Written by the staff of MHP Salud. A version of this article originally appeared on the MHP Salud blog.
There is no question that the Community Health Worker (CHW) movement has expanded its profile in recent years. From the front lines of the Ebola fight abroad to the constant changes in health care reform here at home, the profession gained profile, utility and respect.
Less prominent, but equally important, has been the growing role of the CHW supervisor. Supervisors are an indispensable component of the CHW profession that requires as much attention, care and training as the CHWs themselves receive.
With more than 30 years’ experience designing, running, evaluating and improving CHW programs, as well as more than 20 years’ experience spreading that knowledge via technical assistance to other organizations around the country, MHP Salud has gained insight, experience and a deep understanding of CHW supervision.
From all our experience, we collected this list of six tips for supervision success, which includes insights from MHP Salud staff who supervise CHWs every day. These six tips can be used to strengthen, solidify and promote the CHW model through the professional development of their supervisors.
1. Not everyone is right for the role.
Just as CHWs must possess innate qualities and life experiences to be successful, their supervisors need some baseline skills and qualities as well.
First, if a CHW supervisor is working with a population that is multilingual, the supervisor must have the ability to communicate in the language used by the CHWs he or she supervises. Additionally, in order to read the landscape of the community served, he or she should have a strong knowledge, understanding of or experience with its culture.
Solid time management and independent working skills are also vital to serve as an effective CHW supervisor. Much of a program manager’s day is spent juggling CHW supervision, reporting to funders and the organization and attending local meetings in order to maintain community partnerships and relationships. These broad responsibilities are only effectively met through careful planning and an ability to prioritize independent work.
Apart from life experience and skills, MHP Salud’s Chief Programming Officer Colleen Reinert says there are some innate characteristics needed. “In relation to specifically supervising the CHWs,” she said, “I would say the most important thing is to trust the work of the CHWs.”
To maximize their impact, CHWs spend much of their time away from the supervisor out in the field. Because of this, neither role will function if a supervisor constantly checks that the CHWs are doing what they said they would be doing. Regular check-ins and management tools are still necessary in CHW supervision, but without trust, no one will be able to get their work done.
Reinert says flexibility is also key. “The work of CHWs is not necessarily a nine-to-five job,” she said, “so a supervisor has to also be flexible in the work that their CHWs are doing.” For example, CHWs may not be able to come into the office at a set time in the morning if they stayed out late the night before at a health fair event. The CHWs are inherently flexible around the schedule of the community they serve, and the supervisor must mimic this flexibility.
2. It’s different from other supervisory roles.
Apart from the other organizational requirements for employees, Reinert says a good CHW supervisor needs to be able to recruit quality CHWs. This requires an ability to spot those characteristics that make a CHW successful: compassion, trustworthiness, empathy and the abilities to motivate other individuals and navigate the health system and social services. “Identifying these things isn’t something you can learn at school or receive training on,” said Reinert.
Once hired, measuring and understanding the CHWs’ performance requires additional specialized skills and experience. Good supervision might include holding team and individual meetings to grasp the realities on the ground in the communities served and the CHWs’ impact on it.
“In another position, effective work might be monitored via sales, or number of phone calls, but in CHW programs, there might not be something so concrete,” said Reinert. “It’s more of an art and less of a science.”
CHW supervision hinges on the supervisor understanding that even though a CHW’s impact may not be as clearly legible as other roles in the health care field, a good supervisor will seek to understand this impact through trust and the ability to listen. “Something I have seen over the years is, as much as CHWs appreciate support and seek support, they’re also generally not very willing to express concern when they’re not receiving the support that’s needed,” said Reinert.
She says it is important for managers and upper managers to remember to ensure that there is that time or environment to allow the CHWs to express their needs or concerns that they have within the community and within their organization.
3. Good CHW supervisors champion the work of their staff.
As the CHW movement is expanding and being applied in a larger variety of organizations, health care systems and federal governments, it will be key to find ways for both CHWs and their supervisors to maintain the integrity of the CHW profession. “I don’t want to see it turn into something that it’s not,” said Reinert. “Supervisors have a huge role in ensuring that that doesn’t happen.”
To successfully do this, the supervisor must understand the work of a CHW. They may have been a CHW themselves. If not, they need to have spent enough time getting to know the work of a CHW so that they can appreciate the unique role CHWs play and the challenges and successes that come with that role.
It is also important that supervisors advocate for their CHWs—both internally and externally. Within some organizations, like MHP Salud, who are wholly focused on and invested in the CHW model, advocating for the role of their staff may not be a challenge. In others, such as hospital systems, CHW program services may be a small component of the organization’s work. In these cases, the rest of the employees may lack a full understanding of what a CHW is actually doing, and it is often up to the supervisor to educate them.
Supervisors are also key in promoting the CHW professional movement outside of their own organization. “It is important to have CHWs participate in conferences, whether to present on their own program, to network or to gain more professional development,” said Capacity-Building Assistance Program Director Anne Lee.
Experienced supervisors who understand the CHW point of view can also amplify that viewpoint in group-settings to ensure that the CHW voice is heard.
Instinto Maternal Program Director Randi McCallian says she has learned that supervising CHWs is about more than simply ensuring a job gets accomplished.
“As a supervisor, I try to remember that my role is two-fold,” said McCallian, “to reach program goals and ensure fidelity to the program plan, but to also allow for the professional growth and experience of those I supervise.”
4. There is more than one way to run and supervise a program.
As the profession grows, it is increasingly common for programs to employ CHWs with varying levels of responsibilities. A multi-tiered model is used to distribute the responsibilities of CHWs based on the time commitment and expectations of their position, which can range from a part-time volunteer to a full-time staff member.
When used effectively, this model allows a program to maximize resources, extend the reach of CHWs and create a greater program impact. “Regardless of the CHW tier,” said Reinert, “what’s important to remember is that all CHWs still require a supervisor, coach or mentor—somebody providing support.”
Just as program form can vary, so can the communication between supervisors and their CHWs. With recent advances in technology, it is easy to have proper communication with the CHWs if they receive appropriate tools. “Several years ago, it could have been that a supervisor sends an email a CHW, and it took a week for the CHW to get access to the email in order to respond,” said Reinert.
These days, especially if an organization can provide proper communication to a CHW, such as a smartphone and internet services, it’s possible for a CHW to remain in the field and communicate with their supervisor remotely a majority of the time.
Though Colonia Community Project Program Director Moises Arjona, Jr. spends the majority of his time supervising CHWs remotely while they provide door-to-door outreach in the field, he finds it invaluable to change up his supervisory style occasionally and shadow his staff in the field in order to understand the realities of their work up close. “Once you actually work alongside the CHWs, you can appreciate the work that they do and see the barriers they encounter,” he said. “For example, I saw what it was like to go along door-to-door and have the door closed in my face constantly.”
5. Initial plans don’t always pan out, and that’s okay.
With more and more health agencies adopting CHW programs of their own as a way to address social determinants of health, lofty program objectives are sometimes hampered by realities on the ground.
“Often, a development team has designed a program with goals and expectations,” said Reinert, “but when the program begins, and the CHWs are out on the ground doing their work, the numbers that the development team originally identified are unrealistic.”
Supervisor flexibility comes into play in these instances. Otherwise, if a supervisor
continues to push a team of CHWs to meet those goals without making accommodations for the reality of the situation, the CHWs could burn out.
To prevent this, supervisors must be able to listen to their staff to understand the barriers they encounter in the community, so that they can adapt their goals, bring on more staffing or work together to find a solution to a problem.
Instinto Maternal Program Director Randi McCallian says she’s learned that listening is key to revising expectations and solving problems.
“Listen to the CHWs and through them, the community,” she said. “CHWs have a close relationship and understanding of the strengths and needs of a community, so if anything needs to be addressed, their input on strategies that will work is invaluable.”
6. Support is out there.
Currently, there are more opportunities than ever for CHW supervisors to develop their work. Local, state and national CHW associations, conferences and other meetings provide supervisors a chance to network with others in the field in order to receive peer support and learn from best practices.
In 2015, MHP Salud developed several materials and trainings geared toward supporting the work of CHW supervisors, all of which are released on our Resource Portfolio. These tools assist managers in their hiring, supervision, evaluation and greater professional development.
The new Supervision Manual for Promotor(a) de Salud Programs is an 88-page resource available for free download from MHP Salud’s Resource Portfolio. It covers everything from recruiting CHWs to resolving programmatic challenges as they arise, and the Manual’s appendix includes nine tools ready to be personalized for any CHW program. MHP Salud also offers personalized trainings for supervisors across a wide set of managerial topics.
MHP Salud is a national nonprofit organization that implements and runs Community Health Worker programs. These programs provide peer health education, increase access to health resources and bring community members closer. MHP Salud also has extensive experience offering health organizations training and technical assistance on Community Health Worker programming tailored to their specific needs
Rhonda Barcus, Program Specialist
For the past three years, I had the opportunity to work with the Kansas Department of Health and Environment (KDHE) and Sara Roberts, Director of Kansas Office of Primary Care and Rural Health and more recently with Jennifer Findley from Kansas Hospital Association on a Revenue Cycle Management (RCM) project. We supported 19 hospitals in Kansas with technical assistance to assess their current practices and benchmark those against best practices in RCM.
For all the 13 hospitals participating in years one and two, I had the opportunity to talk with their leadership teams at six and nine months about their progress of implementing the best practice recommendations. The progress and outcomes for most of them were astonishing! What really stood out to me were the common themes from the most successful projects. I wanted to share the top three themes with you.
Revenue Cycle Management (RCM) involves the process of patient charge capture from beginning to end, from creation to payment. It includes a number of steps that begins with patient registration and continues through the delivery of care to billing and to eventual payment. It is a process that involves a number of hospital departments: business office, clinical providers, registration, utilization review and coding to name a few. Because of its complexity and the number of staff that “touch” this process and the reliance on detailed, specific and accurate information at each step, hospitals may find that small errors can result in big financial losses, wasted staff time and decreased staff morale. A well-run RCM impacts patient satisfaction while a fragmented process results in frustration and patient dis-satisfaction.
The first step that every team took was to create a revenue cycle team. The team included business office folks, yes, but also included staff from clinical areas, registration, health information management (HIM) and information technology (IT). This team met weekly. Every leader said the success of this project was dependent on frequent meetings so that RCM issues could be addressed quickly and as close to real time as possible. The team looked at any issue or problem involving RCM over the last week and took immediate steps to remedy it. This kept them focused and they were all aware of the need for constant and consistent attention to make steady progress.
A second factor in their success was the focus on pre-registration. Patient information, coverage for upcoming procedures, co-pays and deductibles were all identified prior to a patient coming for their scheduled procedure when possible. Checks and balances were put in place to ensure accurate collection of information since one small error could impact the success of the entire revenue process. Staff were included in discussions about this so that they were very aware how they affected the success of the process.
A final theme, and was the hardest for many hospitals, was requesting payment from the patient! The hospitals were very transparent with the patient prior to coming for services about their financial responsibility at the time of service. Great care was taken to make sure all staff involved had the right education, training and re-education to do this effectively and with sensitivity. The hospitals also talked openly with patients about needing to pay prior balances and some future scheduled procedures were contingent on something being paid on previous balances. More than one hospital noted that this is part of their culture now and the community and patients just accept it. One CEO noted that almost all patients now come prepared with some type of payment. They noted that while many hospitals fear losing patients if they take this step, when done with sensitivity and skill by staff, that fear has been unfounded.
In addition to the common themes in implementation of best practices, all the hospitals were able to identify measurable outcomes. These outcomes included a decrease in accounts receivable, decrease in claim rejection, and an increase in collections. Also significant were the “non-measurable” outcomes. The hospitals all reported that there was better teamwork within and among departments, staff pride in the success of their work and more accountability across the organization!
This article was written by David Mortimer, MDiv, Director of the Hospital Sisters of St. Francis Foundation Innovation Institute, for the January 2017 edition of “Networking News.” The Network Technical Assistance Project is funded by the Federal Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services through a contract to Rural Health Innovations, LLC, a subsidiary of the National Rural Health Resource Center.
I grew up on a rural farm in Wisconsin. Two silos next to the barn were a picturesque fixture, and they were designed to store fodder, forage, or grain. Although they may be a critical feature to some farming livelihoods, silos in rural health care organizations are a metaphor for systems, processes, or departments that operate in isolation. These silos tend to drain the organizational lifeblood because a lack of interaction with other groups can result in inefficiency, missed opportunities for innovation, and even stagnation.
Over the decades, rural health care has been experiencing a cultural shift away from silos. This shift has been accentuated by advances in communications technology and remote presence telemedicine. Many rural organizations have been energized by exploring new self-governed collaborative, network, consortium, and cooperative models that actually replace silos with bridges. The basic idea is that collective action is an indispensable tool to counter the great challenges faced by rural communities.
Articulating the need for collective action
It’s no secret the typical rural health landscape in America faces growing challenges and that rural dwellers face a kind of penalty when compared to urban populations. Not only has rural America experienced declining population, jobs, opportunities, and resources, but a digital divide creates barriers in education, business development, and quality of life. (Many young rural friends of mine graduate high school and leave home, and will never even consider settling down in a community with poor internet connectivity.) Due to demographics and the impact of globalization on local economic development, many rural counties are experiencing an eroding tax base and declining representation in state and federal government.
These complex and incremental changes are causing substantial disparities in patient access to health care—particularly behavioral health—and provider shortages. Because they have less access to health care, rural Americans experience the “distance decay” effect—the lower use of health care services with increasing distance—which can result in more advanced and higher levels of disease. Rural dwellers face greater barriers in follow-up care, appointments, and compliance, and have higher rates of chronic disease, readmissions, and emergency department utilization. While these great challenges might seem overwhelming to rural stakeholders and providers, they have become compelling drivers of collective action and bridge-building.
Recognizing opportunities to collaborate
Collective action allows rural organizations to leverage limited capacity, maximize economies of scale, and share resources. The critical first step on this journey is to identify silos and opportunities for collaboration. Literally, this requires getting the right organizational representatives around a table, and this can happen in a variety of ways. I’ve personally been involved with two networks that successfully navigated this step:
The first step toward sustained collective action from a stakeholder’s point of view always involves the realization that there are tangible opportunities. In the CINC and ITN examples above, charter members began to realize that benefits of collaboration included being able to provide many more services with far fewer resources. Alone, members had little or no capacity, resources, or experience in successfully applying for a federal grant opportunity, but together, members combined the necessary resources to both apply and leverage opportunities with matching funds.
Bringing stakeholders to the table
Shared activities open doors to opportunities for grants, collaborative fundraising, and other opportunities. Alone, most ITN and CINC members would not even be eligible for many federal and state and private foundation funding. Together, network members find they are not only eligible to apply for many grant opportunities, they find they have greater resources to pool financial resources to secure matching grant funding and operationalize new projects. (Another advantage is that having different network member calendar year or fiscal year end dates provides additional year-round financial agility in committing matching funding toward a project of interest, despite thin operating budgets.)
In ITN planning meetings, several small rural hospitals without emergency department telemedicine equipment initially thought they brought little value to the ITN network, only later to learn they had exceptionally high value to the greater network because they would score very high in a USDA Distance and Learning Telemedicine grant application. In fact, their rural status serving high-poverty communities also provided great value to ITN’s other federal grant applications. Successful ITN-led grant applications secured equipment, and they were able to participate in the network’s new emergency department tele-stroke program.
As a network matures, other opportunities often follow. Group purchasing may lead to shared costs and mutual savings. With growth, ITN leverages larger patient volumes to secure better vendor price points for telemedicine services. Other shared network resources (such as job descriptions, workflows, billing and payment protocols) help all members accelerate programs and reduce costs and duplication. Depending on the project, some members contribute specific legal or financial services. Others may contribute advocacy, marketing, or public relations expertise.
Keeping stakeholders engaged
Sustained engagement in network activities by pioneer members is driven by continued benefits and prospective opportunities. Without these, members will naturally lose interest and drop out. Economies of scale experienced in the CINC and ITN examples above include collaborative support to develop new services. These networks also share equipment, allow members to share costly software applications, and even services and staff. Lastly, collaboration provides access to new resources that are only available to larger organizations.
Bridge building will always be more challenging than silo building. As Gregory Bonk noted, “Rural health networking is not easy; it requires time, trust, will, and skills.” He added, “Network members must have the ability to separate their individual goals from the common goals of the network, and the vision to see the potential benefits of joint action.” Bonk outlines key elements of network development that include a compelling need, expected benefits, form and function, and key participants.
New and emerging networks can build momentum with smaller “easy wins” that are communicated to all members, and are followed by other good-faith efforts that are inclusive and innovative in meeting member needs. Eventually, silos are replaced by bridges that are shared by all members, and improve client services and reduce costs. As one network member in CINC commented about their old silo thinking, “We’d never go back.”
About the author:
David P. Mortimer, MDiv, is Director of the Hospital Sisters of St. Francis Foundation Innovation Institute. He serves as the Administrative Director for the Illinois Telehealth Network (ITN) and chairs the Communications Committee for the Chippewa Valley Inter-Networking Consortium (CINC). The Hospital Sisters of St. Francis Foundation Innovation Institute provides program investments and infrastructure to support projects that improve outcomes, increase rural access to care and decrease costs through improved efficiencies.
 Turning Point Initiative. From silos to systems: Using performance management to improve the public’s health. Turning Point National Program Office, p. 3; 2003. http://www.phf.org/resourcestools/Documents/silossystems.pdf
 Wong ST, Regan S. Patient perspectives on primary health care in rural communities: effects of geography on access, continuity and efficiency. Rural and Remote Health (Internet) 2009; 9: 1142. Available: http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=1142 (Accessed 12/31/16).
 Gregory Bonk, Principles of Rural Health Network Development and Management (2000), p. 1.
Data Governance and Ownership: HIT and the Imperative of Strong Electronic Health Vendor Relationships
This article was written by Rene S. Cabral-Daniels, CEO of Community Care Network of Virginia, Inc., for the December 2016 edition of “Networking News.” The Network Technical Assistance Project is funded by the Federal Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services through a contract to Rural Health Innovations, LLC, a subsidiary of the National Rural Health Resource Center
Recent healthcare literature is replete with articles regarding the importance of paying greater attention to healthcare data. Many suggest a healthcare organization’s ability to harness data value is the fulcrum to the organization’s success or failure. While these articles encourage greater use of healthcare data, they often fail to inform health entities of the importance of assuring proper data ownership as well as stewardship, integrity and dissemination.
Data requirements: what they are and what they aren’t
Healthcare leaders may mistakenly believe that compliance with the Health Insurance Portability and Accountability Act (HIPAA) health data protection sections insulate them from any potential legal claims. HIPAA is an important, albeit complex, federal law that addresses both health data protection as well as confidential handling of protected health information (PHI). The determination of data ownership as well as necessary PHI protection is further complicated by the use of electronic health records (EHR). Health records no longer reside on a shelf in a doctor’s office but can now be shared by few keystrokes on a computer. EHR usage changes the parameters of astute data governance responsibility from one concerned with data ownership to one focused on data stewardship.
Recent legislation promoting quality-based payments such as the Medicare Access & CHIP Reauthorization Act (MACRA) and the 824-page final rule describing implementation assure the use of electronic health records will continue to grow. The parameters of this growth are carefully prescribed in section 1848(o)(2)(A)(iii) of MACRA and the definition of “meaningful EHR user” under 42 CFR 495.4, which require eligible professionals to report on Clinical Quality Measures selected by the Centers for Medicare and Medicaid Services using only certified EHR technology, as part of being a meaningful EHR user under the Medicare EHR Incentive Program.
EHR use by providers is already rather substantial. According to the Office of the National Coordinator for Health Information Technology, in 2015, 96 percent of all non-federal acute care hospitals possessed certified health IT. While small rural and small urban hospitals had the lowest rates at 94 percent, 96 percent of critical access hospitals had certified health IT. Clearly, EHR vendors and their products are an integral part of data usage and PHI confidentiality, the keystones of data governance efforts.
Data governance: key component of care delivery models
Many healthcare organizations struggle with data governance. A 2014 American Health Information Management Association (AHIMA) survey of over 1,000 healthcare professionals revealed only 11% characterize their data governance programs as being mature while over 50% of the respondents did not have governance practices in place.[i]
The Health Information Management and Systems Society (HIMSS) has an excellent resource on overcoming data governance obstacles. The article is entitled, “A Roadmap to Effective Data Governance: How to Navigate Five Common Obstacles” and defines data governance as “the exercise of decision-making and authority for data-related matters.” [ii] The article analogizes the importance of having an effective data governance program seamlessly embedded within the overall management and operational practices to patient safety as an integrated component of a comprehensive care delivery model in any healthcare system. One obstacle identified is not addressing data governance from an enterprise perspective, which can perpetuate data integrity challenges.
Data integrity: accuracy, quality, and completeness
Assuring data integrity is certainly an essential component of data governance. Data integrity is defined by the Department of Health and Human Services’ Office of Civil Rights as “the property that data or information have not been altered or destroyed in an unauthorized manner.” Note that the alteration is not limited to intentional alteration; unintentional or mistaken alteration can compromise data integrity.
Data integrity is particularly challenging for both providers and EHR vendors when it concerns patient identity. Accurate patient identity is an imperative. Health information exchange cannot be accomplished in a manner that assures integrity without first assuring patient identity integrity. AHIMA defines patient identity integrity as “the accuracy, quality, and completeness of demographic data attached to or associated with an individual patient. This includes the accuracy and quality of the data as it relates to the individual, as well as the correctness of the linking or matching of all existing records for that individual within and across information systems.” While data integrity must be the cornerstone of any institutional health provider’s data governance principles, individual healthcare providers must communicate often with their EHR vendors to be certain that the correct patient’s health information is the information being exchanged.
Data dissemination: the call to collaborate with vendors
The final area regarding data governance concerns data dissemination. This area has the greatest potential for achieving excellence for providers by nurturing a strong partnership with EHR vendors. Data dissemination is occurring at unprecedented rates, and its future upward trajectory is projected to be even greater. MACRA includes a provision that expands the availability of Medicare claims data which took effect on July 1, 2016. This section expands how qualified entities will be allowed to use and disclose Medicare data under the qualified entity program.
Another MACRA provision that advances data dissemination is one that aligns with earlier efforts promoting interoperability. The tenets of the Certified EHR Technology criteria, which promote application programming interfaces that allow for interoperable data sharing necessary for big data analytics and population health management, will likely be coupled with MACRA’s Advancing Care Information (ACI). ACI will count for 25 percent of the Merit-Based Incentive Payment System (MIPS) attestation score in the first year of participation. MIPS advances population health management and care coordination by utilizing health IT that relies on open application programming interfaces (APIs) and an app-based approach to technology. Because APIs can be customized, providers will need to join forces with EHR vendors if they are to realize the financial benefits afforded by MIPS.
In summary, true data governance will not be possible without a strong partnership with EHR vendors. The partnership must go far beyond payment for services and assuring a business associate agreement (BAA) is executed. The BAA must be customized so that both parties have a meeting of the minds regarding data governance and other important factors that are memorialized in writing. Strong data governance must involve meaningful EHR vendor participation if it is to be sustainable.
Community Care Network of Virginia, Inc. (CCNV), a community health center-owned and governed provider network, was legally incorporated as a statewide network organization in 1996 consistent with the Affiliation Policies of the Bureau of Primary Health Care. CCNV has a long, successful history of providing integrated, network-based services and programs to Virginia’s health centers, including the acquisition and implementation of a centralized practice management system, help desk, and support infrastructure commencing in 1999. Rene Cabral-Daniels currently serves on the NCHN board of directors.
 Cohasset Associates, "2014 Information Governance in Healthcare Survey." American Health Information Management Association, May 2014; at http://www.ahima.org/~/media/AHIMA/Files/HIM-Trends/IG_Benchmarking.ashx
 See 'definitions of Data Governance.' The Data Governance Institute; at
Tis the season to be grateful. Here are just a few of the reasons we have to be grateful for this year.
I am grateful, appreciative and impressed with the Minnesota hospitals that are participating in the Integrative Behavioral Health (IBH) project! As a former clinician, I know the difficulty addressing behavioral health issues, especially when resources are limited. I also know the impact they have on the individual’s quality of life as well as the lives of their families and communities. Thank you for all you do!
I would like to send a thank you to all the networks across our country who are working at improving the access to health care for rural America. The diversity of projects and locations makes it a fascinating group to work with. Their outcomes are amazing. We will have a healthier population in Rural America because of them.
I am grateful for our rural health partners that work with The Center to support the power of rural (FORHP, NRHA, NOSRH, RHIHub, Rural Health Value, Flex Monitoring Team, NCHN, NORC).
I’m incredibly inspired by and grateful for The Heart of New Ulm Project, born out of New Ulm, MN. The 10-year initiative is producing financial and health outcomes that are preventing disease versus treating it after it occurs. The project was just awarded the Most Meaningful Life-impacting Improvement award at the Health Analytics Summit. This rural community is a perfect example of how collaboration and partnerships really can change an entire population’s health!
I’m grateful for all of the organizations and groups like the National Center for Farmworker Health, Research for Indigenous Community Health Center, Arizona Rural Women’s Health Network, and countless others that work to improve the health of vulnerable populations, including rural communities. It’s inspiring to see their outcomes and accomplishments.
I’m grateful and amazed by the passion and persistence of those we work with here at The Center. No matter what our mission and vision statements say, we’re all shooting at the same target; enabling our rural providers to provide the very best quality of care to their communities and keeping rural areas healthy and vital.
Thank you to the thousands of rural health providers (hospitals, clinics, community health centers, health professionals, including EMS volunteers and community health workers) who are dedicated to providing care and improving health outcomes in rural America.
I’m grateful my grandparents have a critical access hospital in the next town from where they live, instead of the next closest hospital another 30 miles away.
I’m grateful for the honor of working to support rural health care. It is an honor to work in an industry that makes a difference in the lives of 2.5 million people not only at just one point in time - they day they are seeking care - but for their future and the future of their loved ones.
I am grateful to the Minnesota Accountable Community for Health (ACH) Teams. These 15 teams have worked so diligently over the past three years to provide Minnesotans with better value in health care through integrated, accountable care using innovative payment and care delivery models. The work they’ve done is not only ground-breaking but truly inspiring. True leaders and pioneers in rural health.
This article was written by Sally Buck, Chief Executive Officer at the National Rural Health Resource Center
Today is National Rural Health Day, an event coordinated by the National Organization of State Offices of Rural Health (NOSORH) to Celebrate the Power of Rural. The National Rural Health Resource Center (The Center) is proud to support this important day by highlighting the community-based solutions and committed providers that overcome the unique health care challenges that rural citizens face. These challenges include a shortage of primary care and mental health physicians and dentists as well as higher rates of poverty and uninsured.
Rural providers are committed to the goals of the United States Health and Human Services, Centers for Medicare and Medicaid Services (CMS) initiative of Better Care, Smarter Spending and Healthier People. At The Center we have seen this demonstrated by working with hundreds of rural health networks, small rural hospitals and State Offices of Rural Health (SORH) as a grantee technical assistance provider. Despite critical access hospitals (CAH), community health centers and rural health clinics being left out of many new innovation payment and care models initially due to their low volume or cost based reimbursement structure, there are many organizations leading the way towards value-based payment and care with an emphasis on quality and outcomes. These include:
Key partners for The Center are SORHs and state Flex Programs in our work to support rural communities and providers with services, information and resources to increase collaboration, improve quality reporting and improvement, recruit health professionals and support access to care by stabilizing hospital operations and finances through technical assistance, education and funding. This national network of rural health organizations and leaders are key to the power of rural.
We see that our vision of “collaborating and innovating to improve the health of rural communities” is happening throughout the country through the dedication, innovation and partnerships and strongly demonstrates the power of rural.
 CMS (2015). Better Care. Smarter Spending. Healthier People: Paying Providers for Value, Not Volume [fact sheet].
 Mueller, Keith and Fred Ullrich (2016). Spread of Accountable Care Organizations in Rural America, Brief No. 2016-5, RUPRI Center for Rural Health Policy Analysis.
 Mueller, Keith and Fred Ullrich (2016). Spread of Accountable Care Organizations in Rural America, Brief No. 2016-5, RUPRI Center for Rural Health Policy Analysis.
 Rural Health System Change Embedded in State Innovation Models (2016) Keith Mueller, RUPRI Center for Health Policy Analysis, Rural Health Value, [PDF - 494 KB]
Strengthening Your Problem-Solving Muscles: How an understanding of Lean can support network objectives
This article was written by Becky Gourde, program coordinator at the National Rural Health Resource Center/Rural Health Innovations, for the November 2016 edition of “Networking News.” The Network Technical Assistance Project is funded by the Federal Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services through a contract to Rural Health Innovations, LLC, a subsidiary of the National Rural Health Resource Center.
Rural health networks are often formed in response to collective challenges or needs arising out of the communities they serve. As part of health care’s current transition from a focus on volume to a focus on value, networks help drive and facilitate performance improvement efforts that contribute to CMS’s approach of Better Care, Smarter Spending, and Healthier People throughout the delivery of health care. Because Lean efforts usually require little, if any, direct financial investment, the related processes and tools can be a useful option for small organizations working to improve the health outcomes of their rural communities.
What is Lean?
In short, Lean is first and foremost a way of thinking that helps solve problems. Many of the ideas that we now categorize as “Lean” were developed out of the automaking industry. Shortly after World War II, Toyota began developing the Toyota Production System, or TPS, which was influenced by several thought leaders in industrial engineering. Although most people associate Lean with the practice of reducing waste and improving process efficiency, at the heart of the Toyota philosophy are a group of management principles characterized by (1) continuous improvement and (2) respect for people.
Their success with the system inspired other automakers and eventually other industries to adopt similar techniques. (Lean is often associated with a similar methodology called Six Sigma, which was developed in the US in the 1980s and 1990s.) Specialized systems of Lean (Lean Healthcare, Lean Sigma Healthcare, etc.) focus on applications particular to the processes involved with caring for patients.
Applying Lean to rural health networks
For networks with a small number of staff (if any), modest infrastructure, and little influence on the direct provision of patient care, how can network leaders derive benefit from learning about the principles and practices of Lean? Interestingly enough, the Lean way of thinking dovetails with the objectives of rural health networks and provides new approaches for building network capacity. The actions listed below offer ideas for how networks can use Lean practices to their best advantage.
1. Tackle complex problems
One of the notions of Lean is that problems are best solved when groups of people representing diverse roles or perspectives come together to identify issues and implement actions to address those issues. This format of problem solving is a common benefit arising out of rural health networks: networks often serve as ideal settings for candid and strategic discussions regarding the challenges being faced in the community. The network participants around the table have the power to collectively enact solutions that take into account multiple factors and perspectives.
The key to addressing problems using Lean is to work on the underlying root causes under your control, rather than wasting time developing plans to alleviate 20 or 30 symptoms of those root causes. There are several Lean tools that facilitate the process of root cause analysis in ways that offer simple frameworks for dialogue and planning.
2. Lead a culture of continuous improvement
Networks function most effectively when they help articulate members’ shared vision for the future of their communities. A shared vision expresses an ambitious and hopeful destination that all members are committed to using as a beacon for developing strategies and activities. The vision and goals are revisited periodically to assess progress and appropriateness, with new goals or elements revised as progress is made and circumstances change.
This iterative process of striving toward better and better outcomes is at the very core of Lean principles. Network leaders are often in the position of facilitating and carrying forward that drive. Understanding Lean’s models for nurturing a mindset of continuous improvement can help guide network leaders through culture reinforcement and change management efforts among members.
In fact, culture is often regarded by Lean experts as the highest priority for organizations wishing to become more effective and efficient: without an open commitment to progress and the empowerment of all participants to take part, performance improvement efforts are doomed to failure.
According to Toyota, this transformation can be accomplished through the “respect for people” principle. Network leaders may recognize the tenets of “respect for people” as their own best practices for network collaboration:
3. Offer education
As central sources for knowledge sharing, networks often allow member organizations to pool resources to pay for training or education that they otherwise couldn’t afford on their own. Because Lean has shown such positive outcomes throughout health care, coordinating and hosting educational opportunities on performance improvement can be a valuable service provided by a network to participating members and partners. The existing network configuration also provides a natural support system for members to get ongoing input from network leaders and from one another as they implement projects to improve outcomes in their own organizations.
If performance improvement support is something a network is interested in pursuing as a value-added service, it may even be a worthy investment for a network director to become certified in Lean or Lean Six Sigma so that they can serve as trainers and project leads for members, preventing members from having to seek out external consultants on a case-by-case basis.
4. Gather and share outcomes
Part of tracking the outputs and outcomes of a network’s work includes selecting measures and gathering data. The “simple” task of determining which metrics are most appropriate can be an intensive and tiresome process in and of itself, before the data collection even begins. Lean training incorporates an entire emphasis aimed at supporting users in what makes a good metric and which factors to consider.
Many of the recommendations around Lean metrics offer valuable guidance for networks involved in evaluation planning:
It’s also helpful for a network to serve as a repository of member data on selected measures that are relevant to the network’s goals. This process of collecting and sharing member information can encourage benchmarking and sharing of best practices among member organizations working in similar areas.
The information-collector role also allows networks to collect the designs of and results from the various improvement efforts being undertaken by member organizations, providing members with a quick way to see what’s been working well (or not so well) in their regions.
You don’t have to become an expert to begin benefitting from an awareness of Lean principles and tools. In fact, performance improvement efforts are often most effective when you start small. If you’ve never been introduced to Lean or a similar methodology before, you may want to look into free or low-cost leaning opportunities (like books or online resources) to see if it would be a valuable investment in your professional development. Or if there’s someone within your network’s member organizations with a background in Lean, you could consider inviting them to a network meeting to review a few ideas that are relevant to a particular network initiative. Selecting one or two new performance management tools to practice with can also help you decide whether to seek out additional training or expertise.
Jamie Martin, Lean Six Sigma Black Belt, SigmaMed Solutions
John Roberts, Lean Healthcare Black Belt, Midwest Health Association Management
Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction by Mark Graban, 2009, Productivity Press
The Six Sigma Book for Healthcare: Improving Outcomes by Reducing Errors by Robert Barry, Amy C. Murcko, and Clifford E. Brubaker, 2002, Health Administration Press
The Toyota Way: 14 Management Principles from the World’s Greatest Manufacturer by Jeffrey K. Liker, 2004, McGraw-Hill
This article was written by Joe Wivoda, CIO of the National Rural Health Resource Center/Rural Health Innovations.
The news is filled with stories of health care organizations that have had their data held hostage by hackers. Sometimes they choose to pay the ransom, sometimes they don’t. Regardless, the damage has been done because it is still a breach of Protected Health Information (PHI) and often needs to be reported to the Office of Civil Rights (OCR) as well as local media. Of the 168,000,000 reported breaches in the OCR database, 126,000,000 list hacking or IT as a factor. Clearly we have to take malicious software, known as “malware”, seriously.
What are the threats?
Malware comes in many forms, from computer viruses, worms, Trojan horses, spyware, adware, scareware and who knows what else! Ransomware, where a user is usually tricked into allowing a malicious program or web page encrypt and hold their data files hostage are getting a lot of attention and causing a lot of stress on IT leaders. Many of these attacks are difficult to stop with traditional AntiVirus software. Some use “social engineering” to convince a user to click on the malware and enable it.
“Warning! Your PC is infected. Click here to clean your PC NOW!”
This is not a virus warning, this is likely a malware attack, perhaps even ransomware!
How do you protect yourself?
Of course every computer on your network needs antivirus, but it is much more than that. In an environment with many computers, which includes all rural hospitals and many other rural providers, it can be difficult to manage all of the updates without central management of the antivirus software. Further, antivirus software will only stop so many threats. Some will get through even with a well-managed antivirus package running, it just depends on how well the users are trained and aware that they are targets!
That message that says “your computer is infected, click here to repair it” might as well say “feel free to click this and we will charge you money to get your data back” because that is one of the likely results. All organizations, including rural health care facilities, need to protect themselves in several ways:
The best intentions and efforts to protect your facility do not mean you won’t get caught by one of these nasty programs! Ransomware in particular seems to be showing up everywhere, and you have to be ready to respond when it does happen (see that mention of “incident response team”? That’s important!)
What if you are a victim of ransomware?
Many rural hospitals and clinics have been hit by ransomware in the last year. CMS and the Office of Civil Rights (OCR) have determined that if Protected Health Information (PHI) has been encrypted then it has been “acquired”. That is a key term! “Acquired” means that it is considered a data breach under HIPAA and needs to be reported.
Do you pay the ransom or not? Either way you will need to report the data breach and offer identity theft protection services to the patients affected, so it becomes a question of cost-benefit analysis. If the ransom is low enough, it may be less expensive than doing a full restore of the data (you do have good, well-tested backups, right?). Even if you pay there is no guarantee that the data-kidnapper will release the data. Now that you have agreed to pay, why wouldn’t you pay a little more? For these reasons most experts feel you should not pay. Estimate what the costs in time, money, patient safety, and other factors are before making the decision to pay the ransom or restore the data.
Rural IT leaders and others need to be aware of the risks that malware presents and understand how to mitigate those risks. The HIPAA regulations provide good practices, like risk assessment and incident response teams, that will protect your network but they need to be put in place. It is very hard in a rural setting to get everything done, particularly when most CAHs and RHCs have limited staff. It is necessary in most cases to use outside experts, at least to some extent. Talk about these threats with your end users and leaders, because they are the front lines in safeguarding your precious PHI!
Fact Sheet: Ransomware and HIPAA
Health IT Playbook
By Jo Anne Preston, MS, Workforce and Organizational Development Senior Manager, Rural Wisconsin Health Cooperative (RWHC). This article (“Introverted Leaders”) was originally published in RWHC’s Leadership Insights.
MYTH: Extraverts make better leaders.
TRUTH: Both strong and weak leaders can be found in any personality style. An even bigger, and often misunderstood truth: personality traits are not the same as skill.
What does it mean to be introverted?
You might be introverted if you:
✓ Tend to prefer thinking things through before speaking vs. thinking out loud
✓ Find that situations with lots of stimuli tend to drain your energy
✓ Generally are more energized working alone or with a very small group than in an open team setting
No one is “pure” when it comes to personality style, and we are all a complex array of traits. Though it’s not static like our blood type, when it comes to navigating the energy dynamic of our internal and external world, most people lean in one direction more than another.
Stereotypes of extraverted leaders as charismatic and “verbal stand-outs” can sometimes make it tough for introverts to get noticed for leadership opportunities. It’s a little bit like extraverted kids in the classroom who raise their hand with their whole body, drawing all the attention, leaving the more deliberate and internally focused introverted students unnoticed.
When it comes to being a leader, being authentically you is a strength, notes Susan Cain, author of Quiet: The Power of Introverts in a World that Can't Stop Talking. Being “authentically you” starts with spending some time reflecting on who you are, and personality exploration is a fun and useful way to be “positively self-centered.”
Tips for improving your leadership capacity
If you are an introvert:
1. Don’t assume you won’t be a great public speaker! Strongly introverted Susan Cain's TED Talk with 14 million views is just one example of evidence to the contrary. Effective speaking takes practice, and anyone who wants to excel must do the drills. As an extraverted speaker, most of my best ideas I have learned from Cella Janisch Hartline, RWHC Nursing Leadership Senior Manager, who is an extreme introvert AND gifted speaker and educator. She is powerfully engaging, impacting learners like a force of nature, proof that introversion is not the same as talent. It is also not the same as being shy. Introversion is about how you re-energize. After teaching all day she seeks time alone, and understanding personality differences helps me to not take that personally-a huge benefit in our working relationship!
2. Be conscious of your facial expressions. A very common experience among introverts it is that people often ask them, “Are you mad at me?" The introverted thinking face can look a lot like irritation or anger. Be aware that you may feel very approachable, but it doesn’t work if others don’t experience you as such. Isn’t some of this on the other person’s part to assume good intent? Yes. And. We are still accountable for the message we are sending out.
3. Be mindful of the toll that “people-ing” takes on you. A “best use” for personality tools is understanding your own wiring so that you can meet your needs. We all need to know what kind of fuel our engine takes to recharge, and then it’s up to us to go after it. Manage your energy by:
✗ Allowing—and valuing as productive—the thinking time you need before beginning something new
✗ Asking for agendas and written material to review prior to meetings
✗ Seeking out some opportunities to work alone
✗ Asking others for time to think about or process their questions before responding
4. Reveal your thinking. Help others understand your personality and what makes you tick. People want to know what you think, and in a vacuum of information, rumors will fill in the gaps. One daily habit to develop is to ask yourself, “Who might benefit from knowing what is on my mind?”
Understanding your strengths
Skeptical of personality instruments? They can still help if you are open to asking, “What can I learn from personality awareness to make me a better leader?” With an open mind, these tools (and there are many) can help individuals and teams appreciate, rather than fight against, diverse approaches to work and life.
Rural Wisconsin Health Cooperative (RWHC) has been providing affordable and effective services to healthcare organizations since 1979. RWHC is owned and operated by forty rural acute, general medical-surgical hospitals. The Cooperative's emphasis on developing a collaborative network among both freestanding and system-affiliated rural hospitals distinguishes it from alternative approaches. RWHC offers a variety of programs and services to its members as well as to other clients across the nation.
This article was written by Joe Wivoda, CIO of the National Rural Health Resource Center/Rural Health Innovations, for the September 2016 edition of “Networking News.” The Network Technical Assistance Project is funded by the Federal Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services through a contract to Rural Health Innovations, LLC, a subsidiary of the National Rural Health Resource Center.
The Rural Health Information Technology (HIT) Workforce Program wrapped up this August, and we want to take a moment to recognize the amazing work they have accomplished. The Rural HIT Workforce Program was a three-year grant program funded by the Health Resources and Services Administration’s (HRSA’s) Federal Office of Rural Health Policy to support rural health networks in activities relating to the recruitment, education, training, and retention of HIT specialists. The 15 grantees engaged in exciting projects that have made significant impact across the country.
HIT in perspective
This is a difficult time period for the profession of health information technology (HIT). HIT is a new field; we are just beginning to understand HIT roles, and organizations often do not grasp the full value of HIT professionals. In addition, HIT certifications and licensure are in a state of flux.
The 15 grantee networks in the Rural HIT Workforce Program worked within these muddy conditions to define HIT roles and education for the benefit of rural providers. Impressively enough, they are on track to have collectively trained more than 500 individuals. The networks work with hospitals, clinics, FQHCs, emergency services, school districts, public health agencies, and others across over 400 counties throughout rural America. It is truly humbling how many lives have been impacted, directly and indirectly, by their efforts.
Successes among Rural HIT Workforce networks
Here are just a few of the successes the Rural HIT Workforce grantees have shared:
“We successfully employed students in HIT positions at 5 organizations and equipped staff with more HIT knowledge at a 6th organization”
“Helping the smallest Critical Access Hospitals in our state to have some background in Health IT and understand/complete their quality reporting requirements more easily.”
“Through the training we provided, we have over 60 students obtaining certification credentials. All of our 31 network members have obtained MU Level 3.”
“Developed a network of employer partners with active participation in curriculum development, professional practice experiences, work-based learning opportunities and hiring strategies.”
Identifying and surmounting barriers
Of course, there were plenty of challenges along the way as networks worked to achieve these successes. Here are some challenges our grantees experienced and what they did to overcome them:
“Many of the students who enrolled in our program had significant life challenges - illness, family deaths, relocation, unemployment, foreclosure and opportunities - births, marriages, pregnancies. We had to learn early on that life happens and flexibility is necessary. We were able to give students some flexibility with timelines for completing apprenticeships and meeting expectations in order to help them accomplish their goals in the program.”
“Recruiting veterans was a challenge. We increased tuition incentives for veterans which increased our veteran recruiting percentage.”
“Student communication and follow-up quickly became a challenge in our fully online curriculum. However, staff prioritized their schedule around constant outreach, both online, over the phone, and scheduling face-to-face meetings, to establish a comfort level with students and encourage them in low points. The program mandated a face-to-face orientation, which found much success in its implementation and impact throughout the final six months.”
As the new curriculum for HIT education is released by the Office of the National Coordinator for Health Information Technology (ONC) next year, this group will be at the forefront in rolling it out and finding the best ways to use it in their local communities. As the Rural HIT Workforce grantees have shown, the ONC HIT curriculum is a good framework that can be made most effective by modifying it with local needs in mind. Vendor-specific modifications, state reimbursement specifics, or provider-specific workflow training are just a few of the examples of how the grantee networks have been serving their members.
Lastly, the Network TA team at Rural Health Innovations (RHI) would like to say “Thank you” and “See you later” to the Rural HIT Workforce grantees. We wish you continued success and want to remind you to stay in touch with us and with all of your fellow grantees in the years to come. Your work will continue to make a difference in rural communities across our country.
The National Rural Health Resource Center (The Center) is a nonprofit organization dedicated to sustaining and improving health care in rural communities. Rural Health Innovations, LLC is a subsidiary of the National Rural Health Resource Center.