Mission and margin

The watershed moment for OhioHealth came several years ago, during a meeting of the health system's quality of care committee, when senior leaders distributed a detailed list of all of the serious safety events that had occurred at OhioHealth's eight hospitals during the previous year.

“We handed a copy to everyone—nurses, doctors, lay board members—and by the end of the meeting, there wasn't a dry eye in the room,” says David Blom, president and CEO of the not-for-profit, faith-based system, which is headquartered in Columbus. “Parochial interests disappeared, and we all said this is unacceptable. It became the top priority for our whole organization.”

Quality and patient safety had long been areas of focus for the system's member hospitals, Blom says. But it was after that meeting that OhioHealth launched a more sweeping initiative aimed at organizationwide collaboration, data sharing and transparency.

Those efforts seem to be paying off. Three of OhioHealth's hospitals—796-bed Riverside Methodist Hospital, Columbus; 392-bed Grant Medical Center, also in Columbus; and 92-bed Dublin (Ohio) Methodist Hospital—appeared on Truven Health Analytics' 100 Top Hospitals list for 2013, released in February.

Now in its 20th year, Truven's list recognizes top-performing hospitals from a field of more than 2,900, based on performance across measures of mortality, 30-day readmission rates, average length of stay, inpatient expense per discharge and others.

And in a secondary analysis of that dataset, released exclusively to Modern Healthcare, Truven has spotlighted gaps and strengths in hospital performance based on their ownership structure, differences that might shed light on why systems such as OhioHealth have succeeded where others have faltered on the various measures.

Not-for-profit hospitals—especially church-owned not-for-profits—performed better than their for-profit and government-owned peers on metrics of patient safety, mortality and patient satisfaction, according to Truven's latest report. For-profits, on the other hand, excelled in core measures of care for heart attack, heart failure, pneumonia and surgical patients; expense control and profit from operations.

Church-affiliated not-for-profits also scored the highest on overall performance, according to the data (See chart, right).

“Government hospitals demonstrated the weakest balanced performance, with significantly worse performance on core measures and inpatient expenses,” according to Truven's report.

This is the first time that Truven Health Analytics has undertaken an analysis of hospital performance by ownership across all of its measures, says David Foster, principal investigator of the report and lead scientist at Truven's Center for Healthcare Analytics.

“We did this once before, in 2010, but that was just scratching the surface,” he says. “This is the first time we've looked at all of the measures that we use.”

Based in Ann Arbor, Mich., and formerly known as the health business of Thomson Reuters, Truven Health Analytics was formed in June 2012, after Thomson Reuters sold its health division to Veritas Capital, a New York private equity firm, for $1.25 billion.

To compile the ownership report, Foster and his colleagues relied on Truven's database for its 100 Top Hospitals, which uses publicly available claims data from the Medicare Provider Analysis and Review (MedPAR) dataset, the CMS' Hospital Compare database and Medicare cost reports. To determine each hospital's ownership structure, they also matched Medicare provider numbers with American Hospital Association data, Foster says.

Average length of stay was 4.94 days at not-for-profit church-owned hospitals, compared with 5.08 days at for-profit facilities and 5.17 days at government-owned hospitals.

Not-for-profit church-owned hospitals also held the lead on patient satisfaction, according to the report, with an average score of 261.2 on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, compared with an average score of 253.1 for for-profits and 258.4 for government hospitals.

By contrast, for-profits had significantly better core measure scores, garnering an average of 97.3%. Not-for-profit church-owned hospitals averaged 96.5%; other not-for-profits scored 96.2%; and government hospitals averaged 95%.

And for case mix- and wage-adjusted inpatient expense per discharge, for-profits came in the leanest at $5,811, well below the $6,170 average for not-for-profit church-owned hospitals and the $6,633 for government-owned facilities.

“I wouldn't say we were surprised,” Foster says of the results. “It's consistent with what we found when we looked at ownership in 2010. It's probably not surprising to see that for-profits pay close attention to the bottom line and not-for-profits are mission-driven.”

Dr. Bruce Vanderhoff, OhioHealth's chief medical officer, credited much of the system's success to its mission-based culture, which he says has buoyed its efforts to address a number of quality targets, including preventable readmissions. OhioHealth has reduced readmission rates for heart failure patients from about 24%, roughly the national average, down to 14% across the entire system.

“We have a longer-term view about where we want to be,” Blom says. “We don't have shareholders and we're not driven by short-term accountabilities.”

Vinson Yates, president of OhioHealth's Grant Medical Center, recalls an instance when an employee stopped him from going into an isolation room without gloves. “When an associate feels comfortable enough to hold the president accountable, I think that shows we have a good culture in place,” he says.

At Riverside Methodist, another of OhioHealth's hospitals, the first agenda item at every leadership meeting is safety, says Dr. Steve Markovich, the hospital's president and CEO. “It starts at the top,” he says. “We bring in staff members to board meetings and they present good catches. That kind of recognition filters down to everyone.”

Also on Truven's 100 Top Hospitals list this year was Advocate Christ Medical Center, a 672-bed hospital in Oak Lawn, Ill. Dr. William Adair, the hospital's vice president of clinical transformation, says Truven's latest ownership analysis confirms what he believes from his own experience: that people who are drawn to faith-based, mission-driven organizations have similar values, and that bolsters a commitment to patients.

“We take things like safety and mortality very, very seriously,” says Kenneth Feiler, CEO of 264-bed Rose Medical Center, Denver, a Truven 100 Top Hospitals honoree and part of 146-hospital HCA, a for-profit chain headquartered in Nashville. “We do consider ourselves stewards of resources and we look carefully at how we utilize them.”

“We obviously have to maintain our bottom line in order to stay in existence, and that is no lean task,” Adair says, “but we make sure that what we do is always on the side of the people we are serving.”

He cited numerous quality- and safety-related initiatives at Advocate Christ and its parent health system, not-for-profit 10-hospital Advocate Health Care, Oak Brook, Ill., including projects targeting sepsis prevention and improved discharges, as well as a high-reliability program for hospital leaders, launched last fall.

And in April, the hospital began doing daily patient-safety huddles aimed at recognizing staff and addressing issues such as malfunctioning equipment, says Colleen Perez, the hospital's director of quality and regulatory compliance.

“In just our first month, we identified 100 issues and solved 100 issues,” Perez says. “I can't tell you the impact this has had on our organization.”

For-profit hospital leaders, however, balked at the idea that they place less emphasis on quality or are any less patient-centered than their not-for-profit counterparts.

Feiler listed many of the same programs and characteristics—a safety-oriented culture, staff recognition, systemwide improvement initiatives—that not-for-profits did when explaining their success.

“This is our sixth year on Truven's list, and I think that if you walked around here, you would sense that we're working on the fundamentals every day,” Feiler says. “We take it personally when we have a system failure.”

Foster, principal investigator of Truven's latest ownership report, acknowledged that the findings offer few clues about what factors are behind the differences in hospital performance.

“We have to recognize that we can't make causal statements,” he says. “I would caution people to take note of the patterns, but don't imply that we understand or are making value judgments about why things are a certain way. It's more of a hypothesis-generating report, a jumping-off point.”

Centinela Hospital Medical Center, a 369-bed hospital in Inglewood, Calif., marked its second appearance on the 100 Top Hospitals list this year. Linda Bradley, the hospital's CEO, praised Truven's scorecard methodology as a way to gauge overall hospital performance.

Centinela is part of Prime Healthcare Services, a for-profit, 19-hospital system based in Ontario, Calif.

But Bradley paused when considering the results of Truven's latest analysis based on ownership. Such findings don't resonate with her experiences at Centinela, which focuses heavily on quality improvement, safety, mortality and patient satisfaction, she says.

And she credits Prime with fostering improvement throughout the health system and encouraging sharing of best practices.

“I think if any provider—for-profit or not-for-profit—is culturally aligned and has everyone focused on common goals, ownership differences can become non-existent,” Bradley says.

Follow Maureen McKinney on Twitter: @MHMMcKinney