Quality Indicators in Critical Access Hospitals, Small Rural, and Urban Hospitals

Purpose: Critical Access Hospitals (CAHs) have served their rural communities since they were created in the 1990s. CAHs have been exempt from the multiple organizational performance-based approaches that use financial incentives and thus quality indicators targeting CAHs specifically do not exist. Reports have suggested indicators that are appropriate for rural hospitals and CAHs but none have included all types of quality indicators - structures, work processes, outcomes, and quality improvement (QI) activities. Using a subset of the National Database of Nursing Quality Indicators® (NDNQI®) we assessed whether existing indicators for the work environment (structure), patient - and nurse outcomes are appropriate for CAHs. Methods: Using 2017 NDNQI® data on 16 structure and outcome indicators (8 work environment, 6 patient- and 2 nurse outcomes) were extracted. Employing bootstrapped confidence intervals CAHs were compared to other small (less than 50 beds) rural and urban hospitals. Findings: 103 CAHs, 63 small rural hospitals and 91 small urban hospitals had data on at least one indicator (range 87-239 for each indicator). There were no differences between CAHs and other small rural and urban hospitals for 15 of the 16 quality indicators. CAHs had fewer bachelor prepared nurses compared to urban hospitals. Conclusion: Our results suggest that quality indicators for structure and outcomes currently used in approximately 2000 hospitals are also applicable for CAHs. Whether they apply to all 1350 CAHs and can be used to guide benchmarking and QI in CAHs needs further study.