SPRING 2012

DIRECTOR'S COLUMN

Mark Schoenbaum

THE CENSUS AND THE SAFETY NET

The 2012 Minnesota legislature recently adjourned, and candidates are turning their focus to the fall campaign. Members of Congress are also gearing up for the 2012 election. Candidates will be running in districts recently reconfigured by 2010 census results and the decennial redistricting that follows. Driven by the census, there are some important changes in the legislative map. Demographics have also altered the location and characteristics of those who use Minnesota’s rural and urban health care safety net. These changes are connected in important ways.

US Census data for Minnesota, 2010

The central trend reflected in the U.S. Census graphic above is continued growth in the Twin Cities suburbs and a significant increase in populations of color statewide. There is also population loss in many rural counties and static populations in Minneapolis and St. Paul. The fringe areas of the metro area grew, with their blend of suburban and rural territory. Also, poverty rates have increased in a number of suburban counties, accelerated by the 2008 recession.

Minnesota’s demographic changes are confounding how we traditionally think about health care access challenges and the safety net system that responds to them. Population changes have dispersed health care access challenges more evenly across the state. The challenges to finding health care may be economic, geographic, language and cultural, age or disability, depending on the area, but communities across Minnesota now have more of these issues in common than they have had in the past.

For policymakers, there are both federal implications -- largely related to Medicare and the Affordable Care Act -- and numerous state issues. For example, Minnesota’s safety net clinics have historically been located in the inner city and remote rural areas. But these providers are now emerging elsewhere as well: the federal government has funded a southern Minnesota community health center in Mankato, and planning for safety net clinics is underway in Bemidji and in Mille Lacs and Sherburne Counties.

Population changes are, of course, directly reflected in new legislative and congressional districts. The legislative make-up is now predominantly suburban, and as we’ve seen, these districts now include more low-income and minority residents who are likely to seek services through the health care safety net. Growing exurban districts may begin to be affected by rural-like drive time and transportation challenges to finding care at a reasonable distance. And many rural areas will continue to face challenges to sustaining facilities needed to serve an even sparser population.

In the coming decade, policymakers across Minnesota will have more of these issues in common than ever before. Educating all policymakers and elected officials will be essential to maintain and improve Minnesota’s health care safety net over the next 10 years.

Mark Schoenbaum is director of the Office of Rural Health and Primary Care and can be reached at mark.schoenbaum@state.mn.us or 651-201-3859.

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PARTNER FOCUS

"..the single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes."

CREATING A CULTURE OF PATIENT SAFETY IN RURAL CRITICAL ACCESS HOSPITALS

by Janelle Shearer, R.N., B.S.N., M.A., Program Manager, Stratis Health

Stratis Health, a nonprofit Minnesota quality improvement organization, and the Minnesota Department of Health’s Office of Rural Health and Primary Care are addressing patient safety in a new collaborative project dedicated to improving safety culture in rural Minnesota critical access hospitals (CAHs). The following CAHs have signed on to participate in the project, which focuses on achieving organizational changes in each facility to improve the culture of patient safety:

Appleton Municipal Hospital
Cook County North Shore Hospital
Deer River Health Care Center
LakeWood Health Center
New River Medical Center
Perham Health
Rainy Lake Medical Center
Redwood Area Hospital
River's Edge Hospital and Clinic
Sanford Health Bagley

Through this project, Stratis Health is assisting CAHs in assessing their safety culture and providing them with assistance and resources to improve performance in targeted areas of need, such as teamwork, communication and leadership engagement. Adapted from the Institute for Healthcare Improvement Breakthrough Series collaborative model, the project builds on Stratis Health’s previous work on safety culture conducted with 16 Minnesota CAHs in three separate projects.

The new collaborative brings together Minnesota CAHs and provides a forum for discussions and the exchange of ideas and strategies for implementing safer practices and processes. Together teams learn about patient safety theory and proven strategies, try out tools and processes, and leverage resources. They have the opportunity to capitalize on lessons learned and best practices from other CAHs that have successfully applied culture change strategies in their organizations.

Melissa McGinty-Thompson, Clinical Nurse Specialist and Clinical Leader from the Chippewa County/Montevideo Hospital, participated in an earlier safety culture initiative and offers tips for CAHs participating in the new collaborative: "Get as many different disciplines involved in the project from the beginning -- including physicians and front-line staff. And communicate, communicate, communicate!”

The process
Each hospital begins the project by forming a multidisciplinary team dedicated to supporting organizational culture change. The team includes clinical and administrative leaders, physicians, nurses and front-line staff who attend learning sessions, participate in project activities, and regularly test and make improvements.

An initial key step in the project, completing the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture, is designed to help CAHs assess the existing culture of safety in their facilities, identify strengths and areas for improvement, then evaluate improvement efforts. Joint Commission studies on leadership standards show that higher scores on patient safety surveys are correlated with improved clinical outcomes and higher staff retention. The survey assesses areas such as communication openness, feedback related to errors, non-punitive response to errors, frequency of events reported, hospital handoffs and transitions, and management support for patient safety. Stratis Health assists hospitals in interpreting their survey results and in building organizational capacity to improve their culture, and provides regular support including one-to-one coaching calls throughout the project.

Educational sessions include evidence-based models to improve teamwork, leadership and communication, such as the philosophy and practice of a Just Culture and the TeamSTEPPS® approach to improving teamwork and performance. The project ends with a re-measurement survey and analysis of the final results.

Creating shared accountability
In a culture of patient safety, managers recognize there is seldom a single reason for a mistake -- when something goes wrong, it is not necessarily someone’s fault. A chain of events that has gone unnoticed most often leads to a recurring safety problem, regardless of the personnel involved. Solutions are based on prevention, not punishment. Stratis Health Project Manager Janelle Shearer says, “We believe that people come to work to do a good job. Given the right set of circumstances, any of us can make a mistake.”

In the new collaborative, CAHs also learn how to adapt Just Culture principles in their hospitals. Just Culture, a patient safety model developed by David Marx, JD, describes a shared accountability approach to patient safety that recognizes the inevitability of human error and encourages supervisors to avoid inappropriate disciplinary actions. Staff must feel comfortable speaking up about problems, errors, conflicts and misunderstandings without fear of blame or punishment. However, in a Just Culture, individual accountability is not ignored. When incompetence, sub-standard performance and reckless violations are identified through a thorough investigation of facts, corrective or disciplinary action is taken appropriately.

Participating hospitals also learn about the TeamSTEPPS® approach. TeamSTEPPS® focuses on creating high performing teams and increasing awareness of a team’s responsibility for fostering patient safety. Teams learn how to improve information-sharing and resolve conflicts, as well as how to eliminate barriers through engaged leadership, strategic communication, situation monitoring and mutual support.

By the end of this project, the participating CAHs will have a better picture of how to implement a culture of safety in their facilities. “In this rapidly changing health care environment, a cohesive team approach, based on collaboration and direct communication, ensures that patients receive safe, quality care,” said Jennifer Lundblad, PhD, MBA, president, and CEO, Stratis Health. “Open discussion promotes patient-centered care, which assists health care providers in delivering the highest quality and safest care to patients."

Read more about improving patient safety culture:

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SPECIAL FEATURE

Michael Bayliss

Photo of Stephanie Klein
Stephanie Klein

Photo of Alicia Nesvacil and Carol Lundstrom
Alicia Nesvacil and Carol Lundstrom

READY TO WORK: BUILDING THE HEALTH IT WORKFORCE

by Sunny Ainley, Associate Dean, Normandale Community College

In June, 150 students -- ranging from seasoned health care practitioners to information technology professionals -- completed the first six-month, intensive Minnesota Health Information Training Program. The U.S. Department of Health and Human Services and the Office of the National Coordinator for Health Information Technology sponsored the program and Normandale Community College trained the students. Read about three graduates and their expectations, career opportunities and enhanced skills.

Michael Bayliss
When Michael Bayliss’ information technology position at the Bloomington Public Schools system was eliminated, he decided the Minnesota Health IT Program would complement his skills in project workflow and redesign, and his associate’s degree in computer science.

“The program was an excellent opportunity for me to bridge my IT training to the health care industry. While I was still in the program, I met with the Mille Lacs Health System about a practicum. We talked about the program and industry trends. It became clear that Mille Lacs Health System really needed someone with my training to help them implement their electronic health record system. That was a great moment: My skills and everything I had learned in the program were relevant enough to be hired.”

Because Mille Lacs Health System is a small critical access hospital, Bayliss was able to wear many different hats: building information systems, troubleshooting and dealing with project management, workflow redesign and help desks. His work was so valuable that the practicum turned into a paid position with Mille Lacs.

Stefanie Klein
Stefanie Klein entered the MN Health IT Program passionate about holistic medicine and complementary health care. She wanted to incorporate her personal health care experiences and beliefs with her professional information technology background.

After completing the program, Klein joined Mighty Oak Technology, a Minnesota-based certified electronic health record vendor specializing in speech recognition for the chiropractic and specialty clinic industry.

“I’m working with clinics that use integrative health and healing techniques such as acupuncture, yoga and massage to help patients. As a result of my training, I’m able to speak the health care language with the chiropractors, understand what they are saying and translate meaningful use requirements. It is very satisfying to see the role medical records are playing in helping patients. Recently one of our clients was updating a patient’s active medication list when a drug-to-drug interaction alert came up in the electronic health record software. The patient notified the primary care provider who immediately stopped the medication and the muscle weakness that the patient had been experiencing was resolved!"

Alicia Nesvacil
Alicia Nesvacil had been steadily working her way up at HealthPartners -- from quality management into information technology to project management -- when she enrolled in the MN Health IT Program.

“I wanted to focus on meaningful use and incorporate other health information technology related areas into my work at HealthPartners to make things simpler from a patient care standpoint. In trying to improve the process, I saw a gap in quality management and information technology when it came to health records. Knowing and understanding the connection that health information technology has in providing excellent care is a great benefit to our patients. The program helped me make links that weren’t clicking before. Thanks to the resources and the curriculum, I am able to customize the tools, which is very helpful.”

HealthPartners appreciates the link between Alicia’s HIT work and patient care. “HealthPartners is not new to electronic records, but government measures have helped organizations in contributing to better patient care, insuring patient safety, reducing medical errors and giving the patients and doctors the information they need at their fingertips,” said Carol Lundstrom, director of Care Delivery Systems at HealthPartners.

About the program
Normandale Community College is among 17 midwestern community colleges training workers to help health care facilities and medical practices meet the requirements of the Health Information Technology for Economic and Clinical Health Act (HITECH). Estimates based on data from the U.S. Bureau of Labor Statistics, the U.S. Department of Education and independent studies indicate a national shortfall over the next five years of approximately 51,000 qualified health information technology workers as hospitals and physicians move to adopt electronic health care systems.

The colleges are using the HITECH grant funds to provide training to current and future health care workers through a six-month training program. The MN Health Information Technology (HIT) Training Program focuses on four roles:

Practice Workflow and Information Management Redesign Specialist
Clinician/Practitioner Consultant
Implementation Support Specialist
Electronic Health Record/Application Trainer

The training incorporates “hard” technical skills with “soft” skills such as problem solving, decision making and time management. The program is online, distance learning with intermittent face-to-face meetings. To be eligible for the program, students must have experience in an information technology or information system role in business or health care, or have experience as a clinical practitioner or in medical records, health information management, medical billing or in a hospital business office.

Despite the training, finding a permanent position can be challenging. Many health care employers are still unsure which HIT roles and positions their organizations need. Others are reluctant to hire candidates who don’t have prior clinical experience, or who aren’t trained in a specific, proprietary software system (such as EPIC or NextGen). Despite these challenges, 84 percent of recent participants in Normandale’s program have found employment.

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RHAC MEMBER PROFILE

sen. lourey photo
Sen. Tony Lourey

ORHPC TALKS WITH RURAL HEALTH ADVISORY COMMITTEE (RHAC) MEMBER SEN. TONY LOUREY

Please explain your professional work to us.
Before my election to the Senate, I consulted with states and counties around the country to help them restructure and refinance their health and human services departments. My business partners and I brought in expertise on federal regulations and were able to help our clients leverage funds to reform and improve their services.

In the Legislature I serve on the Higher Education and Transportation Committees. But health is where I continue to live and breathe and I am the caucus lead in the Health and Human Services Committee.

And your life away from work…
I have always farmed, but since the Legislature is set up for an agrarian schedule of January through May, I am able to really throw myself into farming. I raise grass-fed beef. I experience the struggles that all farmers have, but I love my cows! My wife runs an apple orchard so we are both working the land.

What do you think are the most important issues facing rural health?
Well, speaking of grass-fed beef and apples, the food we eat is critical to bringing health to our population, and that is not a focus often enough. If we are not eating the right food, we can provide all the health care available and it still won’t matter.

But workforce is also a really tough issue. We need solid primary care and preventive care and this is especially challenging in greater Minnesota because of the changes that have come online for funding medical education.

What do you think would make the most difference for rural health?
We need to change how we fund medical education so graduates are financially able to pursue a career in primary care, if that is the path they choose. Today’s economics essentially force them into specialty fields in order to earn a salary high enough to repay their medical school debt.

Some of the transparency efforts underway in Minnesota have the potential to help us understand this dynamic better. If we do Provider Peer Grouping properly, we have the opportunity to shine a light on today’s funding of medical education. Greater public funding of medical education is warranted, although I am not wedded to any particular approach. We have to look at what we want as a society. If we leave the system as it is, we will continue to bear increasing costs and the heath care workforce needs -- particularly for greater Minnesota -- will become more difficult to meet.

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	View online all previous issues of the Office of Rural Health and Primary Care publications.
DON'T MISS OUT! REGISTER NOW for the JUNE 25-26 2012 RURAL HEALTH CONFERENCE!		Minnesota Office of Rural Health and Primary Care P. O. Box 64882 St. Paul, Minnesota 55164-0882 Phone 651-201-3838 Toll free in Minnesota 800-366-5424 Fax: 651-201-3830 TDD: 651-201-5797 www.health.state.mn.us/divs/orhpc

	MISSION To promote access to quality health care for rural and underserved urban Minnesotans. From our unique position within state government, we work as partners with communities, providers, policymakers and other organizations. Together, we develop innovative approaches and tailor our tools and resources to the diverse populations we serve.

Contents:

SPRING 2012

DIRECTOR'S COLUMN

THE CENSUS AND THE SAFETY NET

PARTNER FOCUS

CREATING A CULTURE OF PATIENT SAFETY IN RURAL CRITICAL ACCESS HOSPITALS

SPECIAL FEATURE

READY TO WORK: BUILDING THE HEALTH IT WORKFORCE

RHAC MEMBER PROFILE

ORHPC TALKS WITH RURAL HEALTH ADVISORY COMMITTEE (RHAC) MEMBER SEN. TONY LOUREY