A Roadmap for Improving the Quality of Care in CAHs:
Recommendations from the April 15 Planning Summit
In April, 2009, a group of quality experts participated in a planning summit to develop a
strategy for improving the quality of care in Nebraska’s Critical Access Hospitals (CAHs).
The summit was facilitated by Keith Mueller, the Interim Dean of the College of Public
Health at the University of Nebraska Medical Center and a national expert on rural health
policy. The purpose of the meeting was to address the following questions:
What are the major challenges and gaps that must be addressed to improve
performance and outcomes?
What are the key elements or ingredients (e.g., good leadership) that are
necessary for CAHs to achieve the “gold” standard?
What are the major strategic objectives for achieving high performance
CAHs across the state?
What are the highest priority strategic objectives?
What are some of the short-term action steps that are needed to achieve
the priorities?
GOAL: Develop a Roadmap to Improve the Quality of Care Provided by
Critical Access Hospitals
Basic Assumptions
1. There is not a standard definition of quality in Nebraska; therefore, it is unknown how
many hospitals could meet the “gold standard.”
2. To achieve the “gold standard”, there must be strong leadership from the CEO, the nursing
director, the QI director, the physicians, and the board.
3. Employees must be empowered and held accountable for achieving the standard.
4. Employees at all levels must be an integral part of the decision-making and action
planning process.
5. Because there is considerable turnover of key employees that are advocates for quality in
CAHs, it is difficult to maintain a positive culture over a long period of time.
6. Improvements in quality often occur incrementally, so a consistent long-term strategy must
be developed.
7. There is not a systematic process for widely sharing best practices among hospitals in
Nebraska.
Strategic Objectives
Standard Definition of Quality
1. Develop a Standard Definition of Quality using the IOM definition of quality and the
AHA’s Hospitals in Pursuit of Excellence initiative.
The Vision – Health care is safe, effective, patient centered, timely, efficient, and equitable.
(IOM Report To Err is Human) This means we must:
Perfect the patient experience. Care must be respectful of, and responsive to, individual
preferences, needs and values.
Create a high reliability culture. Hospital cultures must embrace the transformation of hospitals
into places where each patient receives the best quality care, every single time.
Manage organizational variability. Some variables, such as scheduling of elective surgery, can
be smoothed out to achieve more even patient flow.
Remove waste. This includes removing inefficiencies such as unnecessary process steps and
can have a direct, positive impact on the bottom line.
Eliminate defects. Finding and resolving problem points will result in greater efficiency and
better health outcomes.
Reduce process variation. Using quality tools and frameworks can increase consistency and
reduce errors in both the clinical delivery of care and the policies and procedures that support
care. - AHA Hospitals in Pursuit of Excellence
Action Steps:
A. Refine the current definition and build a consensus among the hospital (quality)
leadership.
B. Define a “career ladder” for quality that includes the minimum standard and the
incremental levels of improved quality.
C. Adapt a model or systems approach that outlines the process (elements) needed to
achieve excellent results (e.g., Baldridge National Quality Program).
Engage/Excite CEOs & Boards
2. Develop resources and tools that will encourage CEOs and the Boards to assume a
leadership role in assuring the delivery of care that meets the NE definition of quality.
Action Steps:
A. Create venues where the CEO and Board champions can share their knowledge
with other hospitals (e.g., EQuIP, workshops, webinars).
B. Identify and implement innovative educational programming (e.g., CAH Quality
Fellowship Program) that is appropriate for administrators and boards with
different backgrounds and experiences (e.g., clinical, financial, or minimal
health experience).
Forum for Sharing/Collaboration
3. Share resources and best practices among CAHs, physicians, and other hospitals
Action Steps:
A. Collect and track data from all CAHs on one statewide quality initiative (e.g.,
pneumonia, readmissions, etc.) so that progress can be measured over time.
B. Create a forum and other opportunities for CAH networks to share their activities
and encourage greater network collaboration.
C. Study, document, and share best practices among CAHs and larger hospitals.
D. Develop more formal mentoring programs for QI professionals, CEOs, and
Physicians.
E. Work with the NMA and other organizations to collaborate on various projects and
share best practices.
Building Capacity
4. Develop new, and improve existing, tools and resources that are needed.
Action Steps:
A. Ensure that all hospitals have access to the tools and resources (e.g., Lean
Thinking, 5 Million Lives Campaign, TeamSTEPPS, QHi, National Quality
Forum, etc.) that support high quality care.
B. Develop a priority list of recommended tools and resources and build capacity to
make them available.
Patient Focus
5. Enhance accountability to the public and policymakers by making outcomes and results
publicly available.
Action Steps:
A. Continue to collect and analyze data on patient results and customer satisfaction
from the AHRQ Hospital Survey on Patient Safety Culture, the QHi Project,
the Clinical Outcomes Measurement System (COMS), the Balanced
Scorecard, etc.
B. Provide strong incentives for all CAHs to participate in Hospital Compare,
HCAHPS, and outpatient quality reporting initiatives and post results which
demonstrate care provided is in the upper quartile for the nation.
C. Develop a best practices framework for using the feedback information and
making changes.
D. Develop methods to measure the return on investment (ROI) of these quality
improvement projects.
Rewards
7. Identify new methods, and continue existing methods, to recognize improved hospital
performance
Action Steps:
A. Continue to recognize outstanding performance through the NHA Quest for
Excellence Award.
B. Encourage CAHs to become involved in the nationally-recognized quality
programs (e.g., CPHQ program).
C. Recognize outstanding results through press releases and other ways.
To the parking lot:
Resources:
Action Steps:
A. Develop education and training to encourage effective communication, skill
sharing, and empowerment methods.
B. Identify and share education, training, and coaching practices that are effective.
C. Develop a “model” plan for recruiting, hiring, and retaining a diverse and creative
workforce.