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A patient arrives at a Kettering Health Network emergency room. The system has seen impressive results from an initiative to improve diagnosis and treatment of sepsis patients in the ER.
A patient arrives at a Kettering Health Network emergency room. The system has seen impressive results from an initiative to improve diagnosis and treatment of sepsis patients in the ER.

Web-exclusive: The process of improvement

Thomson Reuters' annual 10 Top Health Systems study shows how organizations are taking a variety of routes to boost quality, patient safety

By Linda Wilson
Posted: May 30, 2011 - 12:01 am ET

As a result of a process-improvement initiative, Kettering Health Network slashed nearly one day off the average length-of-stay for sepsis and more than $1,000 off the average cost-per-case.

Specifically, length of stay dropped to 4.7 days from 5.5 days, while the cost-per-case dropped to $4,811 from $5,825.

Dayton, Ohio-based Kettering logged these gains in efficiency without increasing its mortality rate for sepsis, which at 9%, is well below the national average of between 30% and 50%.

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To achieve these results, Kettering adopted a standard process to speed up the time necessary to diagnose emergency department patients with sepsis and transfer them to the intensive-care unit.

“Every minute they spend in the emergency department just increases the risk that they are going to be in the hospital longer and have mortality or morbidity or increased length of stay,” says Christina Turner, Kettering's vice president of quality.

The sepsis project is just one of the clinical quality-improvement initiatives that Kettering has tackled in recent years through collaboration among its six member hospitals. As a result, the system landed on the third annual list of the 10 Top Systems from Thomson Reuters. The study was released exclusively to Modern Healthcare.

Thomson Reuters evaluated 285 health systems, comprising 1,944 hospitals, with an average of 6.8 hospitals per system. Thomson Reuters also released a list of the top quintile, totaling 57 systems.

Kettering was one of three systems named to the list of top 10 systems for the third year. The other two were: Advocate Health Care, Oak Brook, Ill., and OhioHealth, Columbus. Mayo Foundation, Rochester, Minn., and Spectrum Health, Grand Rapids, Mich., made the list for the second year. Five other systems made the top 10 list for the first time: Cape Cod Healthcare, Hyannis, Mass; CareGroup Healthcare System, Boston; Maury Regional Healthcare System, Columbia, Tenn.; NorthShore University HealthSystem, Evanston, Ill.; and Partners HealthCare System, Boston.

To be included in the study, systems had to have at least two acute-care hospitals with a minimum of 25 beds each.

The systems were evaluated on eight measures of clinical quality, efficiency and patient satisfaction. The 10 Top Systems performed better than peer systems on all but one measure. The 30-day readmission rate was a virtual tie: 21.0% for top systems, compared with 20.9% for peer systems.

On the other measures, the 10 top systems:

  • Scored 0.72 on the risk-adjusted mortality rate, compared with 1.02 for peer systems (A lower score is better). Cape Cod had the best score among the top 10 at 0.56; Mayo had the worst at 1.16.

  • Scored 0.82 on the risk-adjusted complications index, compared with 0.94 at peer systems (A lower score is better). Maury Regional had the best score among the top 10 at 0.43; CareGroup had the worst at 1.02.

  • Scored 96.6% on the core measures mean percentage, compared with 94.5% at peer systems (a higher percentage is better). Both Advocate and OhioHealth had the best score among the top 10 at 97.7%; CapeCod had the worst at 94.3. The score is an aggregate based on CMS' process-of-care standards for heart attack, heart failure, pneumonia and surgical-infection prevention.

  • Scored 0.87 on the risk-adjusted patient safety index, compared with 1.01 for peer systems. (A lower score is better). Partners had the best score, 0.67, among the top 10 on the index, which is based on the Agency for Healthcare Research and Quality's patient-safety measures. Kettering had the worst score on this index at 1.02.

  • Scored 11.7% on the 30-day mortality rate, compared with 12.7% for peer systems. CareGroup had the best score among the top 10 at 10.3%; Maury Regional had the worst score at 14.1%.

  • Scored 263.5 on the HCAHPS (CMS' Hospital Consumer Assessment of Healthcare Providers and Systems) compared with 257.2 for peer systems. Spectrum Health had the best score among the top 10 at 267.3; NorthShore had the worst score at 246.

  • Scored 4.7 days for the average length of stay, compared with 5.2 days for peer systems. Maury Regional had the best score at 4.3 days; Partners had the worst at 5.3 days.

“The leaders of those (top 10) health systems are doing something right in aligning the CEOs in the hospitals to drive achievement,” says Jean Chenoweth, senior vice president for performance improvement and the 100 Top Hospitals programs at Thomson Reuters.

But while the top 10 systems all earned good scores on clinical quality in the study, they used a variety of organizational structures to achieve those results.

Until this year, Kettering relied on informal collaboration among hospital-level managers of clinical-quality improvement. For example, all of the hospitals in the Kettering network launched improvement projects for sepsis in 2010. The final order set now used in all of the system's emergency departments was based on an amalgamation of the best practices developed at each of the facilities.

Nonetheless, Kettering executives in March 2011 decided to cement those informal collaborative relationships by elevating overall responsibility for clinical quality-improvement to the system level.

“With all of the increased attention on quality and the impact that it is going to have on reimbursement and public reporting, they did feel like they needed one point person at the network whose job it was to define the strategy, determine accountability and monitor progress across the network,” says Turner, who was promoted to vice president of quality for the network. She also retained her duties as the vice president in charge of quality for 408-bed Kettering (Ohio) Medical Center and 163-bed Sycamore Medical Center, Miamisburg, Ohio. A director-level manager coordinates clinical quality-improvement at each of the other hospitals.

CareGroup has a much different approach. The system's four hospitals create and oversee programs and services—including clinical quality improvement—independently because CareGroup's primary function is as a bond-holding company. (The Thomson Reuters analysis did not include Medicare data from Beth Israel Deaconess-Needham).

However, in the quality arena, at least, “there is a healthy exchange of ideas in terms of identification and problem solving,” says Dr. Kenneth Sands, senior vice president of healthcare quality at Beth Israel Deaconess Medical Center, Boston. “If I come up with an issue, it is a very useful collegial support for me to be able to call one of my counterparts at Mount Auburn Hospital or (New England) Baptist Hospital and get an example of a best practice and incorporate that.”

For example, Beth Israel created an antibiotic-stewardship program to avoid antibiotic overuse or misuse many years ago. As part of the program, physicians must seek approval from infectious-disease experts to order certain expensive antibiotics, such as Meropenem. Those rules are programmed into the electronic ordering system, alerting providers about when an antibiotic they wish to prescribe is on the restricted list.

Recently, Sands discussed the program with his counterpart at Mount Auburn, which plans to roll out a similar program, according to Sands.

At Maury Regional Healthcare System, quality initiatives are decided at the system level and carried out at the hospital level. The quality services department at Maury Regional Medical Center provides technical expertise to all three of the system's hospitals.

The way quality projects are implemented varies among the hospitals because “the sizes and focuses of our hospitals are so different,” says Brenda Totty, vice president for quality services at Maury Regional Medical Center. “For example, Wayne (Medical Center, Waynesboro,Tenn.) has virtually no surgeries and Marshall (Medical Center, Lewisburg, Tenn.) is a critical-access hospital.”

Linda Wilson, a former Modern Healthcare reporter, is a freelance writer based in McHenry, Ill. Reach her at

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