Readmissions at an inpatient heart-failure unit at Baylor University Medical Center at Dallas plummeted to 7% from 29% in nine months.

To garner those results, patients participated in a standardized education process and then signed an agreement, signaling their intent to follow their care plans. They also were sent home with a two-week supply of all of their medications.

(View list of 100 Top Hospitals.)

Nurses on the unit followed up with these patients through regular telephone calls, which continued until patients' first post-discharge visit with their cardiologist. The nursing unit's manager developed the program after she attended ABC Baylor, a systemwide quality-improvement training program.

“Quality is everybody's responsibility,” says John McWhorter, president of Baylor University Medical Center and a senior vice president at Baylor Health Care System.

The focus on clinical quality improvement appears to have had an impact because Baylor University Medical Center was named for the first time to the Thomson Reuters 100 Top Hospitals: National Benchmarks for Success, 2012. The hospital's sister institution, Baylor Medical Center at Waxahachie (Texas), was named to the list for the second time.

Thomson Reuters released the list exclusively to Modern Healthcare.

Among this year's 100 Top hospitals, 27 are newcomers to the list. Others are long-time members of the list, including: Munson Medical Center, Traverse City, Mich., which has appeared 14 times; two hospitals in Nashville: Vanderbilt University Medical Center, 13 times, and St. Thomas Hospital, 11 times; and Beth Israel Deaconess Medical Center in Boston, 10 times.

But other well-known organizations that have been perennial members of the list were not on it this year, including NorthShore University Health System, Evanston, Ill.; Advocate Lutheran General Hospital, Park Ridge, Ill.; Northwestern Memorial Hospital, Chicago; Mayo Clinic-Rochester (Minn.) Methodist Hospital; and Brigham and Women's Hospital, Boston.

To select the 100 Top, or benchmark institutions, hospitals with at least 25 beds were scored against others within the same categories: Major teaching hospitals (400 or more beds and high levels of physician education and research); teaching hospitals (200 or more beds and some physician education) and three tiers of community hospitals: large (250 or more beds), medium (100-249 beds) and small (25-99 beds). A total of 2,886 hospitals were included in this year's study.

Data for the Thomson Reuters analysis came from a variety of CMS sources, including cost reports, the Medicare Provider Analysis and Review (MedPAR) data, Hospital Compare, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data.

To be named to the 100 Top list, hospitals must score well as compared with others in their size/teaching-status category, based on a composite score of 14 measures of quality, efficiency, safety and patient satisfaction. They also must score at least at the median level for each of the measures.

Top hospitals outperformed peer hospitals on all 14 measures. For example, top hospitals had:

• Some 5% fewer deaths than expected, while their peers had only 1% fewer deaths than expected.
• Some 7% fewer complications than expected, while their peers had 1% more complications than expected.
• Some 18% fewer adverse patient-safety events than expected, while peer hospitals had as many adverse events as expected.
• A 3% higher median score, 265 on the CMS' HCAHPS survey, compared with peer hospitals' average score of 257.
• Charged an average of $464 less in inpatient expenses per discharge than their peers and had a median length of stay of just over four and a half days compared with nearly five days for peer hospitals.

And like Baylor, the vast majority of the 100 Top, or 85%, are members of systems. Why? “I think this is because the systems themselves have extended electronic medical records to all hospitals in the system. The systems also have created the ability to share best practices and to use standard protocols across the system,” says Jean Chenoweth, senior vice president of performance improvement and 100 Top Hospitals programs at Thomson Reuters. Many hospitals simply would not have the resources to accomplish all of this on their own, she says.

As is the case at Baylor, one area of dogged focus is the implementation of best practices in the treatment of heart failure. Top hospitals are responding, in part, to an upcoming payment program from the CMS, which on Oct. 1 will begin penalizing hospitals for excessive readmissions. Heart failure also figures prominently in the CMS' value-based purchasing program, also slated to begin Oct. 1.

But reducing rates of heart failure readmissions can be difficult, McWhorter says. On a systemwide basis, “we have not seen the needle move on readmissions yet,” he says. “We are working through the process now as to what best practices in our system we can come up with.” Taking a practice from the successful program at Baylor University Medical Center, system executives are evaluating whether it is feasible for nurses or other healthcare workers to check up on newly discharged heart-failure patients via telephone or an in-home visit.

Baylor already has launched numerous other systemwide initiatives to improve its heart-failure metrics. For example, all Baylor-owned physician practices have adopted medical-home programs as a means to keep close tabs on chronically ill patients, such as those with congestive heart failure.

Baylor isn't the only one facing these challenges. The heart-failure readmission rate at the 100 Top overall, 23.7%, was only 1.1% less than the rate at peer hospitals, which was 24.8%.

Scripps Green Hospital, La Jolla, Calif., which was named to the list for the fifth time, also has honed in on heart-failure readmissions. “This is one of those conditions that needs continued vigilance and follow-up with experts,” says Dr. Maida Soghikian, medical director for performance improvement at Scripps Green and a practicing pulmonologist and critical-care specialist.

That is why Scripps Health now wants to implement systemwide a program that Scripps Green created numerous years ago to improve care for heart-failure patients. The hospital hired a physician with expertise in heart failure to create a specialized practice, including an outpatient clinic. The physician also created a set of treatment protocols that his team and Scripps' hospitalists use to care for patients hospitalized with heart failure.

“Our goal is to build it so it works relatively seamlessly in all facilities,” Soghikian says. “The conversation is going on now.”

At the system level, Scripps this year created two 30-day readmission measures for heart failure—one based only on Medicare patients and a second based on all admissions. “If you don't start looking at the data, you don't really know where you are,” Soghikian says.

Scripps Green was among the hospitals that reflected a change in the regional composition of this year's 100 Top winners.

The number of hospitals in the West—including 11 from California—also increased substantially to 16 in 2012, up from six in 2011. The number of Northeastern hospitals rose to 17 on this year's list from 14 in 2011.

The South replaced the Midwest as the region with the largest number of hospitals in the 100 Top—42, up from 29 in 2011—while the Midwest dropped to 25 hospitals this year from 51 in 2011.

The stellar performance of Southern hospitals was dominated by two states: Texas, with 14 hospitals, and Florida, with 13.

Sarasota Memorial Hospital, named to the list for the second time, was one of the 100 Top Hospitals in Florida. The public hospital also is one of the 15 independent institutions on the list.

Although independent, Sarasota Memorial is a member of quality-improvement collaboratives with the Centers for Disease Control and Prevention, the Florida Hospital Association and VHA.

“I don't think independent means you aren't benchmarking with anybody,” says Gwen MacKenzie, president and CEO of Sarasota Memorial Health Care System, which includes the hospital and a variety of outpatient services. The hospital also adopts best practices from top teaching hospitals, MacKenzie says.

Another key to the hospital's success is its inpatient electronic health record, which Sarasota implemented “a dozen years ago” and includes computerized physician-order entry, decision support and medication reconciliation on all inpatient units, MacKenzie says.

“That has served us very well in the quality and safety realm by ensuring that all of the information is at the fingertips of the people taking care of the patients,” MacKenzie says.

Electronic data capture also plays a role in caring for heart-failure patients. Sarasota Memorial discharges heart-failure patients with a telehealth monitor, which transmits information directly to the hospital on weight, blood pressure and oxygenation in the blood. The idea is to respond to changes in patients' status quickly, keeping them out of the hospital with an acute episode of their disease.

“It allows that information to be evaluated by the clinical staff and then communicated to physicians who need it to adjust (patients') plans of care or their medication regimens,” says Fred Jung, executive director of quality and safety at the hospital.

About 30 patients are assigned a telehealth monitor at any given time. The program is offered to all heart-failure inpatients, but not all of them agree to participate.

In the most recent CMS Hospital Compare rankings, Sarasota Memorial's heart-failure readmission rate was 19.7%, compared with a national rate of 24.8%. Jung attributes the hospital's low rate to the cumulative impact of numerous inpatient, outpatient and homecare programs deployed over many years.

“We have had work going on there for more than a decade,” he says.

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