on Rural Health and Human Services
U.S. Department of Health and Human Services
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The National Advisory Committee on Rural Health and Human Services U.S. Department of Health and Human Services |
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Health
Care Quality:
A Report
to the Secretary, The National Advisory April 2003 Acknowledgements This report was
prepared with the assistance of many people. Their time, feedback and
suggestions were critical in helping the Committee meet its deadline and
charge. We wish to acknowledge
the hard work of the Committee members in identifying this topic, developing
an agenda and continuously reviewing and editing the multiple drafts that
led to the final report. In particular we want to thank Mary Wakefied
for chairing the Report Subcommittee and providing invaluable input. We
also wish to thank Keith Mueller for excellent feedback and timely suggestions.
We wish to acknowledge former members, H.D. Cannington, Shelly Crow, Alison
Hughes, John Martin and Tom Nesbitt, for their suggestions, as they participated
in the formation of the report during the early stages. We also wish to
thank the current chair, Governor David Beasley, for keeping the Committee
on track during this process. We also wish
to acknowledge the help of Tim Size of the Rural Wisconsin Health Cooperative,
Sylvia Gaudette Whitlock of the American Health Quality Association, Ira
Moscovice of the Minnesota Rural Health Research Center, Terry Hill of
the Rural Health Resources Center in Duluth, Minnesota, Amy Chanlongbutra,
a HRSA Scholar, and Marcia Brand and Forrest Calico of the Office of Rural
Health Policy. The report would not have been possible without their contributions.
Sincerely, Staff: About
the Committee The National
Advisory Committee The Committee was chartered
in 1987 to advise the Secretary of Health and Human Services on ways to
address health care problems in rural America. Chaired by former South
Carolina Governor David Beasley, the committee’s private and public-sector
members reflect wide-ranging, first-hand experience with rural issues—in
medicine, nursing, administration, finance, law, research, business, and
public health.
For the first 15 years of
its existence, the Committee focused only on health issues. In 2002, the
Secretary expanded the focus of the Committee to include human service
issues as an outgrowth of the Secretary’s Rural Task Force. The Task
Force spent a year examining how the U.S. Department of Health and Human
Services could better serve rural communities, and one of the key findings
of the resulting report is that health and human services are closely
linked. In recognition of this link, the Secretary added five new members,
all experts in the areas of delivering human services in rural communities,
to the re-named Committee (NACRHHS). These Committee members will be appointed
by June of 2003.
Each year, the Committee,
which meets three times a year, submits a report on rural issues to the
Secretary. In addition to the report, the Committee may also produce white
papers on select policy issues. This report on health care quality is
the result of the work of the Committee during the past 12 months. Table
of Contents HEALTH
CARE QUALITY: THE RURAL CONTEXT Health quality
and patient safety has been of interest to the National Advisory Committee
on Rural Health and Human Services throughout its tenure. The Committee
has issued a series of recommendations on this topic since 1988. Most
recently, the Committee published a report on Medicare reform in 2001,
which included a chapter on quality as it relates to Medicare. The issue
of health care quality, though, has implications beyond Medicare. Because
of that, the Committee has decided to revisit this issue in greater detail
and devote its 2003 annual report to this topic. This report seeks
to examine the current state of the debate over health care quality and
patient safety and how it affects rural communities. The focus on improving
quality and reducing medical errors has been gaining momentum for the
past few years thanks to the release of the Institute of Medicine’s
1999 Report, To Err is Human, and two subsequent reports focusing on health
quality. These reports, as well as efforts by the National Health Quality
Forum and several influential business groups, have put the issue of quality
near the top of the nation’s health care agenda. This has been a
welcome development, but while the Institute of Medicine (IOM) reports
have spurred an important dialogue on this issue, there has been little
attention to the rural implications. The Committee
believes that there are important distinctions between the rural health
care delivery system and its urban and suburban counterparts, and that
those distinctions are important to understand within the larger debate.
The difference is driven primarily by scale and scope. The urban setting
features a high volume of patients with an emphasis on inpatient care
and technology-intensive services. The rural setting focuses more on ambulatory
care and features a much lower patient volume. This is not to say that
rural residents should expect or receive a lower quality of care. But,
as the health care system takes new action to improve patient safety and
to ensure the quality of health care services, it is important that any
interventions take into account the unique circumstances of rural health
care providers, patients and their communities. There are examples where
this has not occurred. One is in the area of accreditation. Past efforts
in this area have not recognized the simple fact that rural facilities
are less likely to take part in accreditation activities such as the Joint
Commission on the Accreditation of Health Care Organizations (JCAHO) because
of a perception that the process is not always relevant to them. There
are many other examples as well. While health
service researchers have brought a great deal of energy to the larger
global issues of quality and patient safety, they have given only limited
attention to the rural context. The Medicare Payment Advisory Commission
(MedPAC) and a small number of rural health services researchers have
tried to shed light on the rural issues in recent years, but more work
needs to be done. The Federal government
continues to play a strong role in any activity relating to health quality
and patient safety. The Centers for Medicare and Medicaid Services (CMS),
the Agency for Health Research and Quality (AHRQ) and the Health Resources
and Services Administration (HRSA) all administer programs that have a
direct role in ensuring quality of care and patient safety. The Medicare
conditions of participation and other regulatory requirements are among
the more visible policy levers for ensuring patient safety and promoting
health quality. This is particularly true for rural communities, which
are more dependent on Medicare and Medicaid revenue than their urban counterparts.
CMS’ Quality Improvement Organizations (QIOs) are charged with helping
Medicare providers across the country improve the quality of care delivered
to beneficiaries. AHRQ’s ongoing research and demonstration work
in health care quality is relevant for the entire health care system.
HRSA, through a number of its grant programs for community health centers
and rural hospitals, provides needed resources at the community level
for specific quality activities. Although all
of these programs play a key role, there is also considerably more they
could do to meet the needs of rural communities. The Committee provides
a series of recommendations to begin that process. The Committee also
offers a framework for improving quality in our health care system in
a way that includes rural providers and patients in a fair and equitable
manner. The Committee believes that rural communities may provide the
best starting point for identifying and testing new strategies for improving
health care quality and protecting patient safety. The Committee hopes
this report will support a renewed focus on quality improvement activities
within the Department that engages rural communities and providers, and
that also ensures that these efforts permeate throughout all of the relevant
parts of the health care system. Improving the
quality of health care delivered across America is neither a rural or
urban issue but rather a concern that touches all providers and consumers
of health care services. The country stands at a crossroad on health quality
issues. The findings of the IOM’s 1999 report To Err is Human and
its follow-up 2001 report, Crossing the Quality Chasm: A New Health Care
System for the 21st Century, are a call to action for the entire health
care system. In 2002, IOM released a third report, Leadership by Example,
which challenges the Federal government to take necessary legislative
and administrative measures to serve a leadership role for the nation
in improving quality and safety. As reported in the IOM
report, Crossing the Quality Chasm, there are six aims to strive
for in order to improve the quality of care. These aims are neither
urban nor rural, but universal, and provide orientation for where
rural communities need to focus. However, working to achieve these
goals may require different approaches, considerations, etc. They
are the following: IOM’s reports
have put a new spotlight on the issue of quality and been part of a larger
awakening across the spectrum of stakeholders. The Leapfrog Group, a consortium
of more than a hundred Fortune 500 companies, other large private and
public healthcare purchasers and some hospital members, has also gotten
involved in the emerging health care quality debate. This business group
has identified three initial patient safety standards for urban hospitals
as the focus for health care provider performance and hospital utilization
by beneficiaries of Leapfrog members. They would purchase care from facilities
utilizing the following criteria:
It is important
to recognize, however, that there is concern about requiring an intensivist
at every facility. Other alternatives such as having a regional intensivist
who can monitor patients in the ICU via telehealth technology may be appropriate.
Likewise, a regional approach would be reasonable for computerized physician
order entry. The challenge lies in understanding what these kinds of quality
standards mean for rural communities and whether they are relevant. While
the Leapfrog Group initially focused on urban measures, the Group has
recently devoted attention to consideration of patient safety standards
for rural hospitals, realizing that their focus needed to be system-wide. An
E-ICU: A New Quality Initiative? New and emerging technologies
are often cited as a way to improve quality of care and a Virginia-based
health care system believes it has harnessed technology to reduce
staff demands and improve quality of care in its intensive care
units. For years, Sentara Healthcare
has been dealing with a shortage of both critical care physicians
and nurses. As a result, some hospitals have been forced to staff
ICUs with less experienced nurses. Research has shown that ICUs
staffed by critical care specialists have lower mortality rates
than those staffed by other providers. Because an estimated 500,000
out of the four million people admitted to ICUs die, proponents
are claiming that approximately 54,000 can be saved if the ICUs
are staffed by critical care physicians.1 Sentara created an electronic
ICU (eICU) where specialist physicians and nurses monitor and help
treat critically ill patients in widely scattered hospitals. Each
patient in the eICU has a computer screen which displays vital signs
(heart and respiratory rates, BP and temperature), oxygenation,
lab tests, etc. When the measures or lab tests deviate from the
patient’s baseline, it triggers a visual alarm. This allows
the specialists to be able to respond to the patient in a timely
manner. In addition to being able to monitor patients from offsite,
specialists also have access to a database of clinical guidelines
to help guide treatment. The eICU is only closed from 7 am –
12 pm (when the specialists are making rounds). One eICU affiliated
with Norfolk General showed a decrease in mortality rates by 28%
and the other eICU showed a decrease of 21% during the six month
period after connecting to the eICU. When comparing to the total
number of patients admitted to all four units the previous year,
statistics suggest 90 patients survived who would have previously
died. The National
Quality Forum (NQF) has also been a national leader on health care quality
issues. NQF has brought together a diverse membership that includes consumers,
public and private purchasers, employers, health care professionals, provider
organizations, health plans, accrediting bodies and labor unions. The
members of NQF are working to promote a common approach to measuring health
care quality and fostering system-wide capacity for quality improvement. The Federal Government,
through its administration of health programs such as Medicare and Medicaid
as well as the Department of Veteran Affairs and a host of other programs
has a definite stake in ensuring quality across the health care system.
And, as the IOM’s most recent report notes, the Federal Government,
by virtue of its size and breadth, may be in the most advantageous position
for driving that change.2 Together, the
various public and private sectors are focusing on how to improve health
quality in a more coordinated and sustainable fashion. In so doing, they
are responding to a rapidly changing health care environment. The introduction
of new and more affordable technology, the rapidly expanding use of pharmaceutical
drugs to treat an ever-growing number of diseases and conditions, along
with the great potential of using modern technology to share information
and improve decision making, hold great potential for improving the way
we treat illness.3 The promise of
this technology is as true for the small hospitals and other providers
in the country’s rural areas as it is for the large tertiary care
centers, teaching hospitals and specialty care providers in urban areas.
There is no compromise related to geography in ensuring the delivery of
high quality care. The challenge is in answering the charge from IOM and
others by responding to and addressing the very different challenges faced
by health care providers. This must take into account varying financial,
technological and human resources, and different mixes and volumes of
patients. The current health care system and its ability to ensure high
quality health care delivery is quite variable across rural communities,
and a richer understanding of that variability is needed. Training
and Technology Telehealth and other
health care technology-focused applications continue to gain greater
acceptance and use by health care practitioners, particularly as
a way to improve quality of care. Most health care professional
training programs, by and large, have failed to incorporate this
into training curriculum in any meaningful way. That has forced
practitioners to learn and adapt health care technology on the job,
which greatly slows the diffusion of skills needed to take advantage
of new technologies and the potential they hold for improving quality
of care. This variability,
if continued, has the potential for putting rural America at a disadvantage
by failing to identify, study, apply and develop approaches that account
for the special circumstances of providing quality care in sparsely populated
rural areas. It may also result in a failure to provide the means with
which to ensure some degree of equity in terms of resources for all providers
and patients. The Committee
seeks to ensure this does not happen. This report is an attempt to inform
the broader debate about quality by providing the rural context. That
requires an examination of how health care is delivered in rural communities
and what that means within the larger discussion of health care quality.
The report will examine some of the current quality activities underway
within the U.S. Department of Health and Human Services and how those
initiatives affect rural communities, and will make recommendations on
those issues to the Secretary. It will then close with a vision for how
future quality efforts can be as useful in rural communities as they are
in urban and suburban communities across the country.
Health
Care Quality: The Rural Context 1.
Quality in the Rural Context The general concept
of health care quality does not change from urban to rural settings. The
focus remains on providing the right service at the right time in the
right way to achieve the optimal outcome. The only rural-urban variable
within that equation is the context. While the notion of quality remains
constant, the settings in which the care is provided—including their
structures and processes (e.g., transferring patients to larger facilities
vs. being able to keep them for observation)—can be quite different.
The most elementary
differences have to do with scope and scale. The urban setting features
a high volume of patients with an emphasis on technology-intensive and
inpatient services. The rural setting focuses more on ambulatory care
and features a much lower patient volume. Rural health care systems tend
to take care of more elderly patients and patients with more advanced
or chronic conditions possibly due to the delays in getting health care.
Rural residents, particularly those located in more isolated and sparsely
populated communities, have higher risk factors than the general population.4
Rural areas also face greater shortages of health care providers such
as radiology technicians, pharmacists, nurses and, particularly, specialists.
In addition, reimbursement for providers who practice in rural areas tends
to be less than their urban counterparts, particularly for Medicare patients.5
While issues of workforce and reimbursement are not explicitly quality
issues, they do impact the system’s ability to produce quality care. None of these
factors, in and of themselves, means that rural residents should expect
or receive a lower quality of care. Many sectors of the health care system
face unique challenges. At the same time, all of these factors have an
impact on rural health care providers and the communities they serve.
Volume
and Errors When looking at errors
in rural hospitals, it is important to focus on not only the number
of errors, but also the type. As noted in the working paper, “The
Environmental Context of Patient Safety and Medical Errors,”
a possible connection between volume and error type is noted. The
authors infer that different types of errors are made at low-volume
versus high-volume facilities. For instance, lower volume facilities
tend to have more errors due to “under-learning” while
higher volume facilities have more errors due to “over-learning.”6 Many rural advocates
believe that the reimbursement system, with its emphasis on administered
pricing and inpatient care that centers on the use of new medical technologies
and procedures, is designed for a high-volume healthcare environment with
a large population. Few of these characteristics apply in the rural environment.
Added to this is the paradox that many rural providers, particularly small
hospitals, tend to have positive overall margins, but negative Medicare
margins. Even so, rural hospitals are highly dependent on Medicare revenue
and although private payers pay them above cost, this represents a smaller
proportion of their payment base when compared to urban hospitals. A resource
disparity for many rural health care providers exists because of scale
and an inability to build reserves for special investment purposes such
as expensive information systems, which can be a means toward quality
improvement. Some rural advocates point to Medicare policy that pays rural
providers at a lower level than their urban counterparts as contributing
to the resource gap. Rural
Medical Error Study Offers a Framework Initial findings from
a study of medication errors in four rural hospitals in Nebraska
show that these facilities had error rates similar to those found
in prevailing national medication error reports. The Nebraska Center
for Rural Health Research at the University of Nebraska Medical
Center is piloting a project to evaluate a system of data collection
and analysis regarding medication errors in four small rural hospitals
in southeast Nebraska. The purpose of the project is to determine
if pooled data and shared resources can overcome rural barriers
to patient safety and quality. An interim evaluation of 225 error
reports completed seven months after the project was implemented
shows that the severity and nature of the medication error reports
from the four pilot hospitals were similar to those in the U.S.
Pharmacopeia’s national MedMARx database of medication error
reports. Specifically, 98% of
the errors reported by the four pilot hospitals and 96% of errors
reported to MedMARx did not result in patient harm. The majority
of reported errors in both databases occurred during the administration
and documentation phases of the medication administration process.
The three most frequent error types in both databases were omission,
wrong dose, and wrong drug. The authors emphasize
two emerging lessons from the interim evaluation. First, aggregation
of data with resource sharing and a common reporting form can overcome
barriers in small rural hospitals so that the baseline measurement
and monitoring of patient care processes necessary for patient safety
and quality improvement initiatives is provided. Second, the overall
quality and systems problems present in medication administration
in four small rural hospitals are similar to those in the larger,
urban facilities represented in the MedMARx data Rural providers
have also struggled to fit into urban-based quality measures. For example,
the Joint Commission on the Accreditation of Health Care Organizations
(JCAHO) accredits hospitals, and that stamp of approval has become a proxy
for quality health care. JCAHO accreditation, however, is another example
of the rural-urban difference. While the JCAHO accreditation is a staple
of urban facilities, some rural advocates or rural providers themselves
question the value of the process in terms of the relevance of the measures.
Of the approximately 2,200 rural hospitals in the United States, 58 percent
are currently accredited by the JCAHO.7
The reasons for
this moderately low participation rate are varied. The JCAHO process is
expensive and time consuming. Rural facilities with minimal financial
and staffing resources often opt not to seek JCAHO accreditation. Still
other rural hospital administrators say the process has little relevance
for rural providers and is primarily geared toward urban providers. Many
rural providers complain that the process diverts valuable resources in
both personnel and associated computer costs. Nonetheless,
rural hospitals and other healthcare providers meet standards of care
as related to quality, for the purpose of complying with Medicare conditions
of participation, state licensing regulations and pressure from commercial
payers. In the special case of Critical Access Hospitals, there is a full
on-site review for certification as a CAH, with a second review one year
later. JCAHO has also developed an accreditation process for CAHs. In 1997, JCAHO
began an initiative named ORYX to build performance-based outcome measures
into its accreditation process. While numerous vendors stepped forward
to supply hospitals with JCAHO-approved performance measurement systems,
only a few catered to smaller rural facilities. Rural hospitals not participating
in the JCAHO accreditation default to the state survey and certification
process which is the Federal Government’s vehicle (through Medicare)
for assuring quality. This is, however, a very weak vehicle since some
states lack the expertise and resources. JCAHO, however, has indicated
an interest in working with rural providers to address their concerns
and some progress has been made. In recognizing the unique characteristics
of some rural healthcare providers, JCAHO is reaching out to provide an
accreditation process specifically tailored to Critical Access Hospitals,
as is the American Osteopathic Association. While these are positive signs
for the future, it remains to be seen whether these efforts are relevant
and positively impact quality across the rural spectrum. Collecting and
analyzing data is fundamental to quality improvement, and clinical data
reporting requirements help accomplish this objective. However, the infrastructure
(human resources with quality knowledge, and technical resources such
as information systems) necessary for making this happen require financial
investments that rural facilities with fairly fragile financial circumstances
will have trouble meeting. This is supported by the IOM report Leadership
by Example: Coordinating Government Roles in Improving Health Care Quality
which states that “a similar substantial grant program should be
considered to assure the proliferation of an information technology infrastructure
that can ultimately support clinical care and enable performance measurement
as a seamless process.” Technology
Can Alter Local Perceptions of Care The perception of quality
often plays a self-fulfilling role in rural communities. A recent study by the
University of California-Davis8 looked
at the role technology played in local perceptions of quality of
care. The study, “Perceptions of Local Healthcare Quality:
The Impact of Telemedicine on Seven Rural Communities,” looked
at seven Northern California rural communities. UC-Davis surveyed
them over the phone before telemedicine was introduced into their
community and then again, approximately one year after initiation
of the technology. Each participant community was chosen because
it is considered a medically underserved area (MUA), a medically
underserved population (MUP), or a health professional shortage
area (HPSA). A randomized, controlled design study was implemented
to obtain 500 completed pre- and post-telemedicine surveys, respectively.
Residents were asked about their perception of the quality of their
local health care system, understanding of telemedicine, use of
community and non-community primary and specialty medical services,
and reasons why they would travel outside their community for health
care services. Between April 2000 through September 2001, 182 consultations
from 16 clinical specialties occurred with the help of telemedicine.
Results of the questionnaire surveys showed that residents’
opinions towards the quality of local health care increased favorably
after the introduction of telemedicine. In addition, the survey
found that residents who perceived their local health care services
to be of poor quality tend to leave their communities in search
of services. Perception of health care quality is associated with
patient satisfaction, which can have an impact on the financial
viability of the community. New initiatives
are needed which develop measures relevant to the types and characteristics
of providers found in most rural communities. To date, the emphasis has
been on the inpatient setting; most rural experts believe that the emphasis
eventually needs to include the ambulatory setting. As IOM notes, “a
large proportion of care, particularly in the management of chronic illness,
is delivered from the offices of small group practices or individual clinicians,
settings for which very little quality measurement exists.”9
This would allow the focus to also include quality measures for common
conditions ranging from diabetes to depression. By expanding
the focus of quality activities, experts could also begin examining how
new technologies are incorporated and how different levels of providers
can work together. For example, patients needing extended stays in intensive
care units (ICUs) should be treated by intensivist physicians, either
locally or at a distance, as recommended by the Leapfrog Group. However,
given the cost related to staffing ICUs in that manner, small ICUs treating
few patients for short stays (presumably transferring others to larger
institutions) as well as those treating patients for longer stays, need
to provide quality care without intensivists on site. It is important
to provide appropriate care regardless of the length of stay. This may
mean using telecommunications to connect the intensivists to the staff
on site (see Textbox on Tele-ICU). Other rural hospitals
that are unable to treat patients in their ICUs (if they have them), will
nonetheless need to be prepared to treat, or at least to stabilize, patients
with conditions normally treated in an ICU. Appropriate standards would
specify how that should be done. 2.
Rural Quality: The Research Perspective The body of literature
focusing on quality of care in rural areas is relatively modest. Rosenblatt
and Moscovice wrote one of the first major pieces that focused exclusively
on the rural context of quality.10 Subsequent
research has focused on JCAHO accreditation for rural hospitals and disease-specific
quality studies with an eye toward teasing out rural and urban differences.
Few of these studies have been national in scope. In 2001, MedPAC
produced its first-ever report focused exclusively on rural Medicare issues
that devoted a chapter to the issue of quality.11
The report noted that quality of care delivered to Medicare beneficiaries
and the beneficiaries’ use of recommended services was similar, with
the only exception being those rural beneficiaries in the most isolated
areas. Rural researchers and experts generally supported the points raised
in MedPAC’s discussion of rural Medicare quality issues. There was, however,
one notable exception. The primary difference of opinion centered on MedPAC’s
concern about low patient service volume in rural areas given what the
Commission cites as mounting evidence that shows a link between higher
volume furnished by acute-care hospitals and improved clinical outcomes.
An analysis of the MedPAC report noted that the majority of services where
the volume-outcome association has been made are for services not routinely
provided in rural facilities, such as coronary artery bypass graft surgery,
and are procedures for which rural populations are usually referred to
urban facilities.12 A
Rural-Urban Difference? A study conducted by
the University of Washington finds that smaller hospitals may be
less likely to follow a standard of care for heart attack victims.
The study reviewed the
records of 135,759 Medicare beneficiaries age 65 and above from
February 1994 to July 1995 and examined the quality of care provided
to Acute Myocardial Infarction (AMI) patients. It concluded that
patients discharged from rural hospitals were less likely to receive
several of the recommended AMI interventions than those discharged
from urban hospitals. However, in no geographic classification (urban,
large rural, small rural, remote small rural) were all hospitals
adhering to all guidelines (for example, the percentage of patients
receiving aspirin during the first 24 hours ranged from a high of
55.9% in urban areas to a low of 47.8% in remote small rural areas).
The proportion of hospitals in urban and rural locations with complete
adherence to all recommendations was nearly identical.13
The Committee’s
previous work on this issue concurs with findings of RUPRI as it relates
to concerns about volume. While volume is a commonly cited influence for
factors that differentiate urban and rural settings, the Committee is
concerned about relying strictly on volume-outcome measures of quality.
It is, however, a proxy for a variety of other things that may be occurring,
including the mix of providers available, their clinical background, the
level of technical support for clinicians, the health status and usage
patterns of the population, the availability of resources, and the access
to services, to name a few. Furthermore, there is a significant need to
expand quality measurement and improvement beyond the inpatient setting. The questions
are how to ensure high quality for frequently performed interventions
and how to address procedures that may not be frequently performed but
still must be done in a time-sensitive way to achieve optimal patient
outcomes. For example, the administration of clot-dissolving drugs in
the event of myocardial infarction or stroke must be done promptly and
cannot wait for transportation. Quality of care is compromised with a
potential impact on patient outcomes if these procedures are not performed
in a timely manner. Given the low volume of this procedure in a rural
setting, it is unlikely it would stand up against an urban tertiary care
center if assessed only through the standard volume-outcome relationship.
For any individual patient, including those in a rural setting, the ability
to provide that service is critical. In these situations, it isn’t
so much a question of volume versus outcome but rather an issue of measuring
services that are either performed or not performed. The Committee believes
that when volume-outcome measures are applied for rural facilities, they
should reflect common rural procedures. The Committee
believes the infrastructure of rural health care delivery systems and
the financial reimbursement system that supports it must assure that the
system is able to provide quality care in those instances when time is
critical. This would include the cost of stocking pharmaceuticals, having
trained emergency medical technicians, maintaining diagnostic equipment,
and having sufficient inpatient capacity. In many ways, there is a comparative
link to what is being learned as the nation responds to the bioterrorism
threat. Sometimes, the system has to accept “waste” or “inefficiency”
because it needs the capacity to deliver a service when it is needed.
Given the infrequent
demand and limited resource base, rural residents do not expect to have
immediate access to the full range of clinical services that are available
in most urban areas. However, people in smaller rural communities should
have a base level of services available locally that includes, for example,
the ability to stabilize patients prior to transfer to a distant facility.
Several services should also include telehealth links that allow for the
provision of some vital services via telehealth technology (such as teleradiology)
that are not available locally. In the end there are standards of care
that must be universally applied by which all providers should be judged.
For instance, of those services provided in rural facilities, the quality
of care and related patient outcomes should not vary by rural versus urban
facilities or within rural facilities themselves. Rather, quality improvement
efforts should be designed so that where performance does not measure
up, rural facilities have the infrastructure and assistance within quality
improvement programs to achieve the needed improvement in quality of care
with the expectation that quality meets the established standard across
the range of routine services. There are other standards that can be met
only when there are sufficient resources (dollars and expertise) to do
so.
The Congress has pushed DHHS
to take a leadership position on health care quality, and rightfully so.
The reauthorizing and redirection of the Agency for Health Research and
Quality (AHRQ) in 1999 from what used to be known as the Agency for Health
Care Policy and Research is, perhaps, one of the most visible signs of
a newfound focus on health care quality within DHHS. The agency has been
designated as the lead Federal agency on quality of care research, with
new responsibility to coordinate all Federal health care quality improvement
efforts and health services research.14
In addition to AHRQ’s
work, several other DHHS agencies and operating divisions play a key role
in promoting and ensuring quality health care services. The Centers for
Medicare and Medicaid Services (CMS), through its administration of Medicare,
Medicaid and the State Children’s Health Insurance Program (S-CHIP)
has a number of ongoing activities focusing on quality improvement, although
none of these programs has an express rural focus.
The Health Resources and Services
Administration (HRSA) also has a stake in the ongoing push to ensure health
quality, which includes the reduction of medical errors. HRSA administers
a wide range of grant programs from community health centers and rural
health outreach to large block grant programs such as Maternal and Child
Health and the Ryan White program. While these programs affect all providers,
rural communities are most directly impacted by the community health center
program and those programs operated by the Office of Rural Health Policy
(ORHP).
Federally qualified health
centers, about half of which are either in rural areas or serve rural
populations, have been involved in a number of HRSA-sponsored quality
initiatives for the past few years. ORHP runs two small grant programs
that focus on improving quality in rural settings. One focuses on quality
activities as they relate to Critical Access Hospitals. The other focuses
on small hospitals with 50 beds or less.
All of these agencies and
offices play a key role in ensuring the quality of health care services
and this report touches only briefly on the broad scope of quality activity
that is going on across the Department. The Committee, however, believes
that some of the specific quality activities within AHRQ, CMS and HRSA
bear further attention.
CMS: Lost Opportunities
for Rural? CMS attempts to ensure quality
through its survey and certification of clinicians and facilities, the
use of conditions of participation regulations for health care providers
and the ongoing efforts of the Quality Improvement Organizations (QIOs,
which used to be known as Peer Review Organizations or PROs). Over the
years CMS has invested in quality-focused demonstration programs, such
as coordinated care demonstration programs, which may include rural participants.
They have not initiated any rural-specific demonstrations. In each of
these areas, CMS policies affect all providers but the policies have particular
relevance for rural providers that serve a disproportionately higher percentage
of Medicare beneficiaries than their urban and suburban counterparts. RHCs:
New Quality Guidelines CMS also certifies and
oversees the operations of more than 3,448 rural health clinics
(RHCs), which are key access points across rural America and which
are located in rural areas that are either health professional shortage
areas (HPSAs) or medically underserved areas (MUAs). RHCs were authorized
in 1977 to improve access to care for Medicare and Medicaid beneficiaries
and receive reasonable cost reimbursement under Medicare. Approximately
70 percent of the RHC patient population is insured through Medicaid
or Medicare.15 CMS is finalizing regulations
that will create an expanded quality orientation for RHCs that was
mandated in the Balanced Budget Act of 1997. That provision required
that RHCs establish performance improvement measures through a Quality
Assessment and Performance Improvement (QAPI) program and the final
rule implementing that provision is expected to be issued early
in 2003. The new rules will formalize what many RHC experts say
these clinics have been doing all along. However, as noted earlier,
Congress and DHHS need to also provide adequate resources and guidance
to help providers respond to that charge. The CMS program that most
directly reaches out to providers to work on quality improvement at the
community and state level is the QIO program. Participation with the QIO
is voluntary on the part of the provider. Both this Committee and MedPAC
have noted that the structure of the QIO program does not contain strong
enough incentives to encourage QIOs to work with rural providers to improve
quality of care across a range of clinical conditions.20
The QIOs are evaluated based
on their ability to improve state-wide averages on a range of disease
indicators. MedPAC notes in its June 2001 report that the QIOs face incentives
to focus their national quality improvement activities on high-volume
providers that tend to be in urban areas because that gives them the best
chance for showing state-wide improvement.21
Consequently, QIOs, which operate on a fixed budget under contract to
CMS, are less likely to focus their efforts on small low-volume environments.
The QIOs new Seventh Scope
of Work, issued in 2002, was very ambitious. It included, for the first
time, a specific task for focusing on rural populations, paired with an
option to also focus on underserved populations. In addition to the ongoing
quality improvement projects that were similar to the prior scope of work,
the new scope of work also included significant new activities in public
education and reporting. The first phase of the public reporting began
in November of 2002 with the release of comparative quality data for the
17,000 nursing homes across the country. Future plans call for similar
releases of data for home health agencies and hospitals and physicians
offices. CMS, through the QIOs, is currently field testing some hospital
reporting measures on a voluntary basis in Maryland, New York and Arizona.
Although public reporting
is positive, there are some inherent challenges that face rural hospitals,
home health agencies and physicians’ offices. The demand for public
reporting puts extra resource demands on small rural providers and they
may need assistance in complying with the requirements. Final
Quality Assessment and Performance Improvement Condition of Participation
for Hospitals CMS published a new
rule for hospitals instructing them to develop and implement quality
assessment and performance improvement programs (QAPI) that will
identify patient safety issues and aid in the reduction of medical
errors. The rule also allows the implementation of information technology
as part of the QAPI program.
Medicare Conditions
of Participation for hospitals:
While some consumer advocates
welcomed the release of the data, it caused concern in the nursing home
community. The move to public reporting put a great deal of pressure on
the QIOs to offer assistance to these facilities to prepare them for this
reporting process. The QIOs were thus under pressure to do more than they
had previously done and to do so with less money than they received under
the Sixth Scope of Work. CMS provided $744 million to QIOs under the Sixth
Scope of Work but then considered providing only $666 million under the
Seventh Scope of Work. Subsequent negotiations between CMS and OMB resulted
in an agreement to provide additional funds to support the work burden
on the QIOs.22 The requirements for public
reporting are a step in the right direction, provided CMS works with the
provider community and offers QIOs the financial support to make the process
a success. The initial funding shortfall in the first year of the Seventh
Scope is not a good start but the subsequent agreement to provide additional
funds for QIOs to aid nursing homes in their public reporting offers some
hope for the future. It is also important that in moving forward on public
reporting that CMS focus on more than just outcome measures. Outcome measures are helpful
barometers, but for most patients in most situations, assurances that
the process of care is of the highest possible quality is more important
than specific outcomes. A health care provider might be tempted to focus
on achieving publicly reported outcomes (“teaching to the test”)
while not devoting sufficient resources to improving the process of care.
The move toward public reporting
by hospitals has created some concern, particularly among hospital administrators,
about which measures will be reported on and how the data will be used.
One of the chief complaints is that simple reporting of outcome measures
fails to capture the full range of quality activities such as the prevention
of errors, and any corrective actions taken after an error to ensure it
doesn’t happen again. In other words, there is little context given
to the reported numbers. Some rural administrators
are concerned that hospitals (as well as nursing homes and home health
agencies) with low volumes of patients may have statistics that are skewed.
For example, if a hospital sees just a few patients with a specific condition
and just one outcome is bad, the percentage reported will be deceptively
high. Others say simple objective measures fail to take into account health
status and co-morbidities, both of which tend to be worse in rural areas.
Finally, some providers are worried that a good faith effort at reporting
the data may then be used against them in court. Any of those scenarios
could potentially have a chilling effect on data reporting. The Committee
believes that all of these issues need to be discussed and taken into
account before the first public reporting takes place. This is not to say that rural
hospitals should not be a part of any reporting process. In fact, they
should. However, CMS should consult with rural experts to address questions
related to whether the posting of that data should be voluntary or mandatory
or if it might be grouped together among similarly situated facilities.
To its credit, the hospital
industry has taken a proactive approach to the planned reporting requirements.
Late in December of 2002, the American Hospital Association (AHA), the
Federation of American Hospitals (FAH) and the Association of American
Medical Colleges (AAMC) announced plans to work toward having all U.S.
hospitals voluntarily report outcomes of 10 quality measures relating
to the care provided to patients, including millions of Medicare beneficiaries
Managed
Care and Quality Programs Much of the quality
improvement projects are done through managed care, which requires
quality efforts through Medicare+Choice (M+C). Interestingly enough,
Medicare fee-for-service (FFS) participation in quality improvement
(QI) projects is purely voluntary, and that is where a lot of rural
beneficiaries receive their care. The special task required for
M+C is more focused and is not helpful to rural communities. The 10 measures in three disease
areas to be initially reported in the joint program are in the areas of
heart attack, heart failure and pneumonia. The measures adopted by AHA,
FAH and AAMC are process measures rather than outcome measures and should
work well across both large and small settings. At one time, rural advocates
were hopeful that the Seventh Scope of Work would include stronger incentives
for QIOs to work with rural populations. The MedPAC report in June of
2001 generated considerable attention to the need for QIOs to do more
with rural providers. Despite that promising backdrop,
the Seventh Scope of Work has failed to address some of the substantive
rural concerns in how it is structured. Although CMS did add a task that
allowed QIOs to work with rural populations, the task was combined with
underserved populations. While the Committee applauds CMS’ intent
in trying to reach out to rural populations, it is concerned that including
rural in the underserved population task will dilute this much-needed
effort. For example, CMS relies on QIOs showing improvement on statewide
averages and a QIO will find it much more cost effective to focus on a
high-volume urban underserved population rather than reaching out to several
isolated rural areas. The pairing of rural and underserved
in one of the QIO tasks also reflects, at best, a failure to understand
why QIOs have had difficulty reaching out to rural communities. At worst,
this pairing undermines work in reaching underserved populations and looks
more like an attempt to deflect criticism from rural advocates that the
QIOs framework is biased against rural providers and the communities they
serve. AHA,
FAH, AAMC Voluntary Measures Heart attack (Acute
Myocardial Infarction) The reality is the Seventh
Scope of Work serves to ensure that the status quo continues. Preliminary
findings of a study by the University of Minnesota shows that the Seventh
Scope of Work appears to have only modest potential to increase QIO activities
with rural hospitals.23 In those states
that are predominantly rural such as Montana, Wyoming or Maine, the QIOs
will reach out to rural populations because they have to do so. However,
in those states where there are both sizable rural areas and highly populated
urban areas, the QIOs will still have powerful incentives to concentrate
their work where the greatest numbers of people are located. The result
is continuation of an unmet need and an opportunity lost for CMS to reach
out and work with rural providers to improve quality in a substantive
way. Those that nevertheless reach out to rural providers should be recognized
and rewarded. Should CMS seek to improve
the ability of the QIOs to reach out to rural populations, the agency
might also consider coupling this with renewed support for the survey
and certification process. In its June 2001 report, MedPAC noted that
the infrequency of surveys of facilities may affect rural providers more
directly. These providers are most likely to rely on the survey and certification
process to ensure quality as opposed to outside accreditation. The surveys
for many types of facilities are performed infrequently for several reasons
including inadequate funding levels.24
Any effort to improve the ability of the QIOs and the survey and certification
process would provide needed support for rural facilities as compared
to their urban counterparts. AHRQ: Increasing the Focus
on Rural Health The AHRQ has been very productive
in supporting research and dissemination related to health care quality
and, in the process, has also contributed significantly to elevating quality
on the nation’s health care agenda. The agency strives to achieve
a balance between its ongoing research mission and its work on quality
while also administering an ever-growing number of Congressionally earmarked
projects. Disparities
Research at AHRQ The Agency for Healthcare
Research and Quality (AHRQ) has focused its funding on disparities
in health care over the past several years. These investments have
led to an increase in research that includes investigator-initiated
research, new training programs and projects building on previous
AHRQ-supported projects. The current investments
for minority and vulnerable populations are as follows16:
The bulk of the agencies’
quality activities have been global in scope. For example, AHRQ has worked
with CMS to convene a meeting with other Federal agencies and interested
groups to begin developing a public survey (patient satisfaction) tool
to assess hospital performance. These kinds of activities have implications
for both rural and urban communities. The agency has a Congressional mandate
to support research, evaluation and demonstration projects in inner city
and rural areas.17 Toward that end, AHRQ
has supported some rural-focused activities and is currently funding several
rural projects, including three rural quality projects. One study in Montana
looks at the relationship between working conditions of health care providers
and the quality of care in rural hospitals. Another study at the University
of Colorado is developing and testing a patient safety reporting system
that will be examined in several rural settings. The agency also is funding
a study at the University of New Mexico that looks at diabetes prevalence
among Native Americans.18 The Agency also
worked with ORHP in HRSA to convene a meeting of rural experts in 2002
to examine issues related to quality and patient safety in rural communities.
There are plans for a follow-up meeting and a joint paper by the participants.
Some rural advocates would
like to see a more explicit emphasis on rural-specific quality and patient
safety studies, but others are less critical. They point out that AHRQ
has attempted to build a body of knowledge on quality that should be helpful
to all of the health care delivery system, including rural providers.
To this end, the Committee believes it may be helpful to have rural clinicians
at the table with AHRQ to discuss the relevance of AHRQ projects and how
to make them more applicable to rural areas. One of the primary challenges
faced by AHRQ is allocating its funding between its research mission and
its quality mission in a way that supports analysis across the health
care system. Currently, the agency can fund only a small percentage of
studies that are submitted. The Committee believes the real challenge
is increasing the amount of resources available for quality-focused projects.
The Committee does not believe the number of urban-focused projects should
necessarily be reduced and redirected to rural projects. Rather, the Agency
needs enough resources to meet its ambitious charge and to ensure that
rural interests are adequately represented. To date, that has not happened.
However, the President’s 2004 budget includes a $50 million initiative
in AHRQ’s patient safety line around hospital-based information technology
solutions, which includes an emphasis on small community and rural hospitals.19 NIH The National Institutes of
Health (NIH) funds research projects that focus on health care delivery
systems. Although a small portion of the NIH portfolio, these projects
represent a big amount of funding given the recent increase in NIH funding.
There are opportunities for NIH to work with AHRQ and thus to build a
significant body of research focused on improving quality of care through
improvements in the delivery system. For NIH this activity would be considered
putting the best services into practice. This research would need to account
for the unique nature of rural practice locations, which are influenced
by fewer cases. Analyzing specific interactions may not present a valid
portrayal of the quality of care in that institution because of low volume.
The reality of limited volume and the limited range of care settings in
rural areas may influence the practices used by rural providers. That
context needs to be accounted for in any analysis of best practices. HRSA: Small but Targeted
Quality Efforts for Rural Hospitals While AHRQ and CMS have the
more visible Federal roles in promoting health quality and quality improvement,
there are two small programs administered by HRSA that are reaching out
to rural hospitals. These programs, the Rural Hospital Flexibility Grant
program (Flex) and the Small Hospital Improvement Program (SHIP)25,
are relatively new, having been in existence for three years and one year,
respectively. These two programs are but a small part of the overall HRSA
portfolio which focuses more on programs that reach out to vulnerable
communities such as the poor, the uninsured, those with HIV-AIDS and those
reliant on maternal and child health programs. The Flex Program provides
approximately $25 million to 47 eligible states for activities related
to helping hospitals convert to Critical Access Hospital status, promoting
rural health networks, integrating EMS and improving quality. The states
get an average of about $300,000 each to focus on any of the four program
objectives. In several cases, the Flex funding has been used to create
state-wide quality improvement networks that set benchmarks on common
indicators to measure quality improvement. In FY 2002, approximately $2.9
million of the Flex funding was used for quality improvement. The SHIP program has provided
$15 million to rural hospitals to support quality improvement projects
and/or to address issues related to transitioning to the new Medicare
prospective payment systems and complying with the Health Insurance Portability
and Accountability Act. A total of 1,400 hospitals received grants of
slightly less than $10,000 each in FY 2002 with 28 percent of the hospitals
using their funds specifically for quality improvement. Montana
Uses Flex Money to Create a Quality Network Montana is the birthplace
of the Critical Access Hospital (CAH), so it’s only natural
that the state would be taking the lead on quality issues facing
these small hospitals. The State has used some
of its grant funding from the Medicare Rural Hospital Flexibility
Grant program to create a state-wide quality network among its CAHs.
The network has allowed CAHs across the state to collaborate with
each other on a variety of quality improvement activities, provider
education, medical staff credentialing and reporting. The facilities
have worked with the State hospital association and the Flex program
to pool data on key indicators and use those findings to set benchmarks
for quality improvement. The Montana Quality Improvement Network
has also worked with the Montana-Pacific Quality Health Foundation
to promote the use of performance data for nursing homes, home health
agencies and hospitals. Respectively, the Flex and
SHIP programs have supported approximately $5 million in quality improvement
projects in rural America in 2002. While that figure is encouraging, it
also pales in comparison to the QIO program funding. More help may be
on the way, however. The Congress created another grant program to address
quality concerns in rural communities in the Safety Net Bill that passed
late in 2002. This program, the Small Health Care Provider Quality Improvement
Program, which will provide small grants to rural health clinics and small
hospitals, has been authorized but has not yet received an appropriation.
While these activities have
been a step in the right direction, they are but a small step. For example,
the SHIP program’s 2002 funding level of $15 million resulted in
an average award of just under $10,000 for each of the 1,420 eligible
hospitals. The Flex Program has played the role of a catalyst for rural
activities but quality is one of only several program priorities areas
as outlined in the original legislation. These grant programs have been
enormously helpful, yet they have barely begun to address the larger resource
needs facing rural health providers. The Committee believes that
any new strategies which emerge to address concerns over health quality
need to have broad input and participation from the health care system.
To date, the rural voice has not always been a part of those discussions.
The history of the health care system has been dominated by a top-down
diffusion strategy that has often served to isolate or ignore rural concerns.
This has been true on the reimbursement side and the clinical side of
health care where patterns of care, clinical research, and new technologies
are often introduced and designed only with large tertiary care centers
in mind. This model, unfortunately, has served to delay the introduction
of new knowledge and practice patterns in rural areas given the time it
takes for innovation to trickle down into smaller, often geographically
isolated environments that are often resource challenged. Some rural advocates
believe that when it comes to quality improvement, a “trickle down”
strategy to rural areas will never work without addressing the existing
resource inequities that exist between urban and rural providers. In addition,
the ability to bring about real change and improved quality in rural environments
requires a focus beyond inpatient care to also include the ambulatory
and post-acute care setting and preventive elements of health. So far,
the inpatient sector has received the bulk of the attention. To date, the discussion has
been largely global in nature. This runs the risk of assuming that rural
communities are simply a subset of urban communities and that what works
in urban areas will automatically be appropriate for smaller settings.
This pattern has been true from the IOM studies to the bulk of the quality
work done by AHRQ and CMS. It speaks to a fundamental failure to take
into account how rural health care delivery often has characteristics
different from urban systems, including challenges in acquiring content
on quality improvement for practicing professionals and in upgrading information
systems. There are also differences in providers with different sets of
skills and a different mix of patients, services and potential sample
size. This is not to say that quality is lower now in rural areas, nor
that patients treated by rural providers should not expect the highest
possible quality care. Rather, the reality is that the environment is
different. Quality improvement activities predicated on 500-bed tertiary
care hospitals that focus on high-tech and resource intensive procedures
have little relevance for small rural hospitals. Unfortunately, the majority
of the quality discussion to date has failed to acknowledge urban-rural
differences. The ongoing debate and focus
on quality, however, offer a new opportunity for the health care system
in general and rural communities in particular. The rural setting may,
in fact, be the optimal location to introduce new quality and patient-focused
activities. In fact, in this instance, the entire health care system might
be better served by a reversal of this typical diffusion model. As we
look at ways to improve the quality of primary and ambulatory care and
chronic care management (issues that resonate across the health care system
regardless of geography), rural settings offer a unique laboratory. By
testing new strategies in these communities and then allowing the successes
to diffuse toward larger volume environments, we can ensure that we develop
common sense solutions that can be translated to multiple environments.
The Committee believes it
is time for a more inclusive examination of health quality that ensures
improvement for each sector of the health care world. The debate should
focus more on what the future will bring rather than trying to retrofit
past strategies that have served only to perpetuate the status quo. That
lesson is true across both rural and urban settings. The continuing debate over
how to ensure access to high-quality health care services across the health
care system is a unique opportunity to affect change, especially for rural
providers and the patients they serve. They have often been left out of
the discussion in the past and it is imperative that this does not happen
again. As the Federal government and the private sector discuss ways to
improve care, it is essential that rural interests be a part of that larger
discussion. Rural
as a Test Bed There are some inherent
advantages in using rural communities as a test setting for quality
improvement efforts. Many rural areas have geographically disparate
patient populations that are fairly static, often with multiple
generations living in relatively stable settings. This stability
could allow researchers to analyze quality-focused innovations with
a longitudinal focus more easily in rural areas than in more fluid
suburban or urban areas. In fact, if one takes the approach championed
by Don Berwick and other leading quality experts and begins focusing
on disease-specific outcome questions, the assessment of quality
is not near-term but long-term. That kind of longitudinal analysis
of chronic care may be easier to conduct in rural settings. To date, that is not happening.
As the IOM notes in its most recent report, the Federal Government occupies
an incredibly influential position for promoting quality across the health
care system and should use that position of authority to set the standard
for improving quality of care in the health care system26.
The Committee would take that one step further. The Federal Government,
and the Department of Health and Human Services in particular, have a
responsibility for ensuring that its quality improvement activities work
as well in rural communities as they do in urban communities. The Committee
would further propose that the Federal Government and DHHS urge the key
players in the private sector to take the same approach. The Federal policy levers
for promoting quality improvement in the health care sector are tied most
directly to CMS and AHRQ. By and large, these activities have not proven
very adaptable to rural providers. DHHS’ quality efforts sometimes
reflect an unintentional but very real urban focus that often is not relevant
for rural communities. CMS’ QIO program and AHRQ’s current efforts
are examples of this phenomenon. The current pace of quality
activities, initiatives, studies and findings continues to increase. That,
overall, is one of the more positive developments in the health care system
in the past few years. One of the challenges facing rural communities
is reacting to so many possible directions all at once. NQF and DHHS can
play a unique role in helping to link all the parties together. More discussion
is needed to help rural leaders survive and grow in a world where people
are increasingly “steered” from one provider to another based
on “report cards”. The Committee believes the health care system
at large needs to move from this positive but somewhat chaotic state to
some alignment where it can invest in improvement in a way that is relevant
to all levels of care. CMS Quality
Improvement Organizations AHRQ and
NIH HRSA 1.
Brown, David. “Intensive Care, From A Distance, ‘Electronic
ICU’ Helps Cut Mortality Rates.” Washington Post. June
2, 2002.
2.
Corrigan, Janet M.; Greiner, Ann; Erickson, Shari M. Institute of Medicine,
National Academy of Sciences. Fostering Rapid Advances in Health Care:
Learning from System Demonstrations. November 19, 2002.
3.
Committee on Quality of Health Care in America, Institute of Medicine,
National Academy of Sciences. Crossing the Quality Chasm: A New Health
Care System for the 21st Century. March 2001.
4.
The Centers for Disease Control, National Center for Health Statistics.
Health, United States, 2001. Urban and Rural Health Chartbook.
August, 2001.
5.
The National Advisory Committee on Rural Health. Medicare Reform: A
Rural Perspective. May 2001.
6.
Size, Tim, Executive Director, Rural Wisconsin Health Cooperative. Personal
correspondence. January 31, 2003.
7.
Medicare Payment Advisory Commission (MedPAC). Report to Congress: Selected
Medicare Issues. June 2000. Table 2-2, p. 44.
8.
University of California-Davis. Perceptions of Local Healthcare Quality:
The Impact of Telemedicine on Seven Rural Communities. In progress.
9.
Corrigan, J.M.; Eden, J. and Smith, B.M. Leadership by Example: Coordinating
Government Roles in Improving Healthcare Quality. The Institute of
Medicine of the National Academies of Science, Committee on Enhancing
Federal Healthcare Quality Programs. 2002.
10.
Moscovice, I. and Rosenblatt, R. “Quality of Care Challenges for
Rural Health”. Journal of Rural Health 16(2), Spring 2000.
p.168-176.
11.
MedPAC. Medicare in Rural America. June 2001. p. 42. 12.
The Rural Policy Research Institute Health Panel. Comments on the June
2001 Report of the Medicare Payment Advisory Commission: Medicare in Rural
America. September 28, 2001. p. 11-12. 13.
Baldwin, Laura-Mae; MacLehose, Richard F.; Hart, L. Gary; Beaver, Shelli
K.; Every, Nathan; Chan, Leighton. WWAMI. Quality of Care for Acute
Myocardial Infarction in Rural and Urban U.S. Hospitals. June
2002. 14.
S. 580, “The Healthcare Research and Quality Act of 1999,” enacted
in the 106th Congress and signed into law by the President on December
6, 1999. 15.
Ricketts et al., p. 5 and 8. 16.
Agency for Healthcare Research and Quality (AHRQ). AHRQ Resources for
Research on Reducing Ethnic and Racial Inequities in Health Care,
December 2001. AHRQ Pub. No. 02-P009. 17.
S. 580, “The Healthcare Research and Quality Act of 1999”, Section
901(c ) 18.
AHRQ. Fact Sheet. AHRQ Focus on Research: Rural Health Care. March
2002. 20.
MedPAC. Report to the Congress: Medicare in Rural America and the
National Advisory Committee on Rural Health, Medicare Reform: A Rural
Perspective. 22.
“CMS and OMB Strike Deal On Three-Year Budget for 7th Scope of Work.”
Inside CMS. Nov. 21, 2002. 23.
Moscovice, Ira. Presentation to the American Health Quality Association
National Conference, Orlando, Florida. Feb. 7, 2003. 24.
MedPAC, Medicare in Rural America. 25.
Section 1820(g)(3) of the Social Security Act authorizes these two grant
programs. Although statutorily based in the Social Security Act, the programs
are administered by HRSA rather than CMS. 26.
Corrigan, et al. Leadership by Example: Coordinating Government Roles
in Improving Healthcare Quality.
AAMC - Association
of American Medical Colleges ACE (Inhibitor) - angiotensin-converting
enzyme inhibitor AHA - American Hospital
Association AHRQ - Agency for Health
Research and Quality AMI - Acute Myocardial
Infarction CAH - Critical Access
Hospital CMS - Centers for Medicare
and Medicaid Services DHHS - Department of
Health and Human Services eICU - electronic intensive
care unit FAH - Federation of
American Hospitals FFS - fee-for-service
HPSA - health professional
shortage area HRSA - Health Resources
and Services Administration ICU - intensive care
unit IOM - Institute of
Medicine JCAHO- Joint Commission
on the Accreditation of Health CareOrganizations M+C - Medicare Plus
Choice MUA - medically underserved
areas MUP - medically underserved
population NACRHHS - National
Advisory Committee NIH - National Institutes
of Health NQF - National Quality
Forum ORHP - Office of Rural
Health Policy PROs - Peer Review
Organizations (now known as Quality ImprovementOrganizations or QIOs) QAPI - Quality Assessment
and Performance Improvement QI - quality improvement QIOs - Quality Improvement
Organizations (formerly Peer Review Organizations or PROs) RHC - rural health
clinic S-CHIP - State Children’s
Health Insurance Program SHIP - Small Hospital
Improvement Program |