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Editor's note: This is an excerpt from Cheryl Clark's Aug. 26 piece on quality improvements at rural hospitals.

It isn't every day that rural hospital officials eagerly discuss their abysmal practice scores in crucial care areas like heart failure or hip and knee surgery.

But Cleveland Regional Medical Center in Shelby, NC, and United Hospital Center in Clarksburg, WV, now wear their low rankings almost like war medals.

That's because that poor performance is now history. Today, four years later, the facilities have improved their care of patients so dramatically in four important categories, they've become innovators for other hospitals throughout the country.

Cleveland and United are two of 40 rural hospitals and 190 urban hospitals participating in the Centers for Medicare & Medicaid Services' "pay for performance" demonstration project, organized by Premier Inc.

Ironically, officials for the two hospitals say, the "pay" for their performance isn't the motivator for their participation. Improving care and getting recognized for it, however, are. But improvement required innovation.

One of the strategies that helped at Cleveland, for example, was to ask case managers to follow their patients back to their homes to find out why they have such high readmission rates.

The story of one patient illustrated the difficult problems in their rural area. She had so little money for food, much less medications; her cabinet contained but one can of soup. Other patients who were advised to limit their salt intake didn't know that meant sodium, too.

"It's sometimes especially hard for our elderly to manage that, or to understand," says Liz Popwell, Cleveland's vice president and chief ancillary officer. Her 241-bed hospital's rates of readmissions had been much too high. More counseling and one-on-one sessions helped educate patients to change their diets.

At United, an important reason to participate in the project was an internal assessment done several years ago that "found that the hospital tended to react when problems occurred, rather than work proactively to improve quality," said a June report on United's success by the Commonwealth Fund.

So, when appropriate documentation required by the surgeons was routinely missing, for example, the hospital staff took a tougher stance. Mark Povroznik, director of quality initiatives for the 318-bed United, was a key part of that.

"Once, when it was clear that a particular surgeon was negatively affecting a department's performance, Povroznik announced in a department meeting that, 'Your group efforts are noted and appreciated, but achievement of the department's goal is being held back by one of your colleagues; we're hoping we won't have to disclose who this is," according to the Commonwealth Fund report. The surgeon's compliance improved immediately.

Rural hospitals still have more improvements to make overall. But for Popwell and Povroznik, at least, there is the drive to continue to improve.