As a result, St. Paul, Minn.-based HealthEast in 2008 implemented a set of evidence-based best practices to manage patients' risk of blood clots as well as complications from anti-coagulants. For example, advanced-degree pharmacists with special training are available to manage the anti-coagulants—including interpreting blood tests—if admitting physicians choose to hand off the process.
View the lists Pharmacy-based management of anti-coagulant therapy is but one example of HealthEast's agenda to help physicians and nurses improve quality. “The bedside caregivers are constantly challenged to be delivering the right care, at the right time—every time,” says Craig Svendsen, chief medical quality officer for HealthEast.
The four-hospital health system coordinates quality efforts centrally, garners input and support from front-line caregivers and harnesses the power of electronic health records to roll out new initiatives.
The corporatewide strategy worked. HealthEast is one of 10 top-ranked health systems in a new report—Thomson Reuters' 100 Top Hospitals: Health Systems Quality/Efficiency Study. Released exclusively to Modern Healthcare, the study evaluated 252 health systems—with a total of 1,720 hospitals—on measures of clinical quality and efficiency. The top 10 represent the top 2.5% of the systems studied.
The health systems study used information for 2007 from two public databases: Medicare Provider Analysis and Review, or MedPAR, and the CMS' Hospital Compare.
HealthEast was one of nine members of the top 10 that are based in the Midwest. The remaining system—Prime Healthcare Services—is based in Victorville, Calif. Prime also is the only for-profit organization ranked in the top 10. Prem Reddy, a well-known cardiologist, is chairman of Prime, which owns 13 hospitals in California. The company is known for buying faltering hospitals and then turning them around.
Like HealthEast, Prime's systemwide approach to clinical-quality improvement, such as implementation of a standardized process to assess and prevent all types of wounds, helped the system make the top 10 list.
Prime also made the list despite some negative publicity. In 2007 the Los Angeles Times reported that state regulators found deficiencies in patient-safety standards at Prime hospitals on four occasions between 2002 and 2007. For example, one case involved a young, uninsured boy with kidney failure who was discharged from the emergency room at Desert Valley Hospital in Victorville in 2003. Reddy told the newspaper that the boy's condition was stable when he was sent home—which was done after consulting with a specialist.
In an interview last month with Modern Healthcare, Michael Sarrao, vice president and legal counsel for Prime, said the problems in each of the four cases were corrected promptly, and state regulators were satisfied with the changes.
In addition to releasing the list of Prime and other health systems in the top 10, Thomson Reuters also made public the list of 50 systems that ranked in the top quintile, or top 20%.
This is the first Thomson Reuters “study that has attempted to measure health systems as entities unto themselves and what they stand for in terms of the quality of the care that they are providing to the various communities they serve,” says Jean Chenoweth, senior vice president of performance improvement and the 100 Top Hospitals programs at Thomson Reuters.
To be part of the study, systems needed at least two acute-care hospitals with a minimum of 25 beds each. The bulk of the systems, 74%, included in the study had between two and five hospitals, while two systems had more than 100 hospitals.
Five measures of performance were used to evaluate systems: mortality, complications, patient safety, length of stay and use of evidence-based practices.
Unlike the annual 100 Top Hospitals analysis, the systems study didn't include measures of financial performance because there isn't a source of reliable publicly available financial data at the system level, according to Thomson Reuters.
The study uses a balanced score-card methodology, so each of the five measures is weighted equally in the study. To make the list of the top 10, systems must score at least as well as the median level of performance on each of the five measures evaluated in the study.
Overall, the systems in the top 10 performed better than expected:
- The risk-adjusted mortality index for the top 10 systems was 0.82—17.6% lower than a score of 1 for peer systems (a lower score is better).
- The complications index for the top 10 was 0.83—16.8% lower than a score of 1 for peer systems (a lower score is better).
- The patient-safety index was 0.97 for the top 10 systems—3% lower than the score of 1 for peer systems (a lower score is better).
- The core measures average score, which measures adherence to evidence-based practices, was 93.5% at top 10 systems, compared with 88.7% for peer systems.
- The average length of stay was five days at the top 10 systems—10.7% lower than 5.6 days at peer systems.
There was a wider difference in performance when the top quintile was compared with the bottom quintile. For example:
- The mortality index for the top quintile was 0.85—25.4% lower than 1.14 for the bottom quintile.
- The complications index for the top quintile was 0.87—19% lower than 1.08 for the bottom quintile.
- The patient-safety index for the top quintile was 0.95—12.7% lower than 1.08 for the bottom quintile.
- The core measures score for the top quintile was 90.7% compared with 87% for the bottom quintile.
- The length-of-stay index for the top quintile was 0.92—15.8% better than 1.09 for the bottom quintile.
The study's results indicate that not all systems address quality improvement at the corporate level—or do so successfully, Chenoweth says. “Many of them were formed for economic reasons, like to gain access to cheaper capital. Some of them were formed for operational efficiencies, but not necessarily for improving quality,” she says. She also says that in an era of public reporting of quality data, system-level board members and executives should ask themselves: “Does the mission of the health system need to change if it doesn't have quality in its mission?”
Systems in the top 10 often use three ingredients for successful quality improvement: a corporate-level coordinating committee, ample involvement in planning from front-line caregivers, and a systemwide electronic health record. At Trinity Health, Novi., Mich., another system among the top 10, “we have a long history of executing collaborative, practice improvement activities across the system. It is the way we practice,” says Paul Conlon, senior vice president of clinical quality and patient safety. A corporate clinical leadership council at 28-hospital Trinity includes chief medical, nursing and pharmacy officers from all hospitals. The council decides which quality-improvement projects the system will pursue. For each initiative, the council then assembles a team of front-line caregivers and support staff, such as quality-improvement or information-systems experts, to develop a plan for improving the pertinent patient-care processes. “This is not a top-down approach,” Conlon says.
Trinity relies on a common clinical information system to speed introduction of its quality initiatives, Conlon says. For example, Trinity created an electronic order set this year on pediatric dosages for anti-viral drugs, which were implemented in response to concerns about the H1N1 influenza A virus. The new order set was available to physicians 48 hours after the Centers for Disease Control and Prevention issued recommendations on dosages of anti-viral drugs for children.
An EHR also has helped Prime Healthcare roll out new clinical initiatives. One example is a comprehensive program to assess and treat all types of wounds, including bedsores. The wound program was started at Huntington Beach (Calif.) Hospital, West Anaheim Medical Center, Anaheim, Calif., and in La Palma (Calif.) Intercommunity Hospital in 2006 and expanded to all other hospitals by the end of November 2008.
The first step of the program: assess all patients for wounds in the ER as part of the admissions process. To make sure this happens every time, nurses are required to key into the computer system information about whether patients have wounds. Data must be entered properly or the software won't allow the admissions process to go forward.
“In the past, they would put ‘not applicable' to save time,” explains Mary Ransbury, corporate director of wound and skin management at Prime Healthcare. But now “they cannot bypass skin integrity.” Another change: The information on pre-existing wounds—including digital photographs—is attached to progress notes from admitting physicians—a way of visually reminding them to order treatment plans.
The changes have improved care because caregivers are in sync, Ransbury says. “We are finding there is more collaboration—that is key.”
