Four years ago, 334-bed Medical Center of Aurora (Colo.) started a pilot program aimed at boosting the survival rate of heart-attack patients, part of a broader strategy to grow market share through better clinical outcomes.
Cardiologists from the hospital trained local paramedics and firefighters to evaluate advanced electrocardiograms in the field, giving them authority to contact the cardiac catheterization lab so the clinical team could be mobilized for an incoming heart-attack patient.
Aurora reduced its average "door-to-balloon" time-the time between when a patient arrives and when he or she receives an emergency angioplasty-to 78 minutes, versus the recommended guideline of 90 minutes and a national average of around 120 minutes. The hospital estimates the program saves 30 lives per year.
"We're constantly doing quality measurement and reporting outcomes to make sure our times don't drop," says Sylvia Young, president and chief executive officer at the medical center.
Given that approach, it's no coincidence that Medical Center of Aurora for the first time has landed on
Solucient's 100 Top Hospitals for 2003, the 11th annual ranking by the healthcare information firm.
The list takes a uniform approach to identify hospitals that excel on a range of clinical and financial measures when stacked against their peers. Evanston, Ill.-based Solucient says the institutions with the highest aggregate scores reflect the top performers in the hospital industry. The 2003 list includes 39 newcomers but also plenty of veterans: Five hospitals have made the list for eight years, two have been on it seven times and a half-dozen have made it six times.
The study included all 3,095 U.S. acute-care hospitals with 25 or more in-service beds, using the Medicare Provider Analysis and Review data set from 2001 and 2002. Solucient used its own hospital database (culled mostly from 2002 Medicare cost reports) to generate the financial ratings used in the study.
By the numbers
The list splits the 100 Top Hospitals into five categories: Major teaching hospitals (400 or more beds and high levels of physician education and research); teaching hospitals (200 or more beds); and three tiers of community hospitals, large (250 or more beds), medium (100-249 beds) and small (25-99 beds).
The study measures hospitals against the average of their peers on nine benchmarks:
* Mortality rates were 17.5% lower at the 100 Top Hospitals compared with hospitals in their peer groups.
* The rate of complications was 12.9% lower at hospitals on the list.
* Average length of stay was 3.52 days, or 10.6% shorter than the 3.94 days at peer-group hospitals.
* Expenses per discharge (adjusted for case and wage mix) were 16.2% lower, or $4,147 per discharge, compared with $4,950 for peer hospitals.
* Operating margins averaged 8.97% versus a 2.46% average for peer hospitals.
* Growth in the percentage of patients served in their communities averaged 4.74% for the 100 Top Hospitals versus a dip of nearly 0.62% for other hospitals.
* Cash flow-to-debt ratio was 0.35 vs. 0.16 for peer hospitals.
* Assets per discharge-a measure of the investment in plant, property and equipment in relation to operating capacity-were 10.9% higher.
* Coding specificity, which measures how accurately hospitals gather and record clinical data, was rated slightly higher at the 100 Top Hospitals.
Solucient estimates that if all inpatient Medicare patients received the level of care that the 100 Top Hospitals provide, an additional 95,000 patients would survive each year; some 77,400 patient complications would be avoided and about $8.8 billion would be saved annually.
While the Medical Center of Aurora's Cardiac Alert program is an example of an effort to lower mortality rates, the 1,600-employee hospital east of Denver also has worked to improve operations and reduce costs.
It aggressively targeted contract labor costs, for example, by offering signing bonuses as high as $15,000 to critical-care and emergency room registered nurses in exchange for a two-year commitment. Young says those expenses more than offset the $40,000 cost of hiring and retraining new nurses, and helped reduce RN turnover to 17% from 30%.
The medical center's two-pronged focus on clinical improvement and cost-cutting is a hallmark of hospitals that make the list year after year, says Jean Chenoweth, executive director of Solucient's 100 Top Hospitals program.
"In healthcare, we've tended to focus on those who give direct care," Chenoweth says. "But delivery of care is so complex that unless we can look at overall organizational performance, instead of looking narrowly at clinical performance, improvement cannot take place on a consistent and permanent basis."
Many hospitals might not fully recognize that clinical problems are often rooted in operational or strategic decisions, Chenoweth says. For example, outcomes might suffer because the lab isn't turning around test results as quickly as it should. Sometimes a blood type isn't available for a transfusion because of supply problems. Or a slowdown in triage during certain ER shifts bogs down the admission process.
While there's no secret elixir for making the list, Chenoweth-who says she has visited more than 100 recognized hospitals over the years-says Solucient is learning more every year about what makes the winners tick.
One common thread: The chief executive is "a very clear communicator" of the hospital's goals and the performance benchmarks it's shooting for.
"When they set a goal to be a 100 Top Hospital, the winners make it an easily understood goal for everyone in the organization," Chenoweth says. "Because everyone has a role in cost, efficiency, quality and delighting the customer."
Chenoweth says that at many of the perennial winners, even rank-and-file staffers are cognizant of the specific metrics on which that the hospital is measured. Some have posted the Solucient benchmarks around the hospital.
Growth in business, reputation
Solucient also considers a hospital's ability to grow its business as a common trait of list regulars.
To that end, a new benchmark was added this year: The growth in percentage of community served, a metric Solucient says reflects a hospital's reputation and patient satisfaction.
"If a hospital is able to provide good care and have a good reputation in their community-think of it as market share-we'd expect to see that percentage growing over time," says David Foster, Solucient's vice president of clinical informatics. "That's an indication the hospital is doing the right things."
One of those is Advocate Lutheran General Hospital, a 548-bed teaching hospital in Park Ridge, Ill., which has made the list eight out of 11 years, including the past six. The problem is, Lutheran General's reputation in its suburban Chicago community has outpaced the facility's capacity, leaving it scrambling to accommodate the overflow of patients, says Bruce Campbell, the facility's CEO.
The long-term solution is a $120 million capital expansion, including a $25 million operating suite scheduled to open this year. But Campbell says the hospital did not want to forgo growth in the short term.
In 2002 it embarked on an initiative to boost patient access and efficiency of care, part of a broad process-improvement initiative. Operating rooms and other service areas were opened on evenings and weekends, the admission process was streamlined and physicians added to their patient load while taking steps to make sure quality didn't suffer.
"It was a matter of changing the culture, from saying, `We're operating at 100% capacity and can't handle more patients,' to analyzing each step in the process and getting people to buy into the idea that we could be more efficient," Campbell says.
The result: A 3% to 4% increase in inpatient volume and a 5% growth in outpatient volume, Campbell says.
At 358-bed Franklin Square Hospital Center in Baltimore, where emergency department visits have jumped to 85,000 from 56,000 over five years, there has been a focus on streamlining the process of getting ER patients into beds.
The facility-which cracked the 100 Top Hospitals list for the first time this year, in the teaching hospitals category-invested in a stat lab for its ER to move patients through faster while improving outcomes. The lab helps cut the cycle time for test results from 25 minutes to seven, Franklin Square President Carl Schindelar says.
"Our approach was to make improvements that would make things simpler and easier for patients, but that we're also going to improve efficiency and volumes," Schindelar says. "Over time we've been able to take care of more patients with fewer people."
Why should hospitals care if they make the 100 Top Hospitals list? For more reasons than the recognition and marketing fodder, Chenoweth says.
The stakes are growing larger when it comes to bench-marking, as a number of health plans tinker with various formulas that tie reimbursement to performance. Chenoweth says it is critical for hospitals to have a system for measuring performance and bench-marking themselves against both local and national competitors.
"The growth of pay-for-performance schemes in their various forms is absolutely significant," Chenoweth says. "Knowing what is the highest performance possible to be able to identify areas for improvement is essential for the board and management to ask the right questions across the organization."
Mike Colias is a freelance writer based in Chicago. He can be reached at [email protected].
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