Rural health industry experts said they were delighted that they are starting to be included in national quality-improvement discussions and are optimistic that they can help their urban counterparts improve quality at their facilities.
Last week, the Institute of Medicine released Quality Through Collaboration: The Future of Rural Health, a report that examined what needs to be done to improve quality at rural facilities (Nov. 1, p. 4). Although many rural providers felt slighted that they had been left out of national quality-improvement initiatives up until now, the general sentiment was positive that the IOM had finally turned its attention to them.
"The report nicely captured the scope of issues that are facing rural providers," said Terry Hill, executive director of the Rural Health Resource Center, a Duluth, Minn.-based not-for-profit group under contract with HHS' Office of Rural Health Policy to provide national resources for improving rural health.
Hill and other rural industry experts are scheduled to meet this week in Arlington, Va., to discuss how to put the IOM recommendations into action. Among the topics to be discussed at the meeting are profiles of rural health quality models. Residents of rural communities make up about 20% of the U.S. population, but until now they haven't been openly included in the push for national quality improvement.
The IOM's new report takes into account some of the unique obstacles rural providers face, such as limited resources, a lack of access to capital and a geographically spread-out patient base. With those challenges in mind, the report attempts to spell out ways for rural providers to achieve the six aims for improving healthcare quality that were highlighted in the IOM's 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century.
The challenges that rural health providers face weren't singled out in plans to accomplish those goals, which say healthcare should be safe, effective, patient-centered, timely, efficient and equitable. The new report says rural providers can achieve those goals by building communitywide collaborative structures.
Many say those collaborative structures can be built in rural communities and then be applied to urban communities. It's easier to attempt such efforts in communities with smaller populations, said Marty Fattig, chief executive officer of 20-bed Nemaha County Hospital in Auburn, Neb.
"It's like trying to turn around the Titanic compared to trying to turn around a small canoe," he said.
Like the 2001 IOM report, other national quality-improvement efforts have been aimed at urban facilities. The Leapfrog Group, a patient-safety coalition, tailored three of its four quality-safety standards to the larger-volume urban hospitals before designing one that could be applied to lower-volume rural hospitals.
However, those very same lower volumes could provide an ideal setting for experiments in quality improvement that could lead to change across the country, said Alan Morgan, vice president of government affairs and policy for the National Rural Health Association.
"Rural facilities are a great test bed for developing quality initiatives," he said. The facilities are smaller and quality initiatives usually can be implemented more quickly because rural facilities have fewer organizational barriers than large urban facilities, he said.
"The great takeaway from this is in the past we tried new initiatives in the urban settings and tried to make them work in the rural settings," Morgan said. "Here's an opportunity to start with rural and move to urban."
Some expressed concern that the new IOM report calls on existing agencies, such as the Agency for Healthcare Research and Quality-which may not have enough expertise in challenges specific to rural healthcare-to handle the rural quality efforts.
Fattig said he would rather see a separate agency set up to handle rural quality efforts because many existing groups won't likely make the rural providers a priority. Fattig, who said he hadn't seen the IOM report yet, added that it would be good if there was more of a forum for rural hospital administrators to weigh in on the quality issues. Of the 12-member IOM committee that helped craft the report, only one member-Sandral Hullett, CEO of 141-bed Cooper Green Hospital, Birmingham, Ala., was a current hospital executive.
Tim Size, another committee member and executive director of the Rural Wisconsin Health Cooperative, a coalition of 29 rural hospitals in the state, said the report captured the breadth of rural health problems. The report makes several references to workforce shortages at rural facilities and their lack of finances, which limit them from spending on quality-related technology improvements.
Many of the IOM recommendations call for the allocation of federal funds to help rural facilities. One suggests Congress should provide resources to help rural health centers develop electronic medical records. Another calls on HHS to provide the resources in five rural areas to start demonstration projects, which would be aimed at integrating the communities for purposes of delivering healthcare services.
Size said one example of this type of integration is already being tested in Marshfield, Wis. In 2001 the Marshfield Clinic, a physician network, started a program called Healthy Lifestyles, which was intended to address the obesity epidemic by encouraging physical activity and healthy dietary choices. Initiatives by area doctors helped increase the number of walking and bike trails in the community, persuaded schools to serve healthier food, developed an activity guide for Marshfield and hosted community health conferences. The clinic's research shows that if such programs are adopted they could lower a community's diabetes rate.
"This is a way for rural health to give back to the rest of the country," Size said.