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Rural Hospital Flexibility ProgramSmall rural hospitals are an integral piece of the health care system that serves Vermonters. The Vermont Rural Hospital Flexibility Program's (RHFP) purpose is to ensure the best available healthcare to Vermonters in rural areas, by supporting the availability of high quality, coordinated health services and to maintain access to acute and emergency care. Eight of Vermont’s fourteen hospitals are designated as Critical Access Hospitals. Four of the remaining six hospitals are in areas of the state designated as rural by the federal government. The Rural Hospital Flexibility Program was established by the Balanced Budget Act in 1997. The program goal is to improve access to essential health care services in rural areas by:
1. developing state rural health plans
2. designating Critical Access Hospitals
3. developing rural health networks
4. improving emergency medical services (EMS)
5. enhancing quality of care[1]
Rural Hospital Flexibility Program Outline
- What is the Rural Hospital Flexibility Program?
- What is the History of VPQ’s involvement with the Program?
- Current Work
- Next Steps
What is the Rural Hospital Flexibility Program?
The Rural Hospital Flexibility (Flex) Program is a federal initiative to provide funding for improving the quality of healthcare in rural communities. It seeks to do this by:
- Allowing small hospitals the flexibility to reconfigure operations and be licensed as Critical Access Hospital (CAHs);
- Offering cost-based reimbursement for Medicare acute inpatient and outpatient services;
- Encouraging the development of rural-centric health networks; and
- Offering grants to states to help strengthen the rural health care infrastructure.
The US Department of Health and Human Resources states that the “grants are awarded to States for: - Development and implementation of Rural Health Plans with broad collaboration;
- Stabilizing rural hospitals by helping them consider, plan for, and obtain designation as "Critical Access Hospitals" (CAH);
- Supporting CAHs, other providers and communities as they develop networks of care;
- Helping improve and integrate emergency medical services; and
- Improving the quality of care in rural communities.”
This funding has helped thousands of hospitals across the country become Critical Access Hospitals.[2]
What is the History of VPQ’s involvement with the Program?
Twelve of Vermont’s hospitals are situated in areas of the state designated as rural; eight of these hospitals are designated as CAH. VPQ has been part of The Rural Hospital Flexibility (Flex) Program since the fall of 2000 when a part-time position was created to assist in the work of improving health care quality in the rural health networks that surround these hospitals. VPQ was asked to do this by inventorying current QI measures, developing new measures of quality health care and patient safety, creating a committee of expert representatives from participating communities to advise VPQ and the Vermont Department of Health (VDH), reviewing peer review issues, and exploring internet technologies.
In the fall of 2007, VPQ staff, with the support of the VDH Office of Rural Health and Primary Care, began meeting to discuss the creation of the position of Rural Health Quality Improvement Specialist. The primary responsibility of this staff member would be to support and assist the CAHs in preparing for quality surveys conducted by the Vermont Division of Licensing and Protection. Charlie White, Director of Rural Health Quality in New Hampshire, and several Dartmouth Hitchcock Medical Center individuals formerly involved with conducting the survey preparation for Alliance CAHs served as invaluable resources. Each CAH was contacted to determine their quality improvement needs and interest in receiving assistance with survey preparation. Available survey tools were reviewed and evaluated. The final tools selected were developed by the New Hampshire Program.
Current Work
VPQ staff provides the administrative support for the Flex Advisory Committee, a work group including state representatives of community services and QI representatives from participating hospitals. This committee meets quarterly and provides a forum for members of the rural health networks to evaluate the efficacy of the review process, to provide collaboration and coordination of quality improvement work, and to look at how this work is improving care quality and patient safety.
Beginning in 2009, a subgroup of the Flex Advisory Committee was formed to assist in the process of distributing grant funds to the CAHs. The Rural Quality Council (RQC) was charged with creating an annual Request for Proposals (RFP), evaluating the submitted proposals, distributing grant funds, and reporting back to the larger Flex Committee. The RQC began meeting in February and checks were distributed during the first week of April. Eleven applications were received, five hospitals received funding. Funding was provided for implementation of the Bainbridge Calendar[3], reduction of catheter-associated urinary tract infections, reduction of healthcare associated infections attributed to MRSA/MDROs, prevention of shoulder dystocia, and training and use of the Team STEPPS Framework.[4] Grant recipients will report back to VPQ at the end of August and have been asked to share the work they have done with the larger Flex Committee in the fall.
The Rural Health Quality Improvement Specialist has been working to assist CAHs with their required annual quality reviews. Through these reviews common needs have been identified and additional tools introduced for improving and tracking their ongoing quality improvement work. Quarterly meetings of the CAH Quality Managers are facilitated by the Rural Health QI Specialist. In addition, several hospitals have requested assistance with observations of hand hygiene compliance. This was a follow-up to work done by VPQ in 2007 using the Institute for Healthcare Improvement (IHI) Hand Hygiene bundle[5]. The Rural Health QI Specialist regularly assists hospitals by answering questions about interpreting new and old CMS regulations and calling upon the Vermont Division of Licensing and Protection to assure appropriate responses.
A Learning Forum offered in October of 2008 introduced the concept of the Bainbridge Quality Calendar to participants from hospitals in Vermont and New Hampshire. This simple tool can be used in specialty departments throughout the CAH to demonstrate compliance to the Conditions of Participation (CoP) and other regulatory routines. Work has begun with training and implementation of this tool at Springfield Hospital.
Finally, the VPQ staff continues to work to support networking and collaboration among the CAHs at the level of Quality Improvement work. Several meetings were held in conjunction with the Vermont Quality Improvement Collaborative, to introduce Team STEPPS methodology as a way of working to improve communication among staff and to link with improvement projects. Future efforts towards promotion of collaboration among CAHs will be conducted.
Next Steps
In September, VPQ will facilitate the next meeting of the Flex Advisory Committee with a report out on the work done by grant recipients. Based on the information from this meeting, and with input from the RQC, work will begin on the RFP for the 2009-2010 grant cycle. The Rural Health Quality Improvement Specialist will continue working with the CAHs supporting their CoP work and responding to needs as presented.
A logical next step for promoting quality improvement may also involve a Quality Improvement Collaborative among rural hospitals.
[1] http://healthvermont.gov/local/rural/programs.aspx [2] http://ruralhealth.hrsa.gov/funding/flex.htm [4] http://teamstepps.ahrq.gov/
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