Reprint by permission from Hopi Regional Health Care Network

By building a network, providers in Arizona are improving the continuity and quality of care for members of the Hopi and Navajo nations.

By Tom Rowley

Thanks to a budding network, members of the Hopi and Navajo tribes in northeast Arizona are seeing improvement in the quality of care available to them. Hopi Regional Health Care Network started in December, 2004 and has as its members the Hopi Tribe; The Hopi Health Care Center, a critical access hospital operated by the Indian Health Service; Tuba City Regional Health Care Corporation, a private not-for-profit hospital corporation owned and operated by the Navajo Tribe; and Flagstaff Medical Center, a large private not-for-profit hospital. The network's purpose: to improve continuity of care for the region's people while improving the bottom line of the partners' operations.

"If we put the patient at the center, then we should be able to provide a seamless continuity of care," says Daryl Melvin, CEO of Hopi Health Care Center, "And that can also help us improve financial performance."

While the various partners serve the same population and often the same patients and had worked with each other in the past, the arrangements were informal, ad hoc, and at times slowed by inefficiencies. Each facility had its own way of doing things and the ways did not always mesh. As but one example, transferring patients from one facility to another often ran into snags -- slowed by the different procedures and the lack of formalized arrangements. In short, access to care and continuity of care suffered.

On top of that, patients often viewed the partners as competitors, bypassing a facility close at hand in favor of a larger one farther away -- even when quality care was available locally. At other times, patients at Hopi or Tuba City were referred to hospitals several hours away in Phoenix or Tucson (creating a great hardship for families wishing to visit the patient) when they could have gone instead to the much closer Flagstaff Medical Center.

Faced with all of this, the Hopi Tribe and Indian Health Service in 2000 began holding community health planning sessions to hear from the region's residents and health care providers alike their concerns, needs, and wants. At the top of the list each time was better access to care.

"The stakeholders agreed that we needed to look at services all the way around and get everybody access to quality services," says Herman Honanie, Director of the Hopi Office of Health Services.

A network of the providers seemed the logical solution. The Tribe and IHS approached Tuba City and later Flagstaff with the idea. As Honanie puts it, "If we can all push and shove in the same direction, listen to the same concerns -- things can happen. We need to see all of these agencies come together and provide services to everybody on an equal footing. This was long overdue -- we should have initiated something like this years ago."

Both Tuba City and Flagstaff responded favorably to the idea. And with help from the Arizona State Office of Rural Health, which continues to provide technical assistance to the network, the partners applied for and received a network planning grant from HRSA.

The desire to work together notwithstanding, the partners faced challenges in forming the network. The biggest, says Melvin, was "overcoming inertia and the 'we've always done it this way attitude.' We had to get people to see that it could be done much better."

And there were two keys to that, he says. First, was getting CEO-level participants involved in the network design and implementation. "If you have those decision makers in the same room, you're going to get things done."

Second, Melvin says, was simply reminding everyone that, "we're all here for the same reason and that's patient care."

Once the network design was hammered out and a memorandum of understanding and bylaws were agreed upon, the real work of the network began. Under the guidance of part-time Executive Director Laverne Dallas, who also works as a grant writer and health planner for the Hopi Tribe, the network has identified its goals for the first year and mapped out a work plan containing several projects.

• Coordinate case management of transfer patients and thereby improve continuity of the care they receive. Already, case managers from each of the facilities have begun meeting together to agree on common procedures and achieve efficiencies.


• Improve business operations by helping each other with data systems, sharing billing information, and the like. For example, the network hopes to extend Flagstaff Medical Center's electronic health record capacity to the other facilities.


• Create community awareness of the network and let people know that the facilities work together rather than compete against one another. Along those lines, a physician from Flagstaff Medical went on a local radio program to tell listeners about the network, explain that the facilities' services complement one another, and assure them that as patients in any of the network facilities they would receive quality care.


• Create a balanced scorecard with which to measure and then improve performance on a variety of indicators and, as a result, overall performance.

When the scorecard is up and running, says Dallas, it will help the partners individually and collectively balance things like customer satisfaction with financial stability and thereby generate the greatest good. As such it is a way to both measure and achieve the other elements of the work plan. The idea for the scorecard came from Hopi Health Care Center, which has been using its own scorecard for a little more than a year.

"What gets measured, gets done," Melvin says about the center's, and by extension the network's, scorecard. The center's overarching goal is community wellness. Undergirding that goal are four pillars: 1) partnership, patient, and community; 2) quality and safety; 3) staff skills and environment; and 4) funding and finance. For each pillar, there are 10 or so different performance indicators, which the center measures and tries to improve.

"If we succeed on those four pillars the community will get care that exceeds their expectations," says Melvin.

Melvin is pleased with the results so far -- especially with respect to customer satisfaction, which receives very high marks. He's also optimistic about the potential value of the scorecard for the network, the details of which have yet to be worked out.

"We're just really in the early stages of looking at what a balanced scorecard is and how we can use it to look at performance indicators," Dallas says. "It's a tool that will help us look at and develop the network from its conception into the future."

The future, of course, depends to a large extent on funding. And with funds from the network planning grant now used up, Dallas is busy looking for other sources. Unfortunately, HRSA turned down the network's application for a network development grant. Dallas, however, plans to reapply. In the meantime, she's asked the Hopi Tribe -- her employer and by reason of that fact, the network's major funder -- to sustain the network for another year, hoping that the network grant or some other source of funds will come through. She's also working with the network members to beef up their in-kind contributions. The challenge, according to Dallas, is seeing to it that each partner benefits equally. And as with all partnerships, she says, "that's the tricky part."

On top of that, the partners are, as Honanie puts it, under tight financial constraints, making it difficult for them to contribute regardless of the benefits.

"Financially speaking, we're really strapped," Honanie says. "We're out on a limb without solid funding. But we're still trying, looking, hoping to shake the right money tree."