RAP Lesson Learned #1: The Power of a Conversation

Rhonda Barcus, Program Specialist

The Rural Hospital Performance Improvement (RHPI) Project is a federally-funded initiative that supports performance and quality improvement projects in eligible rural hospitals in the eight-state region of the Mississippi Delta. One of the ways hospitals are supported is through onsite, consultant led projects designed to impact operational, clinical, or financial issues. About 2 ½ years ago, we created a process called RAP, Recommendation Adoption Progress, as the vehicle to gather information from the participating hospital administrators concerning the extent to which they were able to implement consultant recommendations, outcomes, and the impact on the hospital and community.

Hired to create and implement this process, my background is actually in behavioral health and organizational development. Pure data collection and analysis is not my passion! But, I do know how to gather information and one of my closely held beliefs is that looking at data in the form of numbers alone will only tell a piece of the story. We began discussing what the RAP process would include and I knew that sending an impersonal questionnaire to be returned to me was not the way I wanted to go. Most people are “surveyed out”!

So RAP became a conversation with the hospital administrator. Yes, it involves the discussion of data and outcomes and “what has this project meant to the bottom line” but more importantly, it has become an opportunity to dive deeper. My first lesson learned was that just having a conversation can become a powerful motivator for the hospital. In the midst of impersonal communication, actually TALKING about the process, keeps the hospital focused. It also is an opportunity to coach and educate about the importance of the non-measureable ways the project impacts the hospital. If we only discussed measurable outcomes, we would miss the value of project impact such as “staff is more engaged” or “managers are taking responsibility for their budget” or “staff are now bringing ideas for quality improvement to their leadership.” While not necessarily measurable, these are the indicators of culture change. What we know is that without a change in the hospital culture or “the way we are”, there would not be sustainability, regardless of the excellence of the project.

And so, my first lesson learned with RAP is that we intuitively named it well. While an outdated term from the 60’s, it’s still a powerful way to receive and share information and build trusting relationships along the way. It’s just the power of a conversation.

Next time, RAP Lesson Learned #2: The Power of Meeting People Where They Are.

When to do a medical procedure when the patient is on aspirin- the answer is..that depends on their risk profile and mine.

        I was asked to do a procedure on a patient taking aspirin.  Aspirin helps prevent heart attacks and stroke but it also promotes bleeding - not good when a doctor is going to use a sharp object like a scalpel or needle on you.  Although the data is not clear, my hospital has a policy to wait 5 days off aspirin if the reason for the procedure is not life threatening.   but this can result in delayed care and patient inconvenience.  Guidelines leave room for clinical judgement.

This is a relatively simplistic example of a broader care issue.  There is no free lunch in healthcare.  Almost everything providers do to patients have the potential to harm.  This may be radiation exposure up through serious complications or death from a simple biopsy or surgery.  How patient's view risk varies.  It seems ironic that we spend more time asking people about their investment risk strategy, than their ideas about health risk. Ideally, providers would know their patients, and something about their willingness to accept risk relative to care options.  

A provider's risk profile is also unknown.  Some seem to be afraid of their own shadow, practicing as if there is a lawyer in the room.  Others are less risk averse, willing to forgo even recommended tests if they feel there is limited value.  In one practice I know of there was a 10 fold difference in mammography call backs comparing senior, more experienced and assured, radiologists and their junior partners.  The art of medicine more than occasionally equates to provider preference.  American healthcare is far from evidence based.  Treatment decisions are strongly influenced by the risk tolerance of provide, what they are willing to miss both for the patient's benefit and (medical-legally) their own.

Ideally there would be time for patients and providers to know each other better.  However, until there is a change in the financial pressures and fragmented care, perhaps healthcare can borrow from the finance industry.  A shared assessment of risk tolerance for both patients and providers might allow a better care match.  Although modern healthcare is often viewed contentiously, care decisions should represent a social contract between a patient and their provider, a willingness to try and move forward in partnership.  There is no guarantees of good health, but at least decisions should align with personal choice. 

Telehealth proof before payment- an antiquated barrier to care

     Telemedicine (tmed) has moved from technology to an opportunity for care.  Where there is limited access to experts (eg...rural stroke care), it is compensated- the right person at the right time can make all the difference.  However, widespread adoption of has been limited by two critical issues. First, licensure issues limit providers from crossing state lines.  Second, and more importantly, payment models are complex.  The same rural service delivered may not be paid for across town in a city.  Additionally, reimbursement for virtual care may be possible for one condition but not another in the same rural hospital.
    Parity legislation attempts to simplify these issues. In short, parity legislation requires, in fact mandates for private insurers, that the same billing codes apply whether the patient is seen is an office or on a computer. Almost every State is considering some form of this legislation.  Unfortunately, “mandate”  equates to cost for many legislatures and most insurers.  Mandate is viewed as a 4 letter word.

    In an effort to slow parity legislation, payers have suggested there needs to be proof tmed’s value related to specific clinical scenarios before payment.  Although this makes sense new drugs and devices, I am less certain it applies to tmed.
    Ultimately, healthcare "value" depends on 2 people- the provider and the patient.  The provider needs to be comfortable they can adequately assess the patient. This may require a physical exam, but more often providers need to see the patient and hear their concerns.  For most patients, a visit to the doctor is about reassurance, getting a sense that their cough isn't cancer, that the pain they feel is normal or worthy of further investigation.  If the provider or the patient feel a virtual visit is insufficient, either can choose to have the visit become an in person experience.  For the cost of one emergency room visit,  we could buy 50 to 100 virtual visits.  Access manages disease before it requires expensive tertiary care. Value is not determined by physical presence, but rather the communication, relationship and ultimately the patient’s outcome.      
    Virtual care offers an additional advantage over the standard office practice.  By eliminating physical barriers, care coordination can improve.  Many chronically ill patients have between 12-18 providers, most whom never meet or talk about the patient.  Leveraging mobile devices, care teams could be together, reducing costs and improving care.

    An alternative approach to no proof/no payment might be a stage introdcution for virtual serivces.  Allow reimbursed, but set a limit for a certain number per month per patient.  This would enable providers and patients to discover the most cost effective virtual alternatives while limiting the perceived financial risk to the payer.      Allow market forces to determine the best possible solutions rather than stifling innovation.  To compare tmed to traditional care would take years of work and thousands of patients.  And in the end we would be left with an ever evolving, and confusing landscape for virtual reimbursement.
    Healthcare in America is in transition.  We are moving from transactional care and reimbursement, get paid for what you do,o shared risk, wellness model.  Virtual care is one of the many tools that can help improve the care/cost curve moving forward.  Hopefully antiquated thinking will not limit tomorrow's possibilities.

Developing a Collaborative Strategy for Patient and Community Engagement

Sally Trnka, Senior Program Coordinator

Health care is about taking care of patients; ensuring that your community members are healthy and taking care of them when they are not.   That much we know.  After all, that’s why many of us got into health care to begin with.  What we don’tknow fully, however, is how to most systematically and effectively ensure that our goal of keeping our community healthy can be achieved. 

The regulators are telling us, through the release of regulations for Stage 2 of Meaningful Use (along with the proposed Stage 3 measures), that we need to develop a plan for exactly how to engage our patients and communities in their health through patient portals and the usage of electronic health records (EHRs). Stage 2 of Meaningful Use ramps up on initial efforts laid out in Stage 1 and will require 50 percent of a provider’s patients to be given access to online health information for viewing, downloading and or/transferring through a patient portal.  Further, providers must have 5 percent of their patients accessing their electronic health information online and must engage in secure, two-way messaging with their provider through the portals. 

That’s a BIG leap from Stage 1, imploring facilities and providers to develop a strategy for how they will implement their portal, how they will educate providers and staff, how to communicate with patients and, ultimately, how to encourage patients and communities to recognize the value of this interaction with their own health.  The common criticism of these provisions is that it places a lot of responsibility for patient engagement in the hands of facilities and providers.  Another perspective is that healthcare providers are held accountable for the level of patient involvement in their own care.

We know that two out of three people would consider switching to a physician who offers access to medical records through a secure Internet connection[1]. We know that 80% of American who have access to their health information in electronic health records use it and 65% who don’t have it, say it’s important to[2]. We know that people who are more engaged in their health actually get better health care[3].

So, where to start?  With the myriad of rules and regulations that seem overwhelming to leadership, how do you prioritize the development and implementation of a comprehensive patient engagement strategy?  The answer lies in the foundational concept of the regulations—it needs to be a COMMUNITY approach.  Health care facilities and providers need to be talking with their patients and community members, local businesses and governmental leadership, regional extension centers and health information exchanges (HIE), and rural health networks to develop a comprehensive strategy.  By developing something collaboratively that is owned by the community reduces the burdens on the individual facilities and empowers patients to utilize something that they helped to create.

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^[1] 2011 Survey of Health Care Consumers in the United States; Key Findings, Strategic Implications. Deloitte Center for Health Solutions, Washington, DC, 2011.

^[2] National Partnership for Women and Families. Making IT Meaningful: How Consumers Value and Trust Health IT. 2012.

^[3] Institute for Health Technology Transformation

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?