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Performance Improvement for Rural Hospitals: Front Line-Driven Change to Decrease Transfer Time from ED to Inpatient Admission
*Authors:* Chasatie Whitley, BSN, RN, CEN, Eddie Perez-Ruberte, MS, Linda Kimsey, PhD, Bettye A. Apenteng, PhD
*Highlights:* A recent performance improvement project undertaken by a Georgia Critical Access Hospital (CAH) demonstrates the potential for use of Plan-Do-Study-Act (PDSA) techniques to improve operations in the area of patient transfers from Emergency Department (ED) to Inpatient Ward. Implemented process improvement, including visual tracking of inpatient hold in the ED and bedside handoff led to reductions in admission decision to ED departure time and delayed or omitted ED admission orders. *Background:* The Georgia Southern Flex Team, funded by the Georgia State Office of Rural Health, assists the state’s CAHs in pursuing financial and operational excellence. Under an ongoing grant, the team contracted with Mr. Eddie Perez-Ruberte, a highly experienced quality improvement professional, to provide a virtual course in PDSA methodology and to engage in one-on-one virtual consulting with interested hospital personnel on PDSA projects. *Project Description:* Monroe County Hospital (MCH) is a 25-bed CAH with a nine-bed emergency department. During the first half of 2020, metrics on avoidable wait time indicated that MCH’s process of admitting patients from the ED needed improvement. Because of unaddressed areas of wait, the “admission decision to ED departure time” had been consistently longer than the organization’s goal for over six months. Given the limited bed availability in the ED (only nine beds), along with the negative patient experience associated with increased wait times, shortening the time from admission decision to ED departure was critical. Click to download full brief Click to download template

Performance Improvement for Rural Hospitals: Front Line-Driven Change to Decrease Transfer Time from ED to Inpatient Admission

Authors: Chasatie Whitley, BSN, RN, CEN, Eddie Perez-Ruberte, MS, Linda Kimsey, PhD, Bettye A. Apenteng, PhD

Highlights: A recent performance improvement project undertaken by a Georgia Critical Access Hospital (CAH) demonstrates the potential for use of Plan-Do-Study-Act (PDSA) techniques to improve operations in the area of patient transfers from Emergency Department (ED) to Inpatient Ward. Implemented process improvement, including visual tracking of inpatient hold in the ED and bedside handoff led to reductions in admission decision to ED departure time and delayed or omitted ED admission orders.

Background: The Georgia Southern Flex Team, funded by the Georgia State Office of Rural Health, assists the state’s CAHs in pursuing financial and operational excellence. Under an ongoing grant, the team contracted with Mr. Eddie Perez-Ruberte, a highly experienced quality improvement professional, to provide a virtual course in PDSA methodology and to engage in one-on-one virtual consulting with interested hospital personnel on PDSA projects.

Project Description: Monroe County Hospital (MCH) is a 25-bed CAH with a nine-bed emergency department. During the first half of 2020, metrics on avoidable wait time indicated that MCH’s process of admitting patients from the ED needed improvement. Because of unaddressed areas of wait, the “admission decision to ED departure time” had been consistently longer than the organization’s goal for over six months. Given the limited bed availability in the ED (only nine beds), along with the negative patient experience associated with increased wait times, shortening the time from admission decision to ED departure was critical.
Click to download full brief
Click to download template

A Role For Scenario Planning In Rural Hospitals
*Authors:* Linda G. Kimsey, Ph.D., Bettye Apenteng, Ph.D., Anna Rose Moore, Angela Peden, MPH
*Highlights:* Scenario planning typically focuses on the future, beyond the normal strategic planning horizon. It has been used primarily by large organizations, but it can be useful to organizations of any size trying to develop strategy for the future. COVID-19 has arguably broadened planners’ perspectives, thus emphasizing potential benefits from scenario planning for organizations, both large and small. Rural hospitals may find some scenario planning beneficial. *Background:* Formal introduction of scenario planning in the U.S. can be traced to Herman Kahn’s use of stories in military planning. Royal Dutch-Shell’s use of scenario planning is widely noted as the first big organizational use. Scenario planning involving plausible future oil pricing that differed from a mere extrapolation of current prices positioned the company to weather unexpected oil market shocks in the 1970s. The requirement to break from status quo, extrapolated forecasting—thereby forcing deeper strategic conversation—is the primary strength of scenario planning. Scenario planning usually focuses on the longer-term—beyond a normal time horizon for strategic planning (Schwartz, 1991), but there is no rule to prohibit its use in a shorter horizon. By asking the question of what might happen, scenario planning can be useful to any organization trying to develop strategy for the future. While it has been utilized by primarily large organizations, this approach offers meaningful contributions to organizations, no matter its size. Click to download full brief

A Role For Scenario Planning In Rural Hospitals

Authors: Linda G. Kimsey, Ph.D., Bettye Apenteng, Ph.D., Anna Rose Moore, Angela Peden, MPH

Highlights: Scenario planning typically focuses on the future, beyond the normal strategic planning horizon. It has been used primarily by large organizations, but it can be useful to organizations of any size trying to develop strategy for the future. COVID-19 has arguably broadened planners’ perspectives, thus emphasizing potential benefits from scenario planning for organizations, both large and small. Rural hospitals may find some scenario planning beneficial.

Background: Formal introduction of scenario planning in the U.S. can be traced to Herman Kahn’s use of stories in military planning. Royal Dutch-Shell’s use of scenario planning is widely noted as the first big organizational use. Scenario planning involving plausible future oil pricing that differed from a mere extrapolation of current prices positioned the company to weather unexpected oil market shocks in the 1970s. The requirement to break from status quo, extrapolated forecasting—thereby forcing deeper strategic conversation—is the primary strength of scenario planning. Scenario planning usually focuses on the longer-term—beyond a normal time horizon for strategic planning (Schwartz, 1991), but there is no rule to prohibit its use in a shorter horizon. By asking the question of what might happen, scenario planning can be useful to any organization trying to develop strategy for the future. While it has been utilized by primarily large organizations, this approach offers meaningful contributions to organizations, no matter its size.
Click to download full brief

CEO Turnover in Georgia Rural Hospitals, 2011-2017
Authors: Bettye A. Apenteng, Ph.D., Samuel T. Opoku, MBChB, Ph.D.; Linda G. Kimsey, Ph.D.; Charles F. Owens, MSA; William A. Mase, DrPH; Angela H. Peden, MPH
*Highlights: The average annual turnover rate in Georgia rural hospitals between 2011 and 2017 was 24%, with a low of 17% in 2012 and in 2015 and a high of 37% in 2016. Between 2011 and 2017, rural hospitals had on average, approximately two CEO changes, with 46% reporting three or more CEO changes. Annual turnover rates were found to be consistently higher in rural prospectively paid (PPS) hospitals, compared to Critical Access Hospitals (CAHs). Background*: Hospital chief executive officer (CEO) turnover rates have increased nationally over the last decade, increasing from 15% in 2007 to 18% in 2017, and after reaching a peak of 20% in 2013 (American College of Healthcare Executives [ACHE], 2008; ACHE, 2018). Unexpected leadership turnover can be disruptive for organizations operating in an ever-dynamic environment like healthcare. The existing literature indicates an inverse relationship between CEO turnover and hospital performance, with a stronger negative impact of turnover on performance in nonprofit hospitals (Brickley & Van Horn, 2002) and among small rural hospitals (Alexander & Lee, 1996). In 2018, the American College of Healthcare Executives (ACHE) estimated the CEO turnover rate in Georgia hospitals to be 20%, higher than the national rate of 18%. There is, however, a dearth of literature on CEO turnover in rural hospitals in the state. The purpose of this research brief is to describe CEO turnover in Georgia’s rural hospitals between 2011 and 2017. Click to download full brief

CEO Turnover in Georgia Rural Hospitals, 2011-2017

Authors: Bettye A. Apenteng, Ph.D., Samuel T. Opoku, MBChB, Ph.D.; Linda G. Kimsey, Ph.D.; Charles F. Owens, MSA; William A. Mase, DrPH; Angela H. Peden, MPH

Highlights: The average annual turnover rate in Georgia rural hospitals between 2011 and 2017 was 24%, with a low of 17% in 2012 and in 2015 and a high of 37% in 2016. Between 2011 and 2017, rural hospitals had on average, approximately two CEO changes, with 46% reporting three or more CEO changes. Annual turnover rates were found to be consistently higher in rural prospectively paid (PPS) hospitals, compared to Critical Access Hospitals (CAHs).

Background: Hospital chief executive officer (CEO) turnover rates have increased nationally over the last decade, increasing from 15% in 2007 to 18% in 2017, and after reaching a peak of 20% in 2013 (American College of Healthcare Executives [ACHE], 2008; ACHE, 2018). Unexpected leadership turnover can be disruptive for organizations operating in an ever-dynamic environment like healthcare. The existing literature indicates an inverse relationship between CEO turnover and hospital performance, with a stronger negative impact of turnover on performance in nonprofit hospitals (Brickley & Van Horn, 2002) and among small rural hospitals (Alexander & Lee, 1996).

In 2018, the American College of Healthcare Executives (ACHE) estimated the CEO turnover rate in Georgia hospitals to be 20%, higher than the national rate of 18%. There is, however, a dearth of literature on CEO turnover in rural hospitals in the state. The purpose of this research brief is to describe CEO turnover in Georgia’s rural hospitals between 2011 and 2017.
Click to download full brief

Georgia Rural Hospital Tax Credit Hospital Executives’ Perspectives, Community Awareness and Program Impact
Authors: Samuel T. Opoku, MBChB, Ph.D.; Bettye A. Apenteng, Ph.D.; Charles F. Owens, MSA; Linda G. Kimsey, Ph.D.; Imaobong Ekpo, MBBS; Emmanuel Akowuah, MSc; Michela Hizine, MPH; Oluwadamilolo (Lola) Onifade, BSN, MHA; William A. Mase, DrPH
*Background*: Eight rural hospitals have closed in Georgia within the last decade, and more are financially distressed. In 2016, Georgia legislation created a state income tax credit for individuals and corporations that donate to qualifying non-profit rural hospitals of their choice. This law, the first of its kind in the US, was intended to provide struggling hospitals with financial support to improve viability. Using a mixed-methods approach, this study assessed the perspective of hospital executives concerning the program, examined community awareness of the program, and evaluated how hospitals used the money to enhance access to care for rural populations. Click to download full brief

Georgia Rural Hospital Tax Credit
Hospital Executives’ Perspectives, Community Awareness and Program Impact

Authors: Samuel T. Opoku, MBChB, Ph.D.; Bettye A. Apenteng, Ph.D.; Charles F. Owens, MSA; Linda G. Kimsey, Ph.D.; Imaobong Ekpo, MBBS; Emmanuel Akowuah, MSc; Michela Hizine, MPH; Oluwadamilolo (Lola) Onifade, BSN, MHA; William A. Mase, DrPH

Background: Eight rural hospitals have closed in Georgia within the last decade, and more are financially distressed. In 2016, Georgia legislation created a state income tax credit for individuals and corporations that donate to qualifying non-profit rural hospitals of their choice. This law, the first of its kind in the US, was intended to provide struggling hospitals with financial support to improve viability. Using a mixed-methods approach, this study assessed the perspective of hospital executives concerning the program, examined community awareness of the program, and evaluated how hospitals used the money to enhance access to care for rural populations.
Click to download full brief

Strategies for Improving Profitability of Rural Hospitals: Are Profitable Hospitals Doing Something Different?
Authors: Bettye A. Apenteng, Ph.D.; Angela H. Peden, MPH; Raymona Lawrence, DrPH; Emmanuel Akowuah, MSc; Samuel T. Opoku, MBChB, Ph.D.; James Stephens, DHA; William A. Mase, DrPH
THE TOP FIVE STRATEGIES adopted by rural hospitals for the purposes of improving financial performance included improving patient satisfaction and care experience, adding new service lines or expanding existing service lines, community outreach, employee engagement, and physician engagement. Profitable hospitals were more likely than other hospitals to have implemented cost-cutting and internal and external stakeholder engagement strategies. *Background*: Nationwide, hospitals, as well as policymakers, are exploring strategies for improving the financial viability of rural hospitals. These efforts are in response to the critical need for sustainable hospital infrastructure in rural America and the negative impact the lack thereof can have on rural health. This study sought to describe efforts undertaken by rural hospitals to improve financial sustainability. Click to download full brief

Strategies for Improving Profitability of Rural Hospitals: Are Profitable Hospitals Doing Something Different?

Authors: Bettye A. Apenteng, Ph.D.; Angela H. Peden, MPH; Raymona Lawrence, DrPH; Emmanuel Akowuah, MSc; Samuel T. Opoku, MBChB, Ph.D.; James Stephens, DHA; William A. Mase, DrPH

THE TOP FIVE STRATEGIES adopted by rural hospitals for the purposes of improving financial performance included improving patient satisfaction and care experience, adding new service lines or expanding existing service lines, community outreach, employee engagement, and physician engagement. Profitable hospitals were more likely than other hospitals to have implemented cost-cutting and internal and external stakeholder engagement strategies.

Background: Nationwide, hospitals, as well as policymakers, are exploring strategies for improving the financial viability of rural hospitals. These efforts are in response to the critical need for sustainable hospital infrastructure in rural America and the negative impact the lack thereof can have on rural health. This study sought to describe efforts undertaken by rural hospitals to improve financial sustainability.
Click to download full brief

Last updated: 5/23/2022