Truven's 100 Top Hospitals focus on standardization to improve outcomes, cut costs

In 2011, nearly 20% of all patients discharged after heart-failure treatment at Stanford Health Care in California were returning within 30 days. Stanford leaders knew the CMS would start penalizing hospitals financially for high readmission rates related to heart failure and other conditions.

“Clinically, we knew we had a problem,” said Dr. Dipanjan Banerjee, clinical assistant professor of cardiovascular medicine for Stanford's medical school. The hospital's discharge planning and follow-up, he added, “just wasn't good enough.” So throughout 2012, the hospital conducted a major effort to standardize and better coordinate care to drive down readmissions.

A multidisciplinary team, including cardiologists, an administrator, a new nurse specialist, and pharmacy and informatics leaders, met once a week. They created a data dashboard, which allowed them to track readmission rates, emergency department usage and medication reconciliation in real time instead of with a three-month lag.

Best practices were standardized. Before discharge, prescriptions are reviewed by a pharmacist, and patients receive an educational session about their medications and dietary needs. Within 48 hours of being sent home, patients receive checkup phone calls and are scheduled for follow-up visits within two weeks.

The efforts have paid off, Banerjee said. As of Jan. 19, the hospital has reduced the readmission rate for heart-failure patients to 6%. For overall readmissions, Stanford avoided penalties during the first round of CMS penalties in fiscal 2013. The federal agency has been assessing hospitals on readmissions for heart failure, heart attack and pneumonia since October 2012.

Its focus on standardization is one factor that landed Stanford on the Truven Health Analytics list of 100 Top Hospitals for 2015. Released exclusively to Modern Healthcare, Truven's 22nd annual top hospitals list recognizes the 100 highest-scoring hospitals out of a total pool of 2,787, including not-for-profit, for-profit and government institutions. The recognition is based on performance across more than a dozen measures, including mortality, complications, length of stay, readmissions, financial performance, patient satisfaction and spending per beneficiary.

Eligible hospitals for the Truven 100 Top Hospitals list are divided by size into five categories. The final list includes 15 major teaching hospitals (400 or more acute-care beds) and 25 teaching hospitals (200 or more acute-care beds). Among community hospitals, 20 large (250 or more acute-care beds), 20 medium (100-249 acute-care beds) and 20 small (25-99 acute-care beds) facilities made Truven's 100 Top list.

The top hospitals performed better than their peers on all measures, according to Truven's national data.

For example, average length of stay for patients at the 100 Top, or benchmark hospitals, was 4.3 days, compared with 4.9 days in the comparison group. For hospitals on the Truven list, risk-adjusted patient complication rates were 4% lower, and risk-adjusted mortality rates were 5.9% lower. They performed slightly better than peers on 30-day readmissions for heart failure, heart attack and other conditions.

In terms of financial performance, the top-rated hospitals had an average operating margin of 14.4%, compared with 3.6% for the peer group. Inpatient expenses per discharge at top-performing hospitals were $6,341, about 3% lower than at peer hospitals. The 100 Top hospitals also saw 2% lower costs per episode in treating Medicare patients. This is the first year that Truven has included that measure.

There were a number of repeat winners this year. Indeed, several hospitals have been frequent winners on the list over consecutive years. “There isn't a lot of high reliability in healthcare yet, but these high-frequency winners are moving toward that kind of reliability,” said Jean Chenoweth, senior vice president of performance improvement at Truven. To achieve that, she added, “you have to shift away from the process of improvement and focus on consistency and uniformity.”

Six hospitals have been on the list at least 10 times each, and consecutively for at least the past three years: Advocate Lutheran General Hospital, Park Ridge, Ill.; Holland (Mich.) Hospital; Mercy Hospital Anderson, Cincinnati; OhioHealth Riverside Methodist Hospital, Columbus; Kettering (Ohio) Medical Center; and St. Thomas West Hospital, Nashville.

This is the 16th time Advocate Lutheran General Hospital has been recognized, which ties it for the most times any hospital has been listed. Last September, Advocate Health Care and NorthShore University HealthSystem announced plans to merge and create a $7 billion academic-suburban regional mega-system. NorthShore's Evanston Hospital is the only other 16-time winner, though it wasn't on the list this year.

“It's two strong organizations coming together. That kind of collaboration can only mean good things for quality and safety,” said Dr. Leo Kelly, vice president of medical management for Advocate Lutheran. “We now have the opportunity to learn from each other.”

A total of 27 states had at least one top-performing hospital, according to the Truven data. While Midwestern states have dominated the list since 2002, California hospitals “came roaring back,” Chenoweth said.

Fourteen of this year's top performers were from California, more than from any other state. Ohio and Illinois had the second-largest number of hospitals represented on the list, with 10 each. “There is a very high degree of focus on quality now, and it shows,” Chenoweth said.

Stanford Health Care was listed for the second time after a two-decade gap. Dr. Raj Behal, the hospital's chief quality officer, said they have focused on innovations to boost quality and value. For example, Stanford piloted a program to send medical students to the homes of high-risk heart-failure patients. These visits revealed several challenges for patients in following post-discharge recommendations, including lack of transportation and confusion over prescriptions. “It was an eye-opener,” Behal said. “Those kinds of (insights) can never come out of databases.”

There were also 15 hospitals on the Truven list for the first time this year. Five of them also received Truven's Everest Award for demonstrating rapid improvement from 2009 to 2013.

One of those Everest winners, Little Company of Mary Hospital, Evergreen Park, Ill., says it has launched improvement initiatives across a number of nationally reported quality measures. To tackle 30-day readmissions, its leaders implemented a care-transition program in 2013, hiring a nurse navigator to help prepare high-risk patients for the transition to their home environment. And in May 2014, the hospital launched a nurse-driven initiative to reduce catheter-associated urinary-tract infections by limiting the use of catheters. The quality team also works with the internal communications team to announce or disseminate these patient-safety campaigns.

Cindy Deuser, Little Company's vice president of quality improvement, said her hospital relies on evidence-based practices to drive care.

Still, she acknowledged there is more work to do. Little Company of Mary is one of 724 hospitals that will see Medicare payments docked by 1% this fiscal year as part of the first year of the CMS' Hospital-Acquired Condition Reduction Program, which penalizes poor performers.

“We drilled down into that data and what we learned is we need to make improvements to our venous thromboembolism rates,” Deuser said. The hospital already has set up a task force to address the issue, and is using a risk score to assess patients' likelihood of developing the blood clots.

Chenoweth said a new pattern arose out of Truven's inclusion of a measure tracking performance on the continuum of care. Hospitals that did better on extended outcome measures also appeared to be working on improved care coordination. In addition, as health systems have moved more patients to outpatient settings, the Truven data suggest inpatient costs rose at some hospitals but not at others. But as hospitals become part of accountable care organizations, it's not clear whether inpatient and outpatient expenses will go down as a result, she said.

One of the biggest challenges, as hospitals of all sizes scramble to improve outcomes, is sustaining those improvements year after year when new measures are added. “Setting a high rate of improvement and achieving high-level performance is hard, but maintaining it requires innovation and is even harder,” Chenoweth said.

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