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Top quality hospitals have higher survival rates, with sicker patients: winners say size or budget not necessarily a key to QI success

Key points

* Patients in the highest quality hospitals have 12% to 20% better survival rates.

* Many improvements were made, but there's a long road ahead to reach ultimate quality goals.

* Benchmarking called the first step to achieving high ranking in hospital report cards.

The latest study from HealthGrades, an independent health care quality company based in Lakewood, CO, shines a bright light on the levels of outcome improvement achieved by the nation's quality leaders. At the same time, their findings and the comments of best performers debunk more than one commonly held perception about what it takes to score near the top on nationwide hospital report cards.

The new study, in which hospitals in the top 5% in the nation in clinical quality were named "Distinguished Hospital for Clinical Excellence" by HealthGrades, showed patients in the highest quality hospitals have 12% to 20% better survival rates for common procedures and diagnoses. What's more, they seem to have found the key to reducing mortality, not in one or two areas, but across the board. More specifically, the study found:

* If all patients went to a Distinguished Hospital for four of the highest volume procedures and diagnoses--coronary bypass, angioplasty, stroke, and community-acquired pneumonia--52,949 lives could have been saved from 2001 to 2003.

* A Medicare patient who underwent heart bypass surgery at a Distinguished Hospital on average had a 15.3% better chance of surviving than a patient who received treatment at an average hospital.

* The improved survival rates at Distinguished Hospitals were 15.4% for stroke, 12.62%, for heart attack (in hospitals where angioplasty and stent treatments were available), and 19.55% for community-acquired pneumonia.

Of particular interest was the fact that the Distinguished Hospitals for Clinical Excellence had better patient outcomes despite the fact that they treated more and sicker patients.

This appears to contradict conventional wisdom that larger academic facilities are at a disadvantage in such rankings--precisely because they tend to treat patients with more serious conditions. And, say winners interviewed by Healthcare Benchmarks and Quality Improvement, many key QI strategies can be performed by nearly any hospital--regardless of size or budget.

The hospitals--229 out of nearly 5,000--were ranked at the top of the list based on the death and complication rates of Medicare patients in 28 common procedures and diagnoses, from hip replacement to bypass surgery, over the years 2001, 2002, and 2003.

"These in-hospital survival differences are significant--they cannot and should not be ignored," says Samantha Collier, MD, HealthGrades' vice president of medical affairs.

"I think the major implication [of the study] is we are making improvements, but we have a long road ahead of us," she continues. "The real implications for the quality manager is we can still do more--and with what we have. In every hospital every day, there's a lot of available knowledge and technological know-how to make the needed improvements."

That is what sets the winners apart, Collier says. "You can't be satisfied with the status quo, and that's exactly the culture they display. They are just never satisfied."

Another characteristic of the winners is consistency, she adds. "We see a lot of consistency from year to year, and we are pleased with that. For one thing, we are using three years of data, which stabilizes the results. Also, it demonstrates this is not a fluke thing--the [multiyear winners] are using best practices and maintaining that over time," Collier explains.

Making quality a focus

"We've made quality a focus of our operations and our strategic plan--part of the expectations we put out for leaders," notes David Spivey, president and CEO of St. Mary Mercy Hospital in Livonia, MI, one of only 30 hospitals to have received Distinguished Hospital awards for both clinical excellence and patient safety. "It obviously helps to have a focus on QI in the organization, and leadership has bought into that--not only administrative, but medical staff as well," he notes. After 40 years as an independent facility, St. Mary Mercy joined Trinity Health in 2000.

The emphasis on quality has begun to manifest itself in a variety of departments, Spivey adds. One of those manifestations is a leadership development program, which is about 3 years old. "We hold two-day retreats quarterly and address issues of quality, finance, and growth," he says.

The meetings have a twofold benefit, Spivey says. "It serves as a way for us to focus leadership around the same goals and objectives," he notes. "Plus, we bring in experts from outside the organization to reinforce our message and to provide education for our leadership group."

The program has been so successful, in fact, that the hospital is launching a "leaders developing leaders" program, so that those who have been through the program already can teach frontline staff.

"They are our everyday true leaders and provide the care that allows you to ultimately be successful," Spivey notes. "So we are growing new leaders and getting people rowing in the right direction; it's all about communication."

Another key to quality improvement has been a management incentive program. "This hardwires the awareness of organizational and departmental objectives." He says incentives range between 7.5% and 15%, depending upon the individual's position. "It has definitely been successful."

Six Sigma plays a part

Six Sigma also has played an important role at St. Mary Mercy. The hospital has five full-time black belts and has had several successful projects. "When I first brought it up, there was some push back," Spivey recalls.

"But it has paid for itself many times over in specific projects that have provided a return, but even more important, it has helped improve the culture. It has helped create a data-driven, evidence-based culture, which forces everyone to upgrade their game," he adds.

DMAIC (define, measure, analyze, improve, and control), a key Six Sigma approach, now is the hospital's process improvement methodology.

Education has been a key to success at another Distinguished Hospital, CHRISTUS Santa Rosa Health Care in San Antonio, which has been named two years in a row.

"We have historically had a heavy commitment to education, and I'm not just talking about nursing and ancillary services but medical education," says Don A. Beeler, FACHE, president and CEO.

"For example, in our children's hospital, we are the academic teaching facility for the University of Texas Health Science Center. On the adult side, 10 years ago, we set up our own hospital-based family-practice residency program. They do a lot to influence quality, and a lot of our medical staff choose to be on those teaching services," he points out.

CHRISTUS Santa Rosa is a large Catholic hospital system, part of CHRISTUS Health, with a downtown campus (a large children's hospital and an adjacent facility) and a medical center campus, which is the extension of an adult hospital. Beeler says this emphasis on education and the hospital winning the HealthGrades award are definitely connected.

"Philosophically, we believe that quality and education are linked," he asserts. "When you work in a teaching environment, it keeps everybody a little sharper, and you have people who want to keep up with the latest practices."

Quality and safety, he continues, "are part of who we are."

In fact, in the facility's vision statement, it says that CHRISTUS Santa Rosa wants to be known for compassion, quality, and service. "We put it in our mission statement and goals," Beeler notes. "We have excellent people in our quality department, and they work closely with the medical staff. It's a journey that never ends."

You don't have to be big

For quality managers whose facilities may not have made HealthGrades' top 5% or who would like to do better in other comparative rankings, here's a bit of good news: You don't have to expand your facility dramatically or have a huge budget at your disposal to achieve the improvements you're after.

"I don't think you need a whole lot of money," Spivey says. "We're not the largest facility in the world; we're essentially a 200-bed community hospital."

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