It isn't every day that rural hospital officials eagerly discuss their abysmal practice scores in crucial care areas like heart failure or hip and knee surgery.
But Cleveland Regional Medical Center in Shelby, NC, and United Hospital Center in Clarksburg, WV, now wear their low rankings almost like war medals.
That's because that poor performance is now history. Today, four years later, the facilities have improved their care of patients so dramatically in four important categories, they've become innovators for other hospitals throughout the country.
Cleveland and United are two of 40 rural hospitals and 190 urban hospitals participating in the Centers for Medicare and Medicaid Services' "pay for performance" demonstration project, organized by Premier Inc.
Ironically, officials for the two hospitals say, the "pay" for their performance isn't the motivator for their participation. Improving care and getting recognized for it, however, are.
The effort is now in the fifth of a six-year run to see if the 230 participating facilities can be motivated by financial rewards to increase their performance in 33 process measures that correlate with better outcomes. But the first year results were a shocker.
"After the first year, we found out we were in the worst decile of all the hospitals in our heart failure discharge instructions," says Liz Popwell, Cleveland's vice president and chief ancillary officer.
Her 241-bed hospital's rates of readmissions were much too high. Scores for other quality measures in heart attack care, pneumonia and hip and knee replacement surgery were not something to advertise either.
Mark Povroznik, director of quality initiatives for a 318-bed United, acknowledges similar lackluster quality. "We ranked in the bottom deciles in nearly everything," he says.
Now after the fourth year, in the four categories of care that Cleveland and United provide--hip and knee surgery, pneumonia, acute myocardial infarction, and heart failure care--the hospitals' scores have vastly improved.
During the four years of the project, Cleveland has received just about $200,000 in rewards, while United has received $333,770, out of a total of $36.5 million paid by the federal government to those best-scoring hospitals.
But if money was supposed to be the motivator, it turns out to not be very important. First of all, the prize money doesn't amount to that much. Public recognition, however, was the key. And neither hospital knew its initial scores would be relatively poor.
The "financial reward was not the motivator. The motivation was that this was the right thing to do," Povroznik says.
Now what's more important, they both say, is the recognition they received from their patients, physicians and peers, and knowledge that they are providing better care that drives all hospitals to keep up the good work.
Another motivator was the idea that they could be innovative.
"To make these changes, we had to start thinking outside the box," says Dotty Leatherwood, vice president of Cleveland Hospital's community relations.
One of the strategies that helped, for example, was to ask case managers to follow their patients back to their homes to find out why they have such high readmission rates.
The story of one patient illustrated the difficult problems in their rural area. She had so little money for food, much less medications; her cabinet contained but one can of soup. Other patients who were advised to limit their salt intake didn't know that meant sodium too.
"It's sometimes especially hard for our elderly to manage that, or to understand," Popwell says. More counseling and one-on-one sessions helped educate them to change their diets.
Another remedy to seeing rapid improvement was to hire special nurses to do real time chart reviews, instead of waiting six months to look for mistakes, Popwell says.
"They'd look at a patient's chart and see things that had slipped through the cracks, such as a patient who had not received an ejection fraction test. That way, we could fix it while the patient was still with us in the hospital rather than catching those mistakes in retrospect on the chart review," she says.
A culture shift was important to make as well, she adds. "The challenge was that now we had these nurses looking over everyone's shoulder, including the physicians. And sometimes they'd say, ‘Hey, you're aggravating us!' But they stopped saying that when they could see the improvement."
At United, an important reason to participate in the project was an internal assessment done several years ago that "found that the hospital tended to react when problems occurred, rather than work proactively to improve quality," said a June report on United's success by the Commonwealth Fund.
"Staff failed to collaborate to set clear priorities" and the system was "data rich, information poor," in that it did not use proven core measures.
Another important key to improvement was to change some ways in which the hospital provided surgical care, including bringing more surgeons and anesthesiologists into the planning process.
"The quality improvement director held one-on-one discussions with the orthopedic surgeons" to focus on appropriate and timely antibiotic administration during hip or knee surgery, the report said.
When appropriate documentation required by the surgeons was routinely missing, the hospital staff took a tougher stance.
"Once, when it was clear that a particular surgeon was negatively affecting a department's performance, Povroznik announced in a department meeting that, ‘Your group efforts are noted and appreciated, but achievement of the department's goal is being held back by one of your colleagues; we're hoping we won't have to disclose who this is," according to the Commonwealth Fund report. The surgeon's compliance improved immediately.
Says Povroznik, "UHC had a long track record of being the lowest cost provider in WV. This alone shows commitments of our executives and associates to the community we serve. So pioneering into the field of quality reporting was not a fear, but a challenge we were eager to embrace. Regardless the initial outcome in performance, we knew we had the team philosophy and medical staff support to overcome and improve."
The 33 quality measures were developed by government and private organizations such as the National Quality Forum, the American Hospital Association and the Leapfrog Group, which found that adherence is highly correlated with better outcomes and improved survival. Coronary artery bypass graft surgery is measured for hospitals that perform open heart surgery.
The strategies include such best practices as always making sure heart attack patients get a beta blocker as soon as they arrive or administering pneumococcal vaccination to patients with pneumonia, giving aspirin to patients treated for heart attack as they are being discharged and making sure heart failure patients have a solid discharge plan.
They measures are "based on scientific evidence and, for continued effectiveness, are often reviewed to account for medical breakthroughs and new research," said Richard Bankowitz, MD, Premier vice president and medical director.
Overall, rural hospitals started out in the first year with aggregated scores in almost every category that were slightly lower than their urban counterparts participating in the project. But one of the most surprising findings after the first three years was that rural hospitals improved at a rate that kept pace with facilities in urban settings, Premier officials said.
For example, in the treatment of patients with heart attack or AMI, rural hospitals started out in year one with a compliance rate of 87%, but improved to 94% by the end of year three. Urban hospitals started out at 89.8% and ended year three with 95.6%
Rural hospitals still have more improvements to make overall, says Alven Weil, spokesman for Premier. During year four awards, the 190 urban hospitals received on average five awards per hospital while the 40 rural facilities received only four.
Also overall, there is still more room for improvement throughout all participating hospitals in many areas, such as pneumonia, Weil says.
For Leatherwood, Popwell and Povroznik, at least, there is the drive to continue to improve. "We now have the culture that likes being the very best," says Leatherwood. "And we know being just 'good' is not good enough."