This article was written by Tim Size, Executive Director, Rural Wisconsin Health Cooperative (RWHC) for the “Networking News” monthly newsletter. The Network Technical Assistance Project is funded by the Federal Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services through a contract to Rural Health Innovations, LLC, a subsidiary of the National Rural Health Resource Center.
This article is abstraction from "Leadership Development for Rural Health" by Tim Size
Leadership is the capacity to help transform a vision of the future into reality.
The significant challenges we face today in healthcare require a form of leadership that is less authoritative and more collaborative. Ronald Heifitz and colleagues at the Stanford Graduate School of Business say it very well. These 'problems require innovation and learning among the interested parties, and, even when a solution is discovered, no single entity has the authority to impose it on the others. The stakeholders themselves must create and put the solution into effect since the problem is rooted in their attitudes, priorities, or behavior. And until the stakeholders change their outlook, a solution cannot emerge.'[1] It is important to not confuse being collaborative with endless stanzas of singing 'Kum By Ya;' collaboration frequently requires strong external catalytic action.
In Leadership Is an Art,[2] Max Depree offers a model for employer-to-employee relationships based on his experience that productivity is maximized by designing work to meet basic employee needs. His vision of the art of corporate leadership brought employees into the decision-making process. DePree's experience is primarily within the world of the Fortune 500, but many have found him to offer a useful framework for non-profit and public sectors.
While DePree was a successful leader of a Fortune 500 Company, some may describe him as impractical, a common descriptor thrown by the 'pragmatists' at 'collaborators.' Robert Greenleaf offers a suggestion that may be helpful in thinking through this dilemma: "For optimal performance, a large institution needs administration for order and consistency, and leadership so as to mitigate the effects of administration on initiative and creativity and to build team effort to give these qualities extraordinary encouragement."[3]
As the executive director of a cooperative of rural hospitals for more than 35 years, it is easier for me than for many to see rural health through the lenses of collaboration, the opportunities it creates, and the threats it endures as a model for organization and community work. We have adopted and adapted DePree's eight leadership principles as a guide for both our internal and external relationships.
To illustrate these leadership principles, the following is as described in the article Managing Partnerships: The Perspective of a Rural Hospital Cooperative. [4]
1. There Is Mutual Trust
Develop relationships based primarily on mutual trust so that the cooperative goes beyond the minimum performance inherent in written agreements. "While responding to a rapidly changing market in 1984, the implementation in six months, from scratch, of a rural-based health insurance company in Wisconsin was only possible due to the prior existence of a basic level of trust among the key actors."
2. Commitment Makes Sense
Participants may join a cooperative to explore its potential; they remain only if they perceive that they are receiving a good return on their investment of time and money. "RWHC offers a broad array of shared services from which hospitals pick and choose according to their individual needs; commitments are made because they have been structured in a way that attempts to maximize the 'fit' for each individual participant."
3. Participants Needed
Each organization must know that it is needed for the success of the cooperative. "It is a major mistake to ever take for granted the participation or commitment of any member. The RWHC communication budget is ample testimony to the importance of early and frequent communication and consultation."
4. All Involved in Planning
The planning is interactive, with the plan for the Cooperative being the result of, and feeding into, the plans of the individual participants. "One theatrical but powerful example of ignoring the need for local input and preferences involved the Cooperative within months of its incorporation in 1979. Two regional health planners were practically driven from the bare wood stage of Wisconsin's historic Al Ringling Theater after their presentation of a unilaterally developed plan for local consolidations and closures. The plan was not implemented and did not contribute to further discussion of how rural healthcare in southern Wisconsin could be improved."
5. Big Picture Understood
Participants need to know where the organization is headed and where they are going within the organization. "RWHC has a motto: 'Say it early and keep saying it.' A number of RWHC's more significant initiatives, such as improving rural hospital access to capital, various quality improvement projects, and advocacy for major education reform within the University of Wisconsin's health professional schools has been multiyear if not indefinitely long efforts."
6. Participants Affect Their Own Future
The desire for local autonomy needs to be made to work for the Cooperative through the promotion of collaborative solutions that enhance self-interest. "When RWHC began operations, many observers were highly skeptical about whether or not it would last, let alone make any real contribution-that rural hospitals' traditional need for autonomy would prevent any meaningful joint activity. Some shared services have been undersubscribed as hospitals have chosen local options when, at least from the perspective of RWHC staff, a cooperative approach offers a better service at a lower cost."
7. Accountability Up Front
Participants must always know up front what the rules are and what is expected of them. "Discussions at RWHC board meetings are frequently comparable to customer focus groups and equally valuable. Participation in all Cooperative shared services requires a signed contract, not so much as to permit legal enforcement, but to ensure that all parties in the partnership have thought through upfront the expectations of all the participants."
8. Decisions Can Be Appealed
A clear non-threatening appeal mechanism is needed to ensure individual rights against arbitrary actions. 'The use of the cooperative strength of RWHC hospitals has been used to enforce an appeals process in a variety of circumstances, including a potential breach of contract by a large health insurer; individually, few could have justified the necessary prolonged legal challenge to enforce the contract but through concerted joint inquiry into the legal options available, further legal action became unnecessary."
In summary, leadership is the capacity to help transform a vision of the future into reality. Individuals who can and will exercise leadership are like a river's current-a part past where we now stand, a part yet to come. We have an ongoing need to remember and to look toward the next 'generation.'
The full text of this article is available at Leadership Development for Rural Health
About
RWHC has been providing affordable and effective services to healthcare organizations since 1979. RWHC is owned and operated by thirty-nine (39) rural acute, general medical-surgical hospitals. The Cooperative's emphasis on developing a collaborative network among both freestanding and system affiliated rural hospitals distinguishes it from alternative approaches. RWHC offers a variety of programs and services to its members as well as to other clients across the nation. RWHC is a current Rural Health Network Development Grantee of the Health Resources and Services Administration, Federal Office of Rural Health Policy. RWHC staff served in early leadership roles and continues to be an active member of NCHN (National Cooperative of Health Networks).
[1] Size T. Special Issue of the North Carolina Medical Journal: Contemporary Issues in Rural Healthcare (in honor of James D. Bernstein), January-February Issue 2006.
[2] Heifitz R, Kania J, Kramer M. Leading Boldly. Social Innovation Review. 2004;Winter:25.
[3] DePree M. Leadership is an Art. New York, NY: Dell 1989.
[4] Greenleaf RK. Servant Leadership. New York, NY: Paulist Press, 1977:60.
[5] Size T. Managing partnerships: The perspective of a rural hospital cooperative. Health Care Manage Rev 1993:18(1):31-41.
Thursday, April 30, 2015
Friday, April 10, 2015
The First Rural Health Hackathon
By: Terry Hill, Executive Director, Rural Health Innovations
Last month I spoke at the first rural health care hackathon
ever held in the United States. “Hacking Rural Medicine” was sponsored by the
Frontier Medicine Better Health Partnership, a network of rural hospitals, and
was held on the campus of the University of Montana in Missoula, MT. The
concept of the “hackathon” comes from the technology industry, and consists of
bringing a diverse group of people together to brainstorm solutions to common
problems, to form new teams to pursue solutions, and ultimately to create
change and spread innovation. The leader responsible for coming up with the
idea and carrying out the implementation of the hackathon process, is Monica
Bourgeau, the Frontier Medicine Partnership’s Chief Operating Officer. She was intrigued by the
concept, appealed to the Massachusetts Institute of Technology (MIT) for
assistance, and then embarked on more than six months of planning to make it
happen. MIT was an enthusiastic partner throughout the process and contributed
students and other experts to help facilitate the event.
%2BTerry.jpg) |
| Terry Hill |
More than 150 participants registered for the Montana
hackathon, representing a diverse background and skill set from 15 states. Friday
evening was reserved for a full agenda of speakers, with presentations ranging
from five to fifteen minutes. I was one of the fortunate few given fifteen
minutes to set the rapidly evolving health care landscape. The basic message I
conveyed was that transformational change is taking place, moving the health
industry from volume- to value-based payment. Rural health providers must begin
now to find their place in the changing value-based health system. Other
speakers provided a similar message, and still others noted the strengths and
assets of rural America, and declared that innovation can be done quicker and
better in rural settings.
Saturday saw the participants discussing issues and problems
in an open space setting, and then break out into diverse teams to propose
solutions and plan action strategies to carry out the associated work. One
group, for example, worked on ideas and strategies to generate needed data for
population health management. One of the participants commented, “We can’t
expect miracles from a three day event, but we’re hoping that some IT innovator
will be able to develop a prototype solution to something we've all been
wrestling with for months. That’s how progress has come in this industry; one
person building on the ideas of another.” Another group, led by primary care
physicians, developed strategies to bring joy and meaning back to medicine and
other health care work. The idea was that besides the bad outcomes for patients
and their communities, health care providers have also fallen victim to a
health care system that has been stressful and often led to disillusionment.
Ideas ranged from education, to integrative health methods, to teamwork, and
mutual support and networking.
.jpg) |
| Hacking Rural Medicine Attendees |
The hackathon is organized like a competition between teams,
and on Sunday the nine teams that formed on Saturday presented their plans of
action. Judges assessed the innovation and practicality of each team’s proposal
and awarded 1st, 2nd, and 3rd place prizes. A crowd’s favorite award was made
as well. First place went to the group planning to build a more practical, accessible
rural health information database. Organizer, Monica Bourgeau, said the
competition was only one fun aspect of a more serious hackathon purpose, “We’re
hoping that besides the innovative ideas and action strategies, one of the
outcomes of this event will be to begin partnerships and personal connections
that will live and produce results long after the event…That’s what’s really
exciting to me.”
My own observation is that this Hackathon provides an
excellent model of how to bring community stakeholders together to solve urgent
rural health problems. Already similar events are being planned in three other
states, and it may be something individual rural community hospitals might want
to contemplate as well. One of the primary challenges rural hospitals face
today is how to most effectively work with their communities and other health
providers in their service area. The need is crucial, partially to maximize the
use of available hospital services, but also because in a value-based reimbursement
system, providers will also be responsible for services outside of their
hospitals. And, with the rural hospitals being challenged more than ever
before, it’s an ideal time to seek partners, collaborators and innovators from
nontraditional sources. The old adage, “All of us” are a lot smarter than any
one of us” has never been truer.
For more information about the Hackathon, contact Terry at thill@ruralcenter.org or go to the Hacking Rural Medicine website.
Wednesday, April 8, 2015
Top Five Reasons Why the Swing Bed Program is Vital to the Long-Term Viability for Critical Access Hospitals and Rural Healthcare
By: Terry J. Hill, Executive Director, Executive Director, Rural Health Innovations, a subsidiary of the National Rural Health Resource Center, a non-profit organization and Mark Lindsay MD, Medical Director, Allevant Solutions
1. Significant Equity Gaps in Rural vs Urban. Access to healthcare is a basic human right. Rural patients are sicker, more likely to suffer from chronic disease, not only have reduced access to primary care but also specialty care. Eliminating cost-based reimbursement for swing bed services in critical access hospitals (CAHs) would place countless rural facilities at risk of closing, this would not only severely limit access of rural residents to post-acute services but place these residents at risk of losing access to care across the care continuum. The 1997 Budget Act was one of the most important legislative efforts to narrow the tremendous gap in equity that has existed and continues to exist in rural communities as it relates to access and scope of services available. Efforts to return to the prospective payment system for swing bed usage in CAHs undermines the intent of the original legislation and does not acknowledge the present gaps and disparities that continue to exist in U.S. and rural healthcare.
2. It is important to focus on Value Equation, not just cutting costs when contemplating reduction of services in rural healthcare. Rural healthcare is a very different model of healthcare delivery. The Value Equation takes into account quality, patient safety, service excellence, and cost over time. It is also vital for healthcare delivery to be equitable with adequate access to all. More than half of all post-acute services today are provided in skilled nursing facilities. Although excellent care is provided by many skilled nursing facilities (SNF), Medicare post-acute care literature as a whole reveals CAHs provide higher quality of care than the SNF care setting. CAHs that provide Medicare beneficiaries with post-acute care have demonstrated readmission rates as low as single digits compared to 20% in SNFs (Lindsay 2013). This gap results in with costs in the billions of dollars. Shifting more of these vulnerable patients from CAH swing bed programs to SNFs will not likely result in improved overall value. The Value Equation for CAH swing bed program should be defined by the following:
Value = Quality Outcomes + Patient Safety (culture) + Service Excellence/ Cost over time
3. CAHs Perform Better than Urban Hospitals and SNFs in Important Areas. CAHS actually outperform SNFs and urban hospitals in virtually every measure in culture of safety and HCAHPS surveys. High quality post-acute care requires teamwork, communication, and collaboration and there is a strong link of clinical outcomes to a positive culture of safety. There is also strong data in the literature that lower nurse staffing ratios are linked to morbidity and mortality. Shifting rural patients from CAH swing bed program (location with highest culture of safety scores and higher staffing ratio) to SNFs (location with lowest culture of safety data and lowest staffing ratios) is not likely to provide higher value. It is important to take into consideration that CAH swing bed patients are potentially sicker than SNF patients and it is more likely that these patients would not likely be accepted by SNFs but would more likely continue to reside in acute care facilities at higher costs associated with a higher specialty mix of providers. CAH swing bed programs have a number of services that are not typically available to SNF patients such as on-site physicians, respiratory therapy, laboratory, radiology, and most importantly the ability to address an acute change in condition. Ouslander reported that more than ½ of the hospital readmissions from SNFs could have prevented if adequate services and processes were in place to address an acute change in condition (Ouslander 2010).
4. Swing Beds Help CAHs Provide Long Term Viability for their Communities. The greatest strength that CAHS provide today is the breadth of primary care services to care for more patients locally across the care continuum. Medicare costs per capita are lower in rural hospitals compared to urban hospitals. One of the challenges that CAHS face today is a shrinking inpatient census. In fact the average daily census in CAHs across the country is under four. The ability to utilize swing beds for CAHS not only reduces the Medicare costs per patient bed day in these facilities, but increases revenues and margins that can help support population health, wellness, and other services. Since 2010, 48 critical access hospitals have closed. Many times CAHs are the primary economic drivers in their communities. Closures not only mean lack of access to quality care or delayed treatment but also loss of jobs.
5. Mayo Post-Acute Care Program, a new model of care focusing on the value of the CAH in the healthcare continuum. The Mayo Post-Acute Care Program was developed in an attempt to address the quality gap that exists with inadequate high quality post-acute care pathways that results in excessive acute care hospital stays, costly readmissions, bottlenecks and reduced acute care hospital flow. The Mayo program established Transitional Care programs in 11 CAHs in MN, WI, and IA and also included ventilator programs in MN and WI. The Mayo Post Acute Care Program resulted in very high quality outcomes, teamwork scores, patient satisfaction, and reduced excessive acute care hospital lengths of stay, readmissions and bottlenecks. CAH swing bed programs have become a preferred discharge destination for Mayo Clinic. The Transitional Care program not only has increased high quality post-acute care pathways but has increased the overall capabilities of the CAH care teams to care for more patients locally across the care continuum. CAHs provide greatest value through breadth of services, allowing majority of patients to be cared for locally, and can be an essential down stream flow for acute hospital complex patients in need of high quality post-acute care, a major gap in our present healthcare system.
Sources:
Lindsay, M. E. (2013). Mayo post-acute program and care continuum. Patient flow: Reducing delay in healthcare delivery. In R.W. Hall (2nd Ed.), International Series in Operations Research and
Management Science, 206: 447-472.
Ouslander, J. G., Lamb, G., Perloe, M., Givens, J. V. H., Kluge, L., Rutland, T., .Saliba, D. (2010). Potentially avoidable hospitalizations of nursing home residents: Frequency, causes, and costs. Journal of the American Geriatrics Society, 58(4):627-635.
1. Significant Equity Gaps in Rural vs Urban. Access to healthcare is a basic human right. Rural patients are sicker, more likely to suffer from chronic disease, not only have reduced access to primary care but also specialty care. Eliminating cost-based reimbursement for swing bed services in critical access hospitals (CAHs) would place countless rural facilities at risk of closing, this would not only severely limit access of rural residents to post-acute services but place these residents at risk of losing access to care across the care continuum. The 1997 Budget Act was one of the most important legislative efforts to narrow the tremendous gap in equity that has existed and continues to exist in rural communities as it relates to access and scope of services available. Efforts to return to the prospective payment system for swing bed usage in CAHs undermines the intent of the original legislation and does not acknowledge the present gaps and disparities that continue to exist in U.S. and rural healthcare.
2. It is important to focus on Value Equation, not just cutting costs when contemplating reduction of services in rural healthcare. Rural healthcare is a very different model of healthcare delivery. The Value Equation takes into account quality, patient safety, service excellence, and cost over time. It is also vital for healthcare delivery to be equitable with adequate access to all. More than half of all post-acute services today are provided in skilled nursing facilities. Although excellent care is provided by many skilled nursing facilities (SNF), Medicare post-acute care literature as a whole reveals CAHs provide higher quality of care than the SNF care setting. CAHs that provide Medicare beneficiaries with post-acute care have demonstrated readmission rates as low as single digits compared to 20% in SNFs (Lindsay 2013). This gap results in with costs in the billions of dollars. Shifting more of these vulnerable patients from CAH swing bed programs to SNFs will not likely result in improved overall value. The Value Equation for CAH swing bed program should be defined by the following:
Value = Quality Outcomes + Patient Safety (culture) + Service Excellence/ Cost over time
3. CAHs Perform Better than Urban Hospitals and SNFs in Important Areas. CAHS actually outperform SNFs and urban hospitals in virtually every measure in culture of safety and HCAHPS surveys. High quality post-acute care requires teamwork, communication, and collaboration and there is a strong link of clinical outcomes to a positive culture of safety. There is also strong data in the literature that lower nurse staffing ratios are linked to morbidity and mortality. Shifting rural patients from CAH swing bed program (location with highest culture of safety scores and higher staffing ratio) to SNFs (location with lowest culture of safety data and lowest staffing ratios) is not likely to provide higher value. It is important to take into consideration that CAH swing bed patients are potentially sicker than SNF patients and it is more likely that these patients would not likely be accepted by SNFs but would more likely continue to reside in acute care facilities at higher costs associated with a higher specialty mix of providers. CAH swing bed programs have a number of services that are not typically available to SNF patients such as on-site physicians, respiratory therapy, laboratory, radiology, and most importantly the ability to address an acute change in condition. Ouslander reported that more than ½ of the hospital readmissions from SNFs could have prevented if adequate services and processes were in place to address an acute change in condition (Ouslander 2010).
4. Swing Beds Help CAHs Provide Long Term Viability for their Communities. The greatest strength that CAHS provide today is the breadth of primary care services to care for more patients locally across the care continuum. Medicare costs per capita are lower in rural hospitals compared to urban hospitals. One of the challenges that CAHS face today is a shrinking inpatient census. In fact the average daily census in CAHs across the country is under four. The ability to utilize swing beds for CAHS not only reduces the Medicare costs per patient bed day in these facilities, but increases revenues and margins that can help support population health, wellness, and other services. Since 2010, 48 critical access hospitals have closed. Many times CAHs are the primary economic drivers in their communities. Closures not only mean lack of access to quality care or delayed treatment but also loss of jobs.
5. Mayo Post-Acute Care Program, a new model of care focusing on the value of the CAH in the healthcare continuum. The Mayo Post-Acute Care Program was developed in an attempt to address the quality gap that exists with inadequate high quality post-acute care pathways that results in excessive acute care hospital stays, costly readmissions, bottlenecks and reduced acute care hospital flow. The Mayo program established Transitional Care programs in 11 CAHs in MN, WI, and IA and also included ventilator programs in MN and WI. The Mayo Post Acute Care Program resulted in very high quality outcomes, teamwork scores, patient satisfaction, and reduced excessive acute care hospital lengths of stay, readmissions and bottlenecks. CAH swing bed programs have become a preferred discharge destination for Mayo Clinic. The Transitional Care program not only has increased high quality post-acute care pathways but has increased the overall capabilities of the CAH care teams to care for more patients locally across the care continuum. CAHs provide greatest value through breadth of services, allowing majority of patients to be cared for locally, and can be an essential down stream flow for acute hospital complex patients in need of high quality post-acute care, a major gap in our present healthcare system.
Sources:
Lindsay, M. E. (2013). Mayo post-acute program and care continuum. Patient flow: Reducing delay in healthcare delivery. In R.W. Hall (2nd Ed.), International Series in Operations Research and
Management Science, 206: 447-472.
Ouslander, J. G., Lamb, G., Perloe, M., Givens, J. V. H., Kluge, L., Rutland, T., .Saliba, D. (2010). Potentially avoidable hospitalizations of nursing home residents: Frequency, causes, and costs. Journal of the American Geriatrics Society, 58(4):627-635.
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