Improving Health Care in Big Ways in Small Communities

Syringa Hospital and Clinics' Joe Cladouhos has a niche serving small communities. Among his keys to success are caring about your staff, being transparent wth the community and being prepared for rapid and unending change.

Small communities are Joe Cladouhos’s specialty.

At the start of his professional career, he spent several years working in environmental conservation in Southeast Alaska, but was then drawn to health-care administration, first in a Juneau medical and dental clinic, and later as president/CEO of Norton Sound Health Corporation, a tribally owned and operated not-for-profit organization in the small town of Nome.

Alaska’s cold Bering Strait region has one hospital in Nome and one clinic in each of 15 villages populated by Inupiaq, Siberian Yupik, and Yup’ik tribes. These facilities serve residents spread out over 44,000 square miles. During Cladouhos’s five-year tenure at NSHC, he spearheaded a major change by helping the health system procure $20 million of federal funding to build new clinics in seven of those outlying villages.

The challenges of creating a systemized care loop involving locally trained community health aides, doctors in Nome, and patients in 15 villages helped prepare Cladouhos for his role as CEO of Syringa Hospital, a Critical Access Hospital, and its three clinics. When he arrived in 2007, Syringa Hospital was 68 years old; it had undergone numerous additions and changes with no master plan to guide the functionality of each new stage. “It was looking kind of long in the tooth, and everyone still used paper charts,” Cladouhos remembers. In addition to the facility issues, private practice physicians tended to move on fairly quickly, disrupting access to consistent primary care.

Eight years later, Cladouhos is running a very different healthcare organization. Syringa Hospital & Clinics (SHC) is currently halfway into a $3 million renovation that has a welcoming ambiance of optimism and a logical sense of order and flow. SHC has a stable medical team, with another physician joining the staff this summer. One of their three clinics is a large medical facility in Grangeville, with a wide range of services, such as primary care, behavioral health, obstetrics, preventive care, surgery, and women’s health. It also features a 128 slice C-T, weekly mobile MRI visits, and consulting and visiting specialists who come monthly, primarily from Lewiston, to support podiatry, surgery, cardiology, adolescent psychiatry, and gynecological surgery and infertility needs. Another is a Rural Health Clinic 23 miles away in the community of Kooskia. Their third clinic contracts with the Veterans Administration to provide outpatient services for over 300 veterans in the area.

“We have a terrific staff, and we’re constantly improving,” says Cladouhos, “and we are thriving. In 2015, we were $100,000 in the black. Updated equipment and services are laid out in a facility that is easy to navigate.”

Care about and support your staff. Cladouhos relishes the variety in his job, working with the staff, board, county commissioners, and city council. He also enjoys stewarding continual improvements, such as SHC’s 40B pharmacy, slated to open later this year. He does whatever he can to make the medical staff members’ lives easier, and keep SHC a satisfying place to work. “People come to see the doctor, not the administrator,” Cladouhos says. “In my role as leader, I want to make life easier for my staff, which in turn leads to more satisfaction and productivity.”

Be transparent and connected with the community. In addition to excellent internal partnerships, external ones are key. “We have good people from the town and outlying areas that support our hospital,” says Cladouhos. Case in point: A Grangeville couple with no heirs provided the catalyst for the renovated medical facility with a bequest of $1.3 million to the hospital. Keeping the community informed supports collaboration. SHC’s board meetings are open, with board packets going to the local newspaper beforehand. Being involved with the City Council, Chamber of Commerce, and Lion’s Club, and serving on the local credit union’s board of directors, helps Cladouhos hear from residents and stay accountable through information-sharing. Always open to feedback—positive and negative—he makes an effort to resolve concerns.

Be prepared for rapid and unending change. Though SHC’s picture is rosy right now, Cladouhos sees the fast and furious pace of changes in health care and believes that an informed administrative vision is crucial to address these unending challenges. “Look around the corner at coming changes,” cautions Cladouhos. “What will happen in three years at the local, state, and federal levels? Recognize what infrastructure you have—or don’t have—to deal with those changes.” Small and rural hospitals face particular challenges. The Affordable Care Act mandates a move from a primarily fee-for-service model to value-based contracting and payment. Small hospitals and clinics will have to adapt to this, just like a big hospital system, but without designated resources to manage the transition. In fact, small rural hospitals may be a dying breed.

According to a study by iVantage, a health analytics company, “The rural safety net is strained, and hospitals across the nation are vulnerable to closure.” In this decade, 50 rural and Critical Access Hospitals have closed, and iVantage has identified 283 additional rural hospitals at risk.1 Fifty-five percent of Syringa’s revenue comes from Medicare patients, and because of upcoming Medicare cuts, this might be a “recipe for going broke,” says Cladouhos. “Here, there is a limit to how many staff we can cut, if it comes to that.” The hospital already operates from a very small tax base. The United States spends 17.5 percent of its Gross Domestic Product on health care, while Idaho spends 6.9 percent.2 Cladouhos understands that despite SHC’s current successes, it may be necessary to consider affiliation with other hospitals to manage upcoming challenges.

Earn the community’s trust and confidence. Whether hospitals and clinics are urban, consolidated, and large, or they are independent and serve small patient populations, they rely on the trust and opinions of the communities they serve. Grangeville isn’t any different. Since the town is small, the actions of individuals, businesses and organizations are highly visible; a perceived lapse in an organization’s excellence can quickly bruise the community’s confidence. Through hard work and dedicated leadership, SHC has earned a positive reputation. “We are a small community,” says Cladouhos. “We have a limited number of people who live here—we take care of them and they take care of us.”

Be trustworthy with patient privacy. In part, trust in a health-care facility is built on protecting patients’ personal information from exposure—accidental distribution on the Internet, gossip in the hardware store, and black market sales by cyber thieves. SHC has a robust, secure, encrypted system that protects patient data and encourages patient engagement through its website and patient portal. They are repeatedly on the Hospitals & Health Networks’ Most Wired awards list based on an industry-standard benchmark study, including the level of IT adoption in hospitals and health systems in the United States.

Identify common needs to build community collaboration. Building such a system was not cheap; because of its faith in SHC, the community passed, in 2008, a ballot measure allowing the district to go into debt for $1.5 million to move from vulnerable paper charts to its current HIPAA-compliant electronic health-records system. At the time, Cladouhos told the community, “This will allow the hospital to take full advantage of a Medicare grant that will reimburse 90 percent of the upgrade cost.” He warned that if the hospital didn’t get the system, they were looking at a “train wreck” down the road.

Remain open to feedback and assessment. “We have pride in how we serve the community,” says Cladouhos. To maintain a good reputation, pride must be based on meeting high standards of care. To assess their services, SHC turns to its patients. They use internal surveys for an immediate glimpse into their patients’ hospital stays. They also rely on the results of the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey, a national, standardized survey of patients’ perspectives on their hospital care and experience. Using common metrics and national standards, HCAHPS makes valid comparisons across hospitals—locally, regionally, and nationally—all available online to the public.5 For more informal communication, Syringa has a Facebook page that gives the organization the opportunity to respond personally to patient comments and attempt to resolve concerns. It also has some presence on, but that site provides no way for SHC to respond to site visitors.

Share accomplishments with the community. As Cladouhos sees it, “Your reputation is as good as what you said or did yesterday.” So, broadcasting successes and honors enhances an organization’s reputation. In addition to press coverage, SHC utilizes some public relations for advertising, particularly their Foundation events.

Health Matters, a quarterly insert in the Idaho County Free Press, routinely includes news about SHC activities and awards. The March 4, 2015, issue ( informed readers that “Syringa is among the top five Rural Hospitals in the nation recognized for Excellence in Quality, and among the top seven Rural Hospitals in the nation recognized for Excellence in Patient Satisfaction.