly.The multistate project began with 3 participating states (California, Colorado, and Hawaii), with the goal of disseminating the services to additional states. To participate, states had to agree to promote the service and provide quitting aids (such as nicotine patches) consistent with those provided to their English and Spanish speakers. We report on the implementation and impact of the counseling service by comparing results from the multistate program with those of the previous efficacy trial. We also report on efforts to disseminate the services to additional states.