Quality Through Collaboration:

1
Quality Through Collaboration The Future Of
Rural Health Tim Size, Executive Director Rural
Wisconsin Health Cooperative Hawaii Rural
Hospital Flex Conference Waikoloa Beach Marriott,
September 30th, 2005
2
Presentation Overview

• Midwest Filter
• Overview of the IOM Report on the Future of
  Rural Health
• What Can I Do Now? Three Perspectives
• Where Rural Can Lead the Way Linking Individual
  Population Health.

3
The IOM Committee on the Future of Rural Health
Care

• Charge to the Committee
• Assess the quality of health care in rural areas.
• Develop a framework for a core set of services
  and infrastructure necessary to deliver those
  services to rural communities.
• Recommend objectives and changes in policies and
  programs required to achieve those objectives.
• Consider implications for federal programs and
  policy.

Committee on the Future of Rural Health Care.
Quality through collaboration the future of
rural health care. Washington, DC National
Academies Press 2004.

4
What IOM Did Before Looking at Rural Health

• In 2001, the Institute of Medicine (IOM) released
  the report Crossing the Quality Chasm A New
  Health System for the 21st Century.
• Based on a large body of evidence documenting
  serious shortcomings in the American health care
  system overall, the 2001 IOM report called for
  fundamental reform of the U.S. health care
  system.
• The report identified six aims for quality
  improvement health care should be safe,
  effective, patient-centered, timely, efficient,
  and equitable.
• The rural report is 8th in the Quality Chasm
  series.

Committee on the Future of Rural Health Care.
Quality through collaboration the future of
rural health care. Washington, DC National
Academies Press 2004.
5
The Committees 5-Part Proposed Strategy

• Adopt an integrated approach to addressing
  personal and population health needs at the
  community-level.
• Establish a stronger quality improvement support
  structure to assist rural systems and
  professionals.
• Enhance human resource capacity of rural
  communities (professional and rural residents).
• Monitor and assure that rural health care systems
  are financially stable.
• Invest in building an information and
  communications technology (ICT) infrastructure.

Committee on the Future of Rural Health Care.
Quality through collaboration the future of
rural health care. Washington, DC National
Academies Press 2004.
6
Chapter 2 Individual Population Health

• Rural communities must reorient their quality
  improvement strategies from an exclusively
  patient- and provider-centric approach to one
  that also addresses the problems and needs of
  rural communities and populations.

Committee on the Future of Rural Health Care.
Quality through collaboration the future of
rural health care. Washington, DC National
Academies Press 2004.
7
Chapter 2 Recommendations

• Congress should provide resources to the DHHS to
  support comprehensive health system reform
  demonstrations in five rural communities.
• Demonstrations should evaluate alternative models
  for achieving greater integration of personal and
  population health services and innovative
  approaches to the financing and delivery of
  health services, with the goal of meeting the six
  quality aims.

Committee on the Future of Rural Health Care.
Quality through collaboration the future of
rural health care. Washington, DC National
Academies Press 2004.
8
Chapter 3 Quality Improvement Infrastructure
A great deal of attention has been focused on
enhancing quality improvement capabilities.
Because of their small scale and low operating
margins, rural providers have found it difficult
to make such investments. Although many elements
will be the same for rural and urban areas, some
customization is needed for rural areas.
Committee on the Future of Rural Health Care.
Quality through collaboration the future of
rural health care. Washington, DC National
Academies Press 2004.
9
Chapter 3 Recommendations

• Establish a Rural Quality Initiative in DHHS to
  coordinate and accelerate efforts to measure and
  improve the quality of personal and population
  health care programs in rural areas..
• Initiative should be coordinated by HRSAs ORHP
  with guidance from a Rural Quality Advisory Panel
  consisting of experts from the private sector,
  state, and local governments with knowledge and
  experience in rural health care quality
  measurement and improvement.

Committee on the Future of Rural Health Care.
Quality through collaboration the future of
rural health care. Washington, DC National
Academies Press 2004.
10
Chapter 4 Strengthening Human Resources
The IOM committee believes that a renewed and
vigorous effort must be made to enhance the
health professions workforce in rural areas. This
effort should focus on enhancing the quality
improvement knowledge and skills of practicing
professionals and the supply and preparedness of
future professionals working in rural areas.
Committee on the Future of Rural Health Care.
Quality through collaboration the future of
rural health care. Washington, DC National
Academies Press 2004.
11
Rural Under-Representation Starts in Med School
Wisconsin Academy of Rural Medicine, Planning
Committee, 7/05
12
Chapter 4 Recommendations

• Congress should provide resources to HRSA to
  expand rural experientially based workforce
  training programs.
• Professional schools should work to (1) to
  attract rural applicants, (2) locate much of the
  educational experience in rural communities, (3)
  expand distance learning programs, (4) make
  greater effort to recruit faculty with experience
  in rural practice and (5) develop rural-relevant
  curricula.
• The federal government should provide financial
  incentives for residency training programs for
  rural tracks by linking some portion of graduate
  medical education payments under Medicare to this
  end.

Committee on the Future of Rural Health Care.
Quality through collaboration the future of
rural health care. Washington, DC National
Academies Press 2004.
13
Chapter 5 Provide Adequate/Target Financial
Resources
Communities must have adequate, appropriately
financial resources. A great deal of
experimentation is under way to better align
payment incentives with the quality aims rural
communities should be part of these efforts. But
rural health care systems have been financially
fragile, and many still have small operating
margins, making it difficult to participate.
Committee on the Future of Rural Health Care.
Quality through collaboration the future of
rural health care. Washington, DC National
Academies Press 2004.
14
Chapter 5 Recommendations

• CMS should establish 5-year pay-for performance
  demo projects in five rural communities starting
  2006.
• ARHQ should produce a report no later than FY 06
  analyzing the aggregate impact of changes in the
  Medicare program, state Medicaid programs,
  private health plans and insurance coverage on
  the financial stability of rural health care
  providers, and detail actions to ensure
  sufficient financial stability.
• HRSA and SAMHSA should conduct a comprehensive
  assessment of the availability and quality of
  mental health and substance abuse services in
  rural areas.

Committee on the Future of Rural Health Care.
Quality through collaboration the future of
rural health care. Washington, DC National
Academies Press 2004.
15
Chapter 6 Utilize Health Information Technology
HIT bridges distances by providing more
immediate access to clinical knowledge,
specialized expertise, and services not readily
available in rural areas. However, many rural
communities are unprepared to participate fully
in the information age.
Committee on the Future of Rural Health Care.
Quality through collaboration the future of
rural health care. Washington, DC National
Academies Press 2004.
16
Chapter 6 Recommendations ( 1 of 2 )

• Include a rural focus in the Office of National
  Coordinator for Health Information Technology
  (NCHIT).
• Provide all rural communities with high-speed
  access to the Internet.
• Eliminate regulatory barriers to the use of
  telemedicine.
• Financial assistance to rural providers for HIT.
• Foster rural HIT collaborations and
  demonstrations.
• Provide ongoing educational and technical
  assistance to rural communities to maximize the
  use of HIT.

Committee on the Future of Rural Health Care.
Quality through collaboration the future of
rural health care. Washington, DC National
Academies Press 2004.
17
Chapter 6 Recommendations ( 2 of 2 )

• Congress should ensure that rural communities are
  able to use the Internet for the full range of
  health-related applications.
• Congress should provide direction and financial
  resources to assist rural providers in converting
  to EHRs over the next 5 years.
• AHRQs Health Information Technology Program
  should be expanded for rural areas.
• NLM, with the NCHIT and AHRQ, should establish
  regional ICT/telehealth resource centers
  interconnected with the National Network of
  Libraries of Medicine.

Committee on the Future of Rural Health Care.
Quality through collaboration the future of
rural health care. Washington, DC National
Academies Press 2004.
18
What Can I Do Now? Three Perspectives

• Leaders Death Dying Cycle
• What Can I do Now?
• RWHC Hospitals Quality Directors Survey Results
• Wisconsin Hospital Association
• University of Minnesota Rural Research Center

19
Quality Leaders Work Through Death Dying Cycle
Data Transparency
Public Measurement Reporting Requirements
Acceptance
Shock Disbelief
Bargaining
Anger
Data Standardization
Leadership Keys to Improving Quality of Care by
Dana Richardson, Vice President, Quality
Initiatives, Wisconsin Hospital Association, 2005
Rural Health Conference
20
Shock Disbelief

• All about the numbers
• Insist on seeing the numbers first
• Question validity/reliability
• Multiple attempts to explain
• Too early to set goals or expectations

Leadership Keys to Improving Quality of Care by
Dana Richardson, Vice President, Quality
Initiatives, Wisconsin Hospital Association, 2005
Rural Health Conference
21
Anger

• Too many measures
• Measures are not important
• Collection and reporting burden is too big
• Someone else is at fault
• Physicians
• Nurses
• Hospitals

Leadership Keys to Improving Quality of Care by
Dana Richardson, Vice President, Quality
Initiatives, Wisconsin Hospital Association, 2005
Rural Health Conference
22
Bargaining

• Are the measures clinically relevant?
• Can these measures be improved?
• How can I collect this data within my budgetary
  restraints?
• How can I demonstrate improvement in these
  measures when patients dont comply?
• Is the incentive worth the effort?

Leadership Keys to Improving Quality of Care by
Dana Richardson, Vice President, Quality
Initiatives, Wisconsin Hospital Association, 2005
Rural Health Conference
23
Acceptance

• When QI is a state of mind, not a project
• All about performance improvement
• Anxious to tell our story good, bad or ugly
• View the customer as the one to whom we are fully
  accountable
• Seek out best practices
• Willing to share data tools and resources with
  others
• Strive to constantly improve

Leadership Keys to Improving Quality of Care by
Dana Richardson, Vice President, Quality
Initiatives, Wisconsin Hospital Association, 2005
Rural Health Conference
24
From RWHC What Can I Do Now? ( 1 of 2 )

• Data Collection Feedback
• collect data on patient care processes and
  outcomes
• develop a reporting format that is easy to read
• report results continually to everyone
• change incident reporting to opportunity for
  improvement
• External Benchmarks
• improve JCAHO Core measure data CHF, AMI CAP
• recognize as important, implement and monitor the
  JCAHO National Patient Safety Goals
• change systems to comply with patient safety
  measures such as requiring site marking,
  identifiers before treatment, etc.
• develop Care Pathways for consistency of care

RWHC Hospitals Quality Directors Survey, 8/05
25
From RWHC What Can I Do Now? ( 2 of 2 )

• respond to insurers measures for quality such as
  compliance with diabetes management
• implement bar code scanning for medication
  administration
• there are a lot of resources God Bless the
  internet!
• Team Work
• promote a non-punitive environment
• work towards a culture of teamwork
• develop small quality action teams
• charter a proactive medication management team
• utilize patient care council to problem solve
  clinical issues
• train/orient new personnel with strong preceptors
• develop stronger physician/nursing relationships

RWHC Hospitals Quality Directors Survey, 8/05
26
From WHA What Can I Do Now? ( 1 of 2 )

• Evaluate where your hospital is related to the
  Death and Dying cycle of change
• Identify impediments to improvement in your
  hospital
• Increase visibility and communication about
  quality issues
• Increase focus on quality at Board meetings
• Find opportunities for your Board and senior
  leadership to interact with physicians and staff
  about quality issues
• Participate in Pay for Performance
• Purchaser pilots
• Incorporate quality targets into senior
  leadership compensation (and staff)

Leadership Keys to Improving Quality of Care by
Dana Richardson, Vice President, Quality
Initiatives, Wisconsin Hospital Association, 2005
Rural Health Conference
27
From WHA What Can I Do Now? ( 2 of 2 )

• Use quality measures to assist decision making
• Public reporting (CheckPoint, Hospital Compare)
• Organizational scorecards/dashboards
• Participate in learning/sharing opportunities
• State Hospital Association Initiatives
• Rural tasks in QIO 8th Scope of Work
• 100K Lives Campaign
• NRHA Quality Initiative
• Develop a comprehensive plan to build a systems
  approach and create a culture of excellence

Leadership Keys to Improving Quality of Care by
Dana Richardson, Vice President, Quality
Initiatives, Wisconsin Hospital Association, 2005
Rural Health Conference
28
From UMRRC What Can I Do Now? ( 1 of 2 )

• Link QI to your mission and strategic plan
• Establish an organizational culture that actively
  supports QI
• Reorient QI strategies from patient or
  provider-centered approach to one that also
  embraces a community/population approach
• Define a relevant quality measure set for your
  hospital
• Invest in MIS that supports QI

Health Care Quality for Rural America by Ira
Moscovice, University of Minnesota Rural
Health?Research Center at the Third Annual
Western Region Flex Conference, 6/05
29
From UMRRC What Can I Do Now? ( 2 of 2 )

• Participate in public reporting initiatives
• Develop QI teams in your hospital that address
  quality and patient safety issues
• Join/develop a network that facilitates QI
  activities for CAHs
• Work with your QIO, state hospital association,
  SORH, and universities on QI activities
• Apply for QI-related grants

Health Care Quality for Rural America by Ira
Moscovice, University of Minnesota Rural
Health?Research Center at the Third Annual
Western Region Flex Conference, 6/05
30
Part III Rural Can Lead the Way

• The healthcare system of the 21st century should
  maximize the health and functioning of both
  individual patients and communities. To
  accomplish this goal, the system should balance
  and integrate needs for personal healthcare with
  broader community-wide initiatives that target
  the entire population.

Fostering Rapid Advances In Healthcare Learning
From System Demonstrations, The Institute of
Medicine of the National Academies of Science,
2002.
31
(No Transcript)
32
How Far Are You Ready to Go?

• NETWORKING A public health department and
  hospital/clinic exchange information about how
  they each support healthy early child
  development.
• COORDINATING A public health department and a
  hospital/clinic do the above and decide to alter
  service schedules so that they can provide their
  combined support in a more user-friendly manner.
• COOPERATING A public health department and a
  hospital/clinic do the above and agree to share
  neighborhood outreach resources to increase the
  effectiveness of their support.
• COLLABORATING A public health department and a
  hospital/clinic do the above and provide skill
  development training for each other's staff to
  enhance each other's capacity to support health
  early child development.

Adapted from Art Himmelmans Collaborating for
a Change
33
Key Barriers to Providers Getting Involved

• Tradition. With some notable exceptions, the role
  of providers has been seen as treating individual
  patients. Concern about the population as a whole
  has been the job of local and state public
  health departments.
• Resources. Providers struggling to address
  traditional responsibilities with tight budgets
  are not looking for new roles that no one will
  pay for.
• Values. The third is the conflict or discomfort
  about addressing population health issues, many
  of which relate to individual behaviors other
  peoples choices and their freedom to make those
  choices.

Unpublished manuscript Population Health
Improvement Rural Hospital Balanced Scorecards
A Conversation, Tim Size, David Kindig Clint
MacKinney
34
A Checklist for Successful Collaborating

• Host organization ready?
• The right partners involved?
• Shared vision unifies partners?
• Partners aware what is expected?
• Partners know partnership goals and objectives?
• People to do the work have been identified,
  staffed and made accountable?
• Best practices have been researched and shared?
• Assets residing within the partnership have been
  mapped?

• Partnership encourages participation in and
  sustainability of its work?
• Partnership actively recruits new members?
• Defined governance model?
• Leadership is effective?
• Communication/outreach plan?
• Financial needs known and addressed?
• Work evaluated/revised?
• Partnership knows challenges that it faces?

The Collaboration Primer by Gretchen Williams
Torres and Frances Margolin
35
Examples of Next Steps Local

• Devote a periodic Board meeting or a portion of
  every Board meeting to review population health
  indicators.
• Add Board members with specific interest and/or
  expertise in community health improvement.
• Create a community health Board subcommittee to
  explore opportunities for partnerships with other
  organizations to improve community health.
• Consider hospital or clinic employees or
  employees of a proactive local employer as a
  community and develop interventions to improve
  employee health. Then, expand the experience to
  the larger community.

Unpublished manuscript Population Health
Improvement Rural Hospital Balanced Scorecards
A Conversation, Tim Size, David Kindig Clint
MacKinney
36
Examples of Next Steps State Regional

• Advocate for improved community health
  measurement techniques and increased community
  health improvement valuation.
• Assist hospitals and clinics, and other
  stakeholders, to begin to link the mission of
  community health improvement to budget,
  operations, and performance measurement.
• Partner with academic institutions to design
  research projects that test hypotheses related to
  provider performance improvement and community
  health measurement.

Unpublished manuscript Population Health
Improvement Rural Hospital Balanced Scorecards
A Conversation, Tim Size, David Kindig Clint
MacKinney
37
Wisconsin Strong Rural Communities Initiative

• The Rural Health Development Council, a
  legislatively appointed advisory group to the
  State of Wisconsins Department of Commerce, is
  looking for six rural Wisconsin communities to
  join it in developing the Strong Rural
  Communities Initiative. The goal of the
  initiative is for rural communities to improve
  their health indicators and health status through
  the development of ongoing, local interventions
  by coalitions that include (1) the local hospital
  and representatives of the medical community, (2)
  the county health department, and (3)
  representatives of other non-health related local
  businesses. Involvement of the local business
  community and the long term potential to reduce
  health care costs is a particular emphasis of
  this initiative.

Wisconsins Strong Rural Communities
Initiative http//www.rwhc.com/SRCI.html
38
Six Interventions by Hospital-Public
Health-Business

• Offering cardiac risk profiles, safe workout and
  proper nutrition instruction and follow-up
  evaluation at area employers.
• Multi-sector teams provide prevention and health
  promotion services to corporate and independent
  worksite locations.
• Health risk assessments and health improvement
  planning for large to small employers as well as
  individuals.
• Promote local primary care and preventive health
  services and build a successful worksite based
  wellness program.
• Increase primary and secondary prevention in
  response to rising obesity rates by targeting
  businesses and their employees.
• Expand fitness program for local police to the
  community.

Wisconsins Strong Rural Communities
Initiative http//www.rwhc.com/SRCI.html
39
The Hospitals Risk of Not Changing

• A frequently cited example of a sectors failure
  to adapt to changing times is the railroads
  falling from monopolies in the late 19th century
  to bankruptcy in the 20th.
• The railroads kept on doing what had been a
  successful business strategy running trains.
  Railroads failed to adapt to a market that was
  redefining transportation as cars, trucks and
  airplanes.
• Healthcare markets are now being redefined
  shifting from purchasing service units to
  purchasing quality outcomes. Importantly,
  quality care is increasingly defined in both
  personal and population perspectives.
• This developing redefinition of healthcare needs
  to be reflected in rural provider strategic
  planning. It is a great opportunity for rural
  health.

Unpublished manuscript Population Health
Improvement Rural Hospital Balanced Scorecards
A Conversation, Tim Size, David Kindig Clint
MacKinney
40
Partial List of Resources

• Association for Community Health Improvement
  http//www.communityhlth.org/
• The Collaboration Primer Proven Strategies,
  Considerations and Tools to Get You Started
  http//www.hret.org/programs/content/colpri.pdf
• The Community Tool Box at http//ctb.ku.edu/
• VHA Health Foundation http//www.vhahealthfoundati
  on.org/vhahf/resources.asp
• Kellogg Leadership for Community Change
  http//www.klccleadership.org/
• Community-Campus Partnerships Tools and
  Resources http//depts.washington.edu/ccph/partner
  ships.html
• Building Stronger Communities for Better Health
  http//www.policylink.org/Research/pdfs/JointCente
  r-Communities.pdf