From the 10th Annual 100 Top Hospitals supplement, published on August 9, 2010.
As healthcare systems are judged more and more on their clinical track record and the safety of their hospital environments, Catholic-owned systems as a group have a big head start on other ownership categories, according to a study of performance on measures of quality, clinical efficiency and perception of care.
Lagging farthest behind Catholic systems were investor-owned hospital groups, with other church-owned systems and secular not-for-profit systems holding the middle ground but closer to the Catholic systems than to the investor-owned chains in their performance rankings.
The findings suggest that leadership at health systems owned by the Catholic Church may be the most active in setting and monitoring achievement of quality goals as well as aligning the management of hospitals within a system in achieving what they see as a mission, says Jean Chenoweth, senior vice president of performance improvement with Thomson Reuters, which conducted the study exclusively for Modern Healthcare.
What's also at work is a changing role for health system governance and leadership, taking responsibility for executing well on clinical performance as well as the purely business and economic reasons that originally drove consolidation into systems, Chenoweth says.
“In these quality, safety and satisfaction areas, the Catholic systems are leading, but what we are really seeing in this picture is an industry that's in transition,” she says. “The Catholic-owned systems tend to lead in this transition, and the rest of the industry is shifting but not quite as fast.”
For two large Catholic systems, the groundwork began at their inceptions about a decade ago, both the result of merging smaller, first-generation Catholic hospital networks.
The 75-hospital Ascension Health, based in St. Louis and operating in 19 states and the District of Columbia, initially made clinical excellence one of five principal system objectives, says David Pryor, the system's chief medical officer. Over the years, it has set concrete goals for all of its hospitals:
- A “call to action” in 2002 to orient all activities around providing healthcare that works, is safe and is accessible to all.
- A commitment in 2003 to achieve excellent clinical care with no preventable injuries by July 2008.
- A campaign launched this year, “Healing without harm,” with the systemwide goal of a 40% reduction in so-called serious safety events by 2014.
“We do mount a national commitment across our organizations around setting some of these goals and moving toward them,” Pryor says. The system board has a quality committee that reviews performance on a regular basis, and it holds management accountable for results, he says.
Meanwhile, Trinity Health, a 30-hospital system based in Novi, Mich., gained the support of its board of directors a decade ago to launch a $400 million initiative for an information technology infrastructure that helps monitor and manage quality of services as well as patient safety, says Joseph Swedish, the system's president and CEO.
“This board, having made the commitment to IT in the year 2000—specifically with the intent for improving quality—is a reflection of the passion that the board carries to improve quality and safety, and in turn what it then has given management to help us do our job better,” Swedish says. Quality improvement is “a day-to-day passion that we live with that I really want to underscore, that it is as important as our financial stewardship.”
When recruiting senior executives, the system makes sure that prospective Trinity leaders are “fully aware of their responsibilities, have the expertise and are committed for the long term to improvements in quality—it's not just about financial performance,” he said.
Size of system may have a bearing on prospects for quality-oriented initiatives, Pryor says. Added to the “consistency of focus” on quality among Catholic systems as part of their mission, “often those systems tend to be large enough that they are able to have multiyear commitments (to quality) that are reliable from a funding standpoint and other approaches, so that the focus never drops off.”
And the payback on that focus, Pryor says, has been “phenomenal” improvements in care. Ascension's push to eliminate preventable injuries or deaths drove its mortality rate 27% lower than expected given the condition of hospitalized patients—that's 5,000 fewer deaths each year, according to the system. Incidence of preventable injuries are well below national averages: pressure ulcer rates 94% lower, ventilator-associated pneumonia 72% lower, birth trauma 62% lower, bloodstream infections 39% lower, according to Ascension.
The IT standardized across the Trinity system now has more than 7.5 million unique records enabling monitoring of evidence-based practices and establishing standards of care that are “very consistent with the healthcare reform legislation recently passed,” Swedish says. The focus on quality and use of data have led to such benefits as 40% faster administration of emergency medication, 30% reduction in patient falls with injury and 9% reduction in mortality, adjusted for severity of illness, Swedish says.
Investor-owned systems by definition don't have a religious-driven mission of quality, but they can still comply with core quality measures religiously. Prime Healthcare Services, a family-owned system of 13 hospitals based in Victorville, Calif., is doing a profitable Medicare business while producing clinical results that put it in the top 20% of the 255 health systems evaluated and rated in 2010 by Thomson Reuters. Prime is the only for-profit system in that quintile.
The system has grown by taking over financially distressed or bankrupt hospitals and applying an infusion of $8 million to $15 million in capital per hospital in the first six months—mainly a standardized implementation of IT for clinical care and performance monitoring, says Prem Reddy, the system's chairman, founder and majority owner.
Then it spends three months introducing a menu of care guides called clinical pathways, giving physicians on staff some leeway to customize them. A full-time medical director, always a practicing physician, is the “enforcer” of pathways, and physician performance is reported quarterly, he said.
“By giving them all these systems, and giving them the clinical pathways that overlay the information systems, they can't get out of the pathways, even if they want to—because the tools that they have work smoothly, and there's no reason to do anything different,” says Reddy, an interventional cardiologist. When pathways are implemented, they “almost simultaneously accomplish 100% compliance with core measures.”
In addition to using federally reported core quality measures, Thomson Reuters ranks hospital systems in its studies according to inpatient mortality and complications, an inpatient safety index, 30-day mortality and readmissions, average length of stay and patient perception of care.
For the study of systems by ownership, a composite score across all the measures was computed for each system, and all 255 were stratified by ownership as defined by the American Hospital Association. The mean performance rank for each category—lower is better—showed the 36 Catholic systems comfortably in front with an average rank of 84. Eleven “other church” systems combined for an average rank of 121, and the 176 secular not-for-profit systems combined for a rank of 129. The 26 identified investor-owned systems combined for a rank of 182. Six systems had missing ownership information in the AHA reference guide.