Qual­ity care­givers

Hos­pi­tals on Tru­ven’s 100 Top list achieve both strong qual­ity, fi­nan­cial per­for­mance

Modern Healthcare - - NEWS - By Mau­reen McKin­ney

Nearly four years ago, a group of physi­cian lead­ers at Van­der­bilt Univer­sity Med­i­cal Cen­ter launched a pro­gram de­signed to en­sure that pa­tients who pre­sented with cer­tain com­plex con­di­tions, such as clot­ting and bleed­ing dis­or­ders, were given the right di­ag­nos­tic tests and ap­pro­pri­ate treat­ments.

Physi­cians un­fa­mil­iar with such con­di­tions would of­ten or­der a slew of costly tests, many of them un­nec­es­sary, and then would strug­gle to ac­cu­rately in­ter­pret the re­sults.

So Nashville-based Van­der­bilt formed di­ag­nos­tic man­age­ment teams that tapped the ex­per­tise of pathol­o­gists and other lab­o­ra­tory medicine spe­cial­ists to guide clin­i­cal de­ci­sion­mak­ing. They give feed­back to treat­ing physi­cians on ap­pro­pri­ate test­ing and treat­ment path­ways for com­plex con­di­tions, in­clud­ing blood can­cers, cer­tain in­fec­tious dis- eases and co­ag­u­la­tion dis­or­ders.

“These are ar­eas where physi­cians are not as fa­mil­iar, so they used to check off ev­ery test un­der the sun,” said Dr. C. Wright Pin­son, Van­der­bilt’s deputy vice pres­i­dent for health af­fairs. “Hav­ing that re­verse con­sul­ta­tion from a pathol­o­gist can re­ally help. Now in­stead of scat­ter-shoot­ing lots of tests, we can pro­vide care that’s ap­pro­pri­ate and ef­fi­cient.”

The use of di­ag­nos­tic man­age­ment teams has re­sulted in shorter times in reach­ing di­ag­noses, fewer un­nec­es­sary tests and pro­ce­dures, shorter lengths of stay and lower costs, he said. It’s one among many im­prove­ment ini­tia­tives that Van­der­bilt’s lead­ers

Ac­cord­ing to Tru­ven’s na­tional com­par­i­son data, those on the 100 Top Hos­pi­tals list out­per­formed peer hos­pi­tals across all 14 mea­sures.

credit with help­ing the 909-bed hospi­tal make its 14th ap­pear­ance on Tru­ven Health An­a­lyt­ics’ 100 Top Hos­pi­tals: Na­tional Bench­marks for Suc­cess, 2014.

Now in its 21st year, Tru­ven’s list, re­leased ex­clu­sively to Mod­ern Health­care, rec­og­nizes 100 high-scor­ing hos­pi­tals from a field of 2,803, based on per­for­mance across mea­sures of mor­tal­ity, 30-day read­mis­sions, aver­age length of stay, op­er­at­ing mar­gin, pa­tient sat­is­fac­tion and other ar­eas.

Ac­cord­ing to Tru­ven’s na­tional com­par­i­son data, those on the 100 Top Hos­pi­tals list out­per­formed peer hos­pi­tals across all 14 mea­sures. For in­stance, in­pa­tient ex­pense per dis­charge for those on the 100 Top Hos­pi­tals list to­taled $5,648, roughly 10% lower than the com­par­i­son hos­pi­tals. Aver­age length of stay among those on the 100 Top Hos­pi­tals list was 4.3 days, com­pared with 4.9 among peer hos­pi­tals not on the list. Hos­pi­tals on this year’s list also per­formed far bet­ter on mar­gins—with an aver­age op­er­at­ing mar­gin of 13.5%—com­pared with 4.1% among the peer group.

Tru­ven, based in Ann Ar­bor, Mich., was formed in June 2012 when Thom­son Reuters sold its health di­vi­sion to Ver­i­tas Cap­i­tal, a New York pri­vate eq­uity firm, for $1.25 bil­lion.

The hos­pi­tals on this year’s list at­trib­uted their per­for­mance to a num­ber of in­ter­ven­tions, in­clud­ing im­proved care co­or­di­na­tion, thought­ful de­ploy­ment of health in­for­ma­tion tech­nol­ogy sys­tems, col­lab­o­ra­tion with front-line care­givers and use of change-man­age­ment strate­gies such as Lean. Seven­teen hos­pi­tals made their first ap­pear­ance on this year’s list, in­clud­ing 279-bed Ad­vo­cate Con­dell Med­i­cal Cen­ter, Lib­er­tyville, Ill., and 65-bed Aurora Me­mo­rial Hospi­tal of Burling­ton (Wis.).

A num­ber of other hos­pi­tals on this year’s list have been rec­og­nized many times, such as 624-bed Ad­vo­cate Lutheran Gen­eral Hospi­tal, Park Ridge, Ill., which has ap­peared 15 times; 796-bed River­side Methodist Hospi­tal, Columbus, Ohio, which has ap­peared 11 times; and 199-bed Lick­ing Me­mo­rial Hospi­tal, Ne­wark, Ohio, which has made the list 12 times. Tru­ven com­piles its list us­ing pub­licly avail­able data from the Medi­care Provider Anal­y­sis and Re­view data set, the CMS’ Hospi­tal Com­pare data­base and Medi­care costs re­ports. El­i­gi­ble hos­pi­tals are di­vided by size into five cat­e­gories: ma­jor teach­ing hos­pi­tals, teach­ing hos­pi­tals, and large, medium and small com­mu­nity hos­pi­tals.

Within those five cat­e­gories, hos­pi­tals are eval­u­ated against one an­other across all mea­sures, in­clud­ing in­pa­tient ex­pense per dis­charge; riskad­justed com­pli­ca­tions; and 30-day read­mis­sion and mor­tal­ity rates for heart at­tack, heart fail­ure and pneu­mo­nia. To make the 100 Top list, hos­pi­tals must rank above their peers on a com­pos­ite score of all 14 mea­sures and they must also score above the me­dian for each mea­sure.

For this year’s list, Tru­ven also tested sev­eral new mea­sures that were not used to de­ter­mine hos­pi­tals’ scores but may be in­cluded in fu­ture it­er­a­tions, said Jean Chenoweth, Tru­ven Health An­a­lyt­ics’ se­nior vice pres­i­dent of per­for­mance im­prove­ment. Those mea­sures in­clude the Medi­care spend­ing per ben­e­fi­ciary mea­sure sched­uled to be in­cluded in the CMS’ value-based pur­chas­ing pro­gram start­ing in fis­cal 2015, as well as 30-day risk-ad­justed read­mis­sion rates for hip- and knee-re­place­ment surg­eries. Those rates re­cently be­came avail­able on the Hospi­tal Com­pare web­site.

Spear­head­ing new qual­ity ini­tia­tives while keep­ing a tight rein on fi­nances is no easy task, par­tic­u­larly for a small hospi­tal, said Mark Kloster­man, pres­i­dent and CEO of St. Joseph’s Hospi­tal Breese (Ill.), a 47-bed fa­cil­ity in a town of just over 4,000.

St. Joseph’s made Tru­ven’s 100 Top Hos­pi­tals list for the first time this year, an achieve­ment Kloster­man at­tributes to its far-reach­ing use of Lean man­age­ment prin­ci­ples. Kloster­man in­tro­duced Lean prac­tices, such as valuestream map­ping, to St. Joseph’s in 2010, when he took the helm. Since then, the hospi­tal staff has un­der­taken a va­ri­ety of ini­tia­tives, in­clud­ing ones

aimed at stream­lin­ing clin­i­cal ser­vices in the hospi­tal’s breast clinic, im­prov­ing in­ven­tory man­age­ment and sim­pli­fy­ing pa­tient ed­u­ca­tion at dis­charge.

“It took a while to get it off the ground, but it’s re­ally grow­ing now,” Kloster­man said of the Lean qual­ity-im­prove­ment pro­gram.

In ad­di­tion, St. Joseph’s Hospi­tal was rec­og­nized on Tru­ven’s an­nual list of Ever­est Award win­ners, a sub­set of hos­pi­tals that ap­pear on the Top 100 Hos­pi­tals list and also met a na­tional tar­get for rate of im­prove­ment over five con­sec­u­tive years. This year’s Ever­est Award list fea­tured 14 hos­pi­tals.

Coo­ley Dickinson Hospi­tal, a 101bed fa­cil­ity in Northamp­ton, Mass., also made the 100 Top Hos­pi­tals list for the first time and earned a place on Tru­ven’s Ever­est Award win­ner list. Dr. Mark Novotny, Coo­ley Dickinson’s chief med­i­cal of­fi­cer, high­lighted a num­ber of re­cent mile­stones, in­clud­ing more than 1,000 days with­out a case of ven­ti­la­tor-as­so­ci­ated pneu­mo­nia.

The big­gest suc­cess has been Coo­ley Dickinson’s un­wa­ver­ing fo­cus on re­duc­ing mor­tal­ity, he said. That fol­lowed a 2010 data anal­y­sis which found sev­eral di­ag­noses for which the hospi­tal’s mor­tal­ity rate was worse than ex­pected. Ini­tially, Coo­ley Dickinson physi­cians were skep­ti­cal of

this ef­fort, ar­gu­ing that the high­erthan-ex­pected mor­tal­ity rates re­flected a pop­u­la­tion of very sick pa­tients and a com­plex hospi­tal en­vi­ron­ment.

But hospi­tal lead­ers im­ple­mented a range of in­ter­ven­tions, in­clud­ing the use of stan­dard­ized pro­to­cols and spe­cial­ized or­der sets for con­di­tions such as sep­sis. Fol­low­ing those moves, the hospi­tal found that over­all ob­served-to-ex­pected mor­tal­ity fell sig­nif­i­cantly, from 1.1 in 2010, or 10% more deaths than ex­pected, to 0.28 in the nine months ended Oc­to­ber 2013, or 72% fewer deaths than ex­pected, Novotny said. Sep­sis mor­tal­ity dropped from 1.39 to 0.82 over the same pe­riod. As the physi­cians saw the mor­tal­ity num­bers creep down­ward, they be­came more en­thu­si­as­tic about ap­ply­ing sim­i­lar strate­gies to other tar­gets. “This kind of suc­cess builds on it­self,” Novotny said.

Staff at West Val­ley Med­i­cal Cen­ter, Cald­well, Idaho, saw that same mo­men­tum take hold as they worked over the past seven years to es­tab­lish pro­cesses and con­tin­u­ously mon­i­tor per­for­mance. The 122-bed hospi­tal was among the first-timers on this year’s list, and also made the list of Ever­est Award win­ners.

West Val­ley has ex­pe­ri­enced just one cen­tral-line-as­so­ci­ated blood­stream in­fec­tion dur­ing the past five years. It also has im­ple­mented a ro­bust fall-preven­tion ini­tia­tive. In ad­di­tion, the hospi­tal worked with HCA, its par­ent sys­tem, and the Cam­bridge, Mass.based In­sti­tute for Health­care Im­prove­ment on a project to boost

pa­tient sat­is­fac­tion. That re­sulted in a num­ber of changes, in­clud­ing the im­ple­men­ta­tion of a manda­tory bed­side re­port in which pa­tients are in­tro­duced to their new care­giver when­ever there is shift change or a move to an­other depart­ment.

“It took time to re­fine it but it is now a stan­dard of care that we ex­pect of our staff,” said Edith Irv­ing, West Val­ley Med­i­cal Cen­ter’s in­terim CEO and chief nurs­ing of­fi­cer.

Scott & White Hospi­tal, Tem­ple, Texas, has made the list nine times, but its lead­ers say they are con­stantly look­ing for ways to im­prove ef­fi­ciency and boost qual­ity. Re­cently they set their sights on short­en­ing the long waits—some­times up to two weeks— to get in for ap­point­ments in the hospi­tal’s am­bu­la­tory clin­ics.

Af­ter care­ful anal­y­sis and use of Lean prin­ci­ples, the team charged with ad­dress­ing the prob­lem de­cided to in­tro­duce same-day clinic vis­its. Team mem­bers let pa­tients know same-day vis­its would be shorter—15 to 20 min­utes—with a longer visit, if needed, to be sched­uled later. In ad­di­tion, pa­tients were told they might not see their usual physi­cian.

Scott & White rolled out same-day vis­its last Oc­to­ber.

“It has worked tremen­dously well,” said Dr. John Er­win, as­so­ciate pro­fes­sor and vice chair of the depart­ment of in­ter­nal medicine at Bay­lor Scott & White Health, which was formed when the two sys­tems merged in 2013. “Those small things are big things to pa­tients.”

Dr. Michael La­posata, pathol­o­gist-in-chief at Van­der­bilt Univer­sity Med­i­cal Cen­ter’s Van­der­bilt Univer­sity Hospi­tal, is a leader of the hospi­tal’s di­ag­nos­tic man­age­ment team ini­tia­tive, which taps pathol­o­gists’ ex­per­tise to im­prove di­ag­noses for com­plex con­di­tions.

This year marks Van­der­bilt Univer­sity Med­i­cal Cen­ter’s 14th time on Tru­ven’s 100 Top Hos­pi­tals list.

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