Attention to detail drives Top 100 Hospitals

Mon Mar 28, 2011 9:26am EDT

Dr. David Cooke of Central DuPage Hospital in Winfield, Illinois. REUTERS/Handout

Dr. David Cooke of Central DuPage Hospital in Winfield, Illinois.

Credit: Reuters/Handout

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(Modern Healthcare) -- To steer Memorial Health Care System through the Great Recession, executives targeted, among other things, length of stay through a program in which case managers closely oversee inpatient admissions.

Called Pace of Care, the program's goal is to "make sure the patient is in the right setting, for the right reason, to receive the right care, at the right time," says Melissa Roden, vice president of quality at Memorial Health, which includes two hospitals sharing a single Medicare identification number in the metropolitan area of Chattanooga, Tenn.

Case managers, who are registered nurses, are deployed in the emergency department and intake center (where admissions from physician's offices are processed) to ensure that potential inpatients' medical conditions warrant an acute-care setting. In situations where a less intense level of care is appropriate, case managers arrange other options, such as home care or a stint at a rehab facility.

Case managers also ensure that the status of patients in observation is resolved within 24 hours and that the care of inpatients moves forward smoothly.

To implement the program, Memorial increased its staff, going from a ratio of one case manager for every 35 to 42 patients to one case manager for every 22 patients. The length of stay at both locations dropped as a result of the program.

At Memorial Hospital, Chattanooga, the length of stay dropped 1.6 percent to an average of 4.73 days so far during the current fiscal year, which began July 1, 2010, compared with fiscal 2009. At Memorial North Park Hospital in Hixson, Tenn., the length of stay dropped 4.75 percent to 4.02 days in the current fiscal year compared with fiscal 2009.

Memorial Health isn't alone in its efforts to battle a weak economy through initiatives to improve operational efficiency or cut costs. That was a formula adopted by other hospitals on Thomson Reuters' 100 Top Hospitals, 2011, which includes Memorial Health, making its eighth appearance on the list, in the large community hospitals category.

Thomson Reuters released the list exclusively to Modern Healthcare.

HOW THE STUDY WAS DONE

To select the top 100 hospitals, or benchmark institutions, hospitals with at least 25 beds were scored against others within the same category: Major teaching hospitals (400 or more beds and high levels of physician education and research); teaching hospitals (200 or more beds and some physician education) and three tiers of community hospitals: large (250 or more beds), medium (100-249 beds) and small (25-99 beds).

A total of 2,914 hospitals were included in this year's study. Hospitals in the top 100 must score well as compared with others in their size/teaching-status category, based on a composite score of the 10 measures. The top 100 hospitals also must score at least at the median level of performance on each of the 10 measures evaluated in the study.

Data for the Thomson Reuters' analysis came from the Medicare Provider Analysis and Review data set for 2008 and 2009, Medicare cost reports for 2009, CMS' Hospital Compare data from 2006 to 2009, and CMS' Hospital Consumer Assessment of Healthcare Providers and Systems survey data for 2009. Hospitals that did not indicate in Medicare claims whether patients' clinical diagnoses were present at the time of admission were excluded from the study. Fifteen hospitals on this year's list are making their first appearance.

BETTER OVERALL SCORES

The top 100 hospitals overall scored better than their peer hospitals on all measures:

* The risk-adjusted mortality index for the benchmark hospitals was 0.91-8.4 percent lower than the index score of 0.99 at peer facilities (a lower score is better).

* The risk-adjusted complications index was 0.91 at benchmark hospitals - 11.3 percent lower than the 1.03 index score at peer hospitals (a lower score is better).

* The patient-safety index was 0.84-13.8 percent lower than the index score of 0.97 at peer hospitals. (a lower score is better.)

* Core measures average score, which shows adherence to evidence-based processes, was 96.2 percent at benchmark hospitals, compared with 94.5 percent peer facilities (a higher percentage is better).

* The 30-day mortality rate was 12.3 percent at top hospitals, compared with 12.9 percent at peer hospitals.

* The 30-day readmission rate was 20.6 percent at top hospitals, compared with 21 percent at peer hospitals.

* Average length of stay was 4.6 days at benchmark hospitals - 8.8 percent shorter than the 5.04 days at peer hospitals.

* Expense per adjusted inpatient discharge was $5,497 at the top 100 hospitals - 7.7 percent lower than the $5,959 at peer hospitals.

* Patient satisfaction had a score of 264-3.5 percent higher than the score of 255 at peer hospitals (a higher score is better).

* Operating profit margin was nearly 11.6 percent at benchmark hospitals, compared with 3.2 percent at peer hospitals.

The fact that the benchmark hospitals had higher profits, lower expenses and shorter lengths of stay probably was a result of their response to the recession, according to Jean Chenoweth, senior vice president of performance improvement and 100 Top Hospitals programs at Thomson Reuters.

"The top hospitals acted much more quickly to deeply cut length of stay and expense, and they did it faster than their peers," Chenoweth says.

"At the same time, they still improved quality. These are leaders who never relent on their insistence on the highest quality even though they have to make major cuts in expense and length of stay."

The disparity between top hospitals and their peers on measures of efficiency was greatest among the small hospitals. Because of the size of those hospitals, "the changes they made had a much deeper impact," Chenoweth says.

Top hospitals in the small-hospital category registered an operating profit margin of 15.4 percent compared with about 1.6 percent for peer hospitals. In a similar vein, the top hospitals' average length of stay was more than three-quarters of a day shorter than peer hospitals: 4.35 days compared with 5.15 days. Expense per discharge was $5,048 for small top hospitals, compared with $5,954 for peer hospitals.

LENGTH OF STAY

Looking at length of stay Central DuPage Hospital, in suburban Chicago, which made the list for the fifth time in the large community hospital category, was among the top hospitals focused on length of stay.

In the fall of 2009, the Winfield, Ill., hospital added a fast-track program to the discharge-planning process for patients undergoing joint replacement procedures. Physical therapists now complete their evaluations of patients who are likely to qualify for the program on the morning of the patient's third day at the hospital. Those who are deemed ready for discharge then attend a patient-education class that morning and are released in the afternoon.

In joint replacements, physical therapists play a critical role in the discharge decision because of their expertise in assessing whether a given patient can get around well enough to go home, says Dr. David Cooke, vice president of quality and safety at Central DuPage.

Home-health nurses visit patients on discharge day, which helps patients feel comfortable with the decision to leave the hospital.

"We have not reinvented the wheel," Cooke says. "Frequently, it is not about coming up with new ideas. It is about effectively executing the ideas that already exist."

Since the program was put in place 18 months ago, the average length of stay for knee and hip replacements has dropped by half a day to three days, Cooke says. The hospital performs about 1,600 joint replacements a year. As a result of the program's success, the hospital is in the early stages of expanding it to congestive heart failure and heart surgery.

Another area of focus among top 100 hospitals is cost-cutting, particularly in materials management. For example, Memorial Health saved $2.5 million in fiscal 2010 by standardizing protocols for the use of bone morphogenetic protein - which is used during spinal surgery to stimulate bone growth, Roden says. The idea is to use it "only in cases where patients are actually going to benefit from its use," Roden says.

Paoli (Pa.) Hospital, which made the top hospital list for the third time, also zeroed in on materials management through purchasing initiatives managed by the hospital's corporate parent organization, Main Line Health. For example, Main Line negotiated new contracts for the primary artificial knees and hips implanted in patients who undergo joint replacement surgery for the first time. The system adopted a "shelf pricing" strategy in which it dictated the price vendors must meet to have their product stocked at Main Line's four hospitals.

‘TALKING TO THE DOCS'

While all eight vendors eventually met the price, orthopedic surgeons had to agree upfront to switch to another vendor if their preferred supplier didn't agree to the price.

"This is me talking to the docs, bringing them through it," says Barbara Tachovsky, president of Paoli Hospital.

The move to a shelf-pricing strategy is expected to save Paoli $150,000 annually.

A total of 16 orthopedic surgeons performed 211 primary knee replacements and 128 primary hip replacements at Paoli Hospital in the fiscal year ended June 30, 2010.

Main Line uses the shelf-price strategy in situations such as joint replacements, where it doesn't make sense to standardize on one or two products, says Christine Torres, vice president of materials management and supply chain at Main Line.

"We like to give our physicians choice. We appreciate their knowledge and their technical abilities around what they have been trained with," Torres says.

(For more coverage by Modern Healthcare, click here )