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Minnesota Department of Health - Office of Rural Health and Primary Care

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Program Area: Support for Quality Improvement

Stratis Health and the Minnesota Hospital Association are leading a collaborative effort with the Minnesota Office of Rural Health and Primary Care (ORHPC), along with several successful mentor hospitals, to guide a cohort of 21 critical access hospitals (CAHs) through a journey to a ‘Culture of Excellence’ that drives performance across all quality and patient safety topics. The critical role of leadership in building a culture underlies the expectation that participating hospital Chief Executive Officers (CEOs) actively participate in the Culture of Excellence project. The Culture of Excellence program is therefore led in each hospital by the CEO, a Culture of Excellence champion, and an interdisciplinary Culture of Excellence team.

The Culture of Excellence program walks the participating hospitals through a local grassroots application of existing quality and patient safety resources and concepts such as customer experience, patient and family engagement, leadership support, board engagement, teamwork and communication, justice and accountability. The notion of hardwiring to sustain gains is built into the program to create lasting change. Key measures of success include Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results and Agency for Healthcare Research and Quality (AHRQ) Culture of Patient Safety surveys, and quality and patient measures specific to the local hospital.

CAHs within this cohort conduct the AHRQ Culture of Patient Safety survey. Participants then examine survey results to identify areas to focus on and form workgroups to move focus areas forward. Participants have shared planned focus areas on monthly calls and will share learnings from activities they have tried.

Please share a success story about reporting quality data or using quality data to help CAHs in your state improve patient care.

The Minnesota Flex Program has contracted with Stratis Health to provide CAH quality reporting support in several ways:

  • Two-day abstraction training sessions which include information on how to abstract and report the Centers for Medicare & Medicaid Services (CMS) inpatient and outpatient and Emergency Department Transfer Communication (EDTC) measures
  • One hour sessions on abstraction and reporting are held during Safer Care Regional meetings, focusing on issues with abstracting the Medicare Beneficiary Quality Improvement Project (MBQIP) measures and providing general question and answer time for participants 
  • Topical webinars are also held

In addition, the Quality Reporting Specialist at Stratis Health is available to take specific questions from CAHs as needed. Minnesota CAHs appreciate her availability and frequently consult with her. All 78 Minnesota CAHs report quality measures, in part due to this intensive help from Stratis Health, and in part due to the fact that by state law, they have been required to report some of the measures.

With Flex funding, Stratis Health and the Minnesota Hospital Association have also provided one-to-one, in-person education and support to nearly every CAH in Minnesota (a handful declined the offer while the great majority eagerly participated). Two quality consultants, one from each organization, made visits to all the participating CAHs and met with a team of people at each hospital, including quality directors, abstractors, nursing directors and Chief Executive Officers (CEOs).

Program Area: Support for Financial and Operational Improvement

The Minnesota Flex Program continues to distribute CAH Financial Indicator Reports (CAHFIR) along with supplemental and more current financial data to help CAHs target areas that represent challenges. Minnesota Flex has identified lower performing hospitals that will continue to receive targeted support as needed, after establishing communications with individual CAHs to identify how the state Flex Program can best support their efforts to build sustainable operations.

New this year is the development of customized summary reports to help CAHs better understand their financial and operational strengths and weaknesses. Financial and operational trends will be evaluated and metrics will be developed to help analyze the larger macro CAH trends versus measure-level trends. Based on the 2016 CAH hospital listing of financially distressed hospitals, the Flex staff and the Minnesota Hospital Association are collaborating to provide commentary reports summarizing multiple data sources related to market, staffing, finances and operations.

Program Area: Support for Population Health Management and Emergency Medical Services Integration

Greater Northwest Emergency Medical Services (GNWEMS) and Stratis Health are leading a collaborative arrangement to facilitate the development of an emergency medical services (EMS) feedback form. The project’s objective is to establish a communication loop from pre-hospital patient interaction, to the local CAH emergency department, to the tertiary care center, back to the local emergency department (ED) and finally back to the initial pre-hospital EMS agency. This pilot project is focusing on trauma and stroke patients and will be expanded to include ST-elevation myocardial infarction (STEMI) and Sudden Cardiac Arrest. Feedback forms from Altru Health System in North Dakota (the tertiary center participating in the project) are serving as the basis for feedback form development specific to Northwestern Minnesota. Two CAHs and three rural EMS agencies are participating in the pilot. Due to limited numbers of cases, it has been difficult to evaluate the project, so Minnesota Flex is expanding into Southwestern Minnesota where more CAHs, tertiary hospitals and EMS agencies will be added to the cohort.

The Minnesota Flex Program is working with a subcontractor to facilitate an Integrative Behavioral Health (IBH) project with cohorts of CAHs from around the state. Participating CAHs identify a behavioral health population to target in their own communities, as well as community partners with which to collaborate. Two cohorts of five CAHs each have been selected to participate by use of an application process that identified those CAHs most ready to integrate mental and behavioral health services into their community based on variables such as leadership, collaborations, identification of a target population, workforce capacity, need, goals and work plan. The interventions with each cohort include one year of assistance with business and clinical management processes for integrating mental and behavioral health services into hospital and primary care settings for the purpose of providing enhanced patient-centered care. CAHs that completed the process in Year 1 share best practices and tools and offer peer support for the CAHs that began in Year 2 and those that will begin in Year 3.

Technical assistance provided to the cohorts includes a variety of strategies including webinars on business and clinical management from subject matter experts, tools, best practices, lessons learned, resources, policy and emerging trends, etc., followed by facilitated discussion with the subcontractor. Conference calls are used to offer feedback on activities as well as guidance on topics such as strategy implementation, leadership and sustainability, strategic planning, measurement, operations and processes and outcomes. Evaluation is underway, including the administration of a Recommendation Adoption Progress (RAP) report, an evaluation tool that captures the degree to which activities have been implemented and services used by program participants.

Progress, successes and challenges to date have been shared through the dissemination of findings at the Minnesota Rural Health Conference, the Flex Advisory Committee, the Rural Health Advisory Committee, and state and national conferences.

Please provide information about Collaboration/Shared Services

The Minnesota Flex Program encourages cohorts of hospitals to work together in projects such as those highlighted above. However, because most CAHs are parts of hospital systems or have historically established, well-run networks, Minnesota Flex participation in network development or maintenance is not a high priority.

Please provide information about any efforts to assist CAHs/communities and partner organizations in the transition to value-based care.

With the assistance the MBQIP contractor, Stratis Health, the Minnesota Flex Program has succeeded in getting all CAHs to report quality measures and identify quality improvement initiatives within their facilities.

Please provide information about network activities in your state to support Flex Program activities.

The Minnesota Flex Program encourages cohorts of hospitals to work together in projects such as those highlighted above. However, because most CAHs are parts of hospital systems or have historically established, well-run networks, Minnesota Flex participation in network development or maintenance is not a high priority.

Please describe how your state Flex Program has enhanced its use of data in the past year.

As part of the Minnesota Flex Program’s contract, Stratis Health works with hospitals on improving how they abstract their data. Stratis Health also provides individualized technical assistance to each hospital for interpreting quality data and applying the knowledge for quality improvement activities.

The Minnesota Flex Program's financial and operational improvement work utilizes the Critical Access Hospital Measurement and Performance Assessment System (CAHMPAS), as well as other financial data supplied through the Minnesota Hospital Association. Along with the quality program contractors, Minnesota Flex provides individualized technical assistance to hospitals, helping them interpret and understand data reports.

Please share any resources or tools that you found useful in your state Flex Program's work this past year that you would recommend to your Flex Program colleagues.

Resources most valuable in Minnesota Flex work have been the organizations in Minnesota that also work with CAHs, EMS and other rural health care entities. The relationships with Stratis Health, the Minnesota Hospital Association, the EMS Regulatory Board Regional Programs and the Minnesota Ambulance Association have proven invaluable. Before the current Flex grant cycle concludes, the Minnesota Flex Program will have a toolkit for integrative behavioral health; the work of developing that toolkit is currently under way.

Program Statistics

Type of Organization State Government
Staffing 2.1 FTEs
Number of CAHs 78
Website URL Organization Website

Flex Program Staff

Zora Radosevich
Flex Director, Minnesota
(651) 201-3859

 Flex Director since April 2018

Tim Held
Rural Health System Development Unit Supervisor/Deputy Director, Minnesota
(651) 201-3868

Specialty Areas / Background

Trauma system coordination

Craig Baarson
Reimbursement Fiscal Analyst, Minnesota
(651) 201-3840

Specialty Areas / Background

Reimbursement and finance

Cindy LaMere
Office Administrative Assistant, Minnesota
(651) 201-3852

Specialty Areas / Background

  • Flex program support
  • Grants management support

This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB1RH24206, Information Services to Rural Hospital Flexibility Program Grantees, $1,100,000 (0% financed with nongovernmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.