Quality caregivers

Nearly four years ago, a group of physician leaders at Vanderbilt University Medical Center launched a program designed to ensure that patients who presented with certain complex conditions, such as clotting and bleeding disorders, were given the right diagnostic tests and appropriate treatments.

Physicians unfamiliar with such conditions would often order a slew of costly tests, many of them unnecessary, and then would struggle to accurately interpret the results.

So Nashville-based Vanderbilt formed diagnostic management teams that tapped the expertise of pathologists and other laboratory medicine specialists to guide clinical decisionmaking. They give feedback to treating physicians on appropriate testing and treatment pathways for complex conditions, including blood cancers, certain infectious diseases and coagulation disorders.

“These are areas where physicians are not as familiar, so they used to check off every test under the sun,” said Dr. C. Wright Pinson, Vanderbilt's deputy vice president for health affairs. “Having that reverse consultation from a pathologist can really help. Now instead of scatter-shooting lots of tests, we can provide care that's appropriate and efficient.”

The use of diagnostic management teams has resulted in shorter times in reaching diagnoses, fewer unnecessary tests and procedures, shorter lengths of stay and lower costs, he said. It's one among many improvement initiatives that Vanderbilt's leaders credit with helping the 909-bed hospital make its 14th appearance on Truven Health Analytics' 100 Top Hospitals: National Benchmarks for Success, 2014.

Now in its 21st year, Truven's list, released exclusively to Modern Healthcare, recognizes 100 high-scoring hospitals from a field of 2,803, based on performance across measures of mortality, 30-day readmissions, average length of stay, operating margin, patient satisfaction and other areas.

According to Truven's national comparison data, those on the 100 Top Hospitals list outperformed peer hospitals across all 14 measures. For instance, inpatient expense per discharge for those on the 100 Top Hospitals list totaled $5,648, roughly 10% lower than the comparison hospitals. Average length of stay among those on the 100 Top Hospitals list was 4.3 days, compared with 4.9 among peer hospitals not on the list. Hospitals on this year's list also performed far better on margins—with an average operating margin of 13.5%—compared with 4.1% among the peer group.

Truven, based in Ann Arbor, Mich., was formed in June 2012 when Thomson Reuters sold its health division to Veritas Capital, a New York private equity firm, for $1.25 billion.

The hospitals on this year's list attributed their performance to a number of interventions, including improved care coordination, thoughtful deployment of health information technology systems, collaboration with front-line caregivers and use of change-management strategies such as Lean. Seventeen hospitals made their first appearance on this year's list, including 279-bed Advocate Condell Medical Center, Libertyville, Ill., and 65-bed Aurora Memorial Hospital of Burlington (Wis.).

A number of other hospitals on this year's list have been recognized many times, such as 624-bed Advocate Lutheran General Hospital, Park Ridge, Ill., which has appeared 15 times; 796-bed Riverside Methodist Hospital, Columbus, Ohio, which has appeared 11 times; and 199-bed Licking Memorial Hospital, Newark, Ohio, which has made the list 12 times.

Truven compiles its list using publicly available data from the Medicare Provider Analysis and Review data set, the CMS' Hospital Compare database and Medicare costs reports. Eligible hospitals are divided by size into five categories: major teaching hospitals, teaching hospitals, and large, medium and small community hospitals.

Within those five categories, hospitals are evaluated against one another across all measures, including inpatient expense per discharge; risk-adjusted complications; and 30-day readmission and mortality rates for heart attack, heart failure and pneumonia. To make the 100 Top list, hospitals must rank above their peers on a composite score of all 14 measures and they must also score above the median for each measure.

For this year's list, Truven also tested several new measures that were not used to determine hospitals' scores but may be included in future iterations, said Jean Chenoweth, Truven Health Analytics' senior vice president of performance improvement. Those measures include the Medicare spending per beneficiary measure scheduled to be included in the CMS' value-based purchasing program starting in fiscal 2015, as well as 30-day risk-adjusted readmission rates for hip- and knee-replacement surgeries. Those rates recently became available on the Hospital Compare website.

Spearheading new quality initiatives while keeping a tight rein on finances is no easy task, particularly for a small hospital, said Mark Klosterman, president and CEO of St. Joseph's Hospital Breese (Ill.), a 47-bed facility in a town of just over 4,000.

St. Joseph's made Truven's 100 Top Hospitals list for the first time this year, an achievement Klosterman attributes to its far-reaching use of Lean management principles. Klosterman introduced Lean practices, such as value-stream mapping, to St. Joseph's in 2010, when he took the helm. Since then, the hospital staff has undertaken a variety of initiatives, including ones aimed at streamlining clinical services in the hospital's breast clinic, improving inventory management and simplifying patient education at discharge.

“It took a while to get it off the ground, but it's really growing now,” Klosterman said of the Lean quality- improvement program.

In addition, St. Joseph's Hospital was recognized on Truven's annual list of Everest Award winners, a subset of hospitals that appear on the Top 100 Hospitals list and also met a national target for rate of improvement over five consecutive years. This year's Everest Award list featured 14 hospitals.

Cooley Dickinson Hospital, a 101-bed facility in Northampton, Mass., also made the 100 Top Hospitals list for the first time and earned a place on Truven's Everest Award winner list. Dr. Mark Novotny, Cooley Dickinson's chief medical officer, highlighted a number of recent milestones, including more than 1,000 days without a case of ventilator-associated pneumonia.

The biggest success has been Cooley Dickinson's unwavering focus on reducing mortality, he said. That followed a 2010 data analysis which found several diagnoses for which the hospital's mortality rate was worse than expected. Initially, Cooley Dickinson physicians were skeptical of this effort, arguing that the higher-than-expected mortality rates reflected a population of very sick patients and a complex hospital environment.

But hospital leaders implemented a range of interventions, including the use of standardized protocols and specialized order sets for conditions such as sepsis. Following those moves, the hospital found that overall observed-to-expected mortality fell significantly, from 1.1 in 2010, or 10% more deaths than expected, to 0.28 in the nine months ended October 2013, or 72% fewer deaths than expected, Novotny said. Sepsis mortality dropped from 1.39 to 0.82 over the same period. As the physicians saw the mortality numbers creep downward, they became more enthusiastic about applying similar strategies to other targets. “This kind of success builds on itself,” Novotny said.

Staff at West Valley Medical Center, Caldwell, Idaho, saw that same momentum take hold as they worked over the past seven years to establish processes and continuously monitor performance. The 122-bed hospital was among the first-timers on this year's list, and also made the list of Everest Award winners.

West Valley has experienced just one central-line-associated bloodstream infection during the past five years. It also has implemented a robust fall-prevention initiative. In addition, the hospital worked with HCA, its parent system, and the Cambridge, Mass.-based Institute for Healthcare Improvement on a project to boost patient satisfaction. That resulted in a number of changes, including the implementation of a mandatory bedside report in which patients are introduced to their new caregiver whenever there is shift change or a move to another department.

“It took time to refine it but it is now a standard of care that we expect of our staff,” said Edith Irving, West Valley Medical Center's interim CEO and chief nursing officer.

Scott & White Hospital, Temple, Texas, has made the list nine times, but its leaders say they are constantly looking for ways to improve efficiency and boost quality. Recently they set their sights on shortening the long waits—sometimes up to two weeks—to get in for appointments in the hospital's ambulatory clinics.

After careful analysis and use of Lean principles, the team charged with addressing the problem decided to introduce same-day clinic visits. Team members let patients know same-day visits would be shorter—15 to 20 minutes—with a longer visit, if needed, to be scheduled later. In addition, patients were told they might not see their usual physician.

Scott & White rolled out same-day visits last October.

“It has worked tremendously well,” said Dr. John Erwin, associate professor and vice chair of the department of internal medicine at Baylor Scott & White Health, which was formed when the two systems merged in 2013. “Those small things are big things to patients.”

Follow Maureen McKinney on Twitter: @MHMMcKinney