Effect of critical access hospital conversion on patient safety.

The Institute of Medicine (IOM) definition of patient safety is “freedom from accidental injury due to medical care, or medical errors” (Kohn, Corrigan, and Donaldson 1999). More than 44,000 Americans die as a result of preventable medical errors each year and national costs of preventable adverse events were approximately $17 billion in 1996 (Kohn, Corrigan, and Donaldson 1999). Rural hospitals play a key role in providing health services in rural areas. Quality of care is one of the main issues that rural hospitals face. In improving quality of care, rural hospitals face several problems, including financial constraints (Moscovice, Gregg, and Klingner 2002), limited resources and knowledge (Moscovice 1989), and staffing (Moscovice and Stensland 2002). It was difficult for many of the smallest rural hospitals to recover their Medicare costs under the prospective payment system (PPS) rates (Moscovice and Stensland 2002; Dalton et al. 2003; Stensland, Davidson, and Moscovice 2004). In order to protect these small, financially vulnerable rural hospitals, the Medicare Rural Hospital Flexibility Program (Flex Program) of 1997 allowed some small hospitals to convert to critical access hospitals (CAH) and changed their Medicare reimbursement mechanism from prospective to cost based (Cameron, Zelman, and Stewart 2001). One objective of the Flex Program is to improve quality of care for those financially vulnerable rural hospitals. The Rural Hospital Flexibility Program Tracking Team conducted a phone survey of 217 CAHs in 2001 and found that most CAHs were involved in a broad range of quality assurance (QA) or quality improvement (QI) activities. Almost all CAHs (99–100 percent) used continuing education programs for staff, medical error reporting policy systems, and hospital QA or QI training initiatives. Eighty-seven percent of CAHs reported the use of data feedback to staff and 38–52 percent of CAHs reported that they strengthened QA/QI activities after converting to CAH status. Only 1–2 percent of CAHs reported that these activities became weaker (Moscovice and Gregg 2001). In their second year survey, they found that all of these activities were stronger over time after CAH conversion (Moscovice, Gregg, and Klingner 2002). Compared with preconversion, 52 percent of hospitals increased pooling or coordinating resources; 31 percent of hospitals increased the number of available QA or QI staff; 19 percent of hospitals increased appropriateness of credentials; 35 percent of hospitals increased use of critical pathway protocols; 38 percent of hospitals increased use of admission protocols; and 43 percent of hospitals increase the use of transfer protocols. Less than 5 percent of hospitals decreased QA/QI-related characteristics (Moscovice and Gregg 2001). While these reports document an increase in QA and QI activities after conversion, no studies have been published to date that examine the effect of conversion on outcomes. The aim of our study is to examine indicators of patient safety over time in Iowa rural hospitals to explore changes that occurred after hospitals converted from PPS to CAH status.