While systems do provide opportunities to lower the cost of care, Chenoweth notes that quality, safety, cost and efficiency must be in balance in order for a hospital to be a top performer. “Those organizations are providing higher value and they're stable,” she says, adding that many systems are taking it upon themselves to implement quality improvement measures.
Prime Healthcare Services, Ontario, Calif., has been an active acquirer of underperforming hospitals, closing on one deal June 1 with two more in the pipeline. The hospitals on its radar were “struggling financially, operationally—pretty much everything,” says Luis Leon, chief operationg officer, who notes that it typically takes about a year to get them up to its standards. “It's a complete overhaul; it's overall from A to Z.”
Some of the resources Prime provides to the new hospitals in its system include running training programs for medical staff, building a case management team, establishing a hospitalist program, and installing a medical director to focus on patient care and quality of care. The system has also strengthened the corporate position of performance improvement director.
“We tend to put emphasis on all those clinical areas that are probably the vehicle to quality and good patient care,” Leon says. “We start from the clinical point of view” and financial benefits follow.
One strategy the system employs is identifying successful practices at one hospital and trying to replicate them across the organization—whether it's a facility that has a particularly efficient linen department or Desert Valley Hospital, Victorville, Calif., becoming the first Prime hospital to win a 100 Top Hospitals award seven years ago.
After Desert Valley won its place on the list, Leon, who was then its administrator, recalls that an effort was made to use the award criteria to reproduce the results across the system.
It's that sort of exchange that helped a facility such as 369-bed Centinela Hospital Medical Center in the underserved community of Inglewood, Calif., earn its spot on the 100 Top Hospitals list, Leon notes. Prime itself, which owns 17 hospitals, has twice been named a 15 Top Health System.
“We are a hands-on system,” Leon says, adding that hospitals are compared against each other and held to task to raise standards. CEOs also meet regularly to discuss what's going well and what's not going well. “For us, the motivation is to be the best.”
At Baystate, which this year was named a 15 Top Health System for the first time, board members set a goal last year of eliminating hospital-acquired infections and getting bloodstream infections down to zero. The system tracked measures that led to those complications and instituted best practices to prevent them, Benjamin notes.
“It essentially starts at a board level and cascades down to the individual level so that everyone is aligned around that goal,” he says.
Health systems, Benjamin notes, have the advantage of being able to tap into a centralized quality department to make improvements across the organization.
“To do quality well, you need an infrastructure,” he says. “From my experience, most health systems take advantage of back room economies of scale to focus not only on financial (measures), but also quality.”
The difference in clinical outcomes between 100 Top Hospitals winners and their peer group is apparent.
In 2005, patients treated at both groups of hospitals had about a 4.3% 30-day risk-adjusted mortality rate. But their performance diverged over the next five years.
“Overall, post-discharge 30-day mortality is going up,” Foster says. But not necessarily at Top Hospitals, which outperformed their peer group every year between 2006 and 2010.
In 2010, the most recent year the study looked at, patients treated at a 100 Top Hospitals facility had about a 4.4% risk adjusted 30-day mortality rate compared with 4.6% for patients treated at a hospital in the comparator group.
Baystate has formalized its focus on patient outcomes in its own Center for Quality of Care, which works closely with its Division for Healthcare Quality. The system established the center in 2008 to conduct research on safety, quality and effectiveness.
Its studies have looked at clinical issues such as getting doctors to wash their hands, improving treatment options for sepsis and inappropriate medication use in surgery patients.
Benjamin notes that the center came to much of the same conclusion in its own work to try to understand why some hospitals improve while others lag behind. “Hospitals that really have robust infrastructure for quality, have leadership for quality, tend to do better,” he says.