Sometimes red is the color of excellence, whether it’s a pair of socks or a line of dots.
Like many hospitals, St. Cloud (Minn.) Hospital does a fall-risk assessment on each incoming patient. Those at risk are issued a pair of red slipper-socks. Their room doors have a magnet picturing autumn leaves to further identify them without making them feel stigmatized. There’s a flag on their electronic health record, and both they and their families get individualized instruction on how to avoid falls.
All these measures, and more, have helped decrease falls at the 439-bed hospital from 4.2 per 1,000 patient days to 3.5, and some units have been fall-free for more than 30 consecutive days. Many of the anti-fall strategies originated at other hospitals, and St. Cloud adopted them as part of a statewide fall-reduction initiative, says Craig Broman, the hospital’s president. “We’re just a sponge picking up new ideas and best practices.”
Like many hospitals, 793-bed Vanderbilt University Medical Center in Nashville uses a standard protocol in its critical-care units to cut the incidence of ventilator-associated pneumonia, or VAP, the most frequently fatal hospital-acquired infection. The protocol has six elements, which include keeping the head of the bed elevated, brushing the patient’s teeth and suctioning pooled secretions in ventilator tubes and airways.
At first, the protocol reduced the number of VAP cases a little bit, but “nothing to write home about,” says C. Wright Pinson, Vanderbilt’ s chief medical officer. Then he got the information technology staff to design a special screensaver for the critical-care units, linked to the institution’s EHR, that lists all the ventilator patients on a unit. Next to the patients’ names, there are six columns for tracking each element of the VAP protocol. A green dot signifies “up to date,” a yellow one means “coming due” and a red one designates “overdue.” A line of red dots means the patient needs immediate attention. The screens are a constant visual reminder of how well the staff is adhering to the protocol, and VAP cases have dropped 65%.
Both St. Cloud and Vanderbilt are among a select group of 16 hospitals that have pulled off a double coup: They’re on a list of the 100 Top Hospitals in the country, based on eight measures: cash-to-debt ratio, complications, expense per discharge, length of stay, mortality, patient safety and total profitability as well as a score based on adherence to evidence-based processes. They’re also among the 100 hospitals that have shown the most improvement over the past five years based on the same measures. The two lists are generated by Thomson Reuters, formerly Solucient, which annually analyzes CMS data such as Medicare cost reports, Medicare Provider Analysis and Review, or MedPAR, and information from the agency’s Web site Hospital Compare.View the complete roster of this year's Performance Improvement Leaders (PDF)
To make the Performance Improvement Leaders roster, it doesn’t matter where a hospital started from, as long as it improved rapidly from there, says Jean Chenoweth, senior vice president of performance improvement and the 100 Top Hospitals programs at Thomson Reuters. “There are management teams who are skilled in getting an organization moving in the right direction, and creating a strong culture of performance improvement,” she says.
On almost all of the measures, the group of performance improvement leaders started out below average, sometimes well below, and overtook their peers to end up above average. For example, while operating profits for all hospitals drifted up slightly over five years, from about 4% to a little bit over, the performance improvement leaders started out at less than 1% and boosted operating profit margins to nearly 7%. A standardized index of patient safety shows all hospitals improving a little bit: as a whole, hospitals registered a decrease in the index from 1.02 to 0.95 over five years (a downward trend is good). The performance improvement leaders, on the other hand, started at 1.09 and ended up at 0.88.
But because there’s more room for improvement when performance is far below average, it’s all the more impressive when a top-performing hospital also improves dramatically, and such hospitals raise the bar for everyone. A 100 Top Hospitals facility that’s also a Performance Improvement Leader probably has a management that’s both committed to performance improvement and tenacious about sticking to its goals, Chenoweth says. And indeed, the hospitals interviewed for this story have explicit goals in place to bring their performance up to high levels on common measures, and keep it there.
Another hospital on both lists, Providence Everett (Wash.) Medical Center, is striving to be in the 90th percentile on all its core measures simultaneously, says David Brooks, the facility’s chief executive officer. The 353-bed hospital is in the midst of a 10-year, $750 million expansion. It’s the single largest project in the history of the parent system, 25-hospital Providence Health & Services, Seattle, and Providence Everett needs to justify the investment by continued sterling performance, Brooks says. “There’s nothing like having a prize, and the need to earn it, to motivate us.”
There’s no room to relax, as Providence Everett found out recently. It has been a historical top-performer on how quickly it moves heart patients from the emergency department to the catheterization laboratory and gets their blocked vessels open. “All hospitals are measuring that now,” Brooks says. “Our raw scores didn’t change, but we looked up one day to find we had dropped down to about average. Everyone else was getting better.” A multidisciplinary team was quickly convened to diagnose areas for improvement, and the hospital brought its scores back into the top quartile within six months.
Vanderbilt adopted a balanced score card three years ago that focused on all aspects of the organization, so that one area wouldn’t improve at the expense of another. CMO Pinson’s bailiwick is quality and service, and he compiled a matrix of more than 100 indicators that at least one outside group, and sometimes many different ones, use to measure performance. He put the most emphasis on common measures such as observed-to-expected mortality and adverse drug events, but set a goal of being in the 90th percentile on all of them within three years. Currently he estimates that 85% of the indicators are at the 90th percentile or above, and the hospital has beaten its mortality-rate goals for three years running.
“There are two 747 planeloads worth of people going home from this hospital each year that wouldn’t have gone home without these efforts,” he says. But he’s not complacent. His list of quality targets changes regularly as certain goals are met. And he looks forward to seeing all hospitals get better.
“The very best of us are only half as good as we really ought to be,” Pinson says. “The exciting thing is to get way out in front, so that people talk about healthcare like they talk about other industries that are really great.”