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Managing What Is Measured: A Rural Hospital's Experience in Reducing Patient Harm

Stargell, Lucretia, F.; Heatherly, Stephen, L.

The Journal for Healthcare Quality (JHQ): May/June 2018 - Volume 40 - Issue 3 - p 172–176
doi: 10.1097/JHQ.0000000000000139
Translation of Research into Healthcare Quality Practice

ABSTRACT Effecting improvement in the small, rural hospital setting is often challenging. Harris Regional Hospital (HRH) is a small, acute care hospital in rural western North Carolina acquired by Duke LifePoint Healthcare in August, 2014. Since that time, HRH has been on a quality journey characterized by a data-driven approach to reducing patient harm events. Using a framework that comprised leadership, performance improvement, and cultural development to cultivate an environment of mutual respect and trust, HRH has demonstrated sustained improvement in patient harm events over a 29-month period from January 2015 to June 2017. The purpose of this article is to provide examples of scalable, effective tactics contributing to quality improvement in the rural hospital environment.

For more information on this article, contact Lucretia F. Stargell at

The authors declare no conflicts of interest.

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Effecting positive change in nationally measured hospital quality and patient safety metrics requires health care provider diligence and focus. Providers and hospitals receiving federal support in both urban and rural settings in the United States are required to meet and incrementally exceed the Centers for Medicare & Medicaid Services (CMS)1 established improvement targets. Aside from federal, state, local, and internal requirements, providing the safest environment with the best possible patient and family experience is what hospitals strive for and what every individual deserves when becoming a patient of a health care provider or facility.

Rural hospitals face unique challenges in ensuring quality and safety including increasing regulatory requirements, decreased reimbursements amidst health care reform efforts, lack of financial reserves, aging equipment and facilities, and increased requirements for efficiency. To achieve the greatest success in meeting or exceeding national quality targets, hospitals must ensure that there is an organizational structure that contains the needed expertise in quality and safety science. The purpose of this article is to describe the experience in a small, rural facility for reducing patient harm. This article will highlight the Healthcare Quality (HQ) Essentials of improvement, safety, and data analytics.2

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Harris Regional Hospital (HRH) is an 86-bed acute care hospital located in Sylva, NC (Jackson County), serving a population of 100,000 people in the western part of the state. The hospital admits approximately 3,600 patients per year, accounting for 13,200 patient days, with a 3.5-day length of stay. The hospital provides an array of inpatient and outpatient services including acute inpatient care, labor and delivery, emergency medicine, and more than two dozen medical subspecialties including cardiology and orthopedics. The Medicare case mix index is approximately 1.5 representing the diversity, clinical complexity, and the needs for resources in the population of patients in the hospital.3

On August 1, 2014, HRH was acquired by Duke LifePoint Healthcare (DLP), a joint venture of the Duke University Health System and LifePoint Health (NASDAQ: LPNT). This health care affiliation network provided the structure to support the quality and safety efforts at HRH, including evidence-informed practices and improvement strategies. Within the organization, oversight for HRH quality and safety efforts is provided through a collaborative hospital executive and medical executive leadership structure, supported by a quality department focused on improvement and regulatory compliance, and accountable to the HRH hospital board of trustees. HRH uses a quality scorecard approach developed by DLP Healthcare to prioritize improvement efforts and monitor progress in meeting targets. The current scorecard includes 31 measures grouped into the following broad categories: Quality and Patient Safety (18 measures), Safety Culture and Engagement (one measure), and Patient Experience (12 measures). The Quality and Patient Safety and Patient Experience categories are correlated with financial targets established through the Value-Based Purchasing methodology. Harris Regional Hospital has received incremental reimbursement, as opposed to penalty levies, for performance in these categories.

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Using the quality scorecard approach, the HRH leadership team identified an opportunity to reduce patient harm, defined as any unintended patient injury resulting from or contributed by medical care. Before 2015, HRH used a harm rate to track performance in patient safety. A harm event in this calculation included those displayed in Table 1. A harm rate was calculated by dividing the total number of harm events by the total number of patient days within a month displayed in Figure 1. The harm rate was conveyed in terms of events per 1,000 patient days. The HRH leadership team, with input from DLP quality experts, agreed that the rate of harm was less meaningful to the health care team than a raw number of harm events, so the metric was revised.

Table 1

Table 1

The current metric is a composite measure that comprises the 14 specific harm categories (Table 1) deemed preventable in the hospital acute care setting, derived from the CMS Partnership for Patients Hospital Engagement Network,4 CMS Value-Based Purchasing1 metrics, and DLP priorities. Harm events are counted using administrative coding data, and National Healthcare Safety Network data5 are included as a scorecard metric.

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Improvement Interventions

In 2015, the HRH leadership team recognized that the number of harm events experienced by patients in the facility was not only in excess of the target established (Figure 1), but also at a level that was not acceptable to hospital personnel or the community.6 The hospital's Chief Executive Officer (CEO) and leadership team deemed reduction in harm events as a top priority and became actively involved in the oversight and execution of activities to drive this improvement. In an effort initiated by the hospital's CEO, Director, Quality and Regulatory/Patient Safety Officer, and Patient Experience Officer, the senior leadership developed a multi-faceted series of interventions to reduce harm, including a communication strategy that transcended the organizational strata and focused evidence-informed practice bundle implementations for specific harms such as falls, catheter-associated urinary tract infections, and early mobility after surgery.

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Intervention: Communication Strategies

The overall strategy, called the “Zero Harm” message, was a broad organizational approach to heighten awareness and increase transparency of patient harm with the medical staff and organizational leadership. The “Zero Harms” message was simple; no harm was acceptable. This message was translated to mean that all employees at every level in the organization own safety. This message was delivered in multiple leadership venues throughout the early part of 2016. To disseminate the message broadly and deeply among its ranks, the hospital produced a video released through the hospital's internal channels. The purpose of the video was to demonstrate the dispersion of responsibility for reducing harm among the hospital staff for patient safety, a characteristic that extends beyond the practitioners who touch patients.

Targeted verbal feedback from staff after the communication strategy video implementation revealed some common themes. The video appealed to the staff at large, regardless of position, clinical or nonclinical. Furthermore, the video emphasized the magnitude of harms in U.S. hospitals from a volume perspective while also punctuating the potential impact of a single harm on one patient and or family.

To support the “Zero Harm” message, the organization developed a harm event review process with the medical staff and hospital leadership team. When identified, all harm events trigger an intense review by an interprofessional team, with a focus on identifying and addressing root and latent causes for the harm event and mitigating risk that may result in similar, future events. Lessons learned are then disseminated to other providers and caregivers in an effort to expose more staff to the event and spread awareness across the hospital.

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Intervention: Focused Evidence-Informed Practice Bundle Implementation (Monitoring)

In addition to the communication strategy that was implemented, HRH also initiated a series of evidence-informed practice, safety improvement interventions. These three safety interventions included reductions in falls with injury and catheter-associated urinary tract infections and early mobility after surgery. The falls reduction intervention included the acquisition of new chair alarms, the implementation of a new fall risk assessment by the nursing staff, and a competency assessment for new and existing nursing staff. The CAUTI reduction intervention included the implementation of a nurse-driven catheter removal protocol, implementation of interprofessional rounding, and daily rounds by infection preventionists. The surgical early mobility intervention included the implementation of same-day physical therapy evaluations for total joint patients, including chart review, home environment assessment via patient and caregiver interview, determination of durable medical equipment needs for home environment, mobility assessment, transfers from bed to chair, and overall mobility with walker. Same-day physical therapy assessments inform additional skilled therapy needs for discharge.

To augment the evidence-informed practice bundle interventions, the HRH improvement team adopted a proactive cultural stance among the leadership team. Hospital and quality leadership teams have developed a process for mindfully asking each day: have we done everything we can to mitigate risk and keep every patient safe and free from harm? This question was made manifest in a variety of safety-oriented settings driven by the Five Foundational Tools for Effective Communication and Problem Solving used at HRH and all DLP hospitals. These strategies include briefs, debriefs, huddles, learning boards, and executive patient safety rounds. Table 2 highlights each strategy and how others in any organization may use these.

Table 2

Table 2

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Over a 2-year time period after the implementation of the improvement interventions, the annual number of harm events has decreased steadily from 131 harms in 2015 to 81 events in 2016 (38% change) and to 24 harm events (82% change) as of June 2017 (Figure 2). A specific goal of eliminating Central Line-Associated Bloodstream Infections (CLABSI) was set at the DLP/LifePoint organizational level in 2017. As of July 2017, HRH has experienced no CLABSIs in a 30-month period.

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Examining harm events and implementing strategies to reduce or eliminate these hazards has resulted in positive quality and safety outcomes at HRH. Implementing evidence-informed practice bundles and using communication strategies to advance a safety culture has resulted in decreased harm within the organization in approximately 24 months. Continued adherence to the strategies implemented and exploration of the most current and best evidence is the goal of the HRH leadership for ensuring sustainability.

Of note, after analysis of the harm event data, the quality team identified that a portion of events could be attributed to the coding process and a potential flaw in the use of administrative data. For example, if a condition or symptom is not recognized on admission and not coded as “present on admission,” and then coded on discharge as occurring during the hospital stay, the event was counted as a “harm event” and was included in the overall calculation of event. Intentional focus was applied to capturing those events that were present on admission so a more accurate count of hospital-acquired harms could be measured. Such review activity occurs before the final patient bill is administered.

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In managing what is measured, HRH has achieved a level of quality performance as evidenced by a reduction in harm that is unprecedented in the hospital's recent history. Progress in reducing harm events occurred as a result of improving data accuracy inclusive of reducing coding errors, creating an environment of relentless focus on evidence-based practices, embracing a data-driven approach to monitor progress, and engaging safety leaders at all levels of the organization who take personal responsibility for hospital performance in specific measures.

The quality journey at HRH is continuous. HRH leadership believes that improvement is fluid and should evolve as new evidence is developed and refined. The improvement journey is owned by the approximately 1,000 employees at HRH who work around the clock, caring for hundreds of patients per day in multiple settings and affecting thousands of patients per year in a rural area of North Carolina. Physicians, staff, and employees are hard-working, committed and compassionate people with a desire to care for others, yet as all humans, are fallible and at incessant risk of error when caring for patients and their families. The HRH commitment to improving quality and patient safety has affected numerous lives because harm events are decreased and patient outcomes are improved.

The quality and safety approach adopted by the HRH leadership team has exemplified the outcomes that may be achieved when small rural facilities partner with academic or larger health care systems to identify evidence-informed best practice quality and safety strategies. The HRH team's experience has also demonstrated how improvement strategies may be translated within the small, rural facility, and achieve sustainable reduction in harm events. Finally, the HRH experience highlights the use of the HQ Essentials of improvement, safety, and data analytics.2

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Authors' Biographies

Lucretia F. Stargell, BA, is vice president, business and service line development for Harris Regional Hospital and Swain Community Hospital, and onsite administrator, Swain Community Hospital. Stargell has held positions in health care strategy and communications since 2003 after working as a print and television journalist and producer. She graduated from Hollins College with a B.A. in Art History, minoring in Communications and completed additional studies in Clinical Psychology at the University of Nebraska at Omaha.

Stephen L. Heatherly, MHA, MBA, is Chief Executive Officer, Harris Regional Hospital and Swain Community Hospital, having served in the role since 2012 after leading finance and strategy at the hospitals since 2001. Heatherly holds a master's degree in health administration from the University of North Carolina at Chapel Hill and a master's degree in business administration from Western Carolina University. He received a B.S. in finance from the University of North Carolina, Asheville.

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1. Centers for Medicare and Medicaid Services. Value-Based Programs. 2017. Accessed July 27, 2017.
2. National Association for Healthcare Quality. Q Essentials. 2016. Accessed June 7, 2017.
3. Health and Hospital Commission. Case Mix Index Definition. 2017. Accessed July 27, 2017.
4. Centers for Medicare and Medicaid Services. Hospital Improvement Innovation Networks. 2016. Accessed July 27, 2017.
5. Centers for Disease Control and Prevention. National Healthcare Safety Network (NHSN). 2016. Accessed August 21, 2017.
6. Agency for Healthcare Research and Quality. Quality Improvement. 2017. Accessed July 27, 2017.
7. Agency for Healthcare Research and Quality. About TeamSTEPPS. Accessed July 27, 2017.
    8. Frankel A, Leonard M. The role of leadership in safe and reliable pediatric care. In: Frush KS, Krug S, ed. Pediatric Patient Safety and Quality Improvement. New York, NY: McGraw Hill; 2014:129–131.

      improvement; rural hospital; safety

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