An Exploration of Quality Assurance Activities within the Texas Critical Access Hospital Program
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Small rural hospitals across the nation continue struggling to maintain adequate access to quality health care services for their communities. Hundreds of hospitals have closed the past two decades, with Texas leading the nation during the 1980s. The hospitals that have remained in operation often have financial difficulties that make the delivery of quality patient care very difficult. A majority of small rural hospitals are characterized by old and used equipment, very small medical staffs, poor informational technology and limited services. These hospitals also have a sizeable dependency on Medicare reimbursement since many of their patients are elderly Medicare beneficiaries. Historically, Medicare has not reimbursed these hospitals for their cost of providing services and this has contributed greatly to their financial distress. Fortunately, the Balanced Budget Act of 1997 has addressed the rural hospital Medicare reimbursement issue through creation of the Critical Access Hospital (CAH) Program. Hospitals that receive the CAH designation are to focus mainly on emergency and out patient services. Inpatient services and the length of stays per patient are to be limited within CAHs. The Medicare reimbursement rate for these hospitals has been raised to a higher "reasonable" cost rate and this gives the CAH a better chance of survival. In addition to higher reimbursement rates, Medicare grants these facilities lower staffing standards and only requires that basic quality assurance activities take place. The tasks associated with extensive quality assurance activities that are common in urban hospitals will not be found in most CAHs. Given their limited scope of services, special staffing allowances and lack of extensive quality assurance requirements, a legitimate concern exists for the types of activities that do take place to ensure the quality of care within these hospitals. The purpose of this research is to explore quality assurance activities within the recently created Texas Critical Access Hospital Program. The conceptual framework for the research is derived from an extensive review of rural health care and Critical Access Hospital regulatory and scholarly literature. A triangulation of methodologies consisting of surveys, interviews and document analysis is used to test the working hypotheses within the research. The triangulation method is useful for this research due to the small population of CAHs within Texas at the time of the study. The research findings indicate that the Texas CAH program is a new program in it's early stage of development. In addition, the findings indicate the need for further development of rural health care networks and peer review organization quality assurance relationships. Fortunately, the leadership at the Texas State Office of Rural Health has identified these areas of needed development and is proactively addressing them.