How have you utilized your results to implement change?
In March 2023, the National Flex partners (Rural Quality Improvement Technical Assistance, Technical Assistance and Services Center, and the Flex Monitoring Team) convened a summit of national subject matter experts to identify the core elements of infrastructure necessary for successful quality efforts in CAHs. A report, Building Sustainable Capacity for Quality and Organizational Excellence, was compiled and served as the framework for the first National CAH Quality Inventory and Assessment. All CAHs were asked to complete the CAH Quality Inventory and Assessment to provide State Flex programs with valuable standardized information to inform programming and assist the hospitals in improving their existing QI programs.
Structural measure to access CAH quality infrastructure based on the nine core elements of CAH quality infrastructure:
Leadership Responsibility & Accountability
Quality Embedded within the Organization’s Strategic Plan
Workforce Engagement & Ownership
Culture of Continuous Improvement through Behavior
Culture of Continuous Improvement through Systems
Integrating Equity into Quality Practices
Engagement of Patients, Partners, and Community
Collecting Meaningful and Accurate Data
Using Data to Improve Quality
The first CAH Quality Inventory and Assessment was due last December with the intent to conduct this measure annually. The RQITA team recently announced that this year’s assessment will open September 16th and must be completed by November 22nd. In our work with numerous CAHs and state Flex programs around the country, we’ve learned about various efforts from CAHs to improve their Inventory and Assessment scores and QI programs based on their December 2023 Assessment results.
Equity – managers use collected data and other available resources to identify inequities
One hospital is using collected data to identify and address health inequities by analyzing patient demographics, health outcomes, and access patterns. The hospital utilizes this information to deploy community health workers to enhance outreach and navigation for underserved populations and is working to establish a mobile health clinic to provide preventive care and education in remote areas. It has also hosted a community fair with local service organizations (i.e., food banks and transportation services) to discuss how the organizations can collaborate to address inequities within the community.
Workforce – the organization has formal onboarding and orientation that embed quality as a priority
A hospital shared they have recently re-examined the onboarding process and created a new onboarding program for all employees – clinical and non-clinical – to emphasize the importance of each organizational role and staffing position in the quality of care and patient experience. The onboarding program models how handling situations differently can improve a patient’s experience and how the patients perceive the quality of care received. For example, when housekeeping leaves tent cards in the patient rooms with their name and how to reach them, it leaves a personal touch, allows the patient to feel appreciated, and provides an avenue for patients and families to contact housekeeping if they need anything.
Strategic Plan – Quality leaders participate in organizational strategic planning
Before completing the first CAH Quality Inventory and Assessment, one hospital’s Quality Director was not participating in strategic planning, and quality was not a component of the organization’s strategic plan. Since the results were released, this hospital’s leadership saw the hospital was not meeting this measure and has since included the Quality Director and Quality Department in leadership’s hospital-wide initiatives. This hospital has plans to hold a strategic planning workshop, including the Quality Director, to incorporate Quality into the hospital’s strategic plan.
Not a Critical Access Hospital? Your hospital can still utilize questions asked in the Quality Inventory and Assessment to identify opportunities to improve your hospital’s quality program.