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Network gives rural facilities strength in numbers
Shared resources, benchmarking enable improved performance
Thirteen rural hospitals in the state of New Hampshire decided several years ago to pool the funding of each hospital's Small Rural Hospital Improvement Grant Program (SHIP) funds to create a network for a QI initiative called the New Hampshire Critical Access Hospital, Quality Improvement Network (QIN). The goal of the collaborative was to overcome challenges common to small, rural hospitals, such as limited resources and data that make it difficult to implement successful initiatives on their own. The sharing of best practices and benchmarking was also seen as a potential benefit.
So far their "bet" appears to be paying off. "You see lots of examples of improvement," asserts Andrew McClure, who has served as project coordinator of the QIN for about six months. He points specifically to examples such as the average composite score for the Surgical Care Improvement Project (SCIP) measures from 2004 to 2010 and the average composite score for congestive heart failure (CHF) treatment.
"We struggled with influenza and pneumonia vaccinations," recalls Sue Marshall, QI director at Monadnock Community Hospital. "Some hospitals ended up putting their assessment of subsequent administration [of the vaccine] on patients' records to see if it had been done, and we had really not thought of doing that. By our involvement with the network it allowed us to see there was a better way to do it and we made significant improvement in our scores." For example, she notes, her facility had been down around 60% for influenza vaccinations; its most recent reading was at 94%. "And pneumococcal vaccines were at 97%, simply by introducing one simple intervention," says Marshall.
"The network was talking about implementing a just culture, and it really helped me think about how to develop our program," adds Sue Ruka, vice president of quality improvement at Memorial Hospital in North Conway. "I met with one or two of the other hospitals, visited their facilities, and got a handle on how to do it."
When it comes to implementing QI initiatives, small rural hospitals face unique challenges that practically make a network like the QIN a necessity, note McClure, Marshall, and Ruka.
"They face two key disadvantages," says McClure. "First, with the volume of care they deliver, a lot of traditional quality metrics apply to conditions that are seen on rarer occurrences, like pneumonia treatment or CHF, so there's a smaller sample size. The other challenge is they have tighter resources, so it's hard to have what's needed to do some of this work."
QI, he continues, depends on comparable data and comparable information. "If you're off on your own and measure yourself, unless you have something to compare it to, you do not know if you're good or bad," he explains. "The benefit of this collaboration is that you can learn from each other and compare results. You need sources of benchmarking and solutions and this allows them to do that."
The pooling of the SHIP funds is also critical, he continues. "If you think about it, something like $9,000 per hospital is not enough to hire a person, but you could conceivably do it by pooling the funds so, for example, I'm like a dedicated consultant to all of the hospitals."
What's more, he adds, even if the 13 hospitals were each able to hire their own consultant, they might be using 13 different approaches. "This way, we can make connections and share information," says McClure. In fact, he says, one of the first things he did was ask the hospitals to review a list of about a dozen topics he provided and tell him which they were really strong on and where they felt they needed help. "If someone needs help in one area, I can connect with a facility that's strong in that area and magnify the impact of my position," he explains.
"We all have to do more with less," says Marshall. "At the director/manager level, we have to wear a lot of hats, and we do not necessarily have a specific team or person for these projects." Personally, she shares, she has been interim vice president of nursing for several months, and also oversees utilization review.
"We all have to multi-task," says Ruka. "I'm vice president of quality, but I also am in charge of elderly services I manage our elderly care facility and infection control. Also, you want to look at things in a quantitative way, but we may have only five patients for a single core measure. Even patient satisfaction is affected; we use Press Ganey, but we have to wait six months to maybe have enough data to make it meaningful."
Addressing the challenges
Marshall says the network has definitely helped address some of these challenges. "The thing they most recently helped with is the HCAPS (Hospital Consumer Assessment of Healthcare Providers and Systems) patient perspective survey," she shares. "Not all hospitals use outside vendors we do not so it's very time-consuming but cost-effective, but in doing that we want to make sure we're getting the biggest bang for the buck. QIN has offered us the opportunity to join with them in the IHI's HCAPS Passport Initiative. Every other week they do a collaborative that you can telephone into and be a part of."
In the "off" week, she continues, "we telephone into the rural health network and brainstorm what will we take away, what works for us, and what does not. It's a tremendous opportunity to think outside the box we often get ourselves in. Through networking and sharing other tools and approaches, it has given us tremendous support to be able do more and do it better."
So, for example, "Working through the QIN, we realized that some hospitals help the patients understand, for example, what their discharge instructions mean," Marshall says. She notes that when the question was asked in the survey, patients indicated they did not really understand what was given to them.
"It has given us the opportunity to help understand where we may need to improve and also explains what we need to do for them," Marshall continues. "We're trying to give them clearer language."
"It has definitely addressed the issue of resources," Ruka adds. "Andy has been great; if something has been updated or if there are new regulatory implications, he'll let us know. He's come in and done audits of our quality processes, and I can look at them and see where we're really doing well and where we can improve. He also arranges conference calls for sharing best practices."
McClure says there are several different vehicles for sharing information. "Through the Foundation for Healthy Communities (which established the QIN), the New Hampshire Hospital Association, and the New Hampshire Quality of Care website, we facilitate collection of CMS core data and HCAPS data and have that posted on this public website, so we have comparative datasets to use," he explains. "Also, through the association we have focused on hand hygiene and developed an assessment tool. In terms of surgical timeouts and checklists, we've collaborated with the World Health Organization. In all instances we share our data."
His regular assessments have also led to collaborative change, he notes. "As I was doing my credentialing assessment, I got the sense we were not consistent in primary source verification processes," he shares. "So we developed a credentialing consensus document how you should verify credentials. Through a collaborative session we agreed it should be done during initial hiring and for re-credentialing."
"The benchmarking we currently use to compare one another for HCAPS is through the Hospital Quality Alliance," says Marshall. "We all submit data into this repository, and through the public reporting initiative we can look and see how well we've done as compared with state and national averages."
In terms of evidence-based medicine, data on heart attacks, pneumonia, heart failure, and surgical care is all data shared, she says, enabling facilities to compare themselves to one another. "The hospital association, along with the state QIO, does a state report and lets us see where we're at, so we do not have to be lumped into the national data," she explains.
"We've had a couple of conference calls around surveys on areas we might feel really strong in, and sharing that with others where we feel we can be helpful," adds Ruka. "One thing we're working on is a disclosure policy transparency and Andy said we were working on something that's a bit unique that was already on his mind, and asked if we wanted to talk to others about it."
McClure adds that the collaborative has given participating facilities more confidence in their ability to deal with QI challenges. "They really wanted to do a good job but they were insecure," he notes. "Now, as long as they follow the collaborative data, they'll know they're doing the same things as 12 other hospitals in New Hampshire."
This should help them with the whole QI process, he continues. "If each hospital hired their own consultant, they would have gotten variable information and would not have been as confident they were doing the same things as other hospitals," he notes.
The good news for other rural facilities across the country, he says, is that the QIN model is replicable. "It absolutely is," he asserts. "It just takes someone to facilitate the collaboration, and as long as the hospitals are interested in working together and sharing information they can do it."
"It's absolutely good for rural states and can be done anywhere," adds Ruka. "You just have to have that resource to go to, that person who can say 'This hospital has dealt with this problem already; let me check with them.' You feel so isolated; this clearinghouse is very helpful."
[For more information, contact Andrew McClure, Project Coordinator, Rural Hospital QI Network, Foundation for Healthy Communities, 125 Airport Road, Concord, NH 03301. Telephone: (603) 415-4274, e-mail: AMcClure@healthynh.com; Sue Marshall, QI Director, Monadnock Community Hospital. Telephone: 603 924-4699 -- Ext 1281; Sue Ruka, Vice President of Quality Improvement, Memorial Hospital, North Conway, NH. Telephone: (603) 356-5461 Ext 194.]