Tallahatchie General Hospital: 5-Star HCAHPs Facility

August 2018
National Rural Health Resource Center (The Center)

Tallahatchie General Hospital (TGH) is an 18-bed, not-for-profit Critical Access Hospital (CAH) and 98-bed nursing facility providing acute care, emergency medicine, rehabilitation therapies, imaging and related outpatient ancillary services to the residents of Charleston, Mississippi and surrounding communities. TGH also operates:

  • Three Rural Health Clinics (RHC) in Charleston, Holcomb and Tutwiler
  • Various community programs including a wellness center, wound care services and outpatient behavioral health

As Jim Blackwood, administrator, states on the hospital website, “At TGH, we pride ourselves on providing two very basic things -- quality in healthcare and excellence in customer service. Quality outcomes and customer service are our primary concerns.”

Carla Brock Wilber, Senior Consultant, with Stroudwater Associates, worked with TGH in 2017, through the Small Rural Hospital Transition (SRHT) project, on a Quality of Care and Transition of Care Project. Center staff recently spoke with Jim Blackwood, CEO; Lisa Smiley, Director of Compliance and DNV Coordinator; Cathy Williams, Director of Quality Assurance and Infection Control and Penny Branch, DON, about the implementation of the consultant recommendations.

Q: What are some of the recommendations that you’ve implemented and what are your next steps?

A: TGH is now a 5-star HCAHPS facility! Within the first six months, the team had already completed 7 out of 10 action items. TGH made deliberate decisions to have all department heads as part of quality and not make it just one person or one department. Blackwood states “(we are) really making quality a culture and not just a department. We want to be a hospital that is survey ready at all times…it’s a mindset.” TGH administers HCAHPs internally and they let patients know they will be getting a survey (and it’s not a bill) and ask them to “help us make ourselves better.” Sample size is a challenge, but they have enough to be reported on Hospital Compare. During the next round, they plan to do written and telephone survey to have a better product. They recently revisited the process of displaying their HCAHPS data in hallways. In addition to reporting metrics at BOD and department head meetings, they hold “department head +1” meetings which also includes an up and coming leader.

TGH focuses on better communication with patients and preparation for discharge. Whiteboards continue to be consistent patient communication tools. Bedside meetings with home health are scheduled during the patient stay to impact that smooth transition. Patient care guides were implemented and have been well received. TGH utilizes the LACE tool to help identify patients at high risk for readmission. Discharge phone calls are made and TGH plans to refocus on this to improve consistency.

TGH is focusing on population health and reaching out to potential patients with diabetes to provide chronic care management and are exploring opportunities to address hypertension and cardiac issues.  They are currently enrolling in a Mississippi statewide ACO and are excited about the synergy being created.

The DON has historically completed leader rounds with patients as close to admission as possible. There are plans to include other leaders in the rotation.

TGH leadership knows that improvement in the hospital is tied to staff engagement. A recent staff satisfaction survey discovered that staff wanted more information from upper management to floor personnel and they want a venue for their voices to be heard. Once a month, brown bag lunches are held for staff and department heads to identify issues and discuss solutions.

Q: What has been the impact of this project so far on TGH?

A: Non-measurable impact includes increased pride for being a 5-star hospital, more awareness of the strengths of the hospital and patient experience, heightened awareness of trends and dips in scores and the “why.”

Q: Lastly, how do you believe this project has helped you move forward in the newly emerging system of health care delivery and payment?

A: “While perhaps not a first adopter, TGH is more prepared and ready for our future environment.”