Medicare's latest HospitalCompare spreadsheet shows 30-day readmission rates for the 166 best- and 292 worst-performing hospitals for patients diagnosed with heart attack, heart failure or pneumonia.
Media coverage focussed on readmission rates because that's the criteria the federal government will use next to impose financial penalties, starting at 1% of Medicare DRG payments, for those hospitals in the worst-performing quartile. The judgment period is now in its third year, with penalties for discharges starting Oct. 1, 2012.
But that same table also shows 30-day mortality rates, and names the 380 hospitals that are better and about 320 that are worse than national average in one or more categories. All-cause, risk-adjusted, 30-day mortality is what the Centers for Medicare & Medicaid Services will use to reward for good performance starting in fiscal year 2014 through value-based purchasing incentives.
All-cause mortality includes all deaths for patients treated for those same three conditions starting on the day of their admission. It's important to remember that these mortality rates include deaths not strictly related to the admitting diagnoses, but would also include, say, deaths from a fall, a medication issue, or even a vehicle collision.
The presumption is that hospitals must work diligently to make sure the patient is well managed even after discharge. Presumably, hospitals that have this oversight may even advise patients not quite well enough to manage a car to not try driving for a few more weeks.
This is good practice because we already know that some hospitals do it much better than others.
Let's return to that same spreadsheet and dig further into these mortality rates. Archived data may be found here. The data shows 20 out of 4,627 hospitals in the nation scoring "Bingo" in their 30-day all-cause mortality.
- Heart attack? Better than U.S. national rate.
- Heart Failure? Better than U.S. national rate.
- Pneumonia? Better than U.S. national rate.
- Another 72 are "better than" in two of the three disease categories.
What's their secret? What do they know, or what do they do, that other hospitals don't, can't, or won't do?
There are just two hospitals with 30-day mortality rates that are "worse than the U.S. national rate" in all three categories. Another 37 hospitals are "worse than" in two of the three. Something – or perhaps lots of things – at those facilities are terribly wrong, but what?
This week, I called some of their leaders to find out.
Hackensack University Medical Center, Hackensack, NJ
First, I chatted with Charles Riccobono, MD, chairman and chief quality and safety officer at 775-bed Hackensack University Medical Center in New Jersey, one of the 20 hospitals with the best mortality rates. He surprised me with his response.
"Nobody knows. There is no tight connection between known specific behaviors that tie well or any study has ever shown are connected with a reduction in mortality," he said.
But he has some good clues: Years ago, Hackensack's leadership started working with the Institute for Healthcare Improvement, the Robert Wood Johnson Foundation and joined a Centers for Medicare & Medicaid Services demonstration project to adopt emerging best practices, he explained.
"We got good at making people comply with what we saw as the science, and we rode that to glory," he said. "We became a well-versed choir of people imbued with a sense that we can make things better."
Okay, but what did you do? I asked again. Why are you so much better at keeping your patients alive?
Riccobono says the most probable underlying reason for lower mortality is the effort his teams spend on reducing infection rates through the use of central line-associated bloodstream infection bundles and checklists. "Our internal data shows that we've reduced mortality through our infection rates," he said.
Beyond that, he offered three initiatives that influence Hackensack's low scores.
1. Rapid response teams rush to the bedside of a patient who unexpectedly and suddenly crashes. "We've increased the numbers of calls to bring expert people to the bedside to prevent this thing called 'failure to rescue,' and the result has been a reduction in codes outside the intensive care unit," he said.
2. Pharmacists are involved in the process of medication reconciliation and how medication gets to patients.
3. Post-discharge planning alone is important, but now Hackensack staff physicians are much more involved as team members in the patient's care. "We bring them in more so we can get them to more reliably share the care of a patient and create real team behavior."
Teamwork is key, Riccobono says. He thinks most healthcare providers, the public or physicians incorrectly think of hospitals as one entity when they are actually numerous units, which have historically functioned very differently. "You can find big differences in the way the various units function," he said. "You can walk down the hallway and find enormously different safety profiles." That needs to change, he says.
So now, Hackensack's leaders are trying to look at unit-based care, and "how to create highly functional and collegial teams" that work similarly across units. "We're training workers to emulate teams like people in nuclear submarines and power plants, where you can't afford to make a mistake."
Yale New Haven Hospital, New Haven, CT
Another high-performing hospital with low readmissions is 996-bed Yale New Haven Hospital. I contacted Thomas Balzecak, MD, vice president of performance management and associate chief of staff.
Many best practices and procedures play a role, including a strong institutional mandate to achieve clearly set goals with "a high level and clear executive level support," he said.
But what is it really? I ask. Balzecak says that if he had to name just a few things, he would point to the speed, experience and precision of Yale New Haven's heart care, especially its catheterization lab and door-to-balloon times, as extremely influential for the hospital's low mortality rates. The cardiology department has high volume, veteran operators.
"It's hard to say that 'yes, there are these three individuals,' when really it's just an incredible team," Balzecak said.
As the saying goes, time equals muscle, and when heart attack and heart failure patients are treated promptly, there is less ischemia, less muscle damage and less mortality down the road.
Those physicians make sure patients see a doctor within a week of discharge, that patients have a list of medications, and physicians follow-up diligently to ensure the meds are taken correctly. Of course, lots of hospitals do that too, but perhaps Yale New Haven's effort is special.
Southwest Mississippi Regional Medical Center, McComb, MS
HospitalCompare lists two hospitals with the highest rates of death in all three categories. And I wondered why.
So I phoned Southwest Mississippi Regional Medical Center in McComb, MS, a 175-bed facility in an underserved area and spoke with CEO Norman Price.
Price explained that a primary reason his hospital scored so poorly was due to an administrative error in which patients designated for palliative care, who presumably were imminently terminal, were incorrectly coded so that the record did not reflect a do not resuscitate order.
"We're really not the worst hospital in the country, (as some press reports had implied) and we're going to prove it," he said.
Additionally, he says that the formula CMS uses to reflect racial disparities and burden of disease seen in so many patients in Southwest's rural region.
"It's poor, and our demographics are 52% African American. We are high in the state with heart disease, hypertension and obesity. And they say it shouldn't matter. Well it does matter. Go to Beverly Hills hospitals and tell me what their heart failure rate is," he said.
Price adds that many of Southwest's patients are also on renal dialysis, and have high rates of stroke.
Now, all the bad publicity has prompted the hospital to change a few things, Price said. One surprise they discovered, when they started to look, was that a cardiologist was not reviewing the charts of all heart attack patients. Now, they've hired more cardiologists to do just that, and staff to call patients on the 7th and 14th day after discharge.
Another problem was that patients were unable to get to a doctor's office so the hospital may buy buses to provide transportation to and from post discharge checkups.
They've also upgraded their ambulance service to cover all areas of Pike County.
With these changes, he says, in a year or two, "we're going to look like a comet."
Piedmont Medical Center, Rock Hill, SC.
Piedmont Medical Center, the other hospital with worse 30-day mortality rates in all three disease categories, could not respond by phone, but their corporate owner, Tenet Healthcare, sent me a one-page statement of their correction plan, which focused on improving process measures.
The statement said the 288-bed hospital would focus on adult smoking cessation counseling and taking blood cultures to assess appropriate antibiotic dosage for pneumonia patients. And it will redesign care for heart failure patients and ensure that patients with a heart attack receive an aspirin when they arrive and aspirin and beta blockers on discharge.
The statement touted several awards the hospital has received from the Joint Commission and the Society of Chest Pain Centers.
"As the science of measuring quality outcomes continues to advance, Piedmont will continue to review the many types of studies available in order to provide information on how we can continually work to improve patient care processes for better outcomes," the statement said.
In case you wondered which were the best performing hospitals in all three disease categories for 30-day all-cause mortality, here's the list.
- Cedars Sinai Medical Center, Los Angeles, CA
- Yale New Haven Hospital, New Haven, CT.
- Mount Sinai Medical Center, Miami Beach, FL
- Evanston Hospital, Evanston, IL
- Saint Joseph Hospital, Chicago, IL
- Alexian Brothers Medical Center, Elk Grove, IL
- Massachusetts General Hospital, Boston, MA
- Beth Israel Deaconness Medical Center, Boston, MA
- Providence Hospital and Medical Centers, Southfield, MI
- William Beaumont Hospital, Troy, MI
- Missouri Baptist Medical Center, Town and Country, MO
- Hackensack University Medical Center, Hackensack, NJ
- Holy Name Medical Center, Teaneck, NJ
- New York-Presbyterian Hospital, NY, NY
- Maimonides Medical Center, Brooklyn, NY
- New York University Hospitals Center, NY, NY
- Portland VA Medical Center, Portland, OR
- Lehigh Valley Hospital, Allentown, PA
- The Methodist Hospital, Houston, TX
- Aurora St. Luke's Medical Center, Milwaukee, WI