The Rural Drive-By...Not as Loud but Equally Deadly

Drive-By’s are happening every day in Rural America.  In this case, it's the resident driving by their local hospital in favor of the city.   Viewed as good enough for the sniffles, but not for more serious issues, rural medicine has an image problem.  Unfortunately, it's hard to make a living treating the sniffles.  Mixed with the sprains and cough, there needs to be cancer patients, heart disease and kidney failure.  And ultimately, as goes the hospital, so goes the economic health of the community.  The rural hospital is often the primary direct and indirect employer of the town.

Keeping the patients they can, sending those they can't

A rural hospital can not compete with their urban counterpart.  Size matters for sub-specialization. Academic center of excellence with cities.  These factors determine "brand" for the consumer.

Ideally, rural centers would work in close collaboration with urban centers .  I am not suggesting a moniker on a building ( "X" Community Hospital in partnership with University of Whatever).  There should be a close relationship where the patient sees equalivant care delivery.  

Ideally, patients would see and talk to their specialty nurses and doctors at their local facility.  Travel would be reserved for serious issues- surgery, advanced radiation.  Infusion, follow-up imaging and other recurrent services would be performed locally but overseen remotely.  This provides shared revenue model for the urban and rural center while the patient gets convenience and reassurance. 

Nerds don't live rural....healthcare as a managed service

Telemedicine (tmed) is an enabler of this vision.    With tmed, the patients can meet and review their results with an oncologist hundreds of miles away.  The nurse from the city can be there during chemotherapy.  When it's time for a bone marrow, it's time to drive.  

To date, tmed has been an expensive proposition.  First, there is all that equipment to buy, and then you have to find a nerd (to feed and water the technology). Nerds are hard to find in small towns.  But, things are changing.  The cloud, aka...servers in the sky, can delivery tmed to a PC or handheld, over a browser.  This frees providers to manage patients, not technology.

And , the timing is good.  The telcos are starting to see an opportunity.  Providers can purchase healthcare infrastructure as a subscription.  Get your movies, your EMR, your system for referral and collaboration, etc..all as a monthly subscription, everything kept up to date, HIPPA and HITECH compliant.  No local nerd is required.

Rural hospitals are integrally to the economic health of their communities.  Unless we want a country of urbanites, care delivery models must evolve. Rural centers should keep the patients they can and send only those they can't.   Collaboration enables better care, patient reassurance and revenue sharing.  Technology has evolved to execute on these business imperatives.  We just have to think about care differently. 

Planning for Excellence: Lessons Learned Through RHPI

Bethany Adams, Senior Program Manager

My first mentor, and now long-term dear friend, always said, “a plan is better than no plan.”  This is probably the best advice that I have ever received in my professional life. I have always kept his words in mind when taking on any project. After working with this mentor for almost six years, I always make a plan for just about everything. However, “the plan” was not the key focus for him. What was important to this leader was that the end goal should always be kept in mind and at the forefront of our daily work. We remained focused on pursuing long-term goals while tackling the current objectives that we were charged to accomplish. 

Through his leadership, we would breakdown huge undertakings into small action steps. The action steps were our ideas. He gave us freedom to tackle the project as we thought best, empowered us to take ownership of the project and encouraged us to perform at our highest level. As a tradeoff for the freedom to manage our projects, we had to show that our objectives were completed through measurable outcomes. 

He made sure that the team received praise for a job well done when we accomplished milestones and demonstrated positive outcomes. If we were struggling to meet a milestone or outcomes were not as desirable as anticipated, he simply redirected the approach to put us back on the right track. He worked with us to apply these “lessons learned” to modify the project to improve future services. Regardless of the level of success, we had data, at least to some degree, that allowed us to make program management decisions for redirecting our approach.   

Other key management lessons he emphasized 1) top leadership should be actively involved in order for a project to be successful; and 2) strategic planning is but only an academic exercise if it’s not executed and lessons learned aren’t applied to improve performance. While these concepts seem so simple now, it was then as is now, quite a challenge! I have learned that there are system approaches that assist executives and managers with simplifying these challenges. Such systems include, for example, the Balanced Scorecard and Studer-Pillar model. In general, each of these approaches provides a mechanism for executives and managers to track measures in various categories for a holistic approach to performance improvement. These systems seem to be very effective as demonstrated through many of the hospital projects that were supported through the Rural Hospital Performance Improvement (RHPI) Project. The RHPI Project is a financial, operational, and clinical performance improvement program for rural hospitals that are located in the Delta region and is funded by the Federal Office of Rural Health Policy (HRSA, DHHS) through a contract to The National Rural Heath Resource Center (The Center). 

Another system approach that guides organizations in thinking strategically about performance improvement is the Baldridge framework for performance excellence. As previous mentor made very clear, if you want measurable outcomes, then one must have “a plan” for it and “be ready for change”! The plan by itself is not enough to be effective. A good strategic plan should include a process to support the execution phase. If it is a project plan, it should clearly outline action steps for staff to implement the recommendations. In addition to having “a plan”, we need additional methods to assist executives and managers in taking a holistic approach to performance management. 

However, hospital executives and clinical managers are not the only ones that need these tools! It is time for rural health care program managers to utilize these system approaches to improve performance of our services. Applying a system to performance improvement would assist us in demonstrating the impact of our programs, and in some cases, assist managers in obtaining outcomes. Our “business” is program management. We must have data to drive our business decision-making to improve our program services and demonstrate its impact. We need outcomes data along with a system approach to assist us with effective program management. These concepts came easy to my mentor because of the way he naturally thought and reasoned through issues, but also it was due to his training. It definitely does not come easy for the majority of us, and especially to those that are new to program management. By utilizing a Baldridge framework, health care program managers could improve their strategic planning for their own projects and increase the possibility of meeting program goals and demonstrating measurable outcomes. Overall, program managers would have a tool to assist them in utilizing federal funds more wisely and effectively while building accountability. 

In very simple terms, the Baldrige framework outlines seven (7) key areas that organizations’ should consider if their executives want to improve performance. Rural health program managers may also apply these 7 key areas to increase effectiveness and build accountability in their own projects. To illustrate this concept, I will highlight how the RHPI Project applies the Baldrige framework to support project development and process improvement. The Baldrige key performance excellence categories are listed below with examples of how the RHPI project develops and manages projects under each area.

1)    Leadership - RHPI requires that the hospital Chief Executive Officer (CEO) to be actively involved and engaged in the performance improvement project recommendations. RHPI on-site consultations are large projects that provide valuable services to eligible hospitals. The CEO role and involvement is critical to the overall success of the project.

2)    Strategic Planning - RHPI works directly with the CEO and the consultant to develop the project scope of work (SOW). The SOW is required to clearly defined purpose, objectives, strategies, sustainability plan, and anticipated outcomes with a work plan and timeline. The SOW is the guide for the project and requires extensive upfront planning, which is a critical start to obtaining measurable outcomes. 

3)    Customers, Partners and Community – RHPI considers financial operational assessments (FOA) a priority as these projects directly impacts the program goals. The primary purpose of the FOA is to improve the financial and operational performance of the hospital by identifying strategies and tactics to increase patient volume, increase payments for services provided, and manage operating expenses. Operational assessments targeting care management and transition of care target reductions in re-admission rates, increase patient safety, and improve HCAHPS scores and core measures. All of which directly affects patient care, the financial viability of the hospital, and overall well-being of the community. 

4)    Knowledge Management, Measurement and Feedback – The SOW should drive the project and define the project outputs and anticipated outcomes. During the planning process, we list the anticipated outcomes in general terms. As the project moves forward to completion, the hospital administrator works with the consultant to 1) clarify the anticipated outcomes and define them as measurable outcomes, and 2) identify indicators to measure the outcomes. Measures should be standard industry accepted financial ratios, operational indicators, and/or quality measures. The recommendations are the “intervention”, which takes time to implement and thus, see performance gains.

5)    Workforce and Culture – Project recommendations are expected to flow down to management levels to be implemented within the hospital and become part of the culture. The CEO should build awareness of the project with their Board members and staff.  Best practice recommendations should be shared with the Board, management team, and front-line staff. The executive and management team should develop an action plan to support the implementation of best practices recommendations. 

6)    Operations and Processes - RHPI projects use a variety of methods and approaches to improve performance, initiate the implementation process and sustain projects.  Majority of RHPI project specifically target operations and quality improvement processes that increase business efficiency. All RHPI project include coaching calls, hands on training and education to staff, and an action planning session with the executive, management and champion teams. Many projects utilize a train the trainer model to embed the improved process in the culture and thus sustain it over time. 

7)    Outcomes and impact – The RHPI Project is a federally funded initiative that supports performance and quality improvement projects in eligible rural hospitals in the Mississippi Delta. As such, the RHPI Project is required to report outcomes for both hospital projects and the program to the Office of Rural Health Policy (HRSA/ DHHS).  Therefore, in Fiscal Year 2010 the RHPI project adopted a new process and report, called the Recommendation Adoption Progress (RAP) report. The purpose of the RAP is to gather information on the adoption of consultant recommendations, and ultimately project outcomes, by interviewing CEOs approximately 9 –12 months post project. The goal of RAP is to demonstrate a hospital’s progress over time by showing the extent to which a facility has implemented consultant recommendations, which are performance improvement best practices. The process has also shown that most hospitals require at least 2 years implementing recommendations. However, because the hospitals are tracking indicators developed in conjunction with the strategic plan, they can justify and explain those variables that could enhance or impede performance gains and losses. 

Again, there are at least three (3) well-known system approaches to performance improvement. These 3 systems include the Balanced Scorecard, Studer-Pillar, and Baldridge framework to performance excellence. Each approach has its strength, but organized a little differently to assist managers in accomplishing strategic plans.  Regardless, all 3 could be used by health care program managers to assist them with improving performance of their programs, thus increase the possibility of showing how their program positively impact the beneficiary. I encourage rural health care program managers to apply some sort of systems approach to assist them with performance management since we are responsible for how federal dollars are being utilized through our programs.

I sincerely appreciate my long-term friend and mentor for his ongoing coaching and support over the years. Because of him, I have had the wonderful opportunity to participate in the RHPI Project for 6 years now. He has taught me that it is my responsibility as a program manager to build accountability with those that benefit from the program.  Moreover, it is my duty to demonstrate how the program is utilizing federal funding. I am just now starting to understand how Baldridge could assist me as a program manager.  It motivates me to continue to seek how it could possibly increase the effectiveness of the RHPI project, and thus, better assist hospitals with their performance improvement efforts. 

HIT Evolution and Meaningful Use Stage 3: From Finance IT to Patient IT

Joe Wivoda, Chief Information Officer

The evolution of information technology (IT) in health care has been remarkable, and very similar to what other industries experienced in the 1980's and 1990's. Health care is definitely behind manufacturing, banking, education, and other industries when it comes to using IT, but we can learn from those industries to (hopefully) leap ahead. The new Meaningful Use Stage 3 Request for Comment made me realize that IT professionals working in health care should perhaps consider this and begin to call themselves Patient Information Technology workers instead.

Meaningful Use Stage 1 started the trend with the requirement that hospitals and clinics provide patients with an electronic copy of their health information upon request. Funny thing is that few people requested it! Medical Record staff did not make it a clear option for patients requesting their information, and staff did not realize the data was displayed in a user-friendly way. It was okay to provide patients with a paper copy of their chart, but some organizations decided that it was necessary to encrypt their electronic copy. This is a misunderstanding, and provides yet another barrier to engaging patients in their care.

Stage 2 took a new approach to patient engagement: Portals and Personal Health Records (PHRs). Not only do half of the patients need to be set up in the portal or PHR, but 5% must actually access and use the information. Like it or not, we will need to get patients used to accessing their information online. Banks have been able to do it, and so have schools, car dealers, and just about every other industry. Heck, I know  exactly when my UPS package arrives at my front door via an email, but it takes several days for a phone call from my physician to tell me my lab test was normal. UPS did not need a government-funded incentive program to begin to offer this service, they did it because customers asked for it and their competition was doing it.

The proposed Stage 3 measures that are currently out for comment take patient engagement even further. Patients will have to have the ability to request amendments to their records and submit patient-generated information. By 2014 I expect there will be blood glucose monitors that connect to your smartphone that will automatically update a designated portal or PHR. Imagine the benefits to patients!  Imagine the concerns from providers ("How do I know that is accurate?").

Health Care IT professionals need to take a lead role in creating excitement around patient engagement technology. Until recently, HIT was primarily Finance-IT, and with meaningful use it has finally become true HIT, but I argue we need to be Patient-IT. If we take a patient-centered approach to everything we do in IT we will make a real impact on the health of patients. If we took a patient-centered approach wouldn't the bills be easier to understand for the average patient? If we took a patient-centered approach wouldn't there be a portal that was user-friendly? Wouldn't we have a help desk for patients to call to get help in understanding how to log in and understand their information? Wouldn't we have higher quality, safer, more efficient processes if we put the patient at the center of our implementations and not the physicians and staff?

Starting today I am going to consider myself a Patient Information Technology worker. It will take a while for me to get used to calling myself that, but I will start today. Will you join me?

Topol's Healthcare in American - At a Crossroads of Innovation and Ossification

I recently read Eric Topol’s Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care.  I highly recommend it.  Dr. Topol’s main premise is that innovative deconstruction of people (patients) into their more base components- (their DNA, RNA and proteins), will help us design better, more personalized treatments for a host of diseases.  

This relates to the science of pharmacogenetics, how our genetics individualize our respond to drugs.  This is in contradistinction to the current pharma model- treat as many people as possible even if the benefits are modest for most.  

Unfortunately, as Topol points out, medicine as an institution, and physicians in particular, have not kept pace.  The system is relatively ossified.  Through a combination of bureaucracy and tradition, medical education has not changed substantially since the last great paradigm shift, Flexner Report, in 1910.  In the face of an information explosion, the subjects I studied in medical school 25 years ago were similar to those my father learned 50 years ago.  Unless something drastic happens my daughter, currently a pre-med, is likely to have a similar curriculum.  This results is a type of healthcare delivery focused on the hospital, not the clinic, emphasizing the heroic not the chronic.  In part, this mismatch has lead to the US spending almost twice what other nations spend for healthcare with no perceptible benefit.  This is not sustainable.  Of course today’s medical students and residents are more likely to Google for answers than open a book.  Physicians no longer have to be walking encyclopedias.  However , the system continues to value test taking over personality.  I personally believe the best test takers do not make the best providers- just the opposite.   

The book regrettably gives short rife to telemedicine and opportunities for collaboration.  With the information explosion, no single provider can have all the answers.  More granular data will only exacerbate this problem.  Healthcare is moving from a one on one sport to more of a team game.  In order to have a sustainable delivery system, each provider will have a role to play to fully realize the value of new, personalized therapies.  Telemedicine can be leveraged to bring the healthcare pyramid, stratified expertise, to the bedside.  Most people think of this as expensive, limited technology.  However, browser based solutions allow telemedicine to be done over devices in your pocket.  Teams can be brought together to enable the right care at the right time.

Overall, I agree with Topol’s primary assessments- granular data will allow more effective, personalized treatments, and that the current educational and care delivery models are ill prepared for these disruptive innovations.  However, ultimately personalized medicine will be a combination of technology and choice.  No therapy, no matter how elegant, is without risk.  The past few decades have taught us that just because we can do something, even extend life, doesn’t mean we should.  The role of the provider and the team will be to understand the patient, their desires and act as a translator in this brave new world of personalized medicine.   

Meeting the Triple Aim Means Accepting Constant Change

Kap Wilkes, Program Manager II

As a sailor I recognize that change is a constant; at every moment the wind and sea require the boat to adjust. Of course these adjustments are not made randomly. I know where I want to end up and I know a lot about my boat and crew.  As a captain and crew that wants to win the race there are a few other things that we have done to increase our odds: we have a plan in place for communicating, we pay attention to the weather, and we have developed our skills and knowledge to be able to quickly adjust. Although the crew on the boat is smart, we have practiced and we are confident in our execution; there are a lot of aspects to keep track of and they are constantly changing.  Some are factors we need to monitor, some are due to the particular people we have working together and others are external to the boat. They all impact us as we move through the course. In fact they are constantly impacting us. We don’t change the game plan mid-race very often, but we are constantly making adjustments to improve our speed and execution. Now here is the thing about sailboat racing, the game isn’t over at the end of one race. We have our eye not only on the finish line but to win the series. To do that, we have to be able to repeat our performance over and over. In between races we continue to hone our skills and build our knowledge; getting ready for the next race. With an eye on winning the series the entire crew engages in the strategic winning cycle.

In the world of health care organizations today, working to improve care to patients, reduce costs, and improve the health of populations, achieving the Triple Aim, is like working to win a sailboat race series.  One of the keys to success is engaging in the strategic winning cycle for handling change and ensuring sustainability. As in the sailboat race, health care organizations have internal and external forces that require agile adjustment to the execution and implementation. Doing this without knowing where you are going, communicating with the rest of the team so they too can make adjustments or checking your surroundings will ensure that you do not cross the finish line first; ever. In fact, if you ignore the interconnected nature of your boat, your crew, and the wind and sea, you will most likely come in dead-last. To avoid this place of distinction is a huge motivator for sailboat crews and for health care organizations too. Because being dead-last means that the people in your community are not receiving the best care possible, or worse, they may lose their local health organization entirely! The strategic planning cycle is dynamic, iterative and it is critical to engage in the process if you want to win improved health for your community:

• Analyzing and planning creates an opportunity to develop strategic objectives to drive an organization toward its mission and vision. Sustainable business strategies are dependent on the active involvement of an organization’s leadership, staff, and board of directors.

• Documenting and communicating the business strategy facilitated through a management framework, such as the Balanced Scorecard, supports the development of critical partnerships, increases staff engagement, and incorporates holistic thinking into planning.

• Implementing and executing the business strategy through carefully selected initiatives operationalizes the strategies; aligning the organization’s actions with its mission and vision.

• Monitoring and adapting progress based on measurable targets, established through a process improvement framework builds capacity within the organization for handling change.

Troubleshooting the strategic winning cycle: if you are already engaged in a strategic winning cycle, but are struggling with working as a team or having trouble with execution then check to make sure your crew knows where you are heading. Your organization’s vision provides everyone with something to aim for and directs your crew’s decisions.  If your organization is at a turning point, perhaps with new leadership or a significant change in your operations or the health care environment, jump into the strategic winning cycle at the Analyze and Plan phase. This is the time to review your surroundings and your plan to see if there are significant course changes that need to be made. If you are well into your implementation be sure to monitor progress so that you can make effective adjustments.  If your boat speed is faltering; check your sails, adjust the helm and put your crew’s knowledge and skills to work.

“Salsafying” Rural Health Care

Sally Trnka, Senior Program Coordinator

I have a friend^* who is a former rural health network director in the great state of Georgia who is really good about coming up with visual representations or activities for the concepts she is trying to communicate.  A couple of years ago she introduced me to a fantastic activity that she did with her Board—they made salsa.  Yep, salsa!  The activity challenged each of her Board members to bring their favorite ingredient in salsa to a meeting.  When they stood around the table, they each put their ingredient into a bowl one at a time; single ingredients going into the bowl.  By the time all the ingredients had been added and mixed together something happened—the whole became indestructible. (Dramatic word used for maximum impact!)  What had been created could no longer be separated and it was better than any of the individual ingredients on their own. 

I have the distinct privilege of working with “salsa”-like organizations every day—a colorful, diverse mix of organizations that come together to address common concerns and tackle mutual goals. Over the last couple of months, I have talked specifically with the Directors of State Office of Rural Health and Flex Program Coordinators who work diligently to support the networks in their states.  In August I was in South Carolina, working with two rural HIT networks and had the distinct pleasure of working in tandem with their Director of Network Activities, Tiffany Simpson-Crumpley, an employee of the South Carolina Office of Rural Health, headed by Director, Dr. Graham Adams.  With her help and guidance, we are able to provide robust technical assistance to those grantees, amongst the others in the state.  In September, I had the honor of sitting in a planning meeting with Karen Madden, State Office Director in New York, who deeply believes in supporting the multitude of rural health networks in her state.   Similar sentiments are shared by Flex Coordinators in Montana, Wisconsin, Florida, Michigan…the list goes on!

More recently I have worked with the Veterans Administration, the National Hospice and Palliative Care Organization and the Minnesota Network of Hospital and Palliative Care, the National Cooperative of Rural Health Networks and the Federal Office of Rural Health Policy.  All of these organizations practice the concept of collectivity; that all of us is better than any one of us.  We need the diverse perspective and experiences of stakeholders in order to ensure that we are able to meet the needs of our customers, partners and patients. 

As we face an increasingly complex health care environment filled with dynamic change, and occasional instability, it is crucial that we look for partnership opportunities at every juncture.  It has been incredibly powerful to see organizations come together with a shared purpose, regardless of competition or different ideas of how to get where they are going.  Ultimately, it needs to be about the patients and the communities we serve.  It needs to be about our increasingly aging population and how we can best serve them as they live out their final years in their rural communities.  About how to address health care disparities and access challenges.  About helping our communities to be happier through health and wellness.  About encouraging our patients to receive care at their local hospitals and clinics because high quality care (at lower costs, most of the time) is available in rural communities. 

Accomplishing all of that under the pressure of rules, regulations and policies determined by our elected officials will be hugely challenging, but there is no need the reinvent the wheel or strike out on your own.  Look for the partnerships, for the mutual-wins and for what is best for your communities, patients and staff, recognizing that your bottom line doesn’t have to decline with partnerships.  Usually, the opposite is true.

Go ahead!  Make salsa!

(* Special thanks to Tara Cramer for this great idea!)