Question

To complete this assignment, review the following Web resource:

A Critical Access Hospital Case Study: Idaho Flex Program: Evaluation 2010

Where not all pertinent information is given in the case itself, search for that information through the South University Online Library or perform a Web search for the required information. Note: Do not search for information beyond the date of the case.

For the situational analysis, you are encouraged to provide a visual presentation of data in your situational analysis and use the analysis tools from your textbook and other analysis tools you have used in your program, such as trend analysis, stakeholder analysis, etc.

Submit your Situational Analysis: External Environment. Include detailed service area competitive analysis.

Answer 1

The Medicare Rural Hospital Flexibility (Flex) Program and small rural hospitals’ conversionto Critical Access Hospital (CAH) status improving the quality of care and performance whileenhancing local emergency medical services? A case study highlighting Mayers Memorial Hospital, Fall River Mills, California, was conducted as part of California’s Medicare Rural Hospital Flexibility (Flex) Program in order to examine and report on these questions.

The Mayers Memorial Hospital case study was completed to identify changes to the community, hospital, and other aspects of health care, that have occurred due to the hospital’s conversion to Critical Access Hospital (CAH) status and its involvement in the Flex Program. The study also aims to identify needs and issues for Flex Program planning purposes. To accomplish this, the following occurred:

•Local health services and community backgroundinformation were collected from April to May 2012 onFall River Mills, California and the surrounding area.

•Interviews of hospital staff, hospital board members, and localemergency medical services (EMS) personnel were conductedin Fall River Mills April 23 and 24, 2012.

•A survey of health care providers (e.g., physicians, physicianassistants, nurse practitioners, nurse anesthetists) working atMayers Memorial Hospital was conducted April – May 2012.The survey response rate was 22 percent.1

•A community focus group was conducted in Falls River Millson April 23, 2012.

Twenty-eight individuals from the hospital service area were included in the case study process.The California Department of Health Services, State Office of Rural Health, administers the Flex Program in California and was the sponsor of the case study.Rural Health Solutions, Wood bury,Minne sota conducted the case study and prepared this report

Documenting the impact of State Flex Program quality initiatives on the quality of services provided by CAHs. State Flex Programs would be well served by the development of outcome measures for their quality improvement initiatives. The new Flex Grant Guidance seeks to move state Flex Programs in this direction.6 The data provided by these outcome measures would enable them to better target their efforts and assist other states in adopting successful quality improvement models and/or modifying their existing programs.

At the same time, the Flex Program in general would benefit from efforts to encourage the dissemination of information and data on the full range of quality improvement activities developed by State Flex Programs and allow states to focus on those activities proven to be successful.

A Core Set of Quality Measures and a System to Report on those Measures are Needed Despite the efforts of the Office of Rural Health Policy to encourage CAHs to publicly report data for at least one quality measure through Hospital Compare, 30% of CAHs do not do so.4 Some Flex Coordinators report concerns expressed by CAHs about the lack of “rural relevance” for many of the Hospital Compare measures, the burden associated with using the CMS CART tool, the small numbers of cases/low patient volume of CAHs for many of the measures, and public reporting of quality data.

Many respondents believe their measures are more “rurally relevant” than those in Hospital Compare. While these initiative-specific measures have the advantage of being accepted by the participating CAHs, they limit comparability across benchmarking initiatives and do not allow the data to be used to report on the impact of the Flex Program or on the quality of services provided by CAHs in general. As mentioned earlier in the paper, there has been little agreement across these quality reporting and benchmarking efforts on the identification of a core set of QI measures that would be applicable to all CAHs. Despite respondents’ concerns over the “uniqueness” of CAHs and developing measures to meet the needs of hospitals participating in specific benchmarking initiatives, we believe CAHs and the Flex Program share a need for a common and consistent set of core measures focusing on diagnoses, conditions, and services across CAHs. These would likely include measures for pneumonia, heart failure, AMI, surgical services, patient transfers, and patient satisfaction in both inpatient and outpatient settings. Ideally, these core measures would be consistent with the core measures in Hospital Compare that are relevant to CAHs and reflect the primary conditions treated by CAHs and the mix of services they deliver.

A group of rural hospital quality experts convened by the National Rural Health Association in January 2010 as part of its Small, Rural Hospital Quality Metrics Project, funded by the Office of Rural Health Policy, supported the development of just such a set of measures. The Report of Findings7 from that meeting recommended that small, rural hospitals (including CAHs and small, rural prospective payment system (PPS) hospitals) track measures for public reporting in the following core areas: pneumonia; heart failure; patient satisfaction using the Hospital Consumer Assessment of Healthcare Providers and System Survey; relevant AMI outpatient/ED measures; transfers (patient information); care coordination (measure endorsed by the National Quality Forum); a subset of the AHRQ patient safety indicators; and pressure ulcers.

The report also identified the following additional areas for future consideration: pain management; deep vein thrombosis; and patient falls. In light of this recognized need for a set of core quality measures relevant to CAHs, we compared the inpatient, ED, and outpatient quality indicators and measures developed by the quality reporting and benchmarking initiatives described in this study to those in Hospital Compare (See Table 1). In comparing these indicator sets, it is apparent that there are areas of consistent overlap in the measures developed by these quality reporting and benchmarking systems and a number of the measures and core areas in Hospital Compare.

This finding suggests that efforts to develop a core set of measures specific to CAHs and other small, rural hospitals might be somewhat easier than some have suggested. Incentives to Encourage CAHs to Publicly Report Quality Data are Needed As discussed earlier in this paper, study respondents identified concerns about public reporting as an impediment to participation in Hospital Compare by some CAHs. These concerns appear to be rooted in the perception that the Hospital Compare measures are not “rural

relevant,” although there is in fact considerable overlap between these measures and those in individual and multi-state CAH reporting systems as well as the potential for problems related to the public reporting of data based on the lower patient volumes experienced by most CAHs. Although these concerns are important, interest in public reporting of hospital quality data remains high and has been supported by key rural advocates including the National Rural Health Association.8 Currently, CAHs do not have the same financial incentives as PPS hospitals to report quality data to Hospital Compare.

Although many state and national rural advocates believe that publicly reporting would have an inherent benefit for CAHs, a small percentage of CAHs (approximately 30%) seem reluctant to report publicly. These hospitals may need to be encouraged to report with more explicit, tangible incentives. The American Recovery and Investment Act (ARRA) of 2009 may encourage additional CAHs to publicly report quality data by providing financial incentives to hospitals, including CAHs, to achieve standards of meaningful use of health information technology; one aspect of which is the reporting of quality measures to CMS.9** It is important to note that, for the first time, CAHs will be required to publicly report quality data to CMS under the ARRA standards of meaningful use instead of being exempted as they were under Hospital Compare.

The extent to which the ARRA incentives will actually encourage additional CAHs to publicly report their quality measures to CMS is uncertain given that the reporting of quality data to CMS is only one aspect of meaningful use. In addition, rural advocates have raised concerns about the adequacy of the incentive payments available to CAHs compared to those available to PPS hospitals and the extent to which CAHs will be able to meet the standards established for meaningful use.14. Given these issues, additional incentives and encouragement are likely to be needed to encourage the remaining CAHs to publicly report. The Flex Program has been and remains an important source of funding and expertise supporting the quality improvement activities of CAHs. With the recent changes to the Flex Grant Guidance and the development of program outcome measures, it is an appropriate time to consider ways in which state Flex Programs can develop consistent measures that allow comparison across benchmarking systems and the production of data to describe the quality of services provided by CAHs and supported by the Flex Program.