Top-performing hospitals know how to use teamwork

A multidisciplinary cardiovascular care team at St. Patrick Hospital in Missoula, Mont., has met every week since March 2013 to go over the charts of patients scheduled for valve-replacement therapy.

Surgeons, cardiologists, a nurse practitioner, cardiographer and physician assistant review whether the procedure is the most appropriate therapy for the patient.

“We have begun to work a lot more cohesively, and we've seen better results,” said Dr. Matt Maxwell, director of cardiovascular surgery at the 193-bed community hospital.

Every month for the past five years, cardiologists and administrators at 173-bed Scripps Green Hospital in San Diego meet with teams from three other hospitals in the Scripps system to implement best practices to reduce clinical variation. The group has tackled complicated issues that include how frequently blood tests are administered and which blood thinners are most appropriate. “Patients get the benefit of a massive and timely collaboration,” said Dr. Paul Teirstein, director of the Prebys Cardiovascular Institute of Scripps Health.

The creation of multidisciplinary teams and the focus on standardizing best practices is paying off at hospitals that rose to the top of this year's list of Truven Health Analytics' 50 top cardiovascular hospitals in the U.S. “We are seeing the beginning of the impact of efforts to provide consistent care,” said Jean Chenoweth, senior vice president of performance improvement at Truven, a research and data firm.

The 16th annual review looked at 1,005 hospitals that provide medical and surgical treatment for heart disease. The list includes the 50 that scored highest on heart attack and heart failure treatments and coronary bypass and angioplasty surgeries. The hospitals are separated into three categories. This year, 15 teaching hospitals with a cardiovascular residency program, 20 teaching hospitals without cardiac residency and 15 community hospitals were listed.

Truven evaluates 20 performance measures drawn from the Medicare Provider Analysis Review, CMS Hospital Compare and Medicare Cost Report data. They include six risk-adjusted clinical-outcome measures that include mortality and complication rates; four extended-outcome measures, including 30-day mortality and 30-day readmissions rates; two sets of clinical-process measures, including one focused on the percentage of patients undergoing coronary-artery bypass who received an internal mammary artery graft; and eight efficiency measures including patients' length of stay and cost per case.

In addition to achieving better quality measures, the 50 top cardiac hospitals had significantly lower average costs compared with the others. Heart-attack treatment cost $1,363 less per patient, while heart-failure treatment was $753 less. Coronary bypass surgery was $4,028 less per patient and coronary angioplasty was $2,998 less. (See chart above). “Complications increase costs, and benchmark hospitals generally had lower complication rates,” said Dr. Janet Young, a lead scientist for Truven. “They were also more efficient, particularly in terms of reducing the length of stay for patients.”

Heart disease is the leading cause of death for men and women in the U.S., killing more than 600,000 each year, according to the Centers for Disease Control and Prevention. About 5.1 million Americans suffer from heart failure, and the healthcare services, medications and missed days of work associated with the disease cost the nation about $32 billion annually.

If all hospitals met the benchmarks achieved by the top hospitals on the procedures evaluated, the result would be 9,449 lives saved, 2,903 complications avoided and an annual savings of nearly $1.1 billion, according to Truven's analysis.

Overall, the top hospitals did significantly better on mortality rates and lengths of stay. When compared with their peers, they had 23.8% fewer patient deaths from heart attack, 19.2% fewer deaths from heart failure, 36.2% fewer deaths among patients undergoing coronary artery-bypass graft surgery and 31.3% fewer deaths among coronary-angioplasty patients. In addition, length of stay was shorter by 15.6% and 10.5% for heart attack and heart failure patients, respectively, at top hospitals, and 10.9% and 16.3% shorter for bypass grafting and angioplasty procedures, when compared with the peer group. “There's a fair amount of room for improvement for the peer group in these areas,” Young said.

However, long-established clinical-process measures (eight are in the study) had no significant impact on performance. “Most of these core measures have been used for years,” Young said. These included, for example, giving heart-attack patients angioplasty within 90 minutes of arrival at the hospital; providing discharge instructions to heart-failure patients; keeping blood glucose for heart-surgery patients under control after surgery; and giving heart-attack patients with elevated cholesterol levels a statin prescription at discharge. “Hospitals have focused efforts on improving them and tend to be compliant close to 100% of the time,” she said.

As cardiovascular hospitals aim to meet quality and safety benchmarks, Chenoweth said one frequent barrier is the ability to provide consistency across systems. “That is a big challenge, but we are starting to see an impact,” she said. A total of six health systems had more than one facility make the list, she noted. HCA had five hospitals represented. Banner Health, Phoenix; CareGroup Healthcare System, Boston; the Mayo Foundation, Rochester, Minn.; and Providence Health & Services, Renton, Wash., each had two on the list. Two hospitals from Tenet Healthcare Corp. that were formerly part of Vanguard Health Systems also made this list.

“We see consistency in airlines, hotels and restaurant chains,” Chenoweth said. Having more than one hospital represented in a system means that “it is possible to raise the bar” on standardization in healthcare.

Among the facilities on this year's list, Scott & White Memorial Hospital in Temple, Texas, a teaching hospital with a cardiovascular residency program, has been recognized the most frequently. Since Truven began the recognition in 1999, that hospital has been among the top performers 12 times. Scott & White became a part of the Baylor Health Care System during an October 2013 merger, and Dr. Greg Dehmer, chief of cardiology at Baylor Scott & White Health, said the integration has presented new opportunities for collaboration.

“We're able to take the best practices of both organizations and blend them,” he said. “It's very easy for us to institute common order sets and adapt new therapy models.”

Among the current systemwide efforts being considered are setting common credentialing and privileges for procedures such as carotid stents, as well as establishing a process for evaluating the value of new devices. Standardizing procedures across systems “is not always popular, but it's probably the best thing for the patient,” Dehmer said. “It's a very good way to make certain you give the right care.”

Creation of collaborative cardiovascular teams lifted performance at several of the top hospitals. Bringing together cardiologists, nurse practitioners, surgeons, hospital administrators and others for regular meetings allowed the best hospitals to review data, set goals for improvement and implement best practices. “There's no substitute for being together in the same room and working on specific problems,” said Teirstein of Scripps Green Hospital.

It takes patience to eliminate physician suspicions, address time commitments and break down other barriers to the process. You have to “park your ego at the door,” said Dr. David Roberts, director of the Heart and Vascular Institute at Sutter Medical Center in Sacramento, Calif.

A patient undergoing a complicated heart procedure usually sees a blur of physicians and other clinicians, including the cardiac surgeon, anesthesiologist, nurse practitioner, interventional cardiologist and physician assistant.

“To be successful and deliver the best care really requires every one of those pieces to be working together,” Roberts said. “It's got to be patient-centric.”

Among the hospitals recognized by Truven this year, five are on the list for the first time. Our Lady of Lourdes Medical Center in Camden, N.J., is a first-timer in the category of teaching hospitals with a cardiovascular residency program.

Four first-timers are in the community hospital category: Lawnwood Regional Medical Center in Fort Pierce, Fla.; Mercy Hospital Anderson in Cincinnati; Northwest Medical Center in Margate, Fla.; and Salem (Ore.) Hospital.

Chenoweth said this reflects efforts by those hospitals to develop centers of excellence.

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