Some Challenges Rural Practices Face in Working on Quality Improvement

Leif Solberg, MD, ESCALATES Dissemination Team Lead


rural challenges


The Cooperatives of EvidenceNOW were each tasked with recruiting 250 diverse small- to medium-sized practices each, which resulted in about 20% of the 1500 participants being from rural areas. Including rural practices in this large initiative is important, but they have their own challenges, as some Cooperatives in EvidenceNOW have experienced.

  • In the Northwest, the medical directors and CEOs of the critical access hospitals they work with are often reluctant to push their rural clinicians to do non-patient care work since they can’t afford to lose even a single physician to additional stress. As a result, they often feel the need to allow them to opt out of participating in one more thing.
  • In the Southwest, they’ve found that when a project involves much data collection, it is often the rural practices that drop out.
  • In Oklahoma, they’ve found that different types of rural practices respond differently to quality improvement project recruitment. Rural FQHCs often are glad to participate and have actually been pushing for QI work for some time. On the other hand, solo or small practices with nearly retired physicians are often less inclined to work on future-oriented initiatives. Finally, health system medical directors often back off of anything that doesn’t contribute directly to their financial priorities (CPC/CPC+).
  • And in Virginia, rural practices are often interested in improvement efforts, but turnover and technology strains may force them to leverage what little community resources are available for direct patient care, and see that as the priority.

While there is still work to be done in understanding how best to work on quality improvement with rural practices, some helpful resources are:

  • Hartung, D. M., A. Hamer, L. Middleton, D. Haxby and L. J. Fagnan (2012). “A pilot study evaluating alternative approaches of academic detailing in rural family practice clinics.” BMC Family Practice 13(1): 129.
  • Brooks, R. G., M. Walsh, R. E. Mardon, M. Lewis and A. Clawson (2002). “The roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: a review of the literature.” Academic Medicine 77(8): 790-798.
  • Conn, J. (2012). “Stalled progress: EHR adoption lags for small, rural practices: studies.” Modern Healthcare 42(18): 16.