The 24th Annual Rural Health Care Leadership Conference is over and it was a good one. We covered a range of topics vital to the survival of rural hospitals: health IT, accountable care, reimbursement, governance and so much more. Here are some closing thoughts:

• Marty Fattig, CEO of Nemaha County Hospital in Auburn, Neb., said rurals are going to have a hard time getting their hands around accountable care organizations. Jamie Orlikoff's comments about "why an ACO" notwithstanding (see the post below), several CEOs echoed Fattig's thoughts that rurals will be challenged to figure out how they can participate in an ACO.
• David Blumenthal cares. As Stephen Stewart, CIO at Henry County Health Center in Mt. Pleasant, Iowa, told me: the fact that Blumenthal came here to deliver a keynote address spoke volumes. Now, he may not have delivered the message folks wanted to hear—that ONC would relax timelines and criteria for rurals—but he came and he listened. The question is: will any of the factors unique to rural hospitals be reflected in the next phases of meaningful use regulations?
• It's all about quality. From Blumenthal to Orlikoff, speakers here noted that patient-centered quality care must become the central business imperative for health care providers.
• Change and leadership: More than 480 rural hospital executives and trustees came to Phoenix this week. It's a record attendance for this excellent meeting. And many came to learn new ways of guiding their institutions through the massive changes that are coming down the round. Session after session highlighted that leaders need to inspire their organization to be innovative, creative and proactive.

So, that's it from chilly Phoenix. I know, I won't get much sympathy from my family and colleagues back in the Windy City, or those of you on the East Coast, but hey, it's barely 40 degrees here today. Hopefully, it will warm up by March, because the way things look now, I won’t be able to get back to Chicago until then. Or, maybe I'll just stick around until next year's meeting.

What is an ACO? That's the question so many of us keep asking, and we are waiting for CMS to propose regulations to give us some guidance. What's the structure? How do we form one?

Well, those are the wrong questions. Leave it to governance guru Jamie Orlikoff to put it into larger perspective. The question we should be asking is: Why an ACO?

"The ACO is the unicorn of health care. Everyone knows what a unicorn is, but have you ever seen one?" He said during his keynote address this morning. The issue isn't how an ACO—or whatever you want to call it—is structured, no; the issue is why your organization must transform into one.

It's all about value. The current health care system of rewarding inefficiency, he said, is unsustainable and will change regardless of what happens politically to the health reform law. It is important to keep in mind that the health reform law isn't driving the change. The economic factors that spurred health reform in the first place are driving change: growing national debt, slow economic growth, the need to cut costs anywhere and everywhere. Value is the new reality and the sooner organizations can adapt to that mindset, the better they'll be positioned to survive.

Trustees, Orlikoff said, are integral to pushing hospitals out of their current comfort zone. Most trustees come from industries that have already been through some sort of evolution/revolution/transformation. The mantra that "health care is different" no longer holds water and trustees need to be more forceful in getting their hospitals to truly transform.

There are three critical questions a board needs to think about during this time of change: 1) What do we believe? 2) Whom do we serve? 3) What do we do? Unfortunately, he suggested, many organizations start at question three, when they should first be answering questions one and two.

Are you a manager or a leader? It seems like a simple question, right?

Consultant Thomas Atchison claims that health care is over-managed and "under-led." We are good at getting results, but not at inspiring people to be the best they can be.

Atchison, who is the president and founder of a company that bears his name, spent the better part of an hour talking about how to inspire and lead. "Leadership is the messy side of human behavior," he said. And clearly leadership is critical during this time of system transformation. Take physician alignment. Atchison said hospital CEOs need to change the way they talk to and about docs. Physicians aren't employees; you don’t "own" a physician group. Instead, docs have be seen and treated as partners. It's important to garner trust and respect, or else the relationship with physicians will disintegrate into conflict.

Atchison had some good one-liners during his talk and got a lot of laughs, but afterwards I talked to a few attendees and they all agreed: physician alignment won't work unless there is mutual trust and respect. And it starts with ensuring everyone has the same set of goals and values. As Atchison said, you can argue around the edges, but the core beliefs that drive care delivery in your institution need to be universal.

At the outset of his speech, Atchison noted that we all get 1,440 minutes each day and asked, "How are you going to use them?" At the end, he suggested you use them to lead and inspire.

It will never cease to amaze me that nearly every health care conference has to have a session on hand hygiene. It is 2011 and we still talking about how to get clinicians to wash their hands before and after touching a patient. Amazing.

But, of course you don't have that problem, right? You have 100 percent compliance. Well, that's what Norma Norton, R.N., director of nursing at Higgins General Hospital, thought. Because the critical access hospital, which is located 48 miles outside of Atlanta, had zero hospital acquired infections, top brass assumed that hand hygiene wasn't a problem. So they were stunned to learn that their baseline compliance was a paltry 20.5 percent.

Sadly, that disparity between belief and reality is pretty common. About two years ago, the Joint Commission Center on Transforming Healthcare launched a program with eight large hospital systems to look at ways of improving hand hygiene. These were big time players in health care—Hopkins, Cedars-Sinai, Trinity. Baseline at those institutions was under 50 percent, according to Melody Dickerson, R.N., who runs the center's hand hygiene program.

Norton and Dickerson spoke during a sunrise (really, pre-sunrise) session on how to improve hand hygiene. Dickerson explained how the center's program, which has since been extended well beyond the initial sites, provides tools for gathering data, assessing the problem and implementing best practices to improve performance.

Higgins General is an excellent example. The hospital instituted a system of "secret shoppers" where fellow staff essentially spied on others to see if they were washing their hands. A few problems were identified: for instance, some people thought that just putting on gloves was just as effective. Also, hand sanitizer dispensers were not located in the best, most convenient places. The hospital made some changes, improved staff training and as of last November, compliance was up to 74 percent.

David Blumenthal feels your pain.

He knows that the federal standards for meaningful use are "painful and difficult," especially for rural hospitals. But…you knew there was a "but," right? But, "We can't hold back this revolution because it is hard," he said, speaking to a packed room here in Phoenix.

The national coordinator for health information technology was speaking of what he deems "The Meaningful Use Era." That, of course, is a reference to the federal regulations for installing and utilizing electronic health records. But to Blumenthal it is much more than that. The Meaningful Use Era is a time when health information will be recorded, stored, shared and, most importantly, utilized by providers to improve the safety and quality of care.

Blumenthal spent much of his speech highlighting his office's accomplishments: formation of 62 regional extension centers which were established to help physicians and small and rural hospitals meet meaningful use standards, $120 million for workforce development, standards development, more than 300 certified EHR products/modules, and the list goes on.

But for this crowd, Blumenthal had to ease some concerns. Rural hospitals are held to the same standards as their larger counter parts when it comes to meeting meaningful use. That has many of the executives and trustees gathered here concerned. They have both financial and staffing constraints. There are infrastructure limitations in many rural areas that lack robust Internet capabilities. Blumenthal acknowledged those challenges. "We know this is a heavier lift for you," he said, adding that the government is here to help. Beyond the RECs, there's the potential to receive advance Medicaid funding to get toward meaningful use. The Health Resources and Services Administration may—depending on budget negotiations—have $12 million in grants available for 40 rural HIT projects. ONC is talking with USDA and FCC to coordinate their broadband funding programs with meaningful use in rural areas. Importantly, ONC is also talking with vendors about the importance of offering affordable products in rural communities.

In an informal poll, attendees were pleased to hear Blumenthal express empathy for their position, but that didn't do much to ease their concerns about meeting the tight timelines. Foreshadowing things to come in stages 2 & 3 of meaningful use, Blumenthal suggested that it would be fair for the federal government to carve out one group (rurals) from the rest of the pack.

As you can imagine, the future is top of mind for the rural hospital CEOs and trustees gathered here in Phoenix. To be more specific, the future in an accountable, value-based, bundled, integrated and coordinated world.

Clinton MacKinney, M.D., talked this morning about how rurals can find their way. MacKinney, an assistant professor at the University of Iowa, told attendees that they need to realize that the payment equation is changing. "Value" is becoming the driver. He spent a fair amount of time talking about how rurals may participate in accountable care organizations once the Medicare regulations are issued later this year. He cautioned the ACO concept seems to be built around an urban model of integration and hospitals owning physician practices. That's not necessarily how rural hospitals are set up. Also, rurals need to think about how referral patterns may change as ACOs are formed, or if new affiliations will be needed.

Ultimately, MacKinney said, rurals need to think about the new world order in terms of improving patient care. Providers need to be more proactive in managing patient health. He wondered why it is that his vet sends him notes a couple of times a year that it is time for his dogs to get their shots, but primary care physicians very rarely notify patients that it is time for their immunizations.

Oh, and a word of warning from Ronnie Musgrove, former governor of Mississippi and current chair of the National Advisory Committee on Rural Health and Human Services: don't get sidetracked by the political chatter going on in Washington or your statehouse. Changes are upon us and providers need to work toward system reform.

Seeing graphic images of patients injured during last year's earthquake in Haiti isn’t exactly what I'm used to after eating breakfast, but, wow, Paul Auerbach, M.D., delivered one heck of an opening keynote at the 24th Annual Health Forum and American Hospital Association Rural Health Care Leadership Conference.

Auerbach is a professor of surgery at Stanford University School of Medicine. He flew with a team of fellow clinicians immediately after the quake last January to provide much needed medical care at University Hospital in Port-au-Prince. I can't do justice to their story in this blog. We've all read about and seen videos of the devastation and the heroic efforts to medical professionals from around the world. But hearing Auerbach retell his experiences was a real eye opener given the debates we are currently having over health care in this country.

He talked about seeing between 500 – 1,000 new patients a day and often the very best care they could provide was to amputate a limb (he noted that he could work in the Stanford ED for weeks at a time and not hear a patient say, "Thanks," but every patient he saw in Haiti said it). Many of those procedures were done without pain medicine, which Auerbach said they ran out of in the first six hours of his deployment. There were no CT scans or X-rays; all diagnosis were made by seeing and touching. "It was some of the best medicine I ever got to practice," he said. The clinicians went on instinct. There was no place to put waste or trash; it piled up outside.

Eventually, though, things began to take shape: Five ORs were established, there was a TB ward, a 24-hour pharmacy, a lab for point of care testing, dialysis, a maternity ward, a 30-bed ICU. Keep in mind that nearly all of these "departments" were in tents or destroyed parts of the hospital. But the point is Auerbach, his team from Stanford and all of the other serving at University Hospital refused to let adversity slow them down. One of the biggest leadership lessons he learned, in fact, was to "stay in motion and seek out problems," because if wait for the problem to find you, it'll be too big by then.

More than one person remarked during a break how Auerbach reminded them of why they got involved in health care to begin with: to make a difference. And this: leaders lead. They don't sit on the sidelines or run from trouble. Auerbach is now working to establish an effective emergency medical system in Haiti.