3
Quality Improvement Activities in Rural Areas

SUMMARY

Health care quality is highly variable and falls far short of what it should be in all environments (see Chapter 2). To improve quality, rural providers, like their urban counterparts, must adopt a comprehensive approach to quality improvement. This approach needs to encompass clinical knowledge and the tools necessary to apply this knowledge to practice, including practice guidelines and computer-aided decision support, standardized performance measures, performance measurement and data feedback capabilities, and quality improvement processes and resources. This chapter examines each of these capabilities, with emphasis on their current state of development in rural health systems and steps that might be taken to enhance quality improvement in rural communities.

It should be noted that this chapter focuses on quality improvement processes and activities, while Chapter 6 addresses information and communications technology infrastructure. These two issues are intricately related: electronic health records, including computerized decision support and web-based communication, offer the potential to vastly improve the effectiveness and efficiency of quality improvement processes and activities.

Serious shortcomings in the quality of care need to be addressed in both rural and urban communities. But confronting the same challenge does not



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Quality Through Collaboration: The Future of Rural Health 3 Quality Improvement Activities in Rural Areas SUMMARY Health care quality is highly variable and falls far short of what it should be in all environments (see Chapter 2). To improve quality, rural providers, like their urban counterparts, must adopt a comprehensive approach to quality improvement. This approach needs to encompass clinical knowledge and the tools necessary to apply this knowledge to practice, including practice guidelines and computer-aided decision support, standardized performance measures, performance measurement and data feedback capabilities, and quality improvement processes and resources. This chapter examines each of these capabilities, with emphasis on their current state of development in rural health systems and steps that might be taken to enhance quality improvement in rural communities. It should be noted that this chapter focuses on quality improvement processes and activities, while Chapter 6 addresses information and communications technology infrastructure. These two issues are intricately related: electronic health records, including computerized decision support and web-based communication, offer the potential to vastly improve the effectiveness and efficiency of quality improvement processes and activities. Serious shortcomings in the quality of care need to be addressed in both rural and urban communities. But confronting the same challenge does not

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Quality Through Collaboration: The Future of Rural Health imply the same solution. As discussed earlier, rural and urban areas vary in their beliefs, customs, practices, and social behaviors, as well as in the availability of human and technological resources. The quality aims are the same—to provide care that is safe, effective, patient-centered, timely, efficient, and equitable—but the means of achieving these aims may differ. In addressing the quality challenge, rural communities must build on their strengths. Ironically, these strengths stem directly from the major weakness of delivering care in rural areas—the scarcity of resources and providers. In rural communities where the need for services far exceeds the available supply, providers may be more willing and able to work together and with their patients and communities to develop a community health system that best meets the needs of individual patients and the entire population. This chapter first sets forth the key components of a health care quality improvement program, and suggests how these components apply in particular to the rural context. The second section reviews the current state of quality improvement efforts in rural areas. The final section presents conclusions and recommendations. KEY COMPONENTS OF A COMPREHENSIVE QUALITY IMPROVEMENT PROGRAM The quality infrastructure needed to support quality improvement involves both national and regional/local components. Successful efforts require leadership, cultural change in organizations, and human resources and technical support. In particular, to achieve the six quality aims cited above (and in Chapter 1), rural communities must establish comprehensive quality improvement programs that include five key components (see Box 3-1). It is important to emphasize that all of these components must be supported by information and communications technology (ICT), including electronic health records (EHRs) and web-based communication. Knowledge of the Science of Quality and Safety Improvement Quality improvement is an ongoing process that draws on a multidisciplinary knowledge base (i.e., statistics, epidemiology, engineering, human factors analysis) and employs many tools (e.g., control charts, root-cause analysis of adverse events) to identify and understand shortcomings and redesign care processes. Knowledge of the science of quality and safety im-

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Quality Through Collaboration: The Future of Rural Health BOX 3-1 Key Components of a Comprehensive Quality Improvement Program Any comprehensive quality improvement program must encompass five key components: Knowledge of the science of quality and safety improvement Clinical knowledge and the tools needed to apply this knowledge, especially practice guidelines, protocols, and computer-aided decision support Standardized performance measures Performance measurement and data feedback capabilities Quality improvement processes and resources Information and communications technology, including electronic health records and web-based communication, provides an essential foundation for all of these components. SOURCE: Adapted from Brent James, IOM Workshop Presentation, 2003. provement is critical to the development of a culture within the health care system and the health care community overall that values quality and embraces opportunities to improve it. As discussed in Chapter 4, this knowledge base is important to three groups of stakeholders: health care leaders, health care professionals, and health care consumers. An understanding of quality and safety (including the current state of quality, as well as quality improvement theory and tools) is essential to community leaders engaged in health system reform. Moreover, quality improvement knowledge—including methods of identifying errors and hazards in care; safety design principles, such as standardization and simplification; quality measurement in terms of structure, process, and outcomes; and methods of designing and testing interventions to improve care processes—is a core competency that all health care professionals should possess (IOM, 2003). Also, rural residents need to understand quality and safety issues if they are to work collaboratively with clinicians to improve care and engage in self-management of their health and health care (Detmer et al., 2003).

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Quality Through Collaboration: The Future of Rural Health Clinical Knowledge and Associated Tools Like their urban counterparts, rural communities need access to clinical knowledge and the tools needed to apply this knowledge to practice. Three types of tools are particularly important—practice guidelines, protocols, and computer-aided decision support. Physicians, nurses, pharmacists, and other clinicians struggle to stay abreast of scientific knowledge. Clinicians can more easily apply the large body of scientific knowledge when it has been translated into practice guidelines by professional groups. To apply scientific knowledge and practice guidelines in rural communities, some additional work is required. Local protocols, (i.e., stepwise instructions to guide local care delivery) must be developed that reflect the specific challenges of rural communities. For example, when highly specialized care is needed (e.g., treatment of trauma due to brain injury), the protocol for a rural community would likely draw upon practice guidelines for head injuries and stabilization and transfer of the patient to a tertiary center. Moreover, to be useful to laypersons in making decisions about their health behaviors and health care, scientific knowledge must be made available in ways that reflect the health literacy of the population, which is a function of many factors, including education, language ability, and culture (see Chapter 4). Finally, the ability of clinicians and patients to apply knowledge and guidelines when making health-related decisions may be enhanced when the knowledge and guidelines are used to develop reminder systems (e.g., computerized reminders to patients and their clinicians that patients are due for an annual pap smear) and alerts (e.g., notice that the patient is about to be prescribed a medication that is contraindicated). As discussed in Chapter 6, the development of EHRs opens up many possibilities to incorporate a wide array of prompts and alerts into clinical practice that draw upon the science base and the full set of patient data available in the EHR. Standardized Performance Measures An appropriate set of standardized performance measures is needed to assess whether performance is consistent with the evidence base and results in improved care processes and patient outcomes. The use of standardized measures makes it possible to compare providers within and across geographic areas for purposes of identifying best practices. Recent years have seen tremendous growth in the use of standardized measurement sets for health plans, hospitals, ambulatory care, nursing homes, and home health care. There are standardized measure sets that are

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Quality Through Collaboration: The Future of Rural Health specific to particular clinical conditions and surgical procedures (e.g., diabetes, thoracic surgery); that assess the quality of nursing care; that assess how well certain core processes are performed (e.g., care coordination); and that rely on patient reports and assessments of care. Rural communities stand to benefit a great deal from the development of these quality measurement tools. Many of the standardized measures included in leading measure sets are applicable to both rural and urban settings. But there are instances where measure sets need to be adapted to be most useful in rural settings, and there are specific implementation challenges that arise frequently in rural settings as well. Casey and Moscovice (2004) identify specific aspects of the rural context that must be considered when applying standardized measure sets for use in rural hospitals: Small size—Small rural provider settings often lack adequate numbers of patients with particular conditions or requiring specific procedures to construct reliable measures. A scarcer and more diverse resource context—Differing resource contexts will lead to different care processes in rural and urban hospitals. For example, a pharmacist is most typically not available 24 hours a day in rural hospitals and community-based pharmacies, necessitating alternative arrangements, such as preparation of certain medications by nursing staff in the hospital or use of an “on call” pharmacist in the community. First-contact and linking role—An important role for many rural hospitals is triage and the stabilization and transfer of emergency cases. Rural measurement sets should include measures for assessing how well this function is performed. Community hub—Rural hospitals are central and influential organizations in their communities; in many rural communities, the hospital is the largest employer in town. Many rural hospitals are assuming a coordinating role to support the development of more integrated community-based care systems. The assumption of this role affords an opportunity to include measures of population health and communitywide service integration in rural measurement sets. This last point, the community hub role, deserves special emphasis. In Chapter 2 of this report, the committee presents an integrated framework for addressing population and personal health care needs, and proposes the conduct of comprehensive health reform demonstrations in five rural communities. Rural communities pursuing such efforts will need communitywide

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Quality Through Collaboration: The Future of Rural Health measurement and monitoring systems that include both population-level measures and measures at the level of the health care delivery system. Also, as discussed in Chapter 5, rural communities incorporating pay-for-performance programs or alternative payment models into a demonstration project may well choose to tie payment incentives to the achievement of population and personal health goals. Efforts are already under way to identify and adapt leading measure sets for application in rural provider sites (Casey and Moscovice, 2004). In particular, the American Hospital Association is currently developing a rural version of the measure sets for myocardial infarction, heart failure, and pneumonia that are used in the National Voluntary Hospital Reporting Initiative (Personal communication, N. Foster, July 9, 2004). For example, since rural hospitals stabilize and transfer patients more frequently than do urban hospitals, the discharge measures need to be adjusted to better reflect and ensure quality of care in patient transfers. Performance Measurement and Data Feedback Capabilities Local health systems must have performance measurement systems capable of monitoring progress across a well-balanced set of standardized performance measures and providing timely feedback to administrative and clinical staff (e.g., comparative reports). At present, most performance measurement and improvement activities rely on data abstracted from paper medical records, culled from administrative datasets, or in some cases maintained in disease registries. While these have historically been the most important data sources and should be fully exploited by quality improvement programs, they have serious limitations. Administrative files and registries lack the comprehensive and clinically rich data necessary to address many important aspects of performance and to adjust for differences such as severity of illness. Abstraction of paper medical records is a slow and resource-intensive process. The same ICT infrastructure (see Chapter 6) that is needed to provide real-time computer-aided decision support to providers can support the performance measurement monitoring process. Quality Improvement Processes and Resources Well-thought-out quality improvement processes with adequate human and technical resources are essential to accomplishing the six quality aims.

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Quality Through Collaboration: The Future of Rural Health Small hospitals and ambulatory practices often lack the resources needed to establish a robust quality improvement program. As noted above, small providers may also lack adequate numbers of patients with specific conditions to conduct certain types of analyses. One alternative is for rural communities to work together in a collaborative fashion to establish communitywide quality improvement programs. These programs might also pool data for all providers in the community and conduct population-based analyses. Another option is for individual rural providers to participate in collaborative efforts sponsored by outside organizations, such as the Institute for Healthcare Improvement or a Medicare Quality Improvement Organization (QIO). CURRENT STATE OF QUALITY IMPROVEMENT EFFORTS IN RURAL AREAS Many rural and urban providers have been slow to adopt state-of-the-art quality improvement techniques. Rural providers in particular have found it difficult to invest in quality improvement because of their small scale and low operating margins (see Chapter 5 and Appendix C). Also, as discussed below, some national quality improvement efforts, designed to meet the needs of the majority of providers, are a poor fit for rural settings. In recent years, some targeted support has been provided for rural quality improvement programs, and there are early signs that these investments are paying off. Quality Improvement Organizations The Centers for Medicare and Medicaid Services (CMS) contracts with 53 QIOs to offer providers assistance with quality improvement (CMS, 2003b). QIOs engage in a variety of activities, including many disease-specific quality measurement and improvement projects and education and complaint resolution for beneficiaries. More recently, QIOs have assumed some responsibility for public reporting of comparative performance data. Concern has been raised that rural providers do not receive their fair share of QIO assistance (MedPAC, 2001; NACRHHS, 2001, 2003). Prior to 2002, QIOs operating on a fixed budget under contract with CMS had little incentive to focus attention on small rural providers because they were evaluated on the basis of their ability to reach a large proportion of the population or to improve statewide averages on a range of quality indicators (CMS,

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Quality Through Collaboration: The Future of Rural Health 2003b). Quality improvement activities focused on large urban hospitals are more likely to impact a sizable segment of the population and/or to result in improved state averages on quality indicators, and have the added advantage of being geographically more accessible to QIO staff. In 2002, CMS modified the scope of work for QIOs to include a specific subtask requiring them to improve care for rural beneficiaries or address racial and ethnic disparities in care (CMS, 2003a). However, the evaluation criteria for QIOs still reward improvements in statewide averages on performance indicators. Many QIOs have likely chosen to satisfy the requirements of this subtask by addressing racial or ethnic disparities in urban areas, again because those areas are more geographically accessible to QIO staff and are home to large health care organizations that have a greater impact on statewide performance. The American Health Quality Association, a membership association representing QIOs, reports that nearly 20 state QIOs are working with critical access hospitals and ambulatory care providers in rural areas (Personal communication, D. G. Schulke, March 18, 2004). Another 17 states, having 20 percent or more of their population residing in rural areas, have no formal rural health project (Personal communication, D. G. Schulke, September 17, 2003). Although the QIO program as a whole focuses too little attention on rural providers, some QIOs, most notably those in states with large rural populations, are extensively involved in rural quality improvement. For example, Qualis Health in Idaho, in collaboration with the Idaho Hospital Association and the Idaho Department of Health and Welfare, is sponsoring a project for critical access hospitals in Idaho (AHQA, 2004). Stratis Health, the Minnesota QIO, is also working with critical access hospitals on a quality collaborative focused initially on heart failure, smoking cessation, and inpatient influenza and pneumococcal immunizations, with the long-term goal of developing quality initiatives in all clinical areas (Stratis Health, 2004). One option for addressing this ongoing concern is to decouple the QIOs’ rural health work from their work on disparities in care by creating separate subtasks for each. This approach is recommended by the National Advisory Committee on Rural Health and Human Services in its recent report to the Secretary of Health and Human Services (NACRHHS, 2003). The American Health Quality Association also supports the creation of separate subtasks, but has proposed that QIOs with either very small or very large rural populations be able to opt out of the rural subtask (Personal

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Quality Through Collaboration: The Future of Rural Health communication, D. G. Schulke, September 17, 2003). QIOs with very small rural populations would be required to work with other stakeholders to try to address the needs of rural beneficiaries. In states with very large rural populations, a separate rural subtask would be redundant, since these states are already focusing a large proportion of their resources on rural areas as a means of improving statewide averages on quality indicators. The committee supports the creation of separate subtasks for rural disparities and for racial and ethnic disparities. Inequities in health, health care, and quality improvement in both areas need to be addressed. Concern has also been raised that many QIOs, given their limited focus on rural areas, lack the knowledge, experience, and tools necessary to offer technical assistance to rural providers. CMS has addressed the need for specialized knowledge and expertise in other areas through the creation of Quality Improvement Organization Support Centers (QIOSCs). One option for dealing with this issue would be to create a QIOSC specific to rural health, which could play a lead role in the development of rural-specific quality measures, educational programs, and improvement tools and approaches. This QIOSC should build on the collaborative effort already under way between the QIOs in Minnesota and Utah/Nevada to field test a set of rural-relevant hospital quality measures. Public Reporting Programs In recent years, both the public and private sectors have launched numerous public reporting initiatives. The Department of Health and Human Services has reporting initiatives focused on the nation as a whole and on states and on health plans and providers (USDHHS, 2001). In addition, many private-sector reporting efforts are sponsored by purchasers, providers, and accreditation entities. Of particular importance are the efforts of The Leapfrog Group, whose members include 150 public- and private-sector organizations that provide health benefits. Following is a brief summary of some of the more significant efforts under way: National Healthcare Quality Report (NHQR)—In December 2003, the Agency for Healthcare Research and Quality (AHRQ) released the first NHQR, providing the country with a snapshot of quality for the nation as a whole (AHRQ, 2003b). The report includes quality measures pertaining to each of the six quality aims, as well as measures applicable to many leading chronic conditions. A companion report, the National Disparities Report,

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Quality Through Collaboration: The Future of Rural Health provides national data specific to rural areas for many of the quality measures associated with effectiveness, patient safety, and timeliness of care, as well as data associated with disparities in access to care among rural residents (AHRQ, 2003a). Medicare Compare—Starting in 1999, CMS began producing comparative performance reports for providers that participate in the Medicare program. The reports are available online through links to the Medicare Compare databases for each provider type. The series now includes Medicare Health Plan Compare,1 Dialysis Facility Compare, Nursing Home Compare, and Home Health Compare (CMS, 2004a). Hospital Compare, to be added in early 2005, is based on voluntary reporting, but the number of participating hospitals is expected to grow rapidly since participation is required for hospitals to receive the full “market basket” payment update under the Prospective Payment System (Public Law 108-173, Section 501) (CMS, 2004b). Since many rural hospitals (i.e., critical access hospitals) are not paid under the Prospective Payment System, they do not have the same incentives to report data publicly. Some rural hospitals have chosen to participate, but overall participation rates will likely be lower for rural than for urban hospitals. The Leapfrog Group—In June 2001, The Leapfrog Group began requesting information from hospitals on an initial set of three safety practices (i.e., leaps): use of computerized physician order entry, evidence-based hospital referral (i.e., referral of patients with certain complex medical procedures to high-volume hospitals), and staffing of intensive care units with doctors who have specialized critical care training (see www.leapfroggroup.org/FactSheets/LF_FactSheet.pdf). In April 2004, Leapfrog added a fourth leap consisting of 30 safe practices (e.g., standardized methods for labeling, packaging, and storing medications; standardized protocols to prevent the occurrence of wrong-site or wrong-patient procedures) identified by the National Quality Forum (NQF, 2003). Leapfrog formally requested data on the first three leaps from urban and suburban hospitals in 24 regions. With the addition of the new safe practices leap, rural hospitals will be encouraged to submit quality data to Leapfrog for the first time. 1   Medicare Health Plan Compare also is referred to as Medicare Personal Plan Finder with links for Medicare Advantage Data and Medigap Data.

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Quality Through Collaboration: The Future of Rural Health Public reporting has raised concern within the rural health care community. For the most part, this concern does not reflect an objection to the public reporting of performance data, but a belief that the current set of measures and reporting formats may not adequately consider the unique characteristics of rural health care delivery. As discussed above, many of the measures in leading measure sets will be appropriate for both urban and rural areas, but not all. In addition, there may be some measures of particular interest to rural communities that would not be of interest to urban. In designing public reports for rural areas, it will be important to identify when rural-to-rural comparisons are appropriate (e.g., emergency medical services response times, stabilization, and transfer). Also, public reports for rural communities as a whole (in contrast with provider-specific reports) may be the most useful and reliable, given the role of rural hospitals as a community hub and the methodological challenge of measurement at the provider level (i.e., small sample sizes). Community-based reports are also consistent with the committee’s recommendation in Chapter 2 to focus attention on both population and personal health issues and to encourage communitywide collaboration. It would be advisable for CMS to work collaboratively with the rural community to identify the subset of measures for which rural/urban comparisons are appropriate and those for which comparisons should not be made, and to modify reporting formats to include explanatory material pertaining to rural/urban differences. Some consideration should also be given to producing a set of reports that present only rural/rural provider comparisons for certain measures, such as timeliness of emergency care (Moscovice, 2004). The committee emphasizes that rural providers should not be excluded from public reporting initiatives. Public disclosure and eventually pay-for-performance payment methods (discussed in Chapter 5) are potentially powerful incentives for encouraging improvements in quality. Rural providers, like urban, will benefit from these external levers for change as long as the performance measures are reliable and valid and the comparative reports are fair. Further, the conspicuous absence of rural providers from public reports may have the unintended consequence of leading rural residents to assume that local providers are of lower quality than more distant providers, a conclusion not supported by the very limited evidence that is available for assessing differences in quality between rural and urban areas (see Chapter 2).

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Quality Through Collaboration: The Future of Rural Health Targeted Rural Quality Programs The Health Resources and Services Administration (HRSA) sponsors various quality programs aimed at rural populations. Although smaller in terms of resources than the quality efforts of AHRQ and CMS, these programs likely have a good deal of impact because they are specifically tailored to the needs of rural areas and sensitive to the constraints faced by rural providers. Three HRSA quality programs are discussed: the Rural Hospital Flexibility Grant Program (Flex), the Small Hospital Improvement Program (SHIP), and quality efforts focused on community health centers and rural health clinics. Also discussed are the quality requirements applicable to rural health clinics. The Medicare Flex program was created in 1997 to provide additional financial support to small rural hospitals designated as critical access hospitals (see Appendix C). As of May 2004, 835 hospitals had been certified as critical access (FMT, 2004; Personal communication, S. Poley, July 7, 2004). HRSA’s grant program provides grants to states to support activities in four areas: helping hospitals convert to critical access status, promoting rural health networks, integrating emergency services, and improving quality. In fiscal year 2004, HRSA awarded approximately $39.7 million in Flex grants to 45 states (Personal communication, J. Riggle, July 2, 2004). More than $4.3 million of this funding was used for quality improvement. One state, Montana, used these funds to create a statewide network among its critical access hospitals to collaborate on ongoing quality improvement activities by linking the network to the regional QIO; the network also supports collaboration on provider education, medical staff credentialing, and public reporting (NACRHHS, 2003). In a telephone survey of more than 200 critical access hospitals conducted in 2000 and again in 2001, the responding hospitals reported significant increases in quality improvement activities, including continuing education programs for staff, data collection for staff feedback, systems to avoid/ prevent errors, and medical error reporting policies (Moscovice et al., 2002). Many reported a redefinition of quality improvement processes, including greater formalization of policies and procedures and increased emphasis on quality improvement as compared with quality assurance. Many of the respondents reported collaboration with an affiliated hospital (47 percent), a QIO (45 percent), or a state hospital association (32 percent) on quality improvement activities. A more recent survey of a subset of critical access hospitals that had reported sizable improvements in their quality-related activities on earlier surveys revealed that four-fifths had implemented one or

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Quality Through Collaboration: The Future of Rural Health more clinical guidelines or protocols; two-thirds had enhanced improvement training for staff; and as a group these hospitals had implemented a wide range of quality improvement activities (e.g., projects focused on pneumonia, congestive heart failure, acute myocardial infarction, or stroke, as well as patient safety initiatives) (Moscovice et al., 1997). In fiscal years 2002 and 2003, the SHIP program provided about $15 million each year to rural hospitals to support quality improvement projects and transitional efforts related to the new Medicare Prospective Payment System and the Health Insurance Portability and Accountability Act (NACRHHS, 2003). A total of 1,400 hospitals received small grants of less than $10,000 each in fiscal year 2002, and 28 percent of these hospitals used some or all of these funds for quality improvement. The approximately 3,500 clinics participating in the rural health clinic program (discussed in Appendix C) must satisfy the requirements of CMS’s quality assessment and performance improvement program (Balanced Budget Act of 1997, Public Law 105-133, Section 4205(b)). That program requires that rural health clinics evaluate clinical effectiveness (appropriateness, prevention), access to care (availability and accessibility, cultural competency, emergency interventions), patient satisfaction, and utilization of clinical services. A 2000 study of 40 rural health clinics in 10 different states found that the clinics’ activities and capabilities varied widely, and few were prepared for implementation of the CMS program (Knott and Travers, 2002). The clinics indicated that technical assistance and staff training in all aspects of quality assurance would be needed to implement the program, along with more time and resources. HRSA also provides support and technical assistance to the approximately 840 community health centers, a little more than one-half of which are located in rural areas (Personal communication, R. C. Lee, May 28, 2004). Technical assistance focuses on chronic care management, disease registries, the application of evidence-based practice guidelines, and quality measurement and improvement. Many community health centers have also been involved in a 6-year health disparities collaborative focused on diabetes (Chin et al., 2004). Accreditation and Certification Programs Accreditation and certification programs have played an important role in encouraging and facilitating the development of quality improvement programs and processes in the hospital sector. As a condition of participating in

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Quality Through Collaboration: The Future of Rural Health the Medicare program, hospitals must be either accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or federally certified. Rural hospitals are less likely to seek accreditation through JCAHO than are urban hospitals. During the 10-year period from 1987 to 1996, the proportion of accredited urban hospitals remained fairly steady at 95 percent, while the proportion of accredited rural hospitals decreased from 62 to 58 percent (Brasure et al., 2000). In a survey of rural hospitals, 79 percent of respondents indicated that the cost of accreditation was a major deterrent, but there were other reasons as well: have no need or see no value (19 percent), standards unrealistic for small rural hospitals (16 percent), already surveyed by other agencies (11 percent), and other concerns regarding the JCAHO process (11 percent) (Brasure et al., 2000). In applying for accreditation, hospitals face two types of costs: survey fees paid to JCAHO (direct costs) and expenses associated with preparing for the survey, such as staff time or consultant fees (indirect costs). Recent changes in JCAHO’s hospital accreditation program intended to streamline preparation should decrease the indirect costs somewhat (JCAHO, 2004). In addition, both JCAHO and the American Osteopathic Association have established special accreditation programs for critical access hospitals (Personal communication, K. Patton, July 7, 2004). It is too early to tell whether these changes will attract a sizable number of new entrants to the accreditation process. As an alternative to accreditation, hospitals can be certified through a review process carried out by state governments. Most rural hospitals have chosen this route. There are no survey fees for certification. Unfortunately, state certification processes are highly variable, and state fiscal constraints often limit the frequency of reviews and the intensity of follow-up activities (Federal Register, 2002). CONCLUSIONS AND RECOMMENDATIONS Many aspects of an effective quality improvement infrastructure will be the same for rural and urban areas, but some aspects need to be customized to reflect key differences between rural and urban health systems and environments. In Chapter 1, the committee embraced the overarching objective that rural Americans, like urban Americans, should have access to the full spectrum of high-quality, appropriate health care. The committee also identified a set of guiding principles for operationalizing this overarching objective. These guiding principles recognize that there will be differences in the

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Quality Through Collaboration: The Future of Rural Health way rural and urban residents access some aspects of care. More specifically, urban areas are usually able to provide local access to the full spectrum of services needed by their population, while rural residents must travel to access certain specialized services. Most rural areas provide access to a core set of services, but are unable to generate an adequate volume of certain specialized services for providers to maintain their skills and financially support their practices (e.g., trauma centers, many subspecialty services). For rural residents who must travel to access certain services, some aspects of the care process are particularly important, such as, stabilization and transfer, and referral and coordination of services. In summary, for the majority of services and patient needs, rural and urban areas should be able to apply the same practice guidelines and performance measures, but for a limited number of areas, quality improvement tools will need to be customized to be relevant within a rural context. For benchmarking purposes, rural providers need access to comparative data, and for some types of measures (e.g., acute myocardial infarction, emergency care, stabilization and referral), rural-specific comparative data will be most relevant. Rural communities must also have the flexibility and assistance needed to develop quality improvement approaches likely to have the greatest impact in a rural context. As discussed in Chapter 2, the committee is encouraging rural communities to develop communitywide collaborative approaches to prioritizing and addressing both personal and population health issues. Communities that pursue this approach may find it preferable to establish communitywide quality measurement and improvement programs, rather than having each provider setting develop its own approach. Communitywide quality programs may also have certain advantages in terms of the sharing or pooling of expertise and data. To this end, the Department of Health and Human Services needs to develop a coordinated and tailored approach to meeting the needs of rural communities. Steps should also be taken to ensure that rural areas receive their fair share of quality improvement resources and technical assistance. Recommendation 2. The Department of Health and Human Services should establish a Rural Quality Initiative to coordinate and accelerate efforts to measure and improve the quality of personal and population health care programs in rural areas. This initiative should be coordinated by the Health Resources and Services Administration’s Office of Rural Health Policy, with guidance from a Rural Quality Advisory Panel consisting of experts from the private sector and state

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Quality Through Collaboration: The Future of Rural Health and local governments having knowledge and experience in rural health care quality measurement and improvement. The agenda of this proposed initiative should include the following: Application of evidence to practice—AHRQ should assume a lead role in adapting clinical practice guidelines developed by professional associations and others to reflect the unique configuration of services, resource constraints, and challenges of rural areas, and in developing educational programs and tools to assist rural communities in applying evidence to practice. Standardized measure set for rural communities—The Rural Quality Advisory Panel should work collaboratively with public and private stakeholders (e.g., CMS, the Quality Interagency Coordinating Committee, AHRQ, the National Quality Forum, JCAHO, the National Committee for Quality Assurance) on the identification of appropriate standardized measures for rural areas, including (1) a subset of measures from leading measure sets that are applicable to rural areas; (2) where necessary, new rural-specific measures; and (3) standardized population health measures to be piloted in rural areas. Public reporting—CMS and the Rural Quality Advisory Panel should work collaboratively to ensure that rural providers are included in public reporting initiatives and that public reports for rural providers make fair and meaningful comparisons. Community-based technical assistance—CMS should ensure that the QIOs devote resources to rural areas commensurate with the proportion of Medicare beneficiaries in a state that reside in rural areas. Consideration should be given to establishing a QIOSC to focus on application of the above standardized rural quality measures to rural areas. The Office of Rural Health Policy should convene a series of regional conferences for critical access hospitals, rural health clinics, community health centers, and other providers to share quality improvement processes and techniques. Data repository—CMS should expand its data repositories to include rural-specific quality data so that rural providers have access to both urban and rural data for benchmarking purposes. REFERENCES AHQA (American Health Quality Association). 2004 (April 22). AHQA Matters (newsletter) 5(9). Washington, DC: American Health Quality Association.

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Quality Through Collaboration: The Future of Rural Health Moscovice I, Gregg WR, Klinger JM. 2002. Rural Hospital Flexibility Program Tracking Project Year Three Report. Chapter 3B: The Maturation of CAH Quality Assurance and Quality Improvement Strategies. Rural Policy Research Institute. Seattle, WA: WWAMI Rural Health Research Center, University of Washington. Moscovice I, Wholey DR, Klingner J, Knott A. 2004. Measuring Rural Hospital Quality. Minneapolis, MN: Rural Health Research Center, University of Minnesota. NACRHHS (National Advisory Committee on Rural Health and Human Services). 2001. Medicare Reform: A Rural Perspective. Washington, DC: Health Resources and Services Administration, U.S. Department of Health and Human Services. NACRHHS. 2003. Health Care Quality: The Rural Context. Washington, DC: Health Resources and Services Administration, U.S. Department of Health and Human Services. NQF (National Quality Forum). 2003. Safe Practices for Better Healthcare: A Consensus Report. Washington, DC: NQF. Stratis Health. 2004. 2003–2004 Critical Access Hospital Collaborative. [Online]. Available: http://www.stratishealth.org/health-care/documents/CAHCollaborative_FinalReport_June2004_000.pdf [accessed July 7, 2004]. USDHHS (U.S. Department of Health and Human Services). 2001. Health, United States 2001 with Urban and Rural Health Chartbook. Washington, DC: U.S. Government Printing Office.