Hospitals of excellence’ outshine others in mortality

Quality chasm’ continues to grow, says report

When it comes to quality improvement, it seems that the best keep getting better, based on the findings of the latest Hospital Quality and Clinical Excellence study from Golden, CO-based HealthGrades Inc. This is the organization’s fourth annual study, analyzing nearly 39 million hospitalizations over the years 2002-2004 at all 5,122 of the nation’s nonfederal hospitals.

The study shows the hospitals in the top 5% (HealthGrades calls them "Distinguished Hospitals for Clinical Excellence") achieved 36% more improvement in in-hospital mortality and 40% more improvement in postoperative complications compared with all other hospitals over the years 2002-2004. Here is a closer look at the study’s key findings:

• According to the study, during 2002-2004, patients at Distinguished Hospitals for Clinical Excellence experienced a "27% lower risk of mortality and 36% more improvement in in-hospital mortality" associated with several conditions.

These include cardiac surgery, angioplasty and stent, heart attack, heart failure, atrial fibrillation, chronic obstructive pulmonary disease, community-acquired pneumonia, stroke, abdominal aortic aneurysm repair, bowel obstruction, gastrointestinal bleed, pancreatitis, diabetic acidosis and coma, pulmonary embolism, and sepsis.

• According to a public release announcing the study, "Medicare patients had, on average, a 14% lower risk of postoperative complications at a Distinguished Hospital for Clinical Excellence for diagnoses and procedures that include orthopedic and neurosurgery, vascular surgery, prostate surgery, and gallbladder surgery.

"For those same procedures and diagnoses, Distinguished Hospitals improved their postoperative complication rates at a 40% faster rate than all other hospitals over the years 2002, 2003, and 2004."

The study also found that "if all patients with any of the 26 conditions studied were treated at Distinguished Hospitals during 2002 to 2004, 152,966 lives could have been saved, and 21,896 complications may have avoided a major postoperative complication."

"In qualitative terms, there is definitely a gap," says Samantha Collier, MD, vice president of medical affairs at HealthGrades and the report’s author. "Everyone’s improving — that’s the good news — but the top hospitals improve at a faster rate, so that accounts for the gap. It’s not closing because the best are doing a better job of getting closer to perfection."

Not surprisingly, Collier says strong leadership was a common element among top performers. "I’m inside hospitals all the time; and in terms of what predicts quality, one of the things I’ve personally seen is strong leadership. There are senior members [of management] who are present at all high-level quality committee meetings," she notes. "For example, if you have a cardiac quality committee made up of physicians, the CEO is present at those meetings. They want to show their staff they are as committed as if it were a financial or strategy meeting."

The boards at those hospitals actually spend a lot of time talking about quality, she continues. "Here’s a simple test: In terms of minutes, how much time is spent on quality at board meetings? It should be at least 50%, or your hospital will not be a top performer."

Collier says quality managers often tell her they are having a hard time getting the information "upstairs" and creating a sense of urgency — which is another predictor of excellence. "If you work with consultants, they may make the presentation for you," she suggests, noting that consultants might actually get the board to listen to them more readily. "The quality manager should go to the consultant and ask them to talk to the CEO or ask them to make a presentation," she suggests. "Ask them to include the information you feel is most important, and to make the recommendation that quality reports need to be a part of every board meeting."

At one of the "Distinguished Hospitals for Clinical Excellence" — Baylor University Medical Center in Dallas — a "top-down" approach also is seen as a key to success, says Irving Prengler, MD, MBA, vice president of medical staff affairs. "Basically, our hospital — as well as our system — places great emphasis on quality and health care improvement," he declares.

But when it comes to actual improvement on the ground, including the key areas of lowering mortality rates and reducing complications, "I attribute our success to looking at many disease processes with a multidisciplined approach," says Prengler. This includes not only physicians and nurses but therapists or "whoever is involved in the type of care we are targeting," he explains. "We have also developed a culture in which people are listening to each other."

At present, the disease processes his facility is focusing on include pneumonia, myocardial infarction, congestive heart failure, as well as preventing surgical infections. "We are very active in [the Boston-based] IHI [Institute for Healthcare Improvement] initiatives such as the 100,000 Lives campaign," Prengler says.

"There is a surgical infection prevention program that people are following nationwide, which asks questions like, are you using the right antibiotics for prophylaxis? Are you giving them within an hour of incision? Are you stopping antibiotics within 24 hours to help reduce resistance?" he says. "Other measures we will be taking on include controlling blood sugars. This is easy to measure, but at the same time we have a protocol for intensive IV insulin therapy, as well as subcutaneous insulin, to try to improve outcomes."

The facility has been involved with the IHI’s "rapid response team" program for several months "and it’s been a very exciting initiative; it’s become part of the hospital culture, and we know it’s making a difference," Prengler observes.

"They can tell you that you either need to act immediately, or perhaps you need to change the treatment plan," he explains. Prengler relates this personal experience: "I’m a hospitalist, and one day I was on the surgery floor and could see there was an emergency. I volunteered my services, but the nurse said, Thanks, but the rapid response team is on the way and we’ve taken care of it.’ This showed me it was becoming part of our culture."

The facility also is dedicated to continuous quality improvement. For example, several years ago, when the core measure for giving antibiotics quickly was eight hours, Baylor’s rate was in the mid-90s. "And if you look at our mortality rate for pneumonia, for example, it earned a five-star rating from HealthGrades, and we were well above the state average," notes Prengler.

Now, however, core measures ask for antibiotics to be given within four hours. "This is a little more difficult to do," he says. "Last month — our best recent month — we were at about 84%-85%, but we’re still not satisfied."

Another facility recognized by HealthGrades, Delray (FL) Medical Center, has sought improvement in key quality areas through a number of strategies — including the pursuit of JCAHO certification as a primary stroke center. "Over 50% of our patient admissions have associated stroke risk factors, so we knew the community needed it," recalls Karen Bibbo, RN, MBA, chief nursing officer at the 407-bed acute care hospital and level II trauma center, adding that the facility received its certification last December. (The facility also received Solucient’s 100 Top Hospitals Award in 2001, 2002, 2003, and 2004.)

One key part of the certification process involved the administration of the clot-busting drug tissue plasminogen activator (tPA). "We had protocols in place for at least a decade, as well as an established ED stroke call panel," notes Bibbo, "but this stroke protocol and the things that go along with it are relatively new."

What needed to be done differently? "Protocols were established to quickly identify and expedite care for these patients," says Bibbo. "There has to be seamless, standardized care, and everyone has to do it 100% of the time."

To help ensure standardization, the facility developed a "Tool Kit" that includes:

  • Clinical pathway for stroke. This is included in the patient’s chart.
  • Daily rounds by a stroke coordinator. This includes review and analysis of stroke PI indicators and a concurrent review of each in-house stroke facilitating patient care.
  • Micromedex. An on-line resource system for nursing that includes information about stroke, stroke care notes, and educational materials.
  • Stroke discharge instructions. These are standardized but patient-specific.

Before the facility sought certification, Bibbo notes, every physician practiced the way he or she wanted to practice; nothing was set in stone. "Going for stroke certification required us to put a protocol in place for every aspect of that patient’s care; we established and standardized our clinical pathways, documentation tools, testing, and treatment," she shares.

The hospital also designated a neurological intensive care unit. "Nurses got specialized training, and we round specifically when there is a stroke patient to be sure all elements of the protocol are in place and to ensure we are not deviating from standardized care," says Bibbo.

When patients present in the ED with signs and symptoms, the ED doc puts a call out to the tPA panel, says Bibbo. "We actually have a rehab hospital — Pinecrest — connected to us, and they can deliver care all the way through to rehab," Bibbo adds. "So we can provide a seamless transition." Pinecrest recently achieved its CARF — certified associated rehab facility — designation, she adds. "After we got ours, they went on and applied for theirs," Bibbo explains.

Delray Medical also uses the rapid response team model. This includes a hospital-based nurse practitioner, the critical care shift manager, and a respiratory therapist. "They quickly and competently respond to unfavorable changes to our inpatients," says Bibbo. The facility also is a participant in the 100,000 Lives campaign.

"We never stand still; we always want to make ourselves better," Bibbo asserts. "We monitor our data, compare it to previous months and years, to other Tenet (South Florida) hospitals, and facilities in the community. We use so many benchmarks — and most important of all, we look at our own numbers and benchmark against ourselves. This is a consistent approach we have that has helped us achieve these kind of awards and designations."

Quality managers who wish to monitor their progress toward excellence can start by asking themselves a few key questions, says Collier. "As a litmus test of where you are with regards to QI, ask yourself if all your teams are multidisciplinary," she recommends. "Are cardiovascular problems, for example, viewed as a physician issue or a system issue? If you silo’ with people who all think alike, you will not get the best solutions."

(Editor’s note: The HealthGrades ratings and Distinguished Hospitals for Clinical Excellence designations are available free of charge at www.healthgrades.com.)