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Improving Patient Safety In Rural Hospitals

Creating a Culture of Safety

Roles of Local, Regional, & Statewide Organizations

Workgroup C mainly consisted of high-level health care administrators with responsibility for shaping their organizations' missions and programs. Members of this group represented viewpoints of hospitals and clinics, insurers and payers, and health care purchasing coalitions and alliances. Due to the nature of this workgroup's composition, the discussion of the six categories of workgroup results centered around big-picture, thematic, culture-change concepts rather than field-specific actions.

Environmental Sketch/Environmental Factors

Workgroup C discussed the rural environment in the context of developing a culture of safety and how local, regional, and statewide organizations can contribute to the effort. Since this group focused on the broad issue of changing organizational culture, their comments reflect various opinions, brainstorms, and "out-of-the-box" conceptual thinking. While much of their report about environmental factors is factual, it is important to remember that this group aimed to push the boundaries of current patient safety conventions and, in doing so, needed to push the boundaries between opinion and fact.

Rural Wisconsin Health Care Factors

  • Rural Wisconsin hospitals know that they can do better in preventing medication errors.
  • Wisconsin's rural hospitals are currently making more use of clinical pharmacists and working towards being able to implement computerized prescriber order entry (CPOE) for the long term.
  • Rural Wisconsin is unique from other rural locales in that it has high levels of health maintenance organization (HMO) market penetration and multi-specialty clinic-based systems.
  • Rural Wisconsin, and the upper Midwest in general, differs from other rural areas in that there is substantial Medicare and Medicaid cost-shifting to the private sector.
  • Employers and insurers in rural Wisconsin are desperate for ways to address cost issues.
  • Most rural Wisconsin hospitals are quite small, with fewer than 50 beds and an average daily census of less than 25.

Rural Health Care Factors

  • Hospitals that stand-alone and hospitals in systems access assistance in substantially different ways.
  • There is a perception among some that the quality of care and services given in rural facilities is lower than that given in urban hospitals. Some believe that, until data to compare rural and urban quality measures is presented, this perception will continue.
  • Rural providers touch most people in the emergency room. Emergency rooms are important to rural communities and a good place to focus patient safety errors.
  • Rural hospitals purchase health insurance for their employees and even as such, pay little to no attention to quality and make benefits decisions based largely on price.
  • Rural and urban consumers are more similar than they are different. Both types of consumers are exercising their many choices in increasingly larger numbers.
  • As more costs shift to the consumer, they will become increasingly concerned with safety issues and actively seek more information about patient safety.

General Health Care Factors

  • Some consumers feel a sense of betrayal by the health care system and the medical community, as a result, have developed a posture of defensiveness.
  • Cost imperatives will necessitate that individuals play a substantially increased role as stakeholders in influencing hospital quality and patient safety agendas (regardless of increased enrollee cost-sharing with employees).
  • A group of large employers has developed the Leapfrog Group initiative to help purchasers focus their actions related to improving patient safety.

Priorities for Patient Safety Initiatives/Ideal Outcomes

In developing a list of priorities for fostering a culture of safety, participants' discussed several different types of priorities. Rather than focusing solely on actions for safety initiatives, participants' comments reflected what they believed to be top priority postures, attitudes, actions, needed buy-in, and models and examples to adapt in order to develop a safety culture effectively.

Priority Posture

  • Rural hospitals believe they can become safer and need not take a defensive posture.
  • Rural hospitals need to challenge the assumption that rural quality is lower than urban quality. It is rarely backed by any data.
  • Double standards for rural and urban hospitals are not acceptable.
  • Societal issues are important. Currently, the health care system is based upon what is expected by payers and not necessarily designed to deliver quality health care.

Priority Attitude

  • Pick your spot and start. It is easy to be overwhelmed by the challenge of changing a large complex system, but hospitals must start somewhere.
  • Focus on doing what is good for rural.
    • If rural hospitals simply mimic the approaches implemented in large urban facilities they are bound to fail.
    • Much can be done by doing what makes sense in the environment.
  • We need to become comfortable trying to do better and to remember that the patient safety challenge is not a crisis.
    • It is fine to recognize that human beings are not perfect, but better to recognize that we can get better.
  • It is important to get beyond the "victim mentality."
    • This is not about purchasers singling out hospitals, but about hospitals coming up to speed.
  • It is a tough world for all businesses and organizations, and hospitals need to take some responsibility and be accountable.

Priority Actions

  • Rural hospitals can implement numerous best practices and can adopt a culture of safety before tackling capital-intensive issues like CPOE. "We just need to get to work."
  • Rural hospitals need to share resources and make greater use of long distance learning opportunities.
  • To develop a culture of safety we need good data.
    • We need trending of that data so that we can see the system improving.
    • When a hospital adopts a non-punitive approach it will see reported problems go up substantially before they are brought down.
  • Employers, payers, providers, and patients need to have more dialogues like the one held in Madison, October 2001. They are all facing the same challenges.
  • Money is only one part of a complex equation. Simply spending more money for quality seems wrong.
  • Workforce issues potentially stand to jeopardize hospitals' ability to improve quality and patient safety.
    • Universities and vocational technology schools are key stakeholders should become much more involved in this dialogue to help address the workforce issues.

Priority Buy-in

  • Employers are greatly interested in this topic.
  • Patient safety needs to be a higher priority for our boards.

Priority Models and Examples

  • The success stories come from organizations taking an integrated approach to safety.
    • Hospitals need to be creative to integrate efforts.
    • All concerned stakeholders need to take ownership of addressing the issue.
  • Improving hospital quality is similar to improving quality in other industries—Improvement requires a change in attitudes and a change in corporate culture.

Actions for Implementing Initiatives

  1. What would it take to implement these particular practices and standards.
  2. Barriers to implementation.
  3. Strengths related to implementation.

In discussing actions for adopting or implementing the listed priorities, the workgroup discussed specific things that hospitals, health system leaders, and the field of health care services can do to further their adoption. The workgroup asked "what would it take?"

Hospitals can:

  • Identify a physician advocate or champion to make any progress with the medical staff.
  • Begin implementing WPSI's (Wisconsin Patient Safety Institute) 10 interventions to reduce medication errors immediately.
  • Utilize Making Health Care Safer: A Critical Analysis of Patient Care Safety Practices and work on implementing a few at a time.
  • Coordinate more effectively with regional centers when patient is transferred in and transferred back.
    • Implement good transfer agreements and better guidelines about when we can serve and when we need to transfer.
  • Develop an admission agreement in Madison to more readily get our patients admitted in Hospital X with HMO X when Hospital Y with HMO Y has a full ICU.
  • Consider the Joint Commission (JCAHO) as a surrogate and focus on the WPSI initial recommendations.
  • Benchmark with similar facilities.

Hospital or health system leaders can:

  • Encourage data driven, non-punitive approaches.
  • Focus on implementing initiatives within a rural context.
  • Encourage better staff use of free information-gathering opportunities, such as less expensive audio-conferences.

The field of health services can:

  • Create a demand for assistance, such as a best practices repository.
  • Remember that not all rural facilities are the same when considering patient safety initiatives.

The workgroup discussed barriers to implementation.

Workforce Barriers

  • Rural organizations lack, and are less likely to get, dedicated resources for patient safety efforts.
  • In rural facilities, many people wear multiple hats and this whole subject quickly becomes overwhelming.

Structural/Systemic/Environmental Barriers

  • Varied parties are asking for a response to patient safety, making it very difficult to focus energies specifically.
  • The lever of using quality report cards stems from the sense that there are no other alternatives for employers, yet it comes across as punitive.
    • It will be a challenge to leverage creating a statewide culture of patient safety and accountability that is not punitive and penalizing.
  • We face the prospect of moving back to discounted fee-for-service purchasing which is in a direction against an emphasis on purchasing quality.
  • The lever of dropping a provider group is not realistic in a rural areas.
  • Multiple and often contradictory external expectations often confounds hospitals with tight resources.
    • We spend so much time and money on JCAHO that it is very discouraging to hear that doing well with JCAHO is not enough
  • Malpractice carriers often send mixed messages.
    • Some believe that while malpractice carriers take some steps to encourage providers to change and better identify problems, they still function under the old paradigm of quality assurance that involves inspecting, identifying, and holding providers personally and/or solely responsible for errors.
    • Following old quality assurance practices directly contrasts with a systems-based approach to addressing medical errors.

Attitudinal Barriers

  • The initial response to the IOM (Institute of Medicine) report was to reinforce the "Gotcha Culture."
    • It will be important to eliminate that mentality to make patient safety strides.

Purchasing Barriers

  • Employers are in the untenable position of needing to purchase higher quality care at lower prices.
    • The Minnesota State employee strike is just the beginning of things to come.
  • Increased cost sharing may not be feasible, particularly with unionized public employees, or have much influence on consumers to make better decisions.

Data/Measurement Barriers

  • Available data does not provide clear guidance about where to act first.
    • Too many competing priorities make it more confusing—both within and besides the patient safety discussion.
    • This is a tough problem to get your arms around.
  • There is little consensus in the state about appropriate uses for collecting and publicizing quality improvement data.
    • Data sets are collected and disseminated according to on the intention behind their use.
    • Intentions for data collection and dissemination can include fostering external accountability by publishing data for purchasers and consumers to use in decision-making; or addressing internal improvement issues by collecting and using data to support internal improvement studies or projects.
  • Validity of quality improvement information and measures continue to be a challenge within rural hospital.

Also discussed were strengths related to implementation.

Structural/Systemic/Environmental Strengths

  • Many people choose to work in rural health and have loyalty and pride in doing so.
  • There are more opportunities for collaboration with rural hospitals through networks such as the Rural Wisconsin Health Cooperative.
    • Group purchasing for things like CPOE, for example, might be more achievable among rural hospitals, given the rural tendency to collaborate.

Attitudinal Strengths

  • Rural hospitals are not asking for exemption from Leapfrog.
  • The second-class label is inappropriate.
  • Rural hospitals are not as consumed by competition.

Other Strengths

  • Reducing variation in practice is key for decreasing errors, and rural has many opportunities to do so.

Suggested Roles for Key Stakeholders in Implementation


  • Do much statewide to assist the local hospitals. We can collect data, research and encourage appropriate State policy changes that will be relevant to small rural hospitals.
  • Provide financial assistance and help coordinate resources.
  • Conduct an analysis of equipment being used in Wisconsin (e.g., which IV pumps are safest).
  • Pick an issue and focus regional and statewide support of it.
  • Survey or publicize the safe practices being used in Wisconsin rather than surveying and publicizing the incidence of problems.
  • Try to reach a national agreement about:
    • Which data we expect to be disclosed and which can be kept private.
    • What we can do to educate the public.
  • Be more thoughtful about what they pay for (Centers for Medicare & Medicaid Services [CMS], insurers, Alliance, etc.) regarding quality.
  • Business needs to set standards for what it will buy and be prepared to take the flack when it drops a provider who can't deliver the quality requested.
  • Educate employees to be better consumers, particularly as we increase "cost sharing" with them.
  • Note that Leapfrog is becoming increasingly sensitive to the provider perspective that multiple purchaser voices about what should or should not be disclosed is confusing and counterproductive.


  • Can participate in MetaStar activities and in ORYX activities, it would be helpful if the State Medical Society and American Medical Association did more to encourage physicians to get more involved with us.
  • Need to establish a basic level of quality and those of us who can't maintain it need to get out of the business.


  • One physician commented, "As a physician, I can assure you that many of my patients challenge my recommendations. Maybe I am trying to be too provocative but I would advise purchasers that "you are on your own" regarding the development of any system of public accountability. We as providers will remain defensive and that no approach will ever satisfy us and lead us to believe that it is fair."


  • We can combine data from ISMP (Institute Of Safe Medication Practices), MetaStar (the WI PRO) and JCAHO.
    • There needs to be public accountability and reporting regarding egregious (extreme/gross/flagrant) errors.
  • From the purchasers perspective, we think we are already paying for quality and we are not looking to pay more (In the room we have purchasers representing over half a million individuals).
  • Currently, costs are going through the ceiling which makes it difficult for purchasers to focus on quality.
    • Some elements of cost inflation are due to quality problems.
    • At the very least, we should be focusing on the "low hanging fruit."
  • As consumers need to share more costs, they will demand more information about providers.
  • Employers frequently purchase insurance, not healthcare. What is the role of insurers in this discussion?
  • We need more of an effort to remove disincentives than to create incentives. This is a key conceptual difference.
  • Leapfrog employers believe that they need to:
    1. To create incentives for disclosure.
    2. Work in good faith to create safe harbors around quality improvement data.
    3. Support malpractice reform.

Researchable Questions

General Research Suggestions

  • Research should be conducted in and about smaller hospitals, not just larger ones.
  • Drill down into the data about the use/benefits of clinical pharmacists in smaller, rural hospitals.
  • We need more research about outcomes in rural hospitals and about the best measures and measurement processes.
  • Hospitals can be seen as the point in the system where a lot of external resources come together. We need more research regarding how we can reduce the variation in these inputs (pumps, uniform bar codes, etc.).
  • We need to pool data about smaller volume facilities to better understand the outcomes of rural ICUs, as an alternative to simply extrapolating from studies of much larger urban ICUs.
  • The research data supporting CPOE was not from small rural hospital; it should be an open question whether this expensive investment is valid for these environments.

Specific Research Questions

  • What variation exists in utilizing critical pieces of equipment and processes?
  • How can quality improvement data be protected?
  • What are hospitals currently doing for patient safety and how we can best learn about their best practices?
  • What are the legislative alternatives for limiting discoverability of incidence reporting?
  • How can education and training programs better prepare practitioners to help develop and be part of "cultures of safety?"
  • What is the relationship between staffing ratios and patient safety?
  • What is the correlation between single task workers and patient safety?
  • How do licensing and regulation sometimes present barriers as well as supports for safety?
    • Example: Single task workers were found to be very successful in nursing homes, and gave better quality care, but this practice was in conflict with a current regulation, so these workers had to eliminated.
    • We need to see more collaboration between RWHC and WHA is needed around this issue.

Additional Comments/Observations

  • We need legislation to deal with the barriers related to discoverability of quality improvement data.
  • The Wisconsin Patient Safety Institute is an important and useful forum for the state to come together to create a state culture of patient safety.
  • There is a general and mistaken assumption that the solutions are the same in all settings (this is basically a misapplication of the "medical model") but sociology and anthropology tell us otherwise.
  • There is no perfect set of behaviors and patients will make choices based on a variety of factors in addition to "data": experiences of friends and families, location, their own values, community support, personality of providers.
  • We need to direct more dollars directly to rural hospitals as seed dollars for patient safety initiatives (this was from an employer representative).

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