Maria Ryan, PhD, APRN, doesn't let the size of her hospital slow her efforts to keep the community healthy. Dr. Ryan serves as CEO of 25-bed Cottage Hospital in Woodsville, N.H., a boarder hospital serving 12 towns in Vermont and 13 in New Hampshire. Though the hospital's inpatient visits per year hovers around 1,000, Cottage Hospital had nearly 50,000 outpatient visits last year, thanks to the hospital's ever-extending reach into the communities it serves.
Here, Dr. Ryan shares her take on improving the health of a population, healthcare's triple aim, her leadership philosophy and more.
Question: I understand you were born, raised and went to school in New Hampshire. How do your ties to the state affect the leadership you provide at Cottage Hospital?
Dr. Maria Ryan: Once you become a New Englander, it stays in your blood for sure. Being a hard worker, valuing integrity, those things stay with you. Most of my career was in the southern states, but I decided to come back. I feel like I can relate to the people in New Hampshire because my core values are so aligned with those of the local citizens.
The people of New Hampshire aren't going to follow someone who doesn't seek to walk the talk. I bond with them and they bond with me because I don't just sit behind a desk.
I've been in vary large institutions that are layered horizontally. A nurse would go to charge nurse, who goes to the director and so on until it gets to the CEO, and the CEO is very far removed. I'm not saying that's right or wrong, but here, we don't get caught up in titles. Titles are not going to preclude me from going out on floor to ask a question to a nurse and won't preclude them from asking me questions, either.
I round for outcomes and we ask that department directors get outside of their offices to interview staff about how their day is going and ask patients questions. It's a way of continually working at communication. Communication in any industry is difficult, so use different avenues to understand what the patients needs are and what the workers needs are.
Q: What steps are you taking at Cottage Hospital to improve population health?
MR: Our new triple aim strategy is focused on diabetes. Every geographical area has unique health issues. For instance, I worked in a hospital in Tennessee and we saw a high incidence of cerebral vascular accidents and our geographical area was defined as the "stroke belt." In my current service area, one of the healthiest states in the union, we have a high incidence of diabetes. We have implemented a program to offer our employees free A1c testing, and we're going to work with primary care providers and our wellness program on ways to educate on weight loss, exercise and nutrition to prevent type 2 diabetes.
That's internal stuff, and we're expanding that externally. We are a rural community, and Cottage is the only hospital in the area with diabetic educator. I am "loaning out" that person to provide services at other hospitals and federally qualified health centers in the area to provide that service to those populations. There's no feeling of competition; we're the only ones with the service so we'll help those other areas too.
We're working with another hospital and federally qualified health center on Miles for Smiles, a program that provides dental care. We're contributing funds so we can provide dental care to our community. We have also been collaborating with the Norris Cotton Cancer Center and going into the community to talk about cancer prevention; for example, we went into elementary schools to talk about sun protection and skin cancer and held seminars at the senior center about the importance of colonoscopies for early detection of colon cancer.
We're stepping up to the plate and providing for the most vulnerable, as we provided $4 million in charity care in 2012, $2 million of which was free medical care. On that same chord, we work on being a socially responsible neighbor. Around Christmas time, we matched donations at a local Toys for Tots and donated more than 250 toys to the community. It's going beyond healthcare and looking at all aspects of what our communities are.
I'm very proud of the culture here of reaching out and not being protective. It's a different mentality. If people have a health problem in this community, they come to their local hospital. If another community is hurting, I help out and vice versa. It's a very different mindset. It's really all about helping people become healthier, not about needing them to come here, and not another hospital.
Q: Beyond population health management initiatives, how else are you working to achieve the triple aim of healthcare?
MR: Besides health and wellness, we're working on patient satisfaction. All department directors work together to see what patients are saying about a department and to change the way we do things to meet the patients’ needs.
In the last three years, we haven't raised prices at all, which is atypical. Our government is broke, and I have a responsibility as an American citizen to bend the cost curve because the cost of Medicare is crushing the country.
We've been able to do this through implementing Lean processes. There's no fat in this hospital! Our Lean initiative is internally driven. Everyone has their own talents, and one of mine is to walk into an area and see waste. It's about teaching people how to look at things differently and have them come up with ideas for change. We did offer outside Lean training for a small team of people that works directly with patients. That team is used in different areas of the hospital upon request.
We have to look at healthcare costs and competencies. Not every hospital should be a full-service hospital; you have to look at what you can do. For instance, I will never do neurosurgery here, that wouldn't be the right thing to do; the volume would be too low. As an industry we need to strategize a little bit better.
Q: With the nationwide physician shortage and your hospital's rural location, how do you approach physician recruitment and retention at Cottage Hospital?
MR: We've gotten some high-level professionals because of the type of exemplary healthcare we want to provide. Physicians can take time with patients and have a great work-life balance. Some physicians still do house calls. We've been able to attract young, smart physicians who are attracted to the fact that there's not a lot of red tape in our hospital; they don't have to go through hoops or committees, if they want to try something new. Also, we are so close to Dartmouth Hitchcock Medical Center, a tertiary care hospital, so providers can continue their medical education on Dartmouth's campus. A few physicians actually teach at Dartmouth Medical School as well, keeping them in academia.
We have a strategy to retain excellent physicians but are looking more to advanced practice registered nurses at this time. We like that model especially if they've worked as a registered nurse in a critical care area in a hospital and then went on to become an APRN.
There are federally qualified health centers that employ most of the physicians in this area and Cottage Hospital will assist with loan repayment for the physicians and APRNs.
Q: What advice would you offer to other critical access and rural hospital CEOs?
MR: In a critical access hospital, it's harder to meet the bottom line, and you have to be active somehow in the operations of the hospital. You have to be out and about. It's harder to change culture in a small place than a large place, because if people don't believe in you they won't follow you. You have to get out from behind the desk and know your people and be involved with them and know what the other hand is doing.
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