Cottage Hospital: Maria Ryan, PhD, APRN, Chief Executive Officer

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Many businesses are required to do more with less, and for hospitals, this pressure increases every day. One small hospital in New England takes a common-sense approach to managing costs and patient care.

Cottage Hospital is a 25-bed critical-access hospital in Woodsville, N.H., serving 26 small towns in the beautiful Upper Connecticut River Valley of New Hampshire and Vermont. There are approximately 40,000 people over age 65 within a 35-mile radius of the hospital. Medicare makes up about 50 percent of the hospital’s payer mix, requiring creative strategies for managing costs.

Cross training

Maria Ryan became chief executive officer in 2010, inheriting a hospital that had experienced decades of financial struggle. But while surrounding hospitals have had to cut staff, Cottage Hospital has been able to maintain staff and benefits through Ryan’s common-sense approach.

She shudders at the thought of mediocrity, saying, “I only want to be associated with the best, and I demand excellence from myself.”

The hospital enjoyed back-to-back financial gains with a greater-than four-percent margin in fiscal year 2011. Part of the organization’s success has been attributed to an increased emphasis on staff training. Cottage runs a lean operation, and nurses must be able to assist in multiple areas of the hospital.

Thus, Ryan focused on ensuring that the staff was cross trained in many areas. All nurses have Basic Life Support certification and many have Advanced Cardiac Life Support and Pediatric Advanced Life Support certifications. The medical staff holds these certifications as well.

“Because everything in nursing is so specialized, it has taken years to accomplish training a staff that can work in multiple departments, but we are willing to invest in them,” Ryan said.

When patient volumes are low in a particular area, Ryan will send staff for training at the local tertiary-care hospital for three months to get experience in a high-volume department. Ryan invested in a computerized life-size mannequin patient, a SimMan, who can simulate a heart attack or trauma situation. The clinical directors are able to run different scenarios in the simulation lab to keep staff competent.

In an effort to maximize the use of patient beds and the experience of cross-trained staff, Cottage Hospital has established a concept known as Variable Acuity Rooms. These rooms are equipped for critical-care or medical /surgical patients.

“By incorporating this concept, nurses now have immediate access to their colleagues, nursing assistants, and unit secretaries, which was a prior deficiency,” Ryan said. “This room concept and design contributed to a holistic view of patient care. This flexibility really adds so much efficiency to a rural healthcare setting.”

Ryan herself has a wealth of knowledge and experience to draw upon. She began her career in nursing and holds a master’s degree in the science of nursing, and she is an Advanced Practice Registered Nurse (APRN). Ryan also achieved a doctorate in healthcare administration. She has been called upon to use her medical knowledge and has often taken care of patients in emergency situations.

Looking for growth

With a high percentage of Medicare patients, it can be hard for a small, rural hospital to find the funds for growth. Previously, Ryan said outpatient services had been the main source of income for the hospital, but inpatient volume has significantly increased.

Most recently, Cottage Hospital has expanded its outpatient services by opening a medical and cosmetic laser center. Ryan said she was skeptical at first about whether the cosmetic side of the laser center would be successful in this economy, but she said the cosmetic side is now driving business more than the medical side. The center has also become a new access point for patients to learn about the hospital.

“The laser center has made us a destination for people who haven’t used our hospital in the past,” she said. “We have a high level of customer service, and these new patients have come back for other services we offer.”

To evaluate growth opportunities, Ryan said the leadership team is constantly looking at new strategies or services and often gets creative ideas from employee forums. She said one employee talked about community-supported agriculture during one forum, which spurred the hospital to increase its purchase of local meat and produce.

“This employee helped us to realize how important we are to the community and that we needed to spread our economic impact around our area,” Ryan said.

Steps like these, along with improvements in patient care, have turned around the hospital’s reputation within the community. Ryan said during a recent visit to a nursing facility that is home to many of the hospital’s patients, people remarked on how much the hospital has changed over the years from a “band-aid facility” to a provider of choice.

Simplifying efficiency

Dedicated to retaining and attracting highly talented individuals and adding services, Ryan is always looking for ways to increase efficiency. Through Lean Six Sigma processes, Cottage Hospital has been able to maintain its staffing levels and create some new jobs as well. Ryan also said that while most rural hospitals around her have closed their birthing centers, Cottage Hospital has been able to maintain this service despite its poor payer mix.

Future plans include adding a 10-bed secured geriatric behavioral-health unit. With the aging population in the community, patients have nowhere nearby to get help when they have behavioral-health issues. Ryan said the unit would be for short-term care and would focus on providing treatment and helping patients to return home.

Looking toward the future, Ryan keeps her focus on simplification–simplifying processes to make workflow more efficient and simplifying the healthcare system to make receiving care easier for patients.

“We really need to simplify how we function,” she said. “The healthcare system can be overwhelming for patients and their families. People get scared when they hear talk of a broken healthcare system, but there are people who care and who want to make a change.”

-by Patricia Chaney

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