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Focus on Rural Health

North Dakota's Critical Access Hospital Quality Network: Collaboration is the Name of the Game

The state's quality network seeks to strengthen hospital care for all North Dakotans.

By Stacy Kusler on

ND CAH Quality Network Logo A healthy workforce is one that sticks together, one that motivates and inspires each team member to be their best, and one that supports individual goals as they align with the goals of the larger group. From housekeeping staff to the chief executive officer (CEO), a healthy workforce is exactly what is necessary within any healthcare organization, regardless of their size or location, to ensure a positive patient experience and ultimately improve patient outcomes. What if this supportive and cohesive environment could be spread across an entire state's network of hospitals, encouraging collaboration by sharing policies and best practices between facilities? Enter the North Dakota Critical Access Hospital Quality Network.

The North Dakota Critical Access Hospital (CAH) Quality Network was established in 2008 for the 36 CAHs to strengthen collaboration and leadership among healthcare organizations and streamline efforts around quality and performance improvement. Nikki Johnson, CEO for Cooperstown Medical Center (CMC), has been able to improve patient care and quality at her facility by using tools made available through the Network.

"The Quality Network has provided excellent opportunities for our leadership team and frontline staff to acquire the knowledge necessary to provide the best quality care possible to our patients at Cooperstown Medical Center," Johnson said. "From the virtual library resources to various Network group meetings and educational offerings, the Network has always been a cost-effective, integral part of process improvement at CMC. We frequently utilize information acquired through this networking to help ensure continuous quality improvement."

The virtual library, as Johnson mentioned, is an online library available to the members of the Network and contains a variety of documents and tools, including hospital survey results, training and management tools, sample policies and procedures, and more.

The existence of a Quality Network is not unique to North Dakota; this model has been implemented in many other states. However, what is unique to North Dakota is that our state has 100 percent participation from all 36 rural or critical access hospitals. This "all-in" participation is a result of the North Dakota CAH leaders' desire to work as a team and to have a shared voice on a local, state, and national level. Jody Ward, RN, MS, APHN, director of the Network, has been leading the team since the Network's start in 2008. She has been instrumental in maintaining 100 percent member participation.

"The Network is a one-stop shop for CAH-specific information," Ward said. Since the beginning, one of the areas of greatest improvement Ward has seen in rural hospitals as a result of the Network has been the sharing of CAH Conditions of Participation deficiencies reported in surveys. When hospitals are surveyed by a state or federal agency, they receive feedback on areas for improvement, which they have been willing to share with their colleagues in the Network. This information sharing has allowed other hospitals in North Dakota to be proactive in improving their facility and clinical processes before their own site is surveyed. "This transparency with each other has come full circle for ND CAHs. In the beginning, CAHs had many more survey deficiencies, and now, as a result of the sharing, there is increased opportunity for learning and implementing best practices that has resulted in CAHs receiving fewer survey deficiencies," Ward said.

Another benefit offered through the Network to improve quality and patient care throughout the state is the staff peer exchange program. Through this program, CAH staff are able to shadow or receive direct training from a peer in another ND CAH. This program is available to a variety of CAH staff, ranging from directors of nursing to chief financial officers (CFOs) and CEOs. Joy Vetter, an RN with Linton Hospital, recently took advantage of the program and connected with staff at Jamestown Regional Medical Center to learn about their processes for risk management and infection control. "I learned about several different items that they were monitoring for infection control, and about different equipment and programs they were using that could also benefit our facility," Vetter said. "I plan on bringing this information back to our committee . . . and implementing some of the useful ideas into our daily routine and practice." When asked if the program was helpful for her, she said, "I had a great experience, and I think the peer-exchange program was very beneficial. It will be nice to continue to have them as contacts for any future questions or advice."

Funding is, of course, vitally important to support a successful statewide network. This is accomplished through the federal Health Resources and Services Administration (HRSA) Medicare Rural Hospital Flexibility (Flex) grant program, administered by the Center for Rural Health. Flex funding is used in three priority areas: (1) quality improvement, (2) financial and operational performance, and (3) health system collaboration and community engagement. Support for quality improvement includes a variety of CAH-specific resources, including the operation of a virtual library for facilities to share best practices and evidence-based protocols, a North Dakota CAH Quality email list, assistance with data collection issues, and hospital reporting for the Medicare Beneficiary Quality Improvement Project, and Hospital Consumer Assessment of Healthcare Providers and Systems. Help for financial and operational improvement includes supporting CAHs in need of financial consultation, as well as hosting financial workshops and CEO/CFO meetings to discuss common issues. Finally, support for health systems development and community engagement includes things like supporting the inclusion of emergency medical services (EMS) into local and regional trauma systems of care, and providing funding for EMS leadership and management training. This area also includes support toward implementation of community projects related to a need identified through a Community Health Needs Assessment.

What is unique to North Dakota is that our state has 100 percent participation from all 36 rural or critical access hospitals.

The Network is a vital hub for implementing a number of statewide healthcare activities that also includes work with the North Dakota Department of Health's Stroke Program, with key partners such as the American Heart Association, to educate all rural and urban hospitals in North Dakota on the use of the Acute Stroke Treatment Guidelines. For hospitals who share providers or who use locum tenens provider coverage, or travel nurse coverage, the goal is for the process of caring for a stroke patient to be the same in all critical access hospitals across the state. The state stroke program is in its fifth year and has the goal of 100 percent participation from North Dakota critical access hospitals, which will allow the sharing and ongoing communication between EMS, CAHs, and the tertiary hospitals in Bismarck, Fargo, Grand Forks, and Minot. Through a variety of quality initiatives, the Network helps sustain a healthy collaboration among the rural hospital healthcare workforce in North Dakota. While the general focus of the Network is dedicated to the CAHs, Network members meet on a regular basis with the six larger hospitals in the state in order to improve care through all levels of the care continuum. Team-based care improves quality and patient-care outcomes. And health systems, as a whole, are able to perform better; healthcare staff are able to perform their jobs more effectively; and patients across the state benefit. For more information about the North Dakota CAH Quality Network, you can visit

This article originally appeared in the Holiday 2014 issue of North Dakota Medicine.

Stacy Kusler Stacy Kusler is the connection between rural healthcare facilities in North Dakota and qualified health professional job seekers. As the workforce specialist, she assists rural facilities to attract medical providers and other health professionals to their communities by sharing job opportunities. Through her position, Stacy is working to reduce the healthcare workforce shortages throughout the state.