There’s strength in num­bers

Hos­pi­tals in sys­tems out­per­form in­de­pen­dent hos­pi­tals on key qual­ity met­rics

Modern Healthcare - - 100 TOP HOSPITALS 2017 - By Maria Castel­lucci

As re­im­burse­ment dol­lars are in­creas­ingly tied to per­for­mance out­comes, it’s harder for small and medium-sized hos­pi­tals to re­main in­de­pen­dent.

The push to value-based care con­sumes con­sid­er­able re­sources in both staff time and money, re­quires a ro­bust tech­nol­ogy in­fra­struc­ture and a healthy ap­proach to data an­a­lyt­ics, as well as a ded­i­ca­tion to root out vari­a­tion and im­prove care across the con­tin­uum. At the same time, providers face ever-shrink­ing re­im­burse­ment for their ser­vices.

These pres­sures, among other mar­ket forces, have led to a sharp de­cline in in­de­pen­dent hos­pi­tals. Of the 4,862 com­mu­nity hos­pi­tals in the U.S., 65% are part of a sys­tem, ac­cord­ing to 2017 data from the Amer­i­can Hos­pi­tal As­so­ci­a­tion; that com­pares with 5,008 com­mu­nity hos­pi­tals in 2009, when 58% were in sys­tems.

While there’s am­ple de­bate on the im­pact con­sol­i­da­tion has on costs, a new study sug­gests that the move­ment of in­de­pen­dent hos­pi­tals to sys­tems might ac­tu­ally be im­prov­ing pa­tient care and help­ing providers achieve bet­ter out­comes.

Small and medium-sized hos­pi­tals that are part of sys­tems per­form bet­ter than their in­de­pen­dent peers on seven of 12 qual­ity and cost met­rics: in­pa­tient mor­tal­ity, 30-day mor­tal­ity, core mea­sures, av­er­age length of stay, in­pa­tient ex­pense, op­er­at­ing profit mar­gin and over­all bal­anced per­for­mance, ac­cord­ing to an ex­clu­sive study con­ducted for Modern Health­care by Tru­ven

Health An­a­lyt­ics, IBM Wat­son Health.

The analysis in­cluded 2,740 hos­pi­tals from Tru­ven’s an­nual 100 Top Hos­pi­tals study, which uses a va­ri­ety of Medi­care pa­tient data to com­pare hos­pi­tals. Or­ga­ni­za­tions are eval­u­ated based on met­rics such as pa­tient-sat­is­fac­tion scores and emer­gency depart­ment wait times.

Tru­ven com­pared 12 per­for­mance met­rics from 2014 to 2015 be­tween in­de­pen­dent hos­pi­tals and hos­pi­tals in a sys­tem. There were 882 in­de­pen­dent hos­pi­tals in­cluded in the study and 1,858 sys­tem hos­pi­tals. Tru­ven de­fined a health sys­tem as hav­ing two or more gen­eral acute-care hos­pi­tals. The hos­pi­tals were also di­vided into five sep­a­rate cat­e­gories: ma­jor teach­ing hos­pi­tals (400 or more acute-care beds), teach­ing hos­pi­tals (200 or more acute-care beds), large com­mu­nity hos­pi­tals (250 or more acute-care beds), medium-sized com­mu­nity hos­pi­tals (100-249 acute-care beds) and small hos­pi­tals (25-99 acute-care hos­pi­tals).

Tru­ven found that there was no sta­tis­ti­cally sig­nif­i­cant dif­fer­ence in per­for­mance met­rics be­tween in­de­pen­dent teach­ing and large com­mu­nity hos­pi­tals ver­sus those af­fil­i­ated with a sys­tem. This is likely be­cause teach­ing hos­pi­tals and large com­mu­nity hos­pi­tals don’t need to rely on a sys­tem as much as small or medium hos­pi­tals, said Jean Chenoweth, Tru­ven’s se­nior vice pres­i­dent of per­for­mance im­prove­ment and the 100 Top Hos­pi­tals pro­gram. Teach­ing hos­pi­tals are of­ten sup­ported by a re­search in­sti­tu­tion and large com­mu­nity hos­pi­tals are boosted by a large pa­tient vol­ume so they are able to sur­vive on their own, she said.

On the other hand, small and medium hos­pi­tals af­fil­i­ated with sys­tems re­ported bet­ter per­for­mance met­rics than their in­de­pen­dent peers, the Tru­ven study found.

Small and medium hos­pi­tals ben­e­fit from the re­sources, staff and tools from their af­fil­i­ate sys­tems to achieve su­pe­rior per­for­mance, Chenoweth said. “The con­sol­i­da­tion of the hos­pi­tal in­dus­try is ac­tu­ally bring­ing higher value to com­mu­ni­ties. The for­ma­tion of sys­tems is al­low­ing medium and small com­mu­nity hos­pi­tals to im­prove.”

Sys­tems of­ten en­able small and medium hos­pi­tals to im­ple­ment an in­te­grated elec­tronic health record sys­tem, new ser­vice lines and best

prac­tices that im­prove qual­ity, said Meg Guerin-Calvert, pres­i­dent of the Cen­ter for Health­care Eco­nom­ics and Pol­icy at FTI Con­sult­ing. In ad­di­tion, a sys­tem might have a pop­u­la­tion health depart­ment fo­cused on help­ing its hos­pi­tals im­ple­ment more value-based care ap­proaches.

“A sys­tem is able to take in in­for­ma­tion and dis­sem­i­nate it to its smaller hos­pi­tals,” Guerin-Calvert said.

Ac­cord­ing to Tru­ven’s analysis, sys­tem hos­pi­tals per­formed on av­er­age at the 55th per­centile for in­pa­tient mor­tal­ity ver­sus in­de­pen­dent hos­pi­tals per­form­ing at the 44th per­centile. In ad­di­tion, length of stay was 6.1 per­cent­age points bet­ter at sys­tem hos­pi­tals com­pared to in­de­pen­dent fa­cil­i­ties.

Al­though Tru­ven found that sys­tem hos­pi­tals re­port bet­ter qual­ity, their abil­ity to lower costs was less clear. Sys­tem hos­pi­tals re­ported lower in­pa­tient ex­penses by 3.5 per­cent­age points, but they per­formed worse in Medi­care spend­ing. Per ben­e­fi­ciary spend­ing was 5.14 per­cent­age points higher at sys­tem hos­pi­tals com­pared with in­de­pen­dent hos­pi­tals.

Given the fact that Medi­care spend­ing per ben­e­fi­ciary cov­ers the en­tire episode of care in­clud­ing 30 days af­ter a pa­tient is re­leased from the hos­pi­tal, it’s not sur­pris­ing sys­tems were spend­ing more, said David Foster, lead sci­en­tist of value-based care an­a­lyt­ics at IBM.

Sys­tem hos­pi­tals are more likely to use re­sources af­ter a pa­tient is dis­charged to pre­vent read­mis­sions, such as us­ing home health ser­vices or en­list­ing care co­or­di­na­tors to fol­low up with pa­tients, Foster said.

Take Peo­ria, Ill.-based OSF Health­Care, which has fo­cused on pre­vent­ing read­mis­sions for Medi­care ben­e­fi­cia­ries across its 11 hos­pi­tals.

The sys­tem has en­listed care co­or­di­na­tors to fol­low up with pa­tients 72 hours af­ter they are re­leased from an OSF hos­pi­tal. The calls are to en­sure the pa­tients have sched­uled a fol­low-up ap­point­ment, picked up their med­i­ca­tions and to check if they have any ques­tions about their care plan.

This prac­tice was im­ple­mented across the sys­tem and has helped re­duce read­mis­sions, said Robert Sehring, OSF’s chief op­er­at­ing of­fi­cer. The sys­tem has been able to keep the read­mis­sion rate be­low 10% be­cause of the ef­forts.

Most of the time, prac­tices are im­ple­mented across the sys­tem in an ef­fort to elim­i­nate vari­a­tion and es­tab­lish stan­dards of care. The elec­tronic health record is a crit­i­cal in­stru­ment to es­tab­lish uni­form pro­to­cols across the hos-

pital, Sehring said.

OSF de­ployed an EHR from Epic Sys­tems Corp. across all of its fa­cil­i­ties. When a best prac­tice has been es­tab­lished—usu­ally by front­line staff—it is baked into the clin­i­cal de­ci­sion sup­port sys­tem. For ex­am­ple, if a pa­tient is di­a­betic, the EHR will prompt the physi­cian to ask if he has re­ceived a re­cent re­nal eye exam.

For OSF St. James-John W. Albrecht Med­i­cal Cen­ter, one of Tru­ven’s 100 Top hos­pi­tals in the small hos­pi­tal cat­e­gory, the in­te­grated EHR en­ables staff to mon­i­tor the qual­ity met­rics at other OSF hos­pi­tals to see how they com­pare to their peers, said Brad Sol­berg, pres­i­dent of the hos­pi­tal in Pon­tiac, Ill.

The in­te­grated med­i­cal record also al­lows for easy tran­si­tion be­tween in­pa­tient and out­pa­tient set­tings. If pa­tients need to be trans­ferred to one of the sys­tem’s larger hos­pi­tals for more spe­cialty treat­ment, their med­i­cal records fol­low them eas­ily so the physi­cian knows what the care plan is, Sol­berg said.

But trans­fer­ring a pa­tient from a smaller hos­pi­tal to the large flag­ship fa­cil­ity in Peo­ria is not the goal. “One of the things we strive for is be­ing able to treat pa­tients closer to their home,” Sehring said. “Our mind­set is how do we en­sure pa­tients get the best care at ev­ery fa­cil­ity.”

Spe­cial­ists from across the sys­tem travel ev­ery day to dif­fer­ent fa­cil­i­ties that need ad­di­tional help. For ex­am­ple, a car­di­ol­o­gist from OSF St. Joseph Med­i­cal Cen­ter in Bloom­ing­ton, Ill., stops by OSF St. James ev­ery day to check in on

pa­tients with heart prob­lems. There is also an elec­tronic-ICU at OSF St. James that al­lows neu­rol­o­gists from across the sys­tem to con­sult with pa­tients suf­fer­ing from a stroke or other brain is­sues.

Sol­berg said with­out its af­fil­i­a­tion with a larger sys­tem, it would be much harder for OSF St. James to stay afloat. “As we look to the fu­ture, there will be more changes and to face that type of en­vi­ron­ment on our own would be quite daunt­ing,” he said.

At Mercy Health-Cincin­nati, one of Tru­ven’s 15 Top Health Sys­tems, its five hos­pi­tals ben­e­fit from the sup­port of a large sys­tem in ef­forts to stan­dard­ize care.

An en­tire qual­ity team at Mercy Health reg­u­larly mon­i­tors out­comes data across the sys­tem to find in­ef­fi­cien­cies and waste, which of­ten leads to new process im­prove­ments. For ex­am­ple, in 2014 the qual­ity team no­ticed high rates of

C. dif­fi­cile in­fec­tions. This colon in­fec­tion can add on av­er­age $7,300 in costs to a sin­gle pa­tient case. In an ef­fort to ad­dress the is­sue, the qual­ity team asked front­line care­givers for solutions. “They came up with so many mar­velous sug­ges­tions,” said Jan­ice Maupin, chief qual­ity of­fi­cer at Mercy Health.

Pro­to­cols were im­ple­mented such as lim­it­ing an­tibi­otic use of drugs known to cause C. diff in­fec­tions and stan­dard­iz­ing guide­lines for spec­i­men col­lec­tion. As a re­sult, C. diff in­fec­tions at Mercy Health-Cincin­nati fell to 138 cases in 2016, down from 260 cases in 2014. Be­yond re­duc­ing pa­tient harm, cost savings tal­lied $890,600.

Maupin said that ef­forts to im­prove pro­cesses of­ten re­sult in re­duced costs be­cause waste in the sys­tem has been iden­ti­fied. “Our or­ga­ni­za­tion does a re­ally good job mon­i­tor­ing costs as we look for vari­a­tion,” she added.

For Fairview Health Ser­vices, a seven-hos­pi­tal sys­tem based in Min­neapo­lis, ef­forts to stan­dard­ize process im­prove­ments have also led to de­creased costs. But ev­ery Fairview hos­pi­tal has a unique set of re­sources avail­able, so when uni­form best prac­tices are im­ple­mented each takes its own ap­proach to fol­low­ing the pro­to­col, said Dr. Beth Thomas, in­terim chief med­i­cal of­fi­cer of Fairview.

When the sys­tem re­cently de­cided it needed to take ac­tion to re­duce sep­sis across the sys­tem, it found a way to im­ple­ment best prac­tices that suited each hos­pi­tal’s sit­u­a­tion. Phar­ma­ceu­ti­cal teams were trained to quickly fill an an­tibi­otic pre­scrip­tion less than two hours af­ter its been or­dered by a doc­tor. How­ever, some Fairview hos­pi­tals don’t have a phar­ma­cist on-site 24 hours a day to fill the or­der. Those hos­pi­tals came up with a new process to ad­dress the prob­lem, such as stor­ing the drugs so they can be quickly ac­cessed by a nurse.

This sys­tem-wide ap­proach is ben­e­fi­cial for Fairview’s smaller hos­pi­tals be­cause it cre­ates great op­por­tu­ni­ties to achieve goals and learn from each other, said John Her­man, pres­i­dent of Fairview North­land Med­i­cal Cen­ter, a 100 Top hos­pi­tal based in Prince­ton, Minn. “When one site has great re­sults, we are very quick to say let’s im­ple­ment it else­where. We are not shy about be­ing in­ven­tive.”

For OSF St. James-John W. Albrecht Med­i­cal Cen­ter, the in­te­grated EHR en­ables staff to mon­i­tor the qual­ity met­rics at other OSF hos­pi­tals to see how they com­pare to peers.

An en­tire qual­ity team at Mercy Health-Cincin­nati reg­u­larly mon­i­tors out­comes data across the sys­tem to find in­ef­fi­cien­cies and waste.

Source: Tru­ven Health An­a­lyt­ics, IBM Wat­son Health

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