Spring Quarterly Newsletter



Photo of spring magnolias in bloom  


photo of Mark Schoenbaum
Mark Schoenbaum


This issue includes an article about FirstLight Health System in Mora, an independent, county-owned hospital that has made major changes in the last few years. As you’ll read, FirstLight took ownership of clinics in two neighboring communities and is making an intense effort to connect with its community and patients as health reform continues to unfold.

The number of independent hospitals has been dwindling for quite some time, and the pace of affiliation has picked up in recent years. A 2013 ORHPC publication for the Rural Health Advisory Committee (RHAC) documented this trend, which has been both rural and urban.

In a survey for the issue brief, CEOs of both affiliated and nonaffiliated Critical Access Hospitals reported similar experiences on matters such as their ability to recruit physicians and other providers, addition of new services, adoption of electronic health records and financial sustainability. Both groups also tended to feel that recent trends in system affiliation will increase access to local health services in rural Minnesota.

Trend in Hospital Affiliation in Minnesota, 1987 - 2012

Graph: Trend in hospital affiliation in MN, 1987-2012 

Trend in Hospital Affiliation in Urban vs. Rural Minnesota, 1987 - 2010

Graph: Trend in hospital affiliation in urban vs. rural MN 

Much has been written about the challenges facing small and independent providers as Accountable Care Organizations (ACOs) begin to materialize. The data is clear that large systems and small providers are rapidly affiliating to reach the population scale and pooled resources generally needed for ACOs and similar models, even while FirstLight and others seem committed to an independent path. It will be interesting to watch as multiple models for reform develop in rural Minnesota and throughout the state.

A striking example of new alliances is the Federally Qualified Health Center Urban Health Network. Ten Federally Qualified Health Centers (FQHCs) in the Twin Cities have formed a loose affiliation to jointly serve Medicaid patients through the state’s Health Care Delivery System demonstration. Even though FQHCs may not be as likely to be absorbed by large systems as other types of providers, it still takes grit and new thinking for independent organizations to band together as a virtual ACO.

On a related note, the Office of Rural Health and Primary Care recently began its first formal strategic planning process in several years. Thanks to those who completed the stakeholder survey for this process. We are first and foremost a customer service organization, and your input will help us respond best to your needs. We updated our mission statement, both to reinforce our commitment to rural and underserved urban communities and to better reflect the responsibilities we’ve been given for statewide initiatives such as the Statewide Trauma System, health workforce analysis and supporting health professions education through the Medical Education and Research Costs Program (MERC). Our new mission statement is:

The mission of the Office of Rural Health and Primary Care is to promote access to quality health care for all Minnesotans.

We work as partners with policymakers, providers, and rural and underserved urban communities to ensure a continuum of core health services throughout the state.

Let us know what you think, and stay tuned for additional details on our next directions.

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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The year 2011 was a big one for health services in Kanabec and Pine Counties. The county-owned critical access hospital in Mora, then known as Kanabec County Hospital, acquired three clinics: one in Mora and two in neighboring Pine County (in Pine City and Hinckley). A new electronic health record (EHR) system was implemented. And the expanded organization, now covering a service area approximately 90 miles by 60 miles, renamed itself FirstLight Health Systems.

Taken together, the multiple changes added up to what one staff person called a “huge upheaval in a small rural community.” In its wake, FirstLight staff stepped back and assessed what needed attention. Their conclusion: The now larger and more complex health system needed to reconnect with its patients and the additional communities now served. Specifically, it needed a better understanding of community members’ needs and perceptions - not only to ensure that the organization was being responsive to those issues, but also to provide its expanded staff with a shared understanding of the patient experience and how to improve it.

Patient engagement + staff engagement

Their approach went beyond most patient satisfaction surveys. FirstLight sought to go deeper, by conducting in-depth “solution-based dialogue” with community members in addition to a more traditional survey. And it is using the findings more intensively as well, by having individual departments across the FirstLight system develop improvement goals and plans - and specific measurements to gauge progress - based on ongoing input from patients.

The project, supported in part by a grant from the Office of Rural Health and Primary Care’s Rural Hospital Flexibility Program (the “Flex” program), had several key components:

  • Initial survey. With the help of an outside consultant, FirstLight conducted a “patient satisfaction and engagement survey” of patients seen in the past year. Importantly, the survey went to patients who had received outpatient services - including the ambulatory clinics, rehab, lab and imaging - as well as inpatient. “This helped address a huge gap we had in outpatient data,” said Dawn Plested, director of communications and patient experience. “We had no idea how we were doing in some of those areas before that.” The results were combined with other hospital survey results (e.g., the Hospital Consumer Assessment of Healthcare Providers and Systems survey, also known as HCAHPS) in an overall presentation.

  • Staff analysis of data. In addition to presenting overall results to the leadership team and Board of Directors, FirstLight held breakout sessions with all patient care areas to analyze the data in more depth and address findings specific to their areas. “I wanted our dictation staff to understand this information just as well as our CEO did,” said Plested.

  • Focus groups. FirstLight held six focus groups, each of which met several times for a total of five hours. The groups targeted key patient populations for the health system: (1) surgery patients; (2) clinic patients; (3) emergency services patients; (4) pregnant women and new mothers; (5) Millennials (ages 8-29 years); and (6) residents of Pine City and Hinckley, new areas for FirstLight. Here, too, staff were very involved: Each department helped craft questions for the focus groups, based on survey data.

  • Patient experience initiatives. Based on the results of the surveys and focus groups, each department has begun planning quality improvement projects directly tied to patient experience. Measurement and data are key components of each initiative, and include customized questions that will be included in future patient surveys and addressed by at least one new Patient Advisory Council.

Successes and surprises

The project has yielded important insights and changes for FirstLight, some of which have already led to measurable improvements. The admitting department, for example, has implemented changes based on the survey and focus group feedback and seen its patient satisfaction scores improve to nearly 100 percent in 2012, a dramatic increase from 2011. The project also uncovered surprises: one department that was expected to excel in patient opinion ended up scoring poorly on the initial survey - “a real shock to staff,” says Plested. Through the focus groups, however, the department was able to ask patients why. This led not only to key information about their services, but helped avoid individual blame. “It took the feeling of personal attack out of it,” said Plested. “It was just very eye opening.”

The project also led to concrete changes, from workflow specifics to broader structural shifts. It has helped identify bottlenecks - again, thanks to the patient perspective - and allowed staff to explore and improve processes that might not otherwise be identified as issues except as experienced by patients. In at least one department, the project led to a different staffing structure. Based on patient feedback, the oncology department switched from a floating-nurse system to a dedicated nurse manager for that group. The switch has resulted not only in greater patient satisfaction - as patients now know and work with the same nurse over time - but more consistent care.

The challenge of change

Like any project involving change, this one also came with challenges and limitations. Measurement was key, yet it was initially difficult figuring out how to obtain sufficient data for individual departments to set S.M.A.R.T. (Specific-Measurable-Attainable-Relevant-Time-bound) goals for their team and measure progress over the long-term. Ensuring buy-in from managers and staff was sometimes challenging, too. “The philosophy of patient experience requires personal sacrifice - it’s not just what’s best for us, it’s what’s best for the patient,” says Plested. “That’s not always in tandem."

Plested credits the commitment of FirstLight’s Board of Directors and its CEO, Randy Ulseth, to helping move the project beyond some of the initial resistance. Involving direct care staff at all steps was also important. Finally, she emphasizes that it is not intended to be a one-time initiative. The goal is to make patient engagement and feedback integral to how the health system operates: “This is an ongoing labor of 'hardwiring excellence' in the patient experience into our culture."

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by Lorry Colaizy, Minnesota J-1 Visa Waiver Program Administrator

According to the American Medical Association (AMA), by 2025 - not very far away - the United States will face a shortage of 130,000 physicians. The recruitment and retention of appropriate numbers of a large variety of health care professionals will continue to be a concern in Minnesota for years to come. One successful program available to the state’s employers to help recruit and retain physicians is the J-1 Visa Waiver Program (also known as the J-1 program).

The J-1 program, administered in Minnesota by the Office of Rural Health and Primary Care (ORHPC), is a federal immigration program that allows states to recommend up to 30 visa waivers every year for physicians who received their medical education in, and are citizens of, another country. The waiver then permits the physician - who would otherwise be required to return home after medical residency - to stay in the state and practice medicine. In doing so, the program affords Minnesota providers an opportunity to recruit from a larger pool of highly trained and highly skilled international doctors they would not otherwise be able to consider.

Requirements for physicians can vary by state, but to qualify for a J-1 waiver in Minnesota, a physician needs to agree to work for at least three years providing direct care to underserved patients. If the employing facility can’t demonstrate a commitment to the underserved, ORHPC will not recommend a visa waiver.

Change and retention

The program has evolved and expanded over the years. In 2004, Congress decided to allow states to recommend specialists for visa waivers, and to allot as many as 10 waivers a year for practice locations not in a defined shortage area, as long as the employing facility could demonstrate a significant number of patients served actually live in shortage areas. Congress is currently considering a number of new ideas to expand the program still further.

The J-1 program has been very successful both in recruiting new physicians and in retaining them in Minnesota. Since the program began in 1994, ORHPC has recommended waivers for 349 physicians. Of those, 211 (60 percent) committed to practice in rural underserved areas and 184 (53 percent) committed to practice in primary care. A complete list of placements by rural/urban and primary care/specialty care is available on the ORHPC website.

Although the program requires that physicians provide clinical care to underserved patients for only three years, many choose to practice in Minnesota for much longer. As of 2012, a full 76 percent of the international physicians who had received J1 waivers between 1996 and 2009 were still licensed to practice in Minnesota. Many remain for 10 years or longer, such as Dr. Andrew Kiragu of Hennepin County Medical Center, whose interview is featured below.

For more information and guidelines for the Minnesota program, visit the Minnesota J-1 Visa Waiver program page.

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Andrew W. Kiragu, M.D., F.A.A.P., received a J1 Visa Waiver through the Minnesota J-1 Visa Waiver Program in 2002. He is currently medical director of the Pediatric Intensive Care Unit at Hennepin County Medical Center (HCMC) and an assistant professor of pediatrics at the University of Minnesota. The J1 program requires that physicians practice in a designated shortage area for three years. Dr. Kiragu has remained at HCMC for nearly 12 years. We recently sat down with Dr. Kiragu in his office at HCMC to talk about his experience as a J1 physician.

Please share your journey - how did you come to be here, practicing medicine in a Minnesota shortage area?

I went to college in Canada at Dalhousie University and then to Howard University in Washington D.C. for medical school. Initially I wanted to go into Family Practice, but in my third year of medical school learned about residency programs in combined Internal Medicine and Pediatrics. The University of Minnesota was one of the programs I looked into.

One of the things that really attracted me to the program was the program director, a gentleman named Michael Shannon, who had done work with an organization called Minnesota International Health Volunteers. He told me about the group’s work in Kenya, where I’m originally from and where he had helped open a clinic. I didn’t discover this until later, but one of the people who had to approve that clinic was my mother, who at the time was Chief Nursing Officer for the City of Nairobi. So I felt a connection and came here, and did my residency and later a fellowship in pediatric critical care.

When I got done I had to make a decision - do I stay or do I go? My family and I elected to stay. As part of my training, I had spent time here at Hennepin as a resident and as a fellow, and got to know a number of the physicians. Around the same time, the J1 Visa Waiver program changed, opening up the opportunity to do subspecialty care while on the waiver; before that, only primary care was allowed. So it seemed like an excellent fit: a place where I had trained and worked with people I liked, and I was able to practice in the field I loved. And I’ve been here ever since.

What keeps you here?

One of the main reasons is the colleagues I work with. They are really dedicated pediatricians who work to help children from underserved communities who might not otherwise have that help. Working with folks who are committed to the mission of this facility has been a motivation for me. Some of my mentors here include Dr. Marjorie Horgan, Dr. Linda Thompson, Dr. Diana Cutts, Dr. Julia Joseph-Di Caprio (my boss) and Dr. Charles Oberg, who hired me.

And then, I think it’s been the work environment - Hennepin has been a good place to work with colleagues from different fields. I interact often with physicians from multiple specialties across the campus who make this a wonderful place to work. In many ways, I feel I’ve been quite lucky to work at HCMC. For the most part it’s been a very rewarding experience. I feel I’ve been able to help, but I’ve also grown a lot as a physician.

What recommendations would you give policymakers and employers looking to retain the skills of J-1 physicians?

That’s a hard question. Having information more readily available about the opportunities and the expectations would be helpful. Also having more opportunities available, as now there are only a limited number of spots available every year, might also help.

In a sense, you have a captive audience: You have a group of physicians who would like to remain in the U.S. They have already worked really hard to get here and they are motivated to continue on the journey they’ve embarked on.

I think the biggest step was made when specialists became eligible for the program, and then allowing people to practice in pockets of need, wherever those are found.

Do you think that making that change, so that we can do waivers for specialists, has made it easier to retain those doctors as well?

I think it has. I don’t know how many other waiver folks in Minnesota are still practicing here, but I figure there are still quite a few. They may not necessarily still be working at the facility they started in, but they’re still within the state. When folks find the spot they want to live, and they are able to practice their specialty, they’re less likely to leave. Because most people, when they like what they’re doing and the people they’re working with - which you guys don’t have much control over - it makes sense to stay. And if they don’t stay at the same place, they may still stay in the state. Minnesota is a great place to live.

What role might international physicians have in alleviating the projected shortage of physicians in the United States and Minnesota?

They will definitely play a role, because the country isn’t growing enough doctors to fulfill the need that will being created as more people seek a physicians care with the coverage they will be able to obtain under the Affordable Care Act (ACA). For many families the ACA means they will be able to see a doctor without worrying if that means their family won’t have food on the table. It’s a good problem to have, but you still need physicians who can see them. International doctors can definitely help fill that gap.

Also, although each of us comes with different backgrounds - different personalities, different levels of expertise - a lot of the J1 waiver docs have had to go through much more rigorous processes to be able to get into the system. So you’re actually getting a good doctor. Many have had to do residency twice, once in their home country and then again in the U.S., and then you have subspecialists. Some of the best physicians and physician-scientists in our state are international physicians. So in that sense, you’re getting a reasonably decent bang for your buck.

The physicians you bring in depend, in part, on the decisions you make with the waivers, and also the choices made by the institutions offering the residency programs. ┬áBy having this waiver process, you are getting good people - and you’re really helping the people of the state. I think if you look at every major medical facility in Minnesota, you’ll find J1 waiver physicians. Canadians, Africans, Indians, Europeans. Across the state, they’re making an impact.

I think it’s been good for the state to have a group of physicians that come from other parts of the world. Hopefully, it’s been reflected to some measure in the health outcomes for the state, too, as well as availability of care. We’ll see what happens when the ACA is fully implemented with regards to meeting the increased need. Minnesota has always been ahead of the curve in health care and hopefully we will continue to lead the way in this regard.

Hennepin County Medical Center is a Level I Pediatric Trauma Center and public teaching hospital located in downtown Minneapolis offering a full spectrum of inpatient and outpatient pediatric care.

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Please explain your professional work to us . . .

I work with Leech Lake Public Health Nursing as the Statewide Health Improvement Program (SHIP) Coordinator and also help implement our Community Transformation Grant activities. Part of my time is also spent in maternal-child health, primarily working with pregnant women to provide childbirth and breastfeeding education.

And your life away from work?

I’m very involved in the Ponemah Community located on Red Lake Nation. I visit frequently and participate in community activities there. I also do a lot of research and outreach around Native American midwifery, including interviewing midwives in Canada and other parts of the United States. I’m trained through DONA International as a birth and postpartum doula. It’s my passion. I do doula work in my spare time, but it goes hand in hand with my professional work too. When I’m visiting with mothers and fathers, I ask, “Do you know your birth story?” As a grandmother it is my right to teach, educate, mentor and provide cultural assistance when asked. If I do not carry the teachings they ask about, I will refer them to others in a good way.

What do you think are the most important issues facing rural health?

The most pressing issues facing rural health that I hear about are mental/behavioral health and oral health.

I am interested in learning more about how past and present health-related policies have changed for Native American communities in the last 50 years. While policies are important, it is up to the people to take charge of their own health issues for themselves and their communities.

What do you think would make the most difference for rural health?

It is important to monitor progress over the short- and long-term to show changes in individual and population health. Our state should consider the challenges related to health disparities and provide funding for cultural awareness trainings, retention of diverse providers, and hold caregivers for children, elders and those with disabilities in high regard. Most important is to maintain a respectful workplace so those accessing health care and public health services feel valued.

The Rural Health Advisory Committee advises the commissioner of the Minnesota Department of Health and other state agencies on rural issues; provides a systematic and cohesive approach toward rural health issues; and encourages cooperation among rural communities and providers. Meeting information is online.

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View online all previous issues of the Office of Rural Health and Primary Care publications.



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

  MISSION: To promote access to quality health care for all Minnesotans. We work as partners with policymakers, providers, and rural and underserved urban communities to ensure a continuum of core health services throughout the state.