Network Spotlight: North Dakota Critical Access Hospital Quality Network

August 2017
North Dakota Critical Access Hospital Quality Network

Network Name North Dakota Critical Access Hospital (CAH) Quality Network
Location Grand Forks, ND
Key Contacts Jody Ward, MS, RN, APHN, Senior Project Coordinator, and Lynette Dickson, MS, RD, LRD, Associate Director, Center for Rural Health, University of North Dakota, School of Medicine and Health Sciences
Mission The mission of the Network is to support ongoing performance improvement of North Dakota's critical access hospitals (CAHs).

ND CAH Quality Network will have an actively engaged Network Executive Committee (8 ND CAHs) who are committed to responding to stated needs, desires and interests of the Network. The Network will serve as a platform for all ND CAHs and provide ongoing performance improvement support.

Lynette Dickson and Jody Ward of the University of North Dakota Center for Rural Health were interviewed by the Network TA team to share information on the North Dakota CAH Quality Network’s characteristics, key learnings, accomplishments, and challenges.

Q: In a nutshell, how would you describe your network?

A: The CAH Quality Network is a common platform for our critical access hospitals in the state to share best practices and resources that are related to quality of care for patients in North Dakota. Not every state has a CAH quality network, and those that do are not always structured the same. Some charge a membership fee to be part of their network, and others, like us, are supported through Flex [Medicare Rural Hospital Flexibility] and other grant dollars.

Our network was established in 2007 through voluntary work of all the critical access hospitals across North Dakota. Through their efforts, a stakeholder committee was established and a network director was hired. There are 36 CAHs in the state, and all 36 voluntarily are members of the network. Members agree to be transparent with one another, and be willing to share and mentor one another as a group.

However, the work we do reaches beyond just a hospital and health care system focus. It's a community-wide effort, looking at social determinants of health, how they impact the CAH network, and what role the CAH network members can play.

Q: What benefits do network members receive?

A: They have access to a platform where they can share best practices, tools, and resources related to quality improvement (QI). We host a virtual library of information and resources shared, and we are able to keep track of what's being shared and make sure documents current.

I think one of the most valued technical assistance we offer is around the Medicare/Medicaid Conditions of Participation (CoPs). When we first started, there wasn't a platform for hospitals to ask one another for support around their survey deficiencies. So we began hosting quarterly survey deficiency calls, or CoP calls. We highlight critical access hospitals that have recently been surveyed, ask them to share their experience about our state-wide surveys, asking CAHs to share what occurred during the survey process, what deficiencies they received, and what were their plans of correction.

Over the years, we’ve seen our hospitals receive fewer and fewer deficiencies. They are sharing their experiences, and it prepares other hospitals to put the correct processes in place. We also developed a CoP checklist formatted with survey tags, which we house on our website and update yearly. Other states have used our model for their own hospitals.

Q: What challenges do you face working in rural health care?

A: We've done a significant number of community health needs assessments for the critical access hospitals that are part of the network. The top needs or concerns raised during that process are behavioral health and workforce shortages. Bed availability is huge for us for behavioral health and/or substance use issues. If you have a patient with a behavioral health crisis, you may only have one or two staff on, in those critical access hospitals, and are more than likely consumed with assisting the patient. Then you may not have enough staff to start calling around and figuring out where there are empty beds available. Often our state is full, and they might have to go across state lines. It just takes a lot of time for placement.

In most of our rural communities, you do not have the expertise locally to appropriately assess that patient to determine whether they should admit them and provide care or whether they need to transport. Then, if a patient needs to be transported, how do you transport, who does the transport, and where do you transport them to? Depending upon the situation, it's sometimes a sheriff doing the transport, or sometimes it's volunteer EMS [emergency medical services]. We have communities where the hospital administrators are also volunteer EMS staff. They may have to leave in the evening and drive four hours one way and four hours another way to transport a patient to a larger town.

Q: On the other side of things, what are the advantages of working in your rural area?

A: Because we are rural and because we're small, we’ve been able to build strong relationships around the state. We know the staff of our hospitals personally, and we’re able to move initiatives forward in spite of the challenges they have, because we’ve built those trust relationships. They trust that what we bring to them is solid and beneficial, and we'll support them with technical assistance and not just dump a project on them. We get out of our offices, we put a lot of miles on our cars, and we go to their rural facilities. They may participate on the quarterly calls, but sometimes it just takes someone to be there face-to-face that makes you put down whatever else you're working on and ask those more specific questions. In a rural state like ours, where our entire population is less than 700,000, we know all the players, and they know us and trust us to have their best interests at heart. That's an incredible benefit.

Q: Tell me about a barrier your members have faced. How has the network helped to address it?

A: Providing our hospitals with support around the CMS Conditions of Participation has been our number-one success, but when we first started the process of collaborating, there was significant mistrust between the CAHs and the Department of Health. The surveyors from the Department of Health were being seen by the hospitals as, “We’re going to catch you doing something wrong.” Those barriers were up and on guard, so to speak. Over the years, they’ve shared their experiences and improved their processes. Now the Department of Health is a frequent flyer on the agendas of our region meetings and our annual meeting, and annually the Department of Health does a “top ten” survey deficiency for North Dakota. The walls have come down. We credit the network for that whole communication piece, bringing the two entities together and building stronger trust. It’s led to a win-win, really, for the Department of Health and the critical access hospitals, and ultimately a win for staff who work in those facilities and ultimately the patients.

Q: What has been a surprising insight over the course of your network’s development?

A: When the network first started, there was often one person at a critical access hospital who was their “QI person.” Now, more often, there are teams of people. We've learned to emphasize that the numbers don't belong to one department; it really is a team of people, a team approach. It’s been very, very fulfilling to see more ownership of quality improvement and patient safety.

It's also been a pleasant surprise to see how the network continues to grow and be a benefit to our rural hospitals and communities. We've become more than just a voice for our own sake. We’ve become involved in a lot of different projects as a result of our relationships, from pharmacy to opioid dependency prevention, treatment and recovery, to pain management to palliative care, besides the required quality initiatives. Communication in the Center for Rural Health is critically important. We try very hard to promote our work with stakeholders around the state, from state agencies to private entities, so they ask us, "Would you like to be engaged in this?” We can't all be in one place, so we certainly work as a team. That is what strengthens the outcomes of the network. We're practicing what we preach.

Q: Based on your experiences as network leaders, what advice would you give to a developing rural health network?

A: Relationships are huge. Know who your critical access hospital administrators and staff are, and take time up front to visit every single one, which goes a long way in building a trust relationship. Figure out who your partners are in your state, and bring them to the table. It's important to reach out and establish relationships long before you're asking them to do something. That way, when you do have an ask, they're hopefully more open to conversation.

Make sure you tell your story: what you have accomplished, what you're doing, who you are. Don't assume folks know who you are. We've been around ten years, and as much exposure as we have, and as much as we've been doing, we still find folks who think they know what the network is but really don't. You can't stop telling the story. Your work is never done.