Mis­sion and mar­gin

Hos­pi­tal per­for­mance con­tin­ues to show wide variation, based on own­er­ship struc­ture, mea­sure­ment met­rics

Modern Healthcare - - PERFORMANCE COMPARISONS, BY HOSPITAL OWNERSHIP - By Mau­reen McKin­ney

The wa­ter­shed mo­ment for OhioHealth came sev­eral years ago, dur­ing a meet­ing of the health sys­tem’s qual­ity of care com­mit­tee, when se­nior lead­ers dis­trib­uted a de­tailed list of all of the se­ri­ous safety events that had oc­curred at OhioHealth’s eight hos­pi­tals dur­ing the pre­vi­ous year.

“We handed a copy to ev­ery­one—nurses, doc­tors, lay board mem­bers—and by the end of the meet­ing, there wasn’t a dry eye in the room,” says David Blom, pres­i­dent and CEO of the not-for-profit, faith-based sys­tem, which is head­quar­tered in Colum­bus. “Parochial in­ter­ests dis­ap­peared, and we all said this is un­ac­cept­able. It be­came the top pri­or­ity for our whole or­ga­ni­za­tion.”

Qual­ity and pa­tient safety had long been ar­eas of fo­cus for the sys­tem’s mem­ber hos­pi­tals, Blom says. But it was af­ter that meet­ing that OhioHealth launched a more sweep­ing

ini­tia­tive aimed at or­ga­ni­za­tion­wide col­lab­o­ra­tion, data shar­ing and trans­parency.

Those ef­forts seem to be pay­ing off. Three of OhioHealth’s hos­pi­tals—796-bed River­side Methodist Hos­pi­tal, Colum­bus; 392-bed Grant Med­i­cal Cen­ter, also in Colum­bus; and 92-bed Dublin (Ohio) Methodist Hos­pi­tal— ap­peared on Tru­ven Health An­a­lyt­ics’ 100 Top Hos­pi­tals list for 2013, re­leased in Fe­bru­ary (See this year’s list be­gin­ning on p. 15).

Now in its 20th year, Tru­ven’s list rec­og­nizes top-per­form­ing hos­pi­tals from a field of more than 2,900, based on per­for­mance across mea­sures of mor­tal­ity, 30-day read­mis­sion rates, aver­age length of stay, in­pa­tient ex­pense per dis­charge and oth­ers.

And in a sec­ondary anal­y­sis of that dataset, re­leased ex­clu­sively to Mod­ern Health­care, Tru­ven has spot­lighted gaps and strengths in hos­pi­tal per­for­mance based on their own­er­ship struc­ture, dif­fer­ences that might shed light on why sys­tems such as OhioHealth have suc­ceeded where oth­ers have fal­tered on the var­i­ous mea­sures.

Not-for-profit hos­pi­tals—es­pe­cially chur­chowned not-for-prof­its—per­formed bet­ter than their for-profit and govern­ment-owned peers on met­rics of pa­tient safety, mor­tal­ity and pa­tient sat­is­fac­tion, ac­cord­ing to Tru­ven’s lat­est re­port. For-prof­its, on the other hand, ex­celled in core mea­sures of care for heart at­tack, heart fail­ure, pneu­mo­nia and sur­gi­cal pa­tients; ex­pense con­trol and profit from op­er­a­tions.

Church-af­fil­i­ated not-for-prof­its also scored the high­est on over­all per­for­mance, ac­cord­ing to the data (See chart, right).

“Govern­ment hos­pi­tals demon­strated the weak­est bal­anced per­for­mance, with sig­nif­i­cantly worse per­for­mance on core mea­sures and in­pa­tient ex­penses,” ac­cord­ing to Tru­ven’s re­port.

This is the first time that Tru­ven Health An­a­lyt­ics has un­der­taken an anal­y­sis of hos­pi­tal per­for­mance by own­er­ship across all of its mea­sures, says David Foster, prin­ci­pal in­ves­ti­ga­tor of the re­port and lead sci­en­tist at Tru­ven’s Cen­ter for Health­care An­a­lyt­ics.

“We did this once be­fore, in 2010, but that was just scratch­ing the sur­face,” he says. “This is the first time we’ve looked at all of the mea­sures that we use.”

Based in Ann Ar­bor, Mich., and for­merly known as the health busi­ness of Thom­son Reuters, Tru­ven Health An­a­lyt­ics was formed in June 2012, af­ter Thom­son Reuters sold its health di­vi­sion to Ver­i­tas Cap­i­tal, a New York pri­vate eq­uity firm, for $1.25 bil­lion.

To com­pile the own­er­ship re­port, Foster and his col­leagues re­lied on Tru­ven’s data­base for its 100 Top Hos­pi­tals, which uses pub­licly avail­able claims data from the Medi­care Provider Anal­y­sis and Re­view (MedPAR) dataset, the CMS’ Hos­pi­tal Com­pare data­base and Medi­care cost re­ports. To de­ter­mine each hos­pi­tal’s own­er­ship struc­ture, they also matched Medi­care provider num­bers with Amer­i­can Hos­pi­tal As­so­ci­a­tion data, Foster says.

Aver­age length of stay was 4.94 days at not­for-profit church-owned hos­pi­tals, com­pared with 5.08 days at for-profit fa­cil­i­ties and 5.17 days at govern­ment-owned hos­pi­tals.

Not-for-profit church-owned hos­pi­tals also held the lead on pa­tient sat­is­fac­tion, ac­cord­ing to the re­port, with an aver­age score of 261.2 on the Hos­pi­tal Con­sumer As­sess­ment of Health­care Providers and Sys­tems (HCAHPS) sur­vey, com­pared with an aver­age score of 253.1 for for-prof­its and 258.4 for govern­ment hos­pi­tals.

By con­trast, for-prof­its had sig­nif­i­cantly bet­ter core mea­sure scores, gar­ner­ing an aver­age of 97.3%. Not-for-profit church-owned hos­pi­tals av­er­aged 96.5%; other not-for-prof­its scored 96.2%; and govern­ment hos­pi­tals av­er­aged 95%.

And for case mix- and wage-ad­justed in­pa­tient ex­pense per dis­charge, for-prof­its came in the lean­est at $5,811, well be­low the $6,170 aver­age for not-for-profit chur­chowned hos­pi­tals and the $6,633 for govern­ment-owned fa­cil­i­ties.

“I wouldn’t say we were sur­prised,” Foster says of the re­sults. “It’s con­sis­tent with what we found when we looked at own­er­ship in

2010. It’s prob­a­bly not sur­pris­ing to see that for-prof­its pay close at­ten­tion to the bot­tom line and not-for-prof­its are mis­sion-driven.”

Dr. Bruce Van­der­hoff, OhioHealth’s chief med­i­cal of­fi­cer, cred­ited much of the sys­tem’s suc­cess to its mis­sion-based cul­ture, which he says has buoyed its ef­forts to ad­dress a num­ber of qual­ity tar­gets, in­clud­ing pre­ventable read­mis­sions. OhioHealth has re­duced read­mis­sion rates for heart fail­ure pa­tients from about 24%, roughly the national aver­age, down to 14% across the en­tire sys­tem.

“We have a longer-term view about where we want to be,” Blom says. “We don’t have share­hold­ers and we’re not driven by short­term ac­count­abil­i­ties.”

Vin­son Yates, pres­i­dent of OhioHealth’s Grant Med­i­cal Cen­ter, re­calls an in­stance when an em­ployee stopped him from go­ing into an iso­la­tion room with­out gloves. “When an as­so­ciate feels com­fort­able enough to hold the pres­i­dent ac­count­able, I think that shows we have a good cul­ture in place,” he says.

At River­side Methodist, an­other of OhioHealth’s hos­pi­tals, the first agenda item at ev­ery lead­er­ship meet­ing is safety, says Dr. Steve Markovich, the hos­pi­tal’s pres­i­dent and CEO. “It starts at the top,” he says. “We bring

“We ob­vi­ously have to main­tain our bot­tom line in or­der to stay in ex­is­tence, and that is no lean task. But we make sure that what we do is al­ways on the side of the peo­ple we are serv­ing.”

—Dr. Wil­liam Adair Vice pres­i­dent of clin­i­cal trans­for­ma­tion Ad­vo­cate Christ Med­i­cal Cen­ter

in staff mem­bers to board meet­ings and they present good catches. That kind of recog­ni­tion fil­ters down to ev­ery­one.”

Also on Tru­ven’s 100 Top Hos­pi­tals list this year was Ad­vo­cate Christ Med­i­cal Cen­ter, a 672-bed hos­pi­tal in Oak Lawn, Ill. Dr. Wil­liam Adair, the hos­pi­tal’s vice pres­i­dent of clin­i­cal trans­for­ma­tion, says Tru­ven’s lat­est own­er­ship anal­y­sis con­firms what he be­lieves from his own ex­pe­ri­ence: that peo­ple who are drawn to faith-based, mis­sion-driven or­ga­ni­za­tions have sim­i­lar val­ues, and that bol­sters a com­mit­ment to pa­tients.

“We ob­vi­ously have to main­tain our bot­tom line in or­der to stay in ex­is­tence, and that is no lean task,” Adair says, “but we make sure that what we do is al­ways on the side of the peo­ple we are serv­ing.”

He cited nu­mer­ous qual­ity- and safety-re­lated ini­tia­tives at Ad­vo­cate Christ and its par­ent health sys­tem, not-for-profit 10-hos­pi­tal Ad­vo­cate Health Care, Oak Brook, Ill., in­clud­ing projects tar­get­ing sep­sis preven­tion and im­proved dis­charges, as well as a high-re­li­a­bil­ity pro­gram for hos­pi­tal lead­ers, launched last fall.

And in April, the hos­pi­tal be­gan do­ing daily pa­tient-safety hud­dles aimed at rec­og­niz­ing staff and ad­dress­ing is­sues such as mal­func­tion­ing equip­ment, says Colleen Perez, the hos­pi­tal’s di­rec­tor of qual­ity and reg­u­la­tory com­pli­ance.

“In just our first month, we iden­ti­fied 100 is­sues and solved 100 is­sues,” Perez says. “I can’t tell you the im­pact this has had on our or­ga­ni­za­tion.”

For-profit hos­pi­tal lead­ers, how­ever, balked at the idea that they place less em­pha­sis on qual­ity or are any less pa­tient-cen­tered than their not-for-profit coun­ter­parts.

“We take things like safety and mor­tal­ity very, very se­ri­ously,” says Ken­neth Feiler, CEO of 264-bed Rose Med­i­cal Cen­ter, Den­ver, a Tru­ven 100 Top Hos­pi­tals honoree and part of 146-hos­pi­tal HCA, a for-profit chain head­quar­tered in Nashville. “We do con­sider our­selves ste­wards of re­sources and

we look care­fully at how we uti­lize them.”

Feiler listed many of the same pro­grams and char­ac­ter­is­tics—a safety-ori­ented cul­ture, staff recog­ni­tion, sys­tem-wide im­prove­ment ini­tia­tives— that not-for-prof­its did when ex­plain­ing their suc­cess.

“This is our sixth year on Tru­ven’s list, and I think that if you walked around here, you would sense that we’re work­ing on the fun­da­men­tals ev­ery day,” Feiler says. “We take it per­son­ally when we have a sys­tem fail­ure.”

Foster, prin­ci­pal in­ves­ti­ga­tor of Tru­ven’s lat­est own­er­ship re­port, ac­knowl­edged that the find­ings of­fer few clues about what fac­tors are be­hind the dif­fer­ences in hos­pi­tal per­for­mance.

“We have to rec­og­nize that we can’t make causal state­ments,” he says. “I would cau­tion peo­ple to take note of the pat­terns, but don’t im­ply that we un­der­stand or are mak­ing value judg­ments about why things are a cer­tain way. It’s more of a hy­poth­e­sis-gen­er­at­ing re­port, a jumping-off point.”

Cen­tinela Hos­pi­tal Med­i­cal Cen­ter, a 369-bed hos­pi­tal in In­gle­wood, Calif., marked its sec­ond ap­pear­ance on the 100 Top Hos­pi­tals list this year. Linda Bradley, the hos­pi­tal’s CEO, praised Tru­ven’s score­card method­ol­ogy as a way to gauge over­all hos­pi­tal per­for­mance.

Cen­tinela is part of Prime Health­care Ser­vices, a for-profit, 19-hos­pi­tal sys­tem based in On­tario, Calif.

But Bradley paused when con­sid­er­ing the re­sults of Tru­ven’s lat­est anal­y­sis based on own­er­ship. Such find­ings don’t res­onate with her ex­pe­ri­ences at Cen­tinela, which fo­cuses heav­ily on qual­ity im­prove­ment, safety, mor­tal­ity and pa­tient sat­is­fac­tion, she says.

And she cred­its Prime with fos­ter­ing im­prove­ment through­out the health sys­tem and en­cour­ag­ing shar­ing of best prac­tices.

“I think if any provider—for-profit or not-for-profit—is cul­tur­ally aligned and has ev­ery­one fo­cused on com­mon goals, own­er­ship dif­fer­ences can be­come non-ex­is­tent,” Bradley says.

Physi­cians at OhioHealth’s River­side Methodist Hos­pi­tal use an in­ter­dis­ci­pli­nary ap­proach to pro­ce­dures in the car­diac catheter­i­za­tion lab.

Karen Bid­good, a reg­is­tered nurse at Rose Med­i­cal Cen­ter in Den­ver, tends to Kathryn Cochran and her new­born. The fa­cil­ity, owned by for-profit chain HCA, has been on Tru­ven Health’s 100 Top Hos­pi­tals list six times.

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