The Alaska State Hospital & Nursing Home Association (ASHNHA, or Hospital Association), in partnership with the Alaska Office of Rural Health Policy (ORHP), took steps in 2003 to form a network of its smallest, most rural hospitals. Hospital leaders met a total of four times in 2003 and began to identify an organizational structure and cooperative approach that all of members could support. What emerged is the Alaska Small Hospital Performance Improvement Network (ASHPIN, or Network), a division within ASHNHA itself, that now has 11 members.

The ASHPIN Board has adopted a mission statement and a set of guiding principles.

Mission

The current ASHPIN mission is:

To improve the clinical, operational, and financial performance of Alaska 's small rural hospitals to ensure patient access to appropriate healthcare services.

Guiding Principles

The Network's “Guiding Principles” are to:

•  collaborate fully as a network, whenever institutionally possible;
•  always be customer and patient focused as an organization;
•  recognize that a well executed program of continuous quality improvement is key to patient and community satisfaction with healthcare;
•  focus also on ongoing financial and operational improvements at each facility;
•  seek to provide a work environment that ensures staff satisfaction; and
•  work to make each small hospital in Alaska self-sustaining.

Listed below are the 11 hospitals that as of September 1, 2004 were members of ASHPIN:

Central Peninsula General Hospital (Soldotna)
Cordova Community Medical Center
Maniilaq Health Center (Kotzebue)
Norton Sound Health Corporation ( Nome )
Petersburg Medical Center
Providence Kodiak Island Medical Center
Providence Seward Community Center
Sitka Community Hospital
South Peninsula Hospital (Homer)
Valdez Regional Health Authority
Wrangell Medical Center .

Six (6) of the eleven (11) Network members are healthcare providers located in medically underserved (MUS) communities serving medically underserved populations.

ASHPIN, still in its formative stages after just a year and two months of full operations, has adopted three goals for its first workplan:

Goal 1: Continue network organizational development;

Goal 2: Develop a strategic plan to address network member clinical & operational communications issues, including development of a functional telehealth / telemedicine system; and

Goal 3: Enterprise development and performance improvement.

The Hospital Association itself has been in existence for over 50 years (organized in 1952). ASHNHA members, in their advocacy role, have for years observed and commented on the effects of frontier living on the health and well-being of Alaskans, representing their various communities' major commitment to the provision of healthcare for their residents and for their region of the State.

Spread out across the State, and located in historically important regional centers, Alaska's 24 medical/surgical hospitals, including two military hospitals and seven hospitals operated by tribal health corporations (including six IHS hospitals), were the only acute care facilities available for many miles, and their staff were often a regions' only healthcare providers. And even as an expanded variety of local healthcare options has come on line over the last few decades, Alaska's rural hospitals remain central to their communities' and their surrounding regions' access to patient care, as well as serving as a key economic factor contributing to the financial viability of many of the State's smaller, but important regional centers.

It is also important to note that of Alaska 's 24 acute care hospitals, all but four of those hospitals have fewer than 100 beds , and of those 20, only two have more than 50 beds. Therefore, 75%, or 18 of Alaska 's 24 hospitals qualify as HRSA Small Hospital Improvement Project (SHIP) hospitals. The four relatively large non-military, medical/surgical hospitals in Anchorage (3) and Fairbanks (1) serve as regional referral facilities for providers from rural areas of the state, and all of Alaska's hospitals serve an area larger – often much larger – than the community in which they are physically located.

Similar to the difficult financial times confronting the communities and regions in which they are located, Alaska's small rural hospitals face not only the problems common to small rural hospitals nationwide, but they face additional and unique problems created by Alaska's geography (i.e., distance and isolation).

Paramount among these problems are difficulty in recruiting and retaining physicians and nurses and financial problems related to declining inpatient use while having to continue to provide emergency care and trauma evacuations/transfers to more sophisticated levels of medical care in larger communities.

In all but the four largest hospitals in Alaska , inpatient occupancy rates fluctuate, often averaging 30% or less of the licensed beds (the average daily census of a number of Alaska 's smallest hospitals is below one). Many of the smaller hospitals also struggle with the problem of seasonal fluctuations in census. The shortages of health care workers, especially nurses, make it difficult to provide care in times of higher census or acuity and meet the needs of suddenly busy emergency rooms.

But unlike small rural hospitals in the rest of the country, the isolation of many of Alaska 's hospitals only exacerbates to a second and third power the difficulties just described, especially those of workforce shortages and costs. The costs associated with living in some of these communities (food, clothing, household needs, transportation) is significantly higher than the costs generally associated with rural communities Outside, where, in fact, you can at least drive to a larger urban community and take advantage of Wal-Mart and Fred Meyer prices.

In 1998, Alaska ranked 48th among the states in the ratio of doctors to residents. Only Idaho and Oklahoma had fewer doctors per 100,000 population. Access to care is also limited by shortages of other health care providers and allied health workers.

The Alaska Center for Rural Health, in a November 2000 survey, identified shortages of nurses, social workers, dentists, dental assistants, pharmacists, opticians, speech pathologists, school psychologists, physical therapists, emergency medical technicians, mental health counselors, medical transcriptionists, radiologists, respiratory therapists, community health aides, and certified nursing assistants.

Alaska wages are no longer high enough to attract qualified healthcare workers from other states (something that Alaska employers were able to use for many years, along with Alaska's allure, as a recruitment tool), and educational programs within the state are not adequate to meet Alaska's healthcare needs. The aging of health professionals in Alaska is another concern, where 25% of registered nurses and 43% of physicians responding to a survey were over 50. As a result, as was previously noted, many census areas and boroughs in Alaska are federally designated as health professional (medically underserved) shortage areas.

Turnover in remote areas also affects the quality of health care, as professionals who have learned the cultural and epidemiological characteristics of a community are replaced by less knowledgeable newcomers. Community leaders in the Yukon-Kuskokwim Delta described the problem poignantly when they listed “physician turnover ratio” as one of their health care priorities for 2001-2002: “When physicians learn, they move away from our region and we have to start all over with new physicians.”

Finally, impacting the quality of local care is the fact that many of the healthcare workers hired to work in rural settings are not of people of color, or even of Alaska Native descent. Attempts to increase the number and proportion of members of under-represented racial and ethnic groups who are primary care providers are important, because ethnically diverse workers are more likely to provide services in a culturally appropriate manner, but these efforts have been largely unsuccessful in Alaska . For example, Alaska Natives trained in healthcare professions often do not practice in areas where health services are in short supply, or in areas with high percentages of under-represented racial and ethnic populations.

As the 21 st Century dawned, Alaska 's small rural hospitals found themselves, as did the rest of the nation's rural facilities, facing significant barriers to their ability to adequately meet the acute care needs of their regions.

In the face of the very serious public health issues facing Alaska, a concomitant increase in demand for access to healthcare, and a nationwide push to ensure quality in healthcare, community, State public health, and local hospital leaders knew they had to find ways to help these hospitals at least face (if not rise to) these challenges. They knew Alaska had to seek a new approach. Complicating this mandate: healthcare financing and healthcare costs were endangering the sustainability of more than a few of Alaska 's small hospitals, hospitals that are the historic and current symbol of healthcare in their communities.

A federal program, the Rural Hospital Flexibility Program (FLEX), offered some potential solutions and Alaska has attempted to use this assistance to take the measure of its frontier facilities. To be eligible for the Rural Hospital Flexibility Program, public and non-profit hospitals must meet certain criteria, including being more than 35 miles from another hospital or being needed to assure access to care for individuals within the community, criteria every Alaskan hospital outside of Anchorage could meet.

As a result, FLEX Program grant dollars in Alaska have supported technical assistance to every small hospital in Alaska , including studies by a majority of the community hospitals that have joined ASHNHA's network. These studies -- and the community process involved in their development -- helped these hospitals carefully examine their markets, community needs, and organizational linkages, all with the intent of assisting them to better understand what they needed to do in order to maximize sustainability. It has allowed Alaska 's small rural hospitals to begin to assess what necessary changes they must make while also assisting by reducing the cost of meeting regulatory requirements, enhancing opportunities for Medicaid and Medicare reimbursement, and increasing flexibility to meet staffing needs.

The program requires hospitals seeking designation as “necessary providers of health care services” or Critical Access Hospitals (CAH's), to establish and maintain formal collaborative networks to assure continuity of care for patients and consultative relationships that enhance quality of care.

By late 2003, seven (7) Alaska hospitals (Wrangell Medical Center, Petersburg Medical Center, Sitka Community Hospital, Cordova Community Medical Center, Providence Seward Medical Center, Valdez Regional Health Authority, and Providence Kodiak Island Medical Center) were designated Critical Access Hospitals.

As of September 1, 2004, in addition to the original seven CAH's, the Nome Hospital, owned and operated by the Norton Sound Health Corporation (a tribal entity), and Maniilaq Medical Center in Kotzebue, an IHS hospital, have also been designated CAH's, meaning that half of Alaska's smallest hospitals are now critical access facilities. Two other hospitals are exploring the value of such designation: Kanakanak, in Dillingham, an IHS facility operated by the Bristol Bay Area Health Corporation, and the Samuel Simmonds Memorial Hospital in Barrow, also an IHS hospital, operated by the Arctic Slope Native Association.

The partnership that developed as the Hospital Association's small rural hospitals worked through the FLEX grant process with the State Office of Rural Health and local communities helped ASHNHA leaders and members realize that significant benefits awaited them collectively and individually, if the collaboration occurring between the small hospitals were to continue and expand. Soon, the Hospital Association took the natural next step and began the process of creating a network.

The Network's current mission statement and statement of guiding principles were adopted during an organizational meeting on April 10, 2003 .

There are also two inpatient psychiatric hospitals in the State: the State's only public hospital and a for-profit hospital serving only children and adolescents; both psychiatric facilities are located in Anchorage .

The over 50-bed facilities, by size: Providence Alaska Medical Center , Anchorage (303 beds); Alaska Regional Hospital , Anchorage (254 beds); Fairbanks Memorial Hospital (162 beds); Alaska Native Medical Center , Anchorage (156 beds); Central Peninsula Hospital , Soldotna (62 beds); and Bartlett Hospital , Juneau (55 beds).

U.S. Census Bureau. Statistical Analysis of the United States . 2000.

Alaska Center for Rural Health. Alaska 's Allied Health Workforce: A Statewide Assessment. University of Alaska Anchorage , March, 2001.

Alaska has no medical or dental schools and consistent training in allied health areas is just beginning; the University of Alaska 's School of Nursing only began seriously increasing enrollment at its three campuses in the fall of 2002 – and only after the addition of considerable private capital from some of the larger ASHNHA member hospitals.

State of Alaska Department of Labor and Workforce Development. The aging of Alaska 's workforce. Alaska Economic Trends. September, 2000. Alaska Center for Rural Health. Alaska Physician Workforce Study. University of Alaska Anchorage , May, 2000.

Yukon-Kuskokwim Health Corporation. Tribal gathering: Priorities. Y-K Messenger, April, 2001.